Effectiveness of Community Based Interventions for Children with Asthma

1. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan

2. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan

3. In asthma, four types of community interventions have been examined Outreach from health care institutions Home based computer programs School based programs Coalitions and partnerships

4. Outreach to patients� homes by community health workers to: Provide self-management education Assist with environmental modifications These efforts have generally comprised community health workers who assist family members in their homes with 1)asthma management and 2) modification of the environment of the house especially the child�s living space.These efforts have generally comprised community health workers who assist family members in their homes with 1)asthma management and 2) modification of the environment of the house especially the child�s living space.

5. Summary of Studies: Community health worker based randomized trials The assessments of these interventions have tended to illustrate that home environments can be modified and some have shown that children who have been targeted by these programs can experience reductions in symptoms and health care use. The assessments of these interventions have tended to illustrate that home environments can be modified and some have shown that children who have been targeted by these programs can experience reductions in symptoms and health care use.

6. Issues Effects of environment change not separated from education Cost of environmental modifications However, in these evaluations, the effects of the home modification have not been tested separately from the education and behavioral change strategies also employed. Further, in some studies where home modification has been achieved and reductions in presence of allergens noted, no differences in the child�s health status have been observed.However, in these evaluations, the effects of the home modification have not been tested separately from the education and behavioral change strategies also employed. Further, in some studies where home modification has been achieved and reductions in presence of allergens noted, no differences in the child�s health status have been observed.

7. Computer Programs for Home Use Computer programs focus on games and problem solving These have focused on games and innovative ways for children to learn about asthma in a form that children are familiar with and like to useThese have focused on games and innovative ways for children to learn about asthma in a form that children are familiar with and like to use

8. Summary of Studies: Computer programs at home randomized trials The majority of these studies have assessed changes in children�s knowledge of asthma. The majority of these studies have assessed changes in children�s knowledge of asthma.

9. Issues Limited success Majority of studies test knowledge Small numbers Overlooks children without computers General knowledge about a disease has been shown in many studies not to correlate strongly with behavioral change. One or two studies have shown changes in symptoms or health care use but these have not involved large numbers of subjects. Further, important targets of change: children in asthma hot spots are the least likely to have access to a personal computerGeneral knowledge about a disease has been shown in many studies not to correlate strongly with behavioral change. One or two studies have shown changes in symptoms or health care use but these have not involved large numbers of subjects. Further, important targets of change: children in asthma hot spots are the least likely to have access to a personal computer

10. School Based Interventions Focus on child�s self-management Conducted with and without school based health services Among community based programs, these are the interventions that have received the most attention in evaluation. Among community based programs, these are the interventions that have received the most attention in evaluation.

11. Summary of Studies: School based randomized trials School based programs have shown positive results regarding the management of children�s asthma, improvement in school performance and reductions in symptoms. School based programs have shown positive results regarding the management of children�s asthma, improvement in school performance and reductions in symptoms.

12. Issues Difficult in school systems with limited resources Replication generally does not occur Sponsorship not forthcoming These programs can be complicated to provide in school systems where resources are limited. There is one example where a program has been widely disseminated but despite promising outcomes, generally, this has not occurred. Although a number of asthma coalitions are working in schools, money for these coalitions is also an issue. These programs can be complicated to provide in school systems where resources are limited. There is one example where a program has been widely disseminated but despite promising outcomes, generally, this has not occurred. Although a number of asthma coalitions are working in schools, money for these coalitions is also an issue.

13. Coalitions and Partnerships 200+ asthma coalitions in the United States Focus on community-wide changes Bring disparate but key groups together There are over 200 asthma coalitions in the U.S. alone. These have become a popular means of seeking community wide change regarding asthma morbidity. The premise is that these forms of community action can bring to the table individuals and organizations that don�t usually collaborate in solving health problems.There are over 200 asthma coalitions in the U.S. alone. These have become a popular means of seeking community wide change regarding asthma morbidity. The premise is that these forms of community action can bring to the table individuals and organizations that don�t usually collaborate in solving health problems.

14. Evaluation Logic Eventual improved health status results from: Health system-wide changes Community-wide policies Coalitions in general and asthma coalitions in particular have predicated their work on the following logic: Ultimate outcomes in the form of reductions in morbidity and health care use will result from system and policy changes Coalitions in general and asthma coalitions in particular have predicated their work on the following logic: Ultimate outcomes in the form of reductions in morbidity and health care use will result from system and policy changes

15. Summary of Studies: Community Coalitions & Partnerships As a result of this logic and of the methodological and financial difficulties associated with conducting population wide research to assess the desired ultimate outcome, evaluation of asthma coalitions and partnerships have been scant. As a result of this logic and of the methodological and financial difficulties associated with conducting population wide research to assess the desired ultimate outcome, evaluation of asthma coalitions and partnerships have been scant.

