Healthy Homes University: A Home-Based Environmental Intervention and Education Program for Families with Pediatric Asthma in Michigan

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1 Prctice Articles Helthy Homes University: A Home-Bsed Environmentl Intervention nd Eduction Progrm for Fmilies with Peditric Asthm in Michign Thoms W. Lrgo, MPH Michele Borgilli, MPH, MSW Courtney L. Wisinski, BS Robert L. Whl, DVM, MS Wesley F. Priem, BS ABSTRACT Environmentl conditions within the home cn excerbte sthmtic children s symptoms. To improve helth outcomes mong this group, we implemented n in-home environmentl public helth progrm Helthy Homes University for low-income fmilies in Lnsing, Michign, from 2005 to Fmilies received four visits during six-month intervention. Progrm stff ssessed homes for sthm triggers nd subsequently provided products nd services to reduce exposures to cockroches, dust mites, mold, tobcco smoke, nd other triggers. We lso provided sthm eduction tht included identifiction of sthm triggers nd instructions on specific behviors to reduce exposures. Bsed on self-reported dt collected from 243 cregivers t bseline nd six months, the impct of sthm on these children ws substntilly reduced, nd the proportion who sought cute unscheduled helth cre for their sthm decresed by more thn 47%. Michign Deprtment of Community Helth, Division of Environmentl Helth, Lnsing, MI Address correspondence to: Michele Borgilli, MPH, MSW, Michign Deprtment of Community Helth, Division of Environmentl Helth, Helthy Homes Section, P.O. Box 30195, Lnsing, MI 48909; tel ; fx ; e-mil <borgillim@mi.gov> Assocition of Schools of Public Helth 14

2 Home-Bsed Peditric Asthm Intervention 15 Asthm prevlence, hospitliztions, nd deths hve incresed stedily mong children over the pst three decdes, bringing this issue to the forefront of public helth. 1 3 This rticle describes nd evlutes n environmentl public helth progrm intended to decrese sthm symptoms in children through environmentl trigger identifiction nd reduction in the home, coupled with multiple, fce-to-fce eduction sessions with cregivers. The progrm ws designed in response to growing body of literture suggesting tht the home environment is ssocited with sthm symptom excerbtion in children. 4 6 Asthm is chronic inflmmtory respirtory disese tht rnges in severity. Episodic cute symptoms cn be induced by upper respirtory infections, exposure to environmentl pollutnts nd llergens, exercise, emotionl distress, nd excitement. Environmentl risk fctors in the home tht re known to ffect childhood sthm symptoms include cockroch, dust mite, nd niml-derived llergens; second-hnd tobcco smoke; mold; chemicls (e.g., household clening products nd pesticides); nd combustion byproducts from wood or nturl gs stoves Some reserch studies hve ttempted to control for single sthm trigger in the home environment with vrying success on respirtory helth outcomes. 10,13 16 Current trends in progrm prctice design tht ddress multiple environmentl triggers in the intervention strtegies revel promising nd consistent findings. The most successful progrms re those tht hve combined environmentl interventions with fce-to-fce eduction over multiple home visits. 7,17 21 The Helthy Homes University Progrm Helthy Homes University (HHU) ws home-bsed environmentl intervention nd helth promotion progrm whose trget popultion ws low-income fmilies with sthmtic children residing in Inghm County, Michign home to Michign Stte University. Household prticiption spnned six months from initil home ssessment to completion, with four home eduction visits conducted within tht time frme. HHU progrm objectives were to increse primry cregiver knowledge bout sthm nd its triggers, improve environmentl conditions within the home, nd reduce child sthm severity. The progrm ws lso designed to reduce unintentionl injuries; however, this rticle focuses on the interventions nd outcomes pertining to sthm. In 2005, the sthm hospitliztion rte for children 18 yers of ge in Inghm County ws significntly higher thn the corresponding sttewide rte (41.2 vs per 10,000). Among the Medicid popultion in 2005, 7.2% of children living in Inghm County showed helth-cre usge consistent with persistent sthm, compred with the 5.3% estimte for the stte (Personl communiction, Elizbeth A. Wsilevich, Division of Genomics, Perintl Helth, nd Chronic Disese Epidemiology, Michign Deprtment of Community Helth, My 2010). Demogrphic nd housing dt from the U.S. Census Bureu s Census 2000 showed tht the t-risk popultion in Inghm County ws concentrted in the city of Lnsing. In 2000, the city popultion ws 119,128 (22% blck, 10% Hispnic). Twenty-four percent of Lnsing s occupied housing stock ws built before 1940, with renters in bout one-third of these units. The city s medin fmily income ws $28,550; less thn one-third of these fmilies mde $14,275. According to the 2000 Comprehensive Housing Assessment Strtegy Dtbook, 40% of renting households in Lnsing hd housing problems, defined s housing cost burden (ffordbility), overcrowding, n incomplete kitchen, or unfinished plumbing. Methods Selection of progrm prticipnts From November 2005 to Mrch 2006, HHU stff visited neighborhood colitions, schools, helth-cre providers, community orgniztions, nd governmentl gencies to mrket the progrm. We recruited households through interest fliers distributed through these venues nd subsequently sent pplictions to interested households. A household ws eligible if there ws t lest one resident child 18 yers of ge with cregiverreported sthm nd the household income ws 80% of the re s medin income. Selection priority ws bsed on weighted nd scored mtrix of fctors listed on the ppliction, including ge of housing, income sttus, single hed of household, number of sthmtic children, sthm symptom severity, nd the presence of environmentl sthm triggers. The flow digrm in Figure 1 illustrtes the number of prticipnts nd withdrwls t key stges throughout the progrm. Interventions We enrolled ll prticipting households in six-month bsic intervention progrm, with subset receiving custom interventions. Criteri for determining which households received custom interventions included condition of home, severity nd number of residents in the home with sthm, household complince with prticiption greement, nd vilbility of products. Households received n introductory pre-intervention

3 16 Prctice Articles Figure 1. Recruitment nd prticipnt flow digrm illustrting number of prticipnts nd withdrwls t key stges throughout the progrm: HHU peditric sthm intervention progrm, Lnsing, Michign, ,119 fliers distributed nnouncing the progrm 926 fliers returned by households interested in the progrm 926 progrm pplictions sent to interested households 588 households provided no further response 338 progrm pplictions received 12 households found to be ineligible 326 households ccepted into progrm nd received pre-intervention home visit 25 households opted out, could not be reched, or did not sign consent form 301 households received bseline intervention home visit 28 households discontinued progrm 247 households received three-month home visit 30 households discontinued progrm 243 households received six-month home visit; 217 households received bseline, three-month, nd six-month home visits; nd 26 households received bseline nd six-month home visits HHU = Helthy Homes University

4 Home-Bsed Peditric Asthm Intervention 17 home visit, bseline intervention home visit for helth eduction nd product instlltion, nd three- nd sixmonth post-intervention home visits. Figure 2 illustrtes specific ctivities tht occurred t vrious stges of the progrm. Before enrollment begn, we cquired Michign Deprtment of Community Helth Institutionl Review Bord clernce for humn subject prticiption. Eductionl bckgrounds of progrm field stff included degrees in biology, medicl technology, nd environmentl science, with prior experience in clinicl reserch, low-income housing, nd environmentl contminnt investigtion. Additionl progrm trining entiled in-home ssessment nd sthm-trigger remedition, sthm mngement, survey techniques, nd motivtionl speking. Pre-intervention home visit. Ech qulified household received one-hour introductory visit. Progrm stff trgeted interventions nd helth outcomes for one subject child in ech household. The purpose of the first visit ws to (1) introduce HHU stff to household members, (2) discuss progrm expecttions nd timelines, (3) obtin informed consent nd prticiption greement, nd (4) perform visul ssessment to Figure 2. Progrm prticiption phses nd ctivities: HHU peditric sthm intervention progrm, Lnsing, Michign, Phse Pre-intervention home visit Bseline intervention home visit Three-month post-intervention home visit Six-month post-intervention home visit HHU Helthy Homes University Activities Complete informed consent nd prticiption greement. Identify sthm triggers nd sfety hzrds per visul ssessment. Determine bsic nd custom products nd services for intervention. Administer bseline household questionnire. Instll bsic products. Educte on sthm-trigger reduction nd injury prevention. Assess intervention effectiveness (household questionnire nd visul ssessment). Instll custom products nd initite custom services. Repet eduction on sthm-trigger reduction nd injury prevention. Assess intervention effectiveness (household questionnire nd visul ssessment). Repet eduction on sthm-trigger reduction nd injury prevention. Provide progrm completion gift certificte nd diplom. identify environmentl sthm triggers nd evlute overll housing condition. Findings of the visul ssessment determined which bsic nd custom intervention products we would provide to the household. Bseline intervention home visit. Progrm stff conducted three-hour bseline intervention home visit within two weeks of the introductory visit. We dministered survey, instlled products, nd provided sthm eduction to the subject child s primry cregiver. The survey cptured demogrphic informtion; fmily history of sthm; knowledge nd presence of sthm triggers; home clening frequency; nd the subject child s sthm symptoms, frequency of medicl visits for sthm, nd sthm mediction usge. Stff designed the bseline questionnire using the following ntionlly recognized ssessment tools: the Centers for Disese Control nd Prevention s Behviorl Risk Fctor Surveillnce System Child Asthm Cll-Bck Survey Questionnire, 22 the Settle-King County Helthy Homes Project Bimonthly Interim Questionnire, 12 nd the ZAP Asthm Project Cregiver Asthm Knowledge Survey Instrument. 23 While the survey ws being conducted, the bsic intervention products (Figure 3) were instlled. After these tsks were completed, stff took the cregiver on wlk-through of the home nd provided tilored, one-on-one eduction bsed on cregiver responses to the survey. HHU stff demonstrted techniques (e.g., furnce filter replcement, clening, nd vcuuming) to reduce sthm triggers. In ddition, we gve cregivers HHU Course Mnul, which included sthm informtion nd locl resources. Post-intervention follow-up home visits. Post-intervention follow-up visits were scheduled for three nd six months fter the bseline intervention home visit. Two HHU stffers were present t ech two-hour home visit; one dministered survey similr to the bseline questionnire. The stff ressessed the home for sthm triggers nd determined if the intervention products provided t bseline were in use. Progrm stff lso reinforced cregiver eduction bsed on their survey responses. When custom intervention products (Figure 3) were llocted to household, the stff provided them t three- or six-month follow-up visits to encourge continued progrm prticiption. Households in which ll four home visits were completed received gift certifictes nd progrm diplom. Dt nlysis We evluted the progrm using survey responses provided by cregivers t the bseline nd six-month visits to mesure chnges in ech of the following

5 18 Prctice Articles res: () cregiver knowledge bout sthm triggers, (b) frequency of vrious ctions to reduce in-home sthm triggers, (c) environmentl conditions within the home, (d) subject child s sthm severity, nd (e) cute, unscheduled medicl cre sought for tretment of the child s sthm. We designted medicl cre utiliztion s cute, unscheduled to differentite it from preventive, well-sthm medicl cre. In ddition, we used visul ssessment dt collected by stff during the pre-intervention nd six-month post-intervention visits to chrcterize key bseline home conditions nd mesure environmentl chnges. For the initil 95 home visits, these home conditions (e.g., presence of bthroom fn) were scertined vi cregiver self-reporting. However, field stff noted discrepncies between wht ws observed nd wht ws reported. Thus, for the remining 148 prticipnts, these environmentl fctors were bsed on stff visul ssessment only. Our nlyses of chnges in home conditions were limited to these 148 households. We limited our nlyses to households who completed the six-month progrm. To mximize study group size, we did not exclude households who did not receive three-month visit. While there is sesonlity to sthm incidence, Figure 3. Intervention products nd services provided to prticipting households: HHU peditric sthm intervention progrm, Lnsing, Michign, Asthm trigger-relted Bsic intervention products Culk Crbon monoxide detector Trsh cn with lid Door mt Fn Fom crck selnt Food continers with securing lids Furnce filters HEPA vcuum nd replcement bgs Pest erdiction gels nd bits Mildew-proof shower curtin Nontoxic clening supplies Pillow nd mttress covers Smoking cesstion kit Custom intervention products/services Bthroom vent instlltion Beds nd pillows Clothes dryer vent repir Crpet removl Dehumidifier Furniture slipcovers Grbge removl Gutter replcement/repir HEPA ir filter unit House clening Lndscping for wter dringe Minor roof repir Plumbing repir Pest extermintion Stove vent instlltion Window ir-conditioning unit Injury hzrd-relted Bsic intervention products Crbon monoxide nd smoke detectors Cbinet sfety locks Child sfety gte Electricl outlet sfety plugs Fire extinguisher First id kit Flshlights Gun trigger locks Mercury-free thermometer Mini-blind cord wind-ups Night-lights Poison control sticker Skid-proof rug pds/rug gripper tpe Skid-proof bthroom mt Step stool Custom intervention products/services Outdoor child ply re improvement Ded bolt for entry door Electricl repir Window repir Stirwell repir HVAC mintennce Household hzrdous-wste removl HHU Helthy Homes University HEPA high-efficiency prticulte ir HVAC heting, ventilting, nd ir conditioning

6 Home-Bsed Peditric Asthm Intervention 19 we did not control for this potentilly confounding fctor becuse fmilies were enrolled continuously during 2½-yer period. We nlyzed responses to survey questions pertining to sthm knowledge, clening behvior, nd sthm severity s continuous dt. For these topics, we compred bseline nd six-month mens nd tested for two-tiled sttisticl significnce using the pired t-test. Dt on whether subject children sought cre t n emergency deprtment, were hospitlized overnight, or hd ny other cute, unscheduled visit to helth-cre provider for tretment of sthm were binry either child sought this cre in the previous six months or did not. Similrly, environmentl conditions either were present or not. We used McNemr s test to exmine chnges in the proportion of children requiring helth-cre visits for sthm nd for the proportion of homes with environmentl conditions relevnt to sthm. Becuse our nlyses involved pired dt (e.g., cregiver responses t bseline nd six months), missing vlue t either bseline or six months necessitted excluding tht dt pir from nlysis. We used SAS version for sttisticl testing. Test results for which p-vlues were 0.05 were considered sttisticlly significnt. RESULTS We ccepted 326 households for the intervention (Figure 1). Of the 301 households in which the bseline intervention home visit ws completed, 243 (81%) completed the six-month progrm nd comprised our study group. Tble 1 chrcterizes the demogrphics of the 243 subject children nd their households t bseline. Their medin ge ws 7 yers, nd there were slightly more mles thn femles. About 25% of the children were reported by their cregivers s multircil, nd 10% were reported s Hispnic. For one-qurter of the households, no other children lived in the home. Slightly more thn hlf (56%) of the households rented their property. Medin income ws $16,640, nd 81% of the households were enrolled in Medicid. The biologicl fther did not reside within 87% of the households. Fifty-eight households filed to complete the progrm becuse of reloction, eviction, foreclosure, or loss of contct with project stff. These 58 subject children hd chrcteristics very similr to those seen in Tble 1. The exception ws tht households of Hispnic children were much less likely to withdrw from the progrm. Tble 2 illustrtes bseline intervention home conditions relevnt to sthm excerbtion. Asthm triggers ssocited with these conditions include mold, dust, dust mites, cockroches, erosol pesticides, rodent urine, nd niml dnder. High reltive humidity provides the necessry moisture for mny of these triggers. More thn hlf of the households hd experienced wter dmge in the previous yer. In ddition, mny Tble 1. Chrcteristics of subject children, s reported by cregivers t bseline (n=243): HHU peditric sthm intervention progrm, Lnsing, Michign, Chrcteristic N Percent Age (in yers) Gender Mle Femle Rce One rce White Africn Americn Other Multircil Not reported Hispnic Helth insurnce Medicid Alone In combintion with other type Prent s employer Other None Number of other children living in home Room where subject child usully sleeps Own room Prent s room Other Biologicl fther does not live in home Household occupncy sttus Homeowner Renter Annul household income $20,000 $20,000 $39,999 $40,000 Cregiver eduction Did not grdute from high school High school grdute; no college At lest some college HHU Helthy Homes University

7 20 Prctice Articles Tble 2. Chrcteristics commonly ssocited with the presence of sthm triggers in prticipting homes t bseline: HHU peditric sthm intervention progrm, Lnsing, Michign, Chrcteristic N Percent Lek, flooding, or other wter dmge in the pst yer Aerosol pesticides (spry or bug bomb) used No working heting system Crpeting nd rugs Fmily room hs crpeting or rug b Subject child s bedroom hs wll-to-wll crpeting or re rugs b Windows Fmily room hs no windows tht cn open b Kitchen hs no windows tht cn open b Primry bthroom c hs neither vent nor window tht cn open b Subject child s bedroom hs no windows tht cn open b 8 23 Air-qulity control Subject child s bedroom hs neither centrl nor room ir conditioning b 87 Subject child s bedroom hs humidifier b 14 rooms lcked the bility to ventilte humidity though window or vent, nd nerly one in 10 subject children hd humidifiers in their bedrooms. Most homes hd crpeting nd/or rugs in the fmily room nd the subject child s bedroom. Floor coverings re prime loctions where children cn be exposed to sthm triggers. The few homes without working heting system presumbly used n lterntive heting source; mny of these sources generte combustion by-products, which re lso sthm triggers. Finlly, ir conditioning llows windows to remin closed during high-llergen sesons nd filters the ir. However, ir conditioning ws lcking in more thn hlf of the subject children s bedrooms. Cregiver knowledge of sthm triggers Progrm stff sked cregivers 37 mostly true-flse/ gree-disgree questions tht included identifiction of specific sthm triggers, pproprite wys to respond to sthm ttcks, nd effects of sthm on dily living Reported by ll 243 cregivers b Dt for these chrcteristics were collected by HHU stff on the visul ssessment form for 148 of the 243 homes. The originl visul ssessment form used for the first 95 households did not include these environmentl chrcteristics but ws revised for use on the remining 148 homes. c Bthroom in which the fmily normlly showers or bthes HHU Helthy Homes University (Tble 3). Overll, respondents nswered n verge of three more questions correctly t six months thn t bseline, thereby improving their overll score from 82.5% to 90.5% (p ). Scores improved for 83% of cregivers, while 10% showed no chnge, nd 7% scored worse. Cregivers scores improved substntilly t six months for mny importnt topics, such s cockroches (96.3% nswered correctly) nd birds (93.8%) s sthm triggers, inhled steroids not hving the sme side effects s orl steroids (93.8%), nd people with sthm knowing how well their lungs re working (88.6%). For severl questions, however, the percent of cregivers responding correctly ws low t six months. Less thn hlf correctly indicted tht sthm symptoms cnnot be worsened by mosquitoes (49.0%), eggs (36.6%), nd chocolte (46.1%), nd tht sthm episodes usully do not occur without wrning (45.9%). Home environmentl conditions During introductory nd bseline ssessments, stff scertined, through cregiver reporting nd stff visul observtion, both the presence of prticulr risk fctors for sthm excerbtion nd the bsence of products tht could be used to reduce the subject child s exposure to triggers. Tble 4 illustrtes the percentge of households with ech risk fctor t bseline nd six months. Households demonstrted improvement for most of the risk fctor mesures. While there ws no sttisticlly significnt chnge in the percentge of cregivers reporting the presence of household indoor pets, fewer reported llowing pets in the child s bedroom: 59.6% t bseline nd 50.5% t six months (p 0.05). Also, substntilly fewer cregivers reported evidence of mold in the home: 58.2% vs. 38.9% (p ). There ws no mesurble chnge in the reported evidence of cockroches, but there ws decrese in the reported evidence of mice or rts: 19.8% vs. 12.8% (p 0.01). Fewer households reported llowing stuffed toys in the child s bedroom: 68.3% vs. 48.3% (p ). There ws some reduction in reported exposure to tobcco smoke, either within the home (21.8% vs. 14.4%) or by nyone cring for the child (51.3% vs. 43.8%) (p 0.005). HHU stff visully observed tht high-efficiency prticulte ir filters nd pillow/mttress covers designed to control dust mites were generlly bsent in the subject children s bedrooms t bseline (bsent for 98.6%, 97.9%, nd 96.5%, respectively). These items were mong the bsic nd custom products supplied or instlled by HHU stff. Among the listed environmentl chnges, the gretest chnge from bseline

8 Home-Bsed Peditric Asthm Intervention 21 to six months occurred in the prevlence of pillow (bsent for 9.9%) nd mttress (bsent for 15.6%) covers (p ). Home clening frequency HHU stff encourged cregivers to frequently perform number of ctions to improve nd mintin the Tble 3. Questions used to mesure sthm knowledge of the subject child s cregiver nd percent of cregivers who nswered correctly for ech question t bseline nd six months: HHU peditric sthm intervention progrm, Lnsing, Michign, Percent of cregivers who nswered correctly Question Bseline Six months Chnge Smoking round child with sthm my mke them cough but it is not hrmful Asthm symptoms cn be mde worse by: Dust Cockroches Mosquitoes Mold, mildew, or fungi Tobcco smoke Hrd, crisp, or crunchy foods Infections Eggs Exercise Pet fish Chocolte Birds Cts Pollen Air pollution Emotionl stress or excitement Dogs Wtching television Dust mites Is sthm n cute or chronic disese? Asthm cn mke you feel bd even if not wheezing Asthm episodes usully occur without wrning Not ll sthm episodes need to be tken seriously Asthmtics only need to see doctor bout sthm when hving n ttck People cn die from hving n sthm ttck If someone tkes sthm mediction everydy, they do not hve to sty wy from things to which they re llergic It is best to wit nd see if sthm symptoms go wy on their own before tking s needed medictions An inhler will deliver useful dose of medicine no mtter how it is used A person with sthm cn become ddicted to their sthm medictions People with sthm hve no wy to know how well their lungs re working During n sthm ttck, it is hrd to blow out ir from the lungs Asthm cnnot be cured, but it cn be controlled People with sthm should not exercise There is nothing you cn do to keep from getting n sthm ttck Asthm is ll psychologicl, tht is, in people s heds Inhled steroids hve the sme side effects s orl steroids Totl Questions were true/flse or gree/disgree except whether sthm ws n cute or chronic disese. HHU = Helthy Homes University

9 22 Prctice Articles Tble 4. Percent of prticipting households with environmentl risk fctors ssocited with sthm excerbtion t bseline nd six months: HHU peditric sthm intervention progrm, Lnsing, Michign, Percent of homes with fctor Risk fctor N Bseline Six months Chnge P-vlue Per cregiver self-report Stuffed toys in child s bedroom Home hs indoor fethered or furry pets Pets llowed in subject child s bedroom Mold hs been seen or musty odor hs been smelled in the subject child s bedroom (pst 30 dys) Mold hs been seen or musty odor hs been smelled in the rest of the home (pst 30 dys) Evidence of cockroches inside the home (pst 30 dys) Evidence of mice or rts inside the home (pst 30 dys) Someone hs smoked inside the home (pst week) Smoker mong those who tke cre of the subject child Per HHU stff visul ssessment b No HEPA ir filter c in subject child s bedroom Mttress cover for controlling dust mites c not used/vilble Pillow cover for controlling dust mites c not used/vilble NS 0.05 NS NS Number of vlid bseline/six-month cregiver response or visul ssessment pirs. If dt for cregiver response (or visul ssessment) were missing, not pplicble, or otherwise invlid for either bseline or six months, tht pir ws excluded from nlysis. b Visul ssessment dt were collected for only 148 of the 243 homes. The originl form used for the first 95 households did not cpture environmentl chrcteristics. c Items provided by HHU stff during the progrm HHU Helthy Homes University NS not sttisticlly significnt HEPA high-efficiency prticulte ir hygiene of their homes. Tble 5 lists the most relevnt of these for minimizing sthm triggers. At six months, cregivers reported tht they hd incresed the frequency with which they performed ech ction. The increses were ll sttisticlly significnt except for wshing sheets nd pillowcses. However, the degree to which they incresed vried by the type of ctivity. They incresed their dusting nd wshing of blnkets nd covers only slightly, but incresed vcuuming by nerly once per month. Most notbly, they nerly doubled the rte of vcuuming upholstered furniture. In ddition, t six months, they reported wshing their child s stuffed toys nerly once month. The increse in the reported rte of chnging their furnce filter ws ffected by HHU stff performing the tsk during the three- nd six-month visits. Subject child s sthm severity Cregivers reported monthly frequencies for subject children experiencing negtive helth effects due to sthm (Tble 6). For ech of the listed indictors of sthm impct, the number of monthly occurrences reported t six months ws less thn reported t bseline, nd ll improvements were sttisticlly significnt. The reductions rnged from 51% (wheezing first thing in the morning) to 71% (missed school due to sthm). Unscheduled medicl cre for subject child s sthm Cregivers were sked in bseline nd six-month surveys if the subject child hd visited n emergency deprtment or been hospitlized overnight for sthm in the previous six months. They were subsequently sked if, besides these events, the child hd seen helth-cre provider for sthm in the pst six months, in which the visit ws unscheduled (i.e., not scheduled more thn 24 hours in dvnce). Figure 4 illustrtes cregiver responses for the three types of medicl cre queried. For ech mesure, the proportion of households who sought medicl cre for the child s sthm decresed substntilly 48% for unscheduled visits to helthcre provider, 53% for emergency deprtment visits, nd 68% for hospitliztions. All three reductions were sttisticlly significnt (p ).

10 Home-Bsed Peditric Asthm Intervention 23 Tble 5. Chnges in cregiver-reported frequency of ctions to reduce in-home environmentl sthm triggers from bseline to six months: HHU peditric sthm intervention progrm, Lnsing, Michign, Men frequency b Action N Bseline Six months Chnge P-vlue Dusting the child s bedroom Dusting the other rooms in the home Vcuuming the floor of the child s bedroom Vcuuming the floors in the other rooms of the home Vcuuming the upholstered furniture in the home Wshing the child s sheets nd pillowcses NS Wshing the blnkets or covers on the child s bed Wshing the stuffed toys in the child s bedroom Chnging the heting system filter Number of vlid bseline/six-month cregiver response pirs. If dt for cregiver response were missing, not pplicble, or otherwise invlid for either bseline or six months, tht pir ws excluded from nlysis. b Times per month, except for chnging the heting system filter, for which frequency is times per yer HHU Helthy Homes University NS not sttisticlly significnt DISCUSSION We found tht fmilies completing the HHU progrm hd modest, yet sttisticlly significnt, improvements in sthm knowledge, self-reported clening hbits, nd in-home environmentl conditions. Among sthmknowledge gins, most noteworthy ws tht one-third of cregivers becme wre tht cockroches re sthm triggers. The most notble gin in self-reported clening hbits pertined to the frequency of vcuuming, especilly upholstered furniture. The most impressive environmentl improvement ws the increse in the percentge of households in which the subject child ws using pillow nd mttress covers designed to control dust mites. These items were provided by the progrm nd required miniml behvior chnge by fmilies. Consistent with the chnges described bove, there were sttisticlly significnt cregiver-reported reductions in peditric sthm severity. The number of dys tht subject children were negtively impcted by their sthm decresed t lest 50% by ll of our mesures. Thus, not only were children experiencing symptoms less frequently, but lso their sthm ws impcting them less, specificlly with missed school dys nd reduced physicl ctivity. In ddition, the percentge of households seeking medicl cre for their child s sthm substntilly decresed for ech of our three mesures: emergency deprtment visits, Tble 6. Chnges in cregiver reports of subject child s sthm severity from bseline to six months: HHU peditric sthm intervention progrm, Lnsing, Michign, Men frequency b Impct of subject child s sthm N Bseline Six months Chnge P-vlue Hd wheezing first thing in the morning Woke up becuse of wheezing, tightness in chest, or cough Hd shortness of breth becuse of sthm Hd wheezing, tightness in the chest, or cough Hd to slow down or stop ply or ctivities becuse of sthm, wheezing, tightness in chest, or cough Missed preschool or school becuse of sthm Number of vlid bseline/six-month cregiver response pirs. If dt for cregiver response were missing, not pplicble, or otherwise invlid for either bseline or six months, tht pir ws excluded from nlysis. b Within the pst 30 dys HHU Helthy Homes University

11 24 Prctice Articles hospitliztions, nd ll other cute, unscheduled medicl visits. When viewed in conjunction with the firly modest improvements in knowledge, clening behvior, nd home environments, these reductions were striking. Previous studies hve demonstrted tht effective helthy homes intervention progrms require multiple home visits. 7,17 21 We designed our progrm on this premise, nd stff mde four in-home visits with most of the prticipting households. One key to progrm success tht studies hve cited is the effectiveness of outrech workers. This is importnt becuse they re the connection between the progrm design nd humn subjects. Specific chrcteristics tht re vitl to outrech worker effectiveness include empthy, subject mtter expertise, nd persistence. While we did not gther quntittive dt evluting our stff, one indiction of their effectiveness in gining prticipnt trust nd buy-in is tht 81% of fmilies who received the bseline visit remined in the progrm for the full six months. The provision of vluble products lso my hve contributed to the high prticipnt retention rte. Helthy People 2010 is ntionl helth-promotion nd disese-prevention inititive 25 tht includes environmentl helth objectives pertining to helthy homes nd helthy community issues. HHU ddressed three of these ntionl objectives: To reduce indoor llergen levels HHU home visits provided sthm-trigger reduction products to households nd educted cregivers on wys they could reduce indoor llergens. To reduce the proportion of housing units tht re substndrd HHU stff corrected physicl housing problems including wter leks, electricl deficiencies, pest infesttions, inoperble heting equipment, crcks nd holes, hnd rils, nd peeling led-bsed pint. To reduce the popultion s exposure to pesticides Figure 4. Percentge of households tht sought unscheduled helth cre for the child s sthm within the pst six months, s reported by cregivers t bseline nd six months, by type of medicl cre received (n=243 for ech type): HHU peditric sthm intervention progrm, Lnsing, Michign, b Type of medicl cre Reductions were sttisticlly significnt (p ) for ech medicl cre type. b Excluded from this ctegory were emergency deprtment visits nd hospitliztions. These were considered unscheduled visits becuse they were not scheduled more thn 24 hours in dvnce. HHU = Helthy Homes University

12 Home-Bsed Peditric Asthm Intervention 25 HHU stff educted households bout integrted pest-mngement techniques nd provided them with trps, bits, food continers, nd trsh cns. Progrm costs The following costs pertin to the products nd services provided for sthm nd injury prevention efforts implemented within the comprehensive progrm. The men cost for the bsic products provided for ll households t the bseline visit ws $387. Twelve percent of the households received custom service, with men cost of $2,647 per household. Stffing nd trvel costs ssocited with home visit were $230, nd dministrtive office function costs were $1,055 per household. Limittions Our progrm hd severl limittions. Some of these could hve ffected our findings, while others inhibit our bility to ttribute the pprent helth improvement to our intervention. The reduction in sthm severity my hve been rtificilly inflted due to reporting bis. Cregivers could hve overstted sthm severity t bseline to justify progrm inclusion nd understted it t completion to provide desirble results. Improvements in clening hbits, likewise, my hve been the result of reporting bis. Becuse HHU stff hd stressed good home hygiene, cregivers my hve embellished their clening hbits t progrm completion to void the embrrssment of not meeting perceived expecttions. Our progrm did not utilize control group. In this cse, n pproprite control group would hve been set of households similr to our intervention group t bseline in terms of housing conditions, child sthm severity, nd vilbility of locl sthm colition. Use of control group ginst which to compre intervention group results is crucil becuse fctors other thn our intervention could hve influenced outcomes. Without control group, we cnnot estimte the effect our progrm lone hd on reducing sthm severity. We did not design the progrm for the purpose of generlizing results to lrger popultion. Such design would hve required recruiting households using probbility smpling methods. The 243 fmilies evluted here were motivted to llevite childhood sthm, s evidenced by their self-selection into the progrm nd their diligence to prticipte through the entire six months. However, our findings my be indictive of results tht other similrly designed progrms could hve when working with motivted fmilies. We did not collect dt on ll of the fctors tht could hve contributed to the observed reduction in sthm severity. The Ntionl Hert, Lung, nd Blood Institute Ntionl Asthm Eduction nd Prevention Progrm s Expert Pnel Report 3: Guidelines for the Dignosis nd Mngement of Asthm 26 cites tht, in ddition to reducing exposure to environmentl sthm triggers, the following re key to the long-term control of sthm: providing optiml phrmcotherpy, ensuring proper use of sthm medictions, hving children mintin norml ctivity levels, nd mintining effective communictions between ptients nd their helth-cre providers. Finlly, we hve no informtion on the impct of our progrm beyond six months, either in terms of peditric sthm severity or improvements to the home environment. Chnges in cregiver behvior my hve been temporry nd due to the Hwthorne effect. Tht is, they my hve modified their behvior simply in response to the fct tht they were being studied. Current sttus Helthy Homes University II In 2008, the Michign Deprtment of Community Helth received grnt funding to continue HHU through For this second version (HHU II), severl chnges were mde to improve the progrm, including redesigning the questionnire; modifying the bsic products provided; offering environmentl smpling nd dditionl products s incentives for progrm complince; performing environmentl smpling for dust mite, cockroch, nd mouse urine llergens; requiring n sthm ction pln nd scheduled well-sthm doctor visits to promote proper mediction usge; utilizing Medicid clims dt, rther thn self-reporting, to identify helth outcomes; nd compring outcomes to control group to evlute effectiveness. CONCLUSIONS Improving the helth of child with sthm requires multifceted strtegy tht ddresses the physicl home environment, helth-cre utiliztion, mediction dherence, nd other extrinsic fctors (e.g., helth behviors nd cregiver involvement). Through eduction with multiple in-home visits by trined stff, fmilies cn gin knowledge bout sthm triggers, effective methods for improving their home environment to minimize these triggers, how to most effectively utilize the helth-cre system, nd the importnce of pproprite use of effective mediction. In the HHU progrm, we conducted multiple home visits nd hd very good prticipnt retention rtes, thnks to dedicted, persistent, nd empthetic stff. We found tht cregivers incresed their wreness of importnt sthm topics nd reported greter

13 26 Prctice Articles frequency of trigger-reducing behviors. The progrm ssisted fmilies in improving home environments by providing nd directly instlling certin products. Progrm stff did not mesure chnges in the use of pproprite sthm medictions or regulr well-sthm doctor visits, but re doing so for HHU II. While we found sttisticlly significnt reductions in sthm severity, we cnnot ttribute these outcomes solely to our intervention becuse of the relince on self-reported dt nd the lck of control group to which we could compre outcomes. Overll, the HHU progrm is promising model for reducing peditric sthm severity mong motivted fmilies. In 2005, primry funding ws provided by U.S. Deprtment of Housing nd Urbn Development (HUD), Office of Helthy Homes nd Led Hzrd Control grnt #MILHH , with dditionl support from the Michign Deprtment of Community Helth (MDCH). The findings nd conclusions in this rticle re those of the uthors nd do not necessrily reflect the conclusions or opinions of HUD or MDCH. The uthors thnk project field specilists nd housing technicl ssistnts Lind Stewrt, Ln Ashley, Mrgret Demps, nd Lin Goodwin for working enthusisticlly nd devotedly with their clients. The uthors lso thnk sthm epidemiologist Elizbeth A. Wsilevich, PhD, MPH, nd environmentl epidemiologist Lorrine L. Cmeron, PhD, MPH, for their support nd expertise in the progrm nd survey design. References 1. Akinbmi LJ, Moormn JE, Grbe PL, Sondik EJ. Sttus of childhood sthm in the United Sttes, Peditrics 2009;123 Suppl 3:S Also vilble from: URL: [cited 2010 Mr 18]. 2. Ntionl Center for Helth Sttistics (US). Asthm prevlence, helth cre use nd mortlity, NCHS helth e-stt [cited 2010 Mr 18]. Avilble from: URL: dt/hestt/sthm/sthm.htm 3. Akinbmi LJ, Schoendorf KC. Trends in childhood sthm: prevlence, helth cre utiliztion, nd mortlity. Peditrics 2002;110: Also vilble from: URL: [cited 2010 Mr 18]. 4. Centers for Disese Control nd Prevention (US). Importnt sthm triggers [cited 2010 Mr 18]. Avilble from: URL: 5. Lnpher BP, Aligne CA, Auinger P, Weitzmn M, Byrd RS. Residentil exposures ssocited with sthm in US children. Peditrics 2001;107: Also vilble from: URL: [cited 2010 Mr 18]. 6. Committee on the Assessment of Asthm nd Indoor Air, Division of Helth Promotion nd Disese Prevention, Institute of Medicine. Clering the ir: sthm nd indoor ir exposures. Wshington: Ntionl Acdemies Press; Morgn WJ, Crin EF, Gruchll RS, O Connor GT, Kttn M, Evns R 3rd, et l. Results of home-bsed environmentl intervention mong urbn children with sthm. N Engl J Med 2004;351: Also vilble from: URL: [cited 2010 Mr 18]. 8. Chilmonczyk BA, Slmun LM, Megthlin KN, Neveux LM, Plomki GE, Knight GJ, et l. Assocition between exposure to environmentl tobcco smoke nd excerbtions of sthm in children. 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Evlution of home-bsed intervention progrm to reduce infnt pssive smoking nd lower respirtory illness. J Behv Med 1994;17: Irvine L, Crombie IK, Clrk RA, Slne PW, Feyerbend C, Goodmn KE, et l. Advising prents of sthmtic children on pssive smoking: rndomised controlled tril. BMJ 1999;318: Also vilble from: URL: 318/7196/1456 [cited 2010 Mr 18]. 15. Phiptnkul W, Cronin B, Wood RA, Eggleston PA, Shih MC, Song L, et l. Effect of environmentl intervention on mouse llergen levels in homes of inner-city Boston children with sthm. Ann Allergy Asthm Immunol 2004;92: Recer GM. A review of the effects of impermeble bedding encsements on dust-mite llergen exposure nd bronchil hyperresponsiveness in dust-mite-sensitized ptients. Clin Exp Allergy 2004;34: Dixon SL, Fowler C, Hrris J, Mofft S, Mrtinez Y, Wlton H, et l. An exmintion of interventions to reduce respirtory helth nd injury hzrds in homes of low-income fmilies. 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Atlnt: CDC; Also vilble from: URL: [cited 2011 Jn 5]. 23. Willims S, Sehgl M, Flter K, Dennis R, Jones D, Boudreux J, et l. Effect of sthm on the qulity of life mong children nd their cregivers in the Atlnt Empowerment Zone. J Urbn Helth 2000;77: SAS Institute, Inc. SAS : Version Cry (NC): SAS Institute, Inc.; Deprtment of Helth nd Humn Services (US). Helthy People: environmentl helth [cited 2010 Mr 18]. Avilble from: URL: Deprtment of Helth nd Humn Services (US). Ntionl Institutes of Helth, Ntionl Hert, Lung nd Blood Institute, Asthm Eduction nd Prevention Progrm. Expert pnel report 3: guidelines for the dignosis nd mngement of sthm. Bethesd (MD): Ntionl Institutes of Helth; 2007.