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Article |

A Randomized Controlled Trial of Asthma Self-management Support Comparing Clinic-Based Nurses and In-Home Community Health Workers:  The Seattle–King County Healthy Homes II Project FREE

James Krieger, MD, MPH; Tim K. Takaro, MD, MPH, MS; Lin Song, PhD; Nancy Beaudet, MS; Kristine Edwards, RN, MN, MPH
[+] Author Affiliations

Author Affiliations: University of Washington School of Medicine and School of Public Health and Community Medicine, Seattle (Dr Krieger); Public Health–Seattle & King County, Seattle (Drs Krieger and Song, and Ms Edwards); Simon Fraser University, Vancouver, British Columbia, Canada (Dr Takaro); and Occupational and Environmental Medicine Program, and Pediatric Environmental Health Specialty Unit, University of Washington, Seattle (Ms Beaudet).


Arch Pediatr Adolesc Med. 2009;163(2):141-149. doi:10.1001/archpediatrics.2008.532.
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Published online

Objective  To compare the marginal benefit of in-home asthma self-management support provided by community health workers (CHWs) with standard asthma education from clinic-based nurses.

Design  Randomized controlled trial.

Setting  Community and public health clinics and homes.

Participants  Three hundred nine children aged 3 to 13 years with asthma living in low-income households.

Interventions  All participants received nurse-provided asthma education and referrals to community resources. Some participants also received CHW-provided home environmental assessments, asthma education, social support, and asthma-control resources.

Outcome Measures  Asthma symptom–free days, Pediatric Asthma Caretaker Quality of Life Scale score, and use of urgent health services.

Results  Both groups showed significant increases in caretaker quality of life (nurse-only group: 0.4 points; 95% confidence interval [CI], 0.3-0.6; nurse + CHW group: 0.6 points; 95% CI, 0.4-0.8) and number of symptom-free days (nurse only: 1.3 days; 95% CI, 0.5-2.1; nurse + CHW: 1.9 days; 95% CI, 1.1-2.8), and absolute decreases in the proportion of children who used urgent health services in the prior 3 months (nurse only: 17.6%; 95% CI, 8.1%-27.2%; nurse + CHW: 23.1%; 95% CI, 13.6%-32.6%). Quality of life improved by 0.22 more points in the nurse + CHW group (95% CI, 0.00-0.44; P = .049). The number of symptom-free days increased by 0.94 days per 2 weeks (95% CI, 0.02-1.86; P = .046), or 24.4 days per year, in the nurse + CHW group. While use of urgent health services decreased more in the nurse + CHW group, the difference between groups was not significant.

Conclusion  The addition of CHW home visits to clinic-based asthma education yielded a clinically important increase in symptom-free days and a modest improvement in caretaker quality of life.

Figures in this Article

Asthma is the most common chronic childhood disease, affecting nearly 9% of American children.1 Concern about pediatric asthma has led to the development of effective self-management education programs.219 Typically, self-management skills are taught in classes or during individual counseling sessions with clinic staff. However, replication of these self-management programs in real-world settings has been fraught with difficulties.20 Attendance is low and drop-out rates are high.2024

Home visits are an alternative means for providing self-management support. Recently, several randomized trials demonstrated that home visits improve asthma control.2532 Most of these studies focused on reducing exposure to household asthma triggers but did not address the medical aspects of self-management, such as effective use of medications and asthma action plans. Evaluation of comprehensive home-visit programs that include both environmental and medical self-management components is needed.

Community health workers (CHWs) are particularly well suited for making visits to low-income, ethnically diverse households that are most affected by asthma health disparities.3340 However, evidence for the effectiveness of CHWs' provision of self-management support is needed.

The Seattle–King County Healthy Homes II Project was a randomized, controlled, parallel-group study. We tested the hypothesis that adding in-home visits by CHWs to traditional clinic-based education by nurses would improve self-management practices, reduce asthma-trigger exposure, and decrease asthma morbidity beyond that seen with nurse education alone.

PARTICIPANTS

Household eligibility criteria were the presence of a child aged 3 to 13 years with clinician-diagnosed asthma that was persistent or poorly controlled; income below 200% of the 2001 federal poverty threshold or the child enrolled in Medicaid; caretaker primary language of English, Spanish, or Vietnamese; and location in King County, Washington. Asthma was considered persistent or poorly controlled if the caretaker reported that his or her child had symptoms or used β-agonist medications more than twice per week; the child was using daily controller medication; or the child had a hospitalization, emergency department visit, or unscheduled clinic visit for asthma in the past 6 months.

Exclusion criteria were plans to move within the next 12 months, no permanent housing, or participation in another asthma research study. Enrollment occurred between November 2002 and October 2004.

We recruited participants from community and public health clinics (94%), hospitals and emergency departments (5%), and community referrals (1%). Caregivers received grocery gift card incentives ($75) for completing data collection. The Children's Hospital and Regional Medical Center institutional review board approved the study. We followed community-based participatory research principles.41,42 A steering committee of community residents with asthma and community-based organizations identified the study question, approved the study design, gave advice on implementation, and commented on the findings.

INTERVENTION

We randomly assigned participants to receive asthma education and support only in clinics from nurses (nurse-only group) or in both clinics from nurses and in participants' homes from CHWs (nurse + CHW group). We used social cognitive theory4345 and the transtheoretical stages of the change model4648 to guide development of the intervention.

RANDOMIZATION

We randomly assigned participants to groups using a permuted block design with varying block size. We stratified randomization into 2 asthma-severity levels (mild and moderate/severe persistent). Sequence numbers and group allocation were concealed in sealed, opaque, numbered envelopes that were centrally prepared and sequentially provided to the research nurse, who assigned participants to study groups. The nature of the intervention made it impossible to mask participants and staff to group assignment.

CHW Home Visits

The CHWs shared ethnic backgrounds with participants and had personal or family experience with asthma. Their clients received 1 intake and an average of 4.5 follow-up visits during the course of a year as well as interim telephone communication. At the intake visit, CHWs reviewed participants' asthma control, self-management practices, and access to medical care. Based on this assessment, results from a home environmental checklist (see “Data Collection” section) and allergy testing, and use of motivational interviewing methods,4951 CHWs developed a set of protocol-driven client and CHW actions.5259 At follow-up visits, CHWs assessed progress and reviewed a core set of educational topics (medication use, action plans, effective use of the medical system, medical adherence, and trigger reduction).6063 Community health workers also provided social support64,65 and advocacy for clients (eg, housing issues, insurance coverage).

Community health workers fit allergen-impermeable bedding encasements on the children's beds66,67 and gave participants a low-emission vacuum with a power head and embedded dirt finder,6870 2-layer microfiltration vacuum bags,71 a high-quality doormat, a cleaning kit, and plastic medication boxes.

Clinic Visits With Asthma Nurses

The project employed 2 types of nurses, existing clinic nurses (25% of participants) and a visiting project nurse, all of whom received the same training.13,63,72,73 Nurses conducted a structured intake that they used in conjunction with allergy test results to develop a client-specific asthma-management plan. They also prepared an asthma action plan,74 which was reviewed by the patient's medical provider. Education began at the initial visit and the nurses offered clients 3 follow-up clinic visits at 3-month intervals.

The nurses referred patients to additional resources, such as social workers and school nurses, and assisted clients in accessing their medical providers (ie, in making appointments). If a child failed to keep an appointment, his or her nurse tried to call the child's home. After completing exit data collection, members of the nurse-only group received a CHW home visit and the full package of environmental resources. All study participants received spacers and allergen-impermeable bedding encasements, and children aged 7 years or older received a peak flow meter.

Care Coordination

Nurses sent visit notes to providers and contacted them directly as needed. The CHW and nurse discussed mutual clients as needed. The CHW sent home-visit reports to providers and communicated directly with them as issues arose.

OUTCOME MEASURES

Primary prespecified outcomes were asthma symptom–free days (self-reported number of 24-hour periods during the prior 2 weeks without wheeze, tightness in chest, cough, shortness of breath, slowing down activities because of asthma, or nighttime awakening because of asthma), Pediatric Asthma Caregiver Quality of Life Scale75 score (range, 1-7, with higher scores indicating better quality of life), and self-reported asthma-related urgent health services use during the last 3 months (emergency department, hospital, or unscheduled clinic visit). Secondary prespecified outcomes included asthma attack frequency (“a time when asthma symptoms were worse, limiting activity more than usual or making you seek medical care”), rescue medication use, days with activity limited by asthma, and missed work and school days due to asthma. Intermediate outcomes included participants' report of asthma self-management behaviors, controller and rescue medication use, exposure to triggers in the home, asthma self-regulation,76 and social support and self-efficacy specific to asthma. We considered participants adherent to asthma-medication use if, during the past 2 weeks, they (1) took medications every day as recommended by their physicians, (2) did not forget to take medication on any day, (3) did not stop using medication on any day, and (4) did not on any day take less medication than prescribed.77

A child was considered to be exposed to tobacco smoke if his or her caregiver reported that at least 1 cigarette was smoked in the home in the past week. Spacer use was adequate if it was used most or all of the time in the past 14 days. We developed scales to measure social support specific to controlling asthma (Cronbach α = 0.87) and self-efficacy in performing asthma-management actions (Cronbach α = 0.86) (data available on request from authors). The asthma-control action score (range, −1 to 11) consisted of medical and trigger-reduction components (use of humidifier is given a score of −1, while other items each contribute 1 point). We used a modified version of the national guideline definition of asthma severity.13 We used standard US census categories to collect self-reported race and ethnicity data.

DATA COLLECTION

Baseline data were collected prior to randomization. Community health workers completed standardized home inspections and questionnaires using a home environmental checklist for participants both in the nurse-only and nurse + CHW groups. The checklist included items on exposure to allergens and tobacco smoke and home conditions contributing to exposures (eg, carpeting, food debris and storage, moisture problems). Research nurses at a general clinical research center collected clinical data and performed skin-prick testing for allergies to dust mite mix, regional mold mix, cats, dogs, cockroaches, and rodents.78,79

We attempted to collect exit data exactly 1 year after baseline data collection. Difficulties in scheduling appointments led to delays for some participants. Half had data collected less than 13 months after baseline and 70.5% less than 15 months (range, 247-737 days). Research nurses collected clinical exit data, and a CHW who did not work with the participant collected environmental data.

SAMPLE SIZE

A group size of 153 participants (the number completing the study) had 80% power to detect differences of 1.35 symptom-free days, 0.33 points in the quality of life score, and 19% in urgent health services use between groups, with α set at 0.05. The minimum clinically significant difference in quality of life is 0.5 points.78

STATISTICAL ANALYSIS

We report the results of an as-randomized analysis that used the baseline value of the outcome variable of interest as the exit value for participants who did not complete the study. We examined baseline differences between groups with the t or χ2 tests and paired t, signed-rank, or McNemar tests for within-group baseline-to-exit changes.

To compare the magnitude of baseline-to-exit changes between groups, we used robust linear and logistic regression models.80 Models included the outcome (exit value) as the dependent variable, group assignment as the primary independent variable, the baseline value of the dependent variable, and covariates (seasons of enrollment and exit, asthma severity at baseline, race/ethnicity, and housing tenure). We identified 2 asthma seasons based on observed monthly variation in symptoms and use of urgent health services among study participants (high season, December-January; low season, February-November). We tested for confounding by participant characteristics (child's age and sex; household income; and caretaker's employment status, education, and relationship to his or her child) by using a coefficient change of at least 10% in the group assignment variable as indicative of confounding. No confounding was present, so these variables were not included in the models.

We computed the number needed to treat for categorical variables using the reciprocal of the risk difference, and for continuous variables using the method of Guyatt et al.81 We used Stata, version 9.0 (Stata Corp, College Station, Texas), for analyses. P < .05 indicated a statistically significant difference. All analyses were 2-tailed.

PARTICIPATION

We identified 1474 children who had provider-diagnosed asthma and reached 969 of their caregivers (66%) (Figure). We enrolled 309 eligible and interested households. Random assignment produced study arms that were balanced with respect to most characteristics, though the nurse-only group had more African American children, fewer Asian children, and more families who owned their homes (Table 1). Of those enrolled, 135 in the nurse-only group and 133 in the nurse + CHW group received the intervention as allocated.

Place holder to copy figure label and caption
Figure.

Participant flowchart. CHW indicates community health worker.

Graphic Jump Location
Table Graphic Jump LocationTable 1. Baseline Characteristics of Study Participants

The study was completed by 271 of the participants (88%): 136 in the nurse-only group (89%) and 135 in the nurse + CHW group (87%), including 3 children who were randomly assigned but did not receive the intervention. Among participants completing the study, members of the 2 groups were similar at baseline except for the aforementioned differences in race and housing tenure.

PRIMARY OUTCOMES
Within-Group Changes

Caretaker quality of life increased in both groups (Table 2) (nurse-only group: 0.4 points; 95% confidence interval [CI], 0.3-0.6; nurse + CHW group: 0.6 points; 95% CI, 0.4-0.8). The number of symptom-free days in the past 2 weeks increased (nurse-only group: 1.3 days; 95% CI, 0.5-2.1; nurse + CHW group: 1.9 days; 95% CI, 1.1-2.8), while the proportion of participants who used urgent health services in the prior 3 months decreased (nurse-only group: 17.6% absolute decrease; 95% CI, 8.1%-27.2%; nurse + CHW group: 23.1%; 95% CI, 13.6%-32.6%).

Table Graphic Jump LocationTable 2. Within-Group and Between-Group Intervention Effects on Outcomes
Intervention Effects

After adjustment, caretaker quality of life improved more in the nurse + CHW group than in the nurse-only group (0.22 points; 95% CI, 0.00-0.44; P = .049), though the difference did not exceed the clinical threshold of 0.5 points (Table 2).82 The number of symptom-free days increased by 0.94 more days per 2 weeks (95% CI, 0.02-1.86; P = .046), or 24.4 more days per year, in the nurse + CHW group. The number needed to treat to increase symptom-free days by 1 day per 2 weeks was 15. The odds ratio comparing use of urgent health services in the nurse + CHW group with the nurse-only group was 0.69 (95% CI, 0.38-1.26; P = .23). The findings were similar when we restricted analysis to only participants who completed the study (data not shown).

The addition of CHW visits was equally effective among prespecified subgroups of participants. In separate regression models for each of the 3 primary outcomes, we did not observe any significant interactions between group allocation and the child's age, baseline asthma severity, baseline symptom-free days, or caretaker's race/ethnicity and education.

SECONDARY OUTCOMES

All secondary outcomes improved significantly in the nurse + CHW group, while only days with activity limitation and missed days of school or work did so in the nurse-only group (Table 2). There were no significant differences between groups.

BEHAVIOR CHANGES

A composite measure of behavior changes (asthma-control action score) improved significantly in both groups (Table 3). Participants in the nurse + CHW group adopted an average of 2.0 new behaviors compared with 1.3 in the nurse-only group, a significant difference. The difference was attributable to increased trigger-control actions rather than medical self-management actions. Social support, self-regulation, and self-efficacy improved equally in both groups, and there were no significant across-group differences.

Table Graphic Jump LocationTable 3. Within-Group and Between-Group Intervention Effects on Intermediary Variables
PROCESS MEASURES

Of the 156 participants in the nurse + CHW group, all received an initial CHW intake visit and 153 received at least 1 CHW follow-up visit. Community health workers made a mean of 3.1 follow-up visits to each participant (median, 3.0; range, 0-5). The mean and median intervals between first and last intervention visits were 52.6 weeks and 51.9 weeks, respectively.

Nurses completed an initial intervention visit with 269 participants (87%) and a mean of 1.0 additional follow-up visits. The number of follow-up visits ranged from 0 to 5. All participants were included in the analysis as assigned, whether or not they completed intervention visits.

The goal of this study was to determine if the addition of in-home asthma self-management support from CHWs would yield additional benefits in asthma control beyond those produced by in-clinic support from asthma nurses. Adding in-home visits resulted in clinically important increases in symptom-free days. While the number of symptom-free days increased in both groups, CHW visits yielded 24 additional symptom-free days per year. Home visits yielded modest increases in caretaker quality of life in both groups, but the increase was clinically significant only in the nurse + CHW group. The addition of CHW visits produced a small, significant improvement. Use of urgent health services decreased in both groups; the addition of CHW visits did not further reduce use. The gains from home visits were equivalent across caregivers of all race/ethnic groups and educational attainments and in children of all ages and degrees of asthma severity and control.

Analysis of intermediate measures suggests that the improved outcomes in the nurse + CHW group may have come from increased caretaker efforts to control asthma. The asthma-control action score increased to a greater extent in the nurse + CHW group, driven primarily by trigger-reduction actions. The CHWs supported participant trigger-control actions by both coaching and providing resources, such as vacuums and bedding covers. Use of controller medications increased equally in both groups. Of note, in our first Healthy Homes study, which focused only on reduction of environmental triggers, use of controller medications did not increase.25 Our data are consistent with the hypothesis that improved trigger control is a key pathway through which home interventions improve outcomes. Most effective home-visit programs described in the literature have focused on indoor trigger-reduction activities.2527,83

Our study is similar to previously reported home-visit studies in its enrollment of minorities and participants with low income; inclusion of indoor environmental trigger reduction; provision of resources to reduce exposures; magnitude of improvements in quality of life25,27,31 and symptom-free days (about 0.8 days per 2 weeks)25,26; and decreases in urgent health services use. This study (and 2 other studies26,32) differs from others in that home visits were made by CHWs; other studies have used professional home visitors. The average number of visits of this study was on the low end of the range (range, 3-9). Understanding the relationship between visit frequency and outcomes merits further study.

It should be quite feasible for organizations that serve similar populations to replicate our program. Using protocols and assessment tools adapted from this project, we have continued to provide CHW services in subsequent service-delivery projects to more than 600 clients.38,84 Local asthma coalitions, health departments, and community health centers have also used our Healthy Homes model to develop CHW programs (replication materials are available at our Web site: http://www.metrokc.gov/health/asthma/healthyhomes/).

Home-visit programs have employed several types of health professionals, such as nurses30 and physicians,29 in addition to CHWs. Using CHWs may be a particularly well-suited strategy to reduce asthma disparities. Community health workers are successful in promoting behavior changes among minorities and clients with low incomes because they come from the same community, share culture and life experiences, and readily establish trusting relationships.34,36,40 More research is needed to clarify the relative benefits of home visits made by different types of visitors.

Providing asthma education in the home offers several advantages over clinic-based approaches, particularly in populations affected by asthma disparities. These populations face significant logistical and psychosocial barriers to attending asthma classes or clinic-based asthma education.33 Home visits may be the only way to reach many of these patients.

Our conclusions are subject to several limitations. We could not mask participants to group assignment given the nature of the intervention. Loss to follow-up could have biased results, but 88% of participants completed the study, with a similar proportion in both groups. Baseline characteristics were similar between groups in those who completed the study.

Our participants were low-income, predominantly minority children with significant asthma. The findings should be generalizable to members of this population who prefer to receive asthma support in their homes. However, 37% of potentially eligible families refused participation and 18% did not complete enrollment, suggesting that in-home visits will not be attractive to all families. Families that did not participate did not differ from those that did with respect to child's age, asthma-symptom days, use of urgent health services, or degree of neighborhood poverty.

We considered designing the study as a comparison of CHW home visits alone with clinic-based nurse education. While this would have been a useful comparison, our primary goal was to compare the benefit of adding CHW home visits to usual care. Current guidelines13 and evidence120 support providing asthma education; therefore, we defined usual care as asthma education in clinical settings. We felt that it would have been unethical not to provide such education to a comparison group.18,19 While lack of such a group raises the concern that the changes in the nurse-only group may have been caused by regression to the mean, temporal trends, or Hawthorne effects,85 the improvements seen in this group are consistent with those observed in other studies.18,19

Resources were not sufficient to permit follow-up of participants after completion of the study to assess the durability of intervention effects. Other studies have shown that benefits from CHW home-visit programs continue after participation in the program.25,26

We did not find a difference between the 2 groups in the use of urgent health services, and the difference in quality of life was small. Our sample size may not have been sufficient to avoid a type II error for urgent use, as the smallest difference we could detect (19%) was greater than the observed difference (5.5%). We may have seen more of an effect if we had included all possible in-home interventions (eg, HEPA [high-efficiency particulate air] filters or professional house-cleaning services), but we did not do so to contain costs and make replication more feasible. Both groups received allergen-proof bedding covers, which may have some benefit in reducing trigger exposure,69,70 thereby decreasing observed differences.

We conclude that adding in-home asthma self-management support from CHWs to in-clinic education from an asthma nurse improves asthma control in a pediatric, low-income, multiethnic population. Participants who received home visits had more symptom-free days and a small increase in caretaker quality of life relative to those receiving only clinic-based services.

Evidence now supports the effectiveness of multiple methods for providing asthma self-management support, including home visits by CHWs and other health professionals, clinic-based individual education, and group education. Perhaps an optimal strategy is to offer patients options for self-management support, recognizing that many patients may choose not to participate in classes or to go to a clinic for asthma education, while others may not desire a visitor in their homes.

Correspondence: James Krieger, MD, MPH, Chronic Disease and Injury Prevention Section, Public Health–Seattle & King County, 401 5th Ave, Seattle, WA 98104 (james.krieger@kingcounty.gov).

Accepted for Publication: July 17, 2008.

Author Contributions:Study concept and design: Krieger, Takaro, Song, and Beaudet. Acquisition of data: Krieger, Takaro, Song, Beaudet, and Edwards. Analysis and interpretation of data: Krieger, Takaro, Song, and Beaudet. Drafting of the manuscript: Krieger and Song. Critical revision of the manuscript for important intellectual content: Krieger, Takaro, Song, Beaudet, and Edwards. Statistical analysis: Krieger and Song. Obtained funding: Krieger. Administrative, technical, and material support: Krieger, Takaro, Song, Beaudet, and Edwards. Study supervision: Krieger and Takaro.

Financial Disclosure: None reported.

Funding/Support: This study was primarily funded by grant 1R01-ES11378 from the National Institutes of Environmental Health Sciences (Dr Krieger). Additional support was provided by the Allies Against Asthma Program of the Robert Wood Johnson Foundation; grant U50/CCU011820-02 from the Centers of Disease Control and Prevention Urban Research Centers Cooperative Agreement; and grant MO1-RR-00037 from the National Institutes of Health to the University of Washington General Clinical Research Center.

Role of the Sponsors: None of the funders or donors played a role in study conduct; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Additional Contributions: Cindy Mai, Margarita Mendoza, and Carol Allen served as CHWs. Karen Brozovich (and Ms Edwards) provided nurse services. Lisa Carol Ross was the project research coordinator. Jeannette Nickens and Scott Jones provided administrative support. University of Washington General Clinical Research Center staff at Children's Hospital and Medical Center were instrumental in data collection. Kristy Seidel, MS, of the University of Washington General Clinical Research Center, provided statistical consultation.

Hoover (Techtronic Industries Co Ltd, Glenwillow, Ohio) provided low-emission vacuums at a discount. Group Health Cooperative of Puget Sound donated enrollment in their Free & Clear tobacco cessation program. The Seattle City Waste Management Division donated green cleaning kits and pails.

Carol Allen, Gail Johnson, Jeffery Hummel, Penny Nelson, John Roberts, James Stout, and Cor VanNiel served on the project steering committee. David Evans, Thomas Platts-Mills, Gail Shapiro, and James Stout served in the scientific advisory group. Evon Hampton, Celese McDuffie, Kelly (Trinh) Nguyen, Thuy Son Nguyen, Ha Vu Minh Ouh Duong, Brianna Painter, Lauretta Perkins, Debra E. Rosenthal, Ana Salinas, Joann Sampson, Nura Sayed, Mary Tranh, Jennifer Tudor, Kim Tyler, Rosie Williams, and Patricia Gayton served in the parent advisory group.

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Krieger  JWTakaro  TKSong  LWeaver  M The Seattle-King County Healthy Homes project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005;95 (4) 652- 659
PubMed Link to Article
Morgan  WJCrain  EFGruchalla  RS  et al.  Inner-City Asthma Study Group: results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351 (11) 1068- 1080
PubMed Link to Article
Eggleston  PAButz  ARand  C  et al.  Home environmental intervention in inner-city asthma: a randomized controlled clinical trial. Ann Allergy Asthma Immunol 2005;95 (6) 518- 524
PubMed Link to Article
Bonner  SZimmerman  BJEvans  DIrigoyen  MResnick  DMellins  RB An individualized intervention to improve asthma management among urban Latino and African-American families. J Asthma 2002;39 (2) 167- 179
PubMed Link to Article
Carter  MCPerzanowski  MSRaymond  A  et al.  Home intervention in the treatment of asthma among inner-city children. J Allergy Clin Immunol 2001;108 (5) 732- 737
PubMed Link to Article
Brown  JVBakeman  RCelano  MPDemi  ASKobrynski  LWilson  SR Home-based asthma education of young low-income children and their families. J Pediatr Psychol 2002;27 (8) 667- 688
PubMed Link to Article
Klinnert  MDLiu  AHPearson  MR  et al.  Outcome of a randomized multifaceted intervention with low-income families of wheezing infants. Arch Pediatr Adolesc Med 2007;161 (8) 783- 790
PubMed Link to Article
Parker  EAIsrael  BARobins  TG  et al.  Evaluation of community action against asthma: a community health worker intervention to improve children's asthma-related health by reducing household environmental triggers for asthma. Health Educ Behav 2008;35 (3) 376- 395
PubMed Link to Article
Gold  DRWright  R Population disparities in asthma. Annu Rev Public Health 2005;2689- 113
PubMed Link to Article
Swider  SM Outcome effectiveness of community health workers: an integrative literature review. Public Health Nurs 2002;19 (1) 11- 20
PubMed Link to Article
Butz  AMMalveaux  FJEggleston  P  et al.  Use of community health workers with inner-city children who have asthma. Clin Pediatr (Phila) 1994;33 (3) 135- 141
PubMed Link to Article
Love  MBGardner  KLegion  V Community health workers: who they are and what they do. Health Educ Behav 1997;24 (4) 510- 522
PubMed Link to Article
Krieger  JKTakaro  TKAllen  C  et al.  The Seattle-King County Healthy Homes Project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environ Health Perspect 2002;110 ((suppl 2)) 311- 322
PubMed Link to Article
Friedman  ARButterfoss  FDKrieger  JW  et al.  Allies community health workers: bridging the gap. Health Promot Pract 2006;7 (2) ((suppl)) 96S- 107S
PubMed Link to Article
Lewin  SADick  JPond  P  et al.  Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005; (1) CD004015
PubMed
Perez  MFindley  SEMejia  MMartinez  J The impact of community health worker training and programs in NYC. J Health Care Poor Underserved 2006;17 (1) ((suppl)) 26- 43
PubMed Link to Article
Israel  BAedEng  EedSchulz  AedParker  Eed Methods in Community-Based Participatory Research for Health.  San Francisco, CA Jossey-Bass2005;
Minkler  MedWallerstein  Ned Community-Based Participatory Research for Health.  San Francisco, CA Jossey-Bass2003;
Bandura  A Social Learning Theory.  Englewood Cliffs, NJ Prentice-Hall1977;
Bandura  A Social Foundations of Thought and Action: A Social Cognitive Theory.  Englewood Cliffs, NJ Prentice Hall1986;
Baranowski  TPerry  CLParcel  GS How individuals, environments and health behavior interact: social cognitive theory. Glanz  KLewis  FMRimer  BKHealth Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA Jossey-Bass1997;
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PubMed Link to Article
Prochaska  JONorcross  JCDiClemente  CC Changing for Good.  New York, NY Morrow1994;
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Colby  SMMonti  PMBarnett  NP Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol 1998;66 (3) 574- 578
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Harland  JWhite  MDrinkwater  CChinn  DFarr  LHowel  D The Newcastle exercise project: a randomized controlled trial of methods to promote physical activity in primary care. BMJ 1999;319 (7213) 828- 831
PubMed Link to Article
National Asthma Education and Prevention Program, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma [NIH publication No. 97-4051].  Bethesda, MD National Institutes of Health, National Heart, Lung and Blood Institute1997;
Etzel  RABalk  SJ Handbook of Pediatric Environmental Health.  Elk Grove Village, IL American Academy of Pediatrics1999;
Institute of Medicine, Clearing the Air: Asthma and Indoor Air Exposures.  Washington, DC National Academy Press2000;
Bierman  C Environmental control of asthma. Immunol Allergy Clin North Am 1996;16 (4) 753- 765
Link to Article
Ashley  PMenkedick  JRWooton  MA  et al.  Healthy Homes Issues: Asthma. Healthy Homes Initiative (HHI) Background Information, Version 3. US Department of Housing and Urban Development; 2006;http://www.hud.gov/offices/lead/library/hhi/Asthma_Final_Revised_04-26-06.pdf. Accessed October 27, 2008
Tovey  EMarks  G Methods and effectiveness of environmental control. J Allergy Clin Immunol 1999;103 (2, pt 1) 179- 191
PubMed Link to Article
Platts-Mills  TAVaughan  JWCarter  MCWoodfolk  JA The role of intervention in established allergy: avoidance of indoor allergens in the treatment of chronic allergic disease. J Allergy Clin Immunol 2000;106 (5) 787- 804
PubMed Link to Article
Eggleston  PA Improving indoor environments: reducing allergen exposures. J Allergy Clin Immunol 2005;116 (1) 122- 126
PubMed Link to Article
American Academy of Allergy Asthma and Immunology, Pediatric Asthma: Promoting Best Practice.  Milwaukee, WI American Academy of Allergy Asthma and Immunology1999;
Roter  DLHall  JAMerisca  RNordstrom  BCretin  DSvarstad  B Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998;36 (8) 1138- 1161
PubMed Link to Article
Clark  NMNothwehr  FGong  M  et al.  Physician-patient partnership in managing chronic illness. Acad Med 1995;70 (11) 957- 959
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Meichenbaum  DTurk  D Facilitating Treatment Adherence: A Practitioner's Guidebook.  New York, NY Plenum Press1987;
Heaney  CAIsrael  BA Social networks and social support. Glanz  KLewis  FMRimer  BKHealth Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA Jossey-Bass1997;
Berkman  LFGlass  T Social Integration, Social Networks, Social Support, and Health. Berkman  LFKawachi  ISocial Epidemiology. New York, NY Oxford University Press2000;137- 173
Ehnert  BLau-Schadendorf  SWeber  ABuettner  PSchou  CWahn  U Reducing domestic exposure to dust mite allergen reduces bronchial hyperreactivity in sensitive children with asthma. J Allergy Clin Immunol 1992;90 (1) 135- 138
PubMed Link to Article
Platts-Mills  TA Allergen avoidance in the treatment of asthma and rhinitis. N Engl J Med 2003;349 (3) 207- 208
PubMed Link to Article
Popplewell  EJInnes  VALloyd-Hughes  S  et al.  The effect of high-efficiency and standard vacuum-cleaners on mite, cat and dog allergen levels and clinical progress. Pediatr Allergy Immunol 2000;11 (3) 142- 148
PubMed Link to Article
Munir  AKEinarsson  RDreborg  SK Vacuum cleaning decreases the levels of mite allergens in house dust. Pediatr Allergy Immunol 1993;4 (3) 136- 143
PubMed Link to Article
Roberts  JWClifford  WSGlass  GHummer  PG Reducing dust, lead, dust mites, bacteria, and fungi in carpets by vacuuming. Arch Environ Contam Toxicol 1999;36 (4) 477- 484
PubMed
Vaughan  JWWoodfolk  JAPlatts-Mills  TA Assessment of vacuum cleaners and vacuum cleaner bags recommended for allergic subjects. J Allergy Clin Immunol 1999;104 (5) 1079- 1083
PubMed Link to Article
National Cooperative Inner City Asthma Study, A Guide for Helping Children with Asthma.  Bethesda, MD: National Institute of Allergy and Infectious Diseases
Wilson  SRStarr-Schneidkraut  N State of the art in asthma education: the US experience. Chest 1994;106 (4) ((suppl)) 197S- 205S
PubMed Link to Article
Gibson  PGPowell  H Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59 (2) 94- 99
PubMed Link to Article
Juniper  EFGuyatt  GHFeeny  DHFerrie  PJGriffith  LETownsend  M Measuring quality of life in the parents of children with asthma. Qual Life Res 1996;5 (1) 27- 34
PubMed Link to Article
Clark  NMGong  MKaciroti  N A model of self-regulation for control of chronic disease. Health Educ Behav 2001;28 (6) 769- 782
PubMed Link to Article
Brooks  CMRichards  JMKohler  CL  et al.  Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales. Med Care 1994;32 (3) 298- 307
PubMed Link to Article
Nelson  H Clinical application of immediate skin testing. Spector  SLProvocative Challenge Procedures. Boca Raton, FL CRC Press1983;148
Demoly  PPiette  VBousquet  J In vivo methods for the study of allergy. Adkinson  NMiddleton's Allergy: Principles and Practice. 6th ed. New York, NY Mosby-Year Book Inc1998;chap 38
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Guyatt  GHJuniper  EFWalter  SDGriffith  LEGoldstein  RS Interpreting treatment effects in randomised trials. BMJ 1998;316 (7132) 690- 693
PubMed Link to Article
Juniper  EFGuyatt  GHWillan  AGriffith  LE Determining a minimal important change in a disease-specific quality of life questionnaire. J Clin Epidemiol 1994;47 (1) 81- 87
PubMed Link to Article
Hoppin  PJacobs  MStillman  L Investing in Best Practices for Asthma: A Business Case for Education and Environmental Interventions.  Boston, MA New England Asthma Regional Council2007;
 Public Health–Seattle & King County. King County Steps to Health. http://www.kingcounty.gov/healthServices/health/chronic/steps.aspx. Accessed January 28, 2008
Greineder  DKLoane  KCParks  P Outcomes for control patients referred to a pediatric asthma outreach program: an example of the Hawthorne effect. Am J Manag Care 1998;4 (2) 196- 202
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Participant flowchart. CHW indicates community health worker.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics of Study Participants
Table Graphic Jump LocationTable 2. Within-Group and Between-Group Intervention Effects on Outcomes
Table Graphic Jump LocationTable 3. Within-Group and Between-Group Intervention Effects on Intermediary Variables

References

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Lemaigre  VVan den Bergh  OVan Hasselt  KDe Peuter  SVictoir  AVerleden  G Understanding participation in an asthma self-management program. Chest 2005;128 (5) 3133- 3139
PubMed Link to Article
Krieger  JWTakaro  TKSong  LWeaver  M The Seattle-King County Healthy Homes project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005;95 (4) 652- 659
PubMed Link to Article
Morgan  WJCrain  EFGruchalla  RS  et al.  Inner-City Asthma Study Group: results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351 (11) 1068- 1080
PubMed Link to Article
Eggleston  PAButz  ARand  C  et al.  Home environmental intervention in inner-city asthma: a randomized controlled clinical trial. Ann Allergy Asthma Immunol 2005;95 (6) 518- 524
PubMed Link to Article
Bonner  SZimmerman  BJEvans  DIrigoyen  MResnick  DMellins  RB An individualized intervention to improve asthma management among urban Latino and African-American families. J Asthma 2002;39 (2) 167- 179
PubMed Link to Article
Carter  MCPerzanowski  MSRaymond  A  et al.  Home intervention in the treatment of asthma among inner-city children. J Allergy Clin Immunol 2001;108 (5) 732- 737
PubMed Link to Article
Brown  JVBakeman  RCelano  MPDemi  ASKobrynski  LWilson  SR Home-based asthma education of young low-income children and their families. J Pediatr Psychol 2002;27 (8) 667- 688
PubMed Link to Article
Klinnert  MDLiu  AHPearson  MR  et al.  Outcome of a randomized multifaceted intervention with low-income families of wheezing infants. Arch Pediatr Adolesc Med 2007;161 (8) 783- 790
PubMed Link to Article
Parker  EAIsrael  BARobins  TG  et al.  Evaluation of community action against asthma: a community health worker intervention to improve children's asthma-related health by reducing household environmental triggers for asthma. Health Educ Behav 2008;35 (3) 376- 395
PubMed Link to Article
Gold  DRWright  R Population disparities in asthma. Annu Rev Public Health 2005;2689- 113
PubMed Link to Article
Swider  SM Outcome effectiveness of community health workers: an integrative literature review. Public Health Nurs 2002;19 (1) 11- 20
PubMed Link to Article
Butz  AMMalveaux  FJEggleston  P  et al.  Use of community health workers with inner-city children who have asthma. Clin Pediatr (Phila) 1994;33 (3) 135- 141
PubMed Link to Article
Love  MBGardner  KLegion  V Community health workers: who they are and what they do. Health Educ Behav 1997;24 (4) 510- 522
PubMed Link to Article
Krieger  JKTakaro  TKAllen  C  et al.  The Seattle-King County Healthy Homes Project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environ Health Perspect 2002;110 ((suppl 2)) 311- 322
PubMed Link to Article
Friedman  ARButterfoss  FDKrieger  JW  et al.  Allies community health workers: bridging the gap. Health Promot Pract 2006;7 (2) ((suppl)) 96S- 107S
PubMed Link to Article
Lewin  SADick  JPond  P  et al.  Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005; (1) CD004015
PubMed
Perez  MFindley  SEMejia  MMartinez  J The impact of community health worker training and programs in NYC. J Health Care Poor Underserved 2006;17 (1) ((suppl)) 26- 43
PubMed Link to Article
Israel  BAedEng  EedSchulz  AedParker  Eed Methods in Community-Based Participatory Research for Health.  San Francisco, CA Jossey-Bass2005;
Minkler  MedWallerstein  Ned Community-Based Participatory Research for Health.  San Francisco, CA Jossey-Bass2003;
Bandura  A Social Learning Theory.  Englewood Cliffs, NJ Prentice-Hall1977;
Bandura  A Social Foundations of Thought and Action: A Social Cognitive Theory.  Englewood Cliffs, NJ Prentice Hall1986;
Baranowski  TPerry  CLParcel  GS How individuals, environments and health behavior interact: social cognitive theory. Glanz  KLewis  FMRimer  BKHealth Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA Jossey-Bass1997;
Prochaska  JODiClemente  CC Stages of and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 1983;51 (3) 390- 395
PubMed Link to Article
Prochaska  JONorcross  JCDiClemente  CC Changing for Good.  New York, NY Morrow1994;
Prochaska  JORedding  COEvers  KE The transtheoretical model and stages of change. Glanz  KLewis  FMRimer  BKHealth Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA Jossey-Bass1997;
Miller  WRRollnick  S Motivational Interviewing: Preparing People for Change.  New York, NY Guilford Press2002;
Colby  SMMonti  PMBarnett  NP Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol 1998;66 (3) 574- 578
PubMed Link to Article
Harland  JWhite  MDrinkwater  CChinn  DFarr  LHowel  D The Newcastle exercise project: a randomized controlled trial of methods to promote physical activity in primary care. BMJ 1999;319 (7213) 828- 831
PubMed Link to Article
National Asthma Education and Prevention Program, Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma [NIH publication No. 97-4051].  Bethesda, MD National Institutes of Health, National Heart, Lung and Blood Institute1997;
Etzel  RABalk  SJ Handbook of Pediatric Environmental Health.  Elk Grove Village, IL American Academy of Pediatrics1999;
Institute of Medicine, Clearing the Air: Asthma and Indoor Air Exposures.  Washington, DC National Academy Press2000;
Bierman  C Environmental control of asthma. Immunol Allergy Clin North Am 1996;16 (4) 753- 765
Link to Article
Ashley  PMenkedick  JRWooton  MA  et al.  Healthy Homes Issues: Asthma. Healthy Homes Initiative (HHI) Background Information, Version 3. US Department of Housing and Urban Development; 2006;http://www.hud.gov/offices/lead/library/hhi/Asthma_Final_Revised_04-26-06.pdf. Accessed October 27, 2008
Tovey  EMarks  G Methods and effectiveness of environmental control. J Allergy Clin Immunol 1999;103 (2, pt 1) 179- 191
PubMed Link to Article
Platts-Mills  TAVaughan  JWCarter  MCWoodfolk  JA The role of intervention in established allergy: avoidance of indoor allergens in the treatment of chronic allergic disease. J Allergy Clin Immunol 2000;106 (5) 787- 804
PubMed Link to Article
Eggleston  PA Improving indoor environments: reducing allergen exposures. J Allergy Clin Immunol 2005;116 (1) 122- 126
PubMed Link to Article
American Academy of Allergy Asthma and Immunology, Pediatric Asthma: Promoting Best Practice.  Milwaukee, WI American Academy of Allergy Asthma and Immunology1999;
Roter  DLHall  JAMerisca  RNordstrom  BCretin  DSvarstad  B Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998;36 (8) 1138- 1161
PubMed Link to Article
Clark  NMNothwehr  FGong  M  et al.  Physician-patient partnership in managing chronic illness. Acad Med 1995;70 (11) 957- 959
PubMed Link to Article
Meichenbaum  DTurk  D Facilitating Treatment Adherence: A Practitioner's Guidebook.  New York, NY Plenum Press1987;
Heaney  CAIsrael  BA Social networks and social support. Glanz  KLewis  FMRimer  BKHealth Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco, CA Jossey-Bass1997;
Berkman  LFGlass  T Social Integration, Social Networks, Social Support, and Health. Berkman  LFKawachi  ISocial Epidemiology. New York, NY Oxford University Press2000;137- 173
Ehnert  BLau-Schadendorf  SWeber  ABuettner  PSchou  CWahn  U Reducing domestic exposure to dust mite allergen reduces bronchial hyperreactivity in sensitive children with asthma. J Allergy Clin Immunol 1992;90 (1) 135- 138
PubMed Link to Article
Platts-Mills  TA Allergen avoidance in the treatment of asthma and rhinitis. N Engl J Med 2003;349 (3) 207- 208
PubMed Link to Article
Popplewell  EJInnes  VALloyd-Hughes  S  et al.  The effect of high-efficiency and standard vacuum-cleaners on mite, cat and dog allergen levels and clinical progress. Pediatr Allergy Immunol 2000;11 (3) 142- 148
PubMed Link to Article
Munir  AKEinarsson  RDreborg  SK Vacuum cleaning decreases the levels of mite allergens in house dust. Pediatr Allergy Immunol 1993;4 (3) 136- 143
PubMed Link to Article
Roberts  JWClifford  WSGlass  GHummer  PG Reducing dust, lead, dust mites, bacteria, and fungi in carpets by vacuuming. Arch Environ Contam Toxicol 1999;36 (4) 477- 484
PubMed
Vaughan  JWWoodfolk  JAPlatts-Mills  TA Assessment of vacuum cleaners and vacuum cleaner bags recommended for allergic subjects. J Allergy Clin Immunol 1999;104 (5) 1079- 1083
PubMed Link to Article
National Cooperative Inner City Asthma Study, A Guide for Helping Children with Asthma.  Bethesda, MD: National Institute of Allergy and Infectious Diseases
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