16. Issues Lack of outcome of studies Support has been from foundations Population data not collected Descriptive data suggests number of coalitions have achieved significant change in the communities where they work. However, these forms of action are not generally viewed by health care institutions as central to their mission. The support for the work of coalitions has tended to come from foundations. Data illustrating the effect on individual patients of the work of coalitions are likely necessary if health care providers/insurers are to see coalitions as worthy of their investment. This is the case even though most providers/insurers state that they are very interested in the type of intermediary outcomes coalitions have been shown to produce.Descriptive data suggests number of coalitions have achieved significant change in the communities where they work. However, these forms of action are not generally viewed by health care institutions as central to their mission. The support for the work of coalitions has tended to come from foundations. Data illustrating the effect on individual patients of the work of coalitions are likely necessary if health care providers/insurers are to see coalitions as worthy of their investment. This is the case even though most providers/insurers state that they are very interested in the type of intermediary outcomes coalitions have been shown to produce.

17. In Summary Good models of interventions exist for: community outreach (CHW) school based programs coalitions and partnerships

18. Trends Less examination of social, behavioral, policy interventions Work of community health workers not being reimbursed No continuing sponsorship for school programs or coalitions Proven programs not disseminated Reinvention of the wheel Asthma fallen off the radar Trends differ by the need and constituency viewed. -reduction in funds available for demonstration and evaluation of community approaches to controlling disease has led to reduction in assessments of social, behavioral and policy interventions. This means fewer innovations being generated and less understanding of the functioning and effectiveness of innovations that are attempted. -community health workers are increasingly viewed by public health oriented providers (journal commentaries, conference presentations) as a means to achieve asthma control but in most areas of the country, their work is not a reimbursable cost - there is increased discussion of schools as a means to reach children with asthma (journal supplements, commentaries, community opinion) yet there is rarely a sponsor in most communities who believes there might be direct financial reward for such sponsorship -there is greater interest in and evidence of community coalitions and partnerships around the country, perhaps a result of greater belief in them as a partial solution to the problem but also need to share resources. However there is little financial support available for them. -where community based interventions have been shown to be effective, generally they have not been continued or widely disseminated. As a result, the wheel continues to be reinvented in local communities around the country at considerable cost. -although many of the social, behavioral, policy influences on the health of children with asthma have been identified, effective clinical practices have been recommended, and promising interventions tested, there is a general public fatigue with asthma and failure to recognize the ongoing threat it poses to children�s health and well being.Trends differ by the need and constituency viewed. -reduction in funds available for demonstration and evaluation of community approaches to controlling disease has led to reduction in assessments of social, behavioral and policy interventions. This means fewer innovations being generated and less understanding of the functioning and effectiveness of innovations that are attempted. -community health workers are increasingly viewed by public health oriented providers (journal commentaries, conference presentations) as a means to achieve asthma control but in most areas of the country, their work is not a reimbursable cost - there is increased discussion of schools as a means to reach children with asthma (journal supplements, commentaries, community opinion) yet there is rarely a sponsor in most communities who believes there might be direct financial reward for such sponsorship -there is greater interest in and evidence of community coalitions and partnerships around the country, perhaps a result of greater belief in them as a partial solution to the problem but also need to share resources. However there is little financial support available for them. -where community based interventions have been shown to be effective, generally they have not been continued or widely disseminated. As a result, the wheel continues to be reinvented in local communities around the country at considerable cost. -although many of the social, behavioral, policy influences on the health of children with asthma have been identified, effective clinical practices have been recommended, and promising interventions tested, there is a general public fatigue with asthma and failure to recognize the ongoing threat it poses to children�s health and well being.

19. Ideas to Enhance Application Initiate a targeted campaign to reach health system influentials: ongoing messages and encouragement to support use of proven programs Provide a compendium of proven programs and �how to�s� as part of the campaign Funders initiate research into effective channels for dissemination of programs Reinvigorate support for community intervention research including evaluation methodology NAEPP, CDC, the Merck Foundation and others have stated and in some cases supported the need to use proven models when intervening in asthma. The need to use proven models should become the mantra in health care systems and community organizations. Communications to influentials in the health care community from key agencies should include this idea as the standard of care. Further, a compendium of the available models should be produced and made widely available in all formats (hard copies, on line) to key players in the health care community. A significant investment by funders (perhaps even collectively) should be made in dissemination research, that is, development of methodologies for making widely available and supporting the initiation of programs, partnerships, policies that have been proven to have a positive effect on children�s asthma. Often this type of research is seen as soft and frilly. Given the state of health care in the US it should be seen as crucial. Reinvigoration by funders of their efforts to support intervention research that reaches across communities and trys to attenuate social and behavioral influences on asthma and asthma management. Applications are only as good as the science that undergirds them. NAEPP, CDC, the Merck Foundation and others have stated and in some cases supported the need to use proven models when intervening in asthma. The need to use proven models should become the mantra in health care systems and community organizations. Communications to influentials in the health care community from key agencies should include this idea as the standard of care. Further, a compendium of the available models should be produced and made widely available in all formats (hard copies, on line) to key players in the health care community. A significant investment by funders (perhaps even collectively) should be made in dissemination research, that is, development of methodologies for making widely available and supporting the initiation of programs, partnerships, policies that have been proven to have a positive effect on children�s asthma. Often this type of research is seen as soft and frilly. Given the state of health care in the US it should be seen as crucial. Reinvigoration by funders of their efforts to support intervention research that reaches across communities and trys to attenuate social and behavioral influences on asthma and asthma management. Applications are only as good as the science that undergirds them.

20. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan