Public Health Nursing Vol. 31 No. 3, pp. 243–252 0737-1209/© 2013 Wiley Periodicals, Inc. doi: 10.1111/phn.12071
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: PROGRAM EVALUATIONS
The Impact of an Urban Home-Based Intervention Program on Asthma Outcomes in Children Laura L. Sweet, M.S.N., R.N.,1 Barbara J. Polivka, Ph.D., R.N.,2 Rosemary V. Chaudry, Ph.D., M.P.H., P.H.C.N.S.-B.C.,3 and Philip Bouton, B.A.1 1 3
Columbus Public Health, Healthy Homes Program, Columbus, Ohio; 2School of Nursing, University of Louisville, Louisville, Kentucky; and Delaware General Health District, Delaware, Ohio
Correspondence to: Laura Sweet, Columbus Public Health, 240 Parsons Ave., Columbus, OH 43215. E-mail: [email protected]
ABSTRACT Objectives: This program evaluation examines the outcomes of a multicomponent urban home-based asthma program implemented through a city health department in a large Midwestern city. The purpose of the program was to improve asthma outcomes by controlling indoor asthma triggers in the home environment. Design and Sample: This was a pre-post evaluation study. Participants received home-based education from a public health nurse or a health educator, cleaning and other supplies, and physical home interventions such as mold abatement and pest control. Asthma outcomes, caregiver quality of life, trigger-related activities, and asthma management activities at baseline and 6 months following the intervention were evaluated using survey data. A total of 115 participants for whom baseline and follow-up data were available were included in this analysis. Measures: This study used parent self-reported quantitative and qualitative data which were collected through baseline and follow-up surveys administered by program staff. Results: Significant reduction in asthma symptom days, nighttime awakenings, days with activity limitation, and albuterol use were observed. Emergency department visits, missed school days, and caregiver missed work days also were significantly reduced, and caregiver quality of life improved. Conclusions: This multifaceted home-based intervention decreased asthma triggers and improved asthma outcomes in children, and improved the quality of life of their caregivers. Key words: asthma, environmental health, program evaluation, urban health.
Background Asthma—the most common chronic childhood disease—affects approximately 7.1 million children in the United States. Childhood asthma contributes to missed school days and reduced quality of life (QOL) (Akinbami, Moorman, & Liu, 2011). The burden of childhood asthma falls disproportionately on children in low-income households and children who are African American (Bloom, Cohen, & Freeman, 2010). In 2009, 14% of children in lowincome households had asthma, compared with 8% of children in middle or upper income households. Furthermore, 17% of African American children had
asthma compared with 8% of White and Hispanic children. Causes of increased prevalence of asthma in low income, urban dwelling, and African American populations remain unclear (Gern, 2010). Factors that may be associated with asthma disparities include poor nutrition, maternal stress, exposure to pollution, and adverse homes environmental conditions (e.g., indoor dampness, inadequate ventilation, and pest infestation). In addition to exacerbating asthma symptoms, certain indoor aeroallergens and pollutants—including cigarette smoke, dust mite allergen, and mold—increase
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the likelihood of children to develop asthma (Institute of Medicine [IOM], 2000; Reponen et al., 2012). Several studies examined whether home-based interventions designed to reduce indoor asthma triggers improved asthma outcomes. Interventions typically involve multiple in-home education visits and provision of supplies and may also include physical interventions such as mold abatement or pest control. In most cases, the educational interventions were provided by a community health worker (CHW), focused on reducing asthma triggers, and included little or no clinical content. Supplies provided varied; items most often provided were mattress and pillow allergen encasings, vacuums with High Efficiency Particulate Air (HEPA) filters, HEPA air purifiers, and integrated pest management supplies (Bryant-Stephens, Kurian, Guo, & Zhao, 2009; Evans et al., 1999; Eggleston et al., 2005; Krieger, Takaro, Song, & Weaver, 2005; Kercsmar et al., 2006; Morgan et al., 2004; Postma, Karr, & Kieckhefer, 2009; Primomo, Johnston, DiBiase, Nodolf, & Noren, 2006). Studies have consistently shown a decrease in days with asthma symptoms following home-based environmentally focused interventions. Impact on health care utilization is more variable. Not all studies showed a reduction in ED visits and not all showed reduction in hospitalizations (BryantStephens et al., 2009; Eggleston et al., 2005; Evans et al., 1999; Kercsmar et al., 2006; Krieger et al., 2005; Morgan et al., 2004; Primomo et al., 2006). Several studies cited above were randomized controlled trials (Eggleston et al., 2005; Evans et al., 1999; Kercsmar et al., 2006; Krieger et al., 2005; Morgan et al., 2004); others were quasiexperimental (Bryant-Stephens et al., 2009; Primomo et al., 2006). Wu and Takaro (2007) reviewed 15 randomized clinical trials published from 1992 to 2006. They concluded that interventions combining education with mechanical methods of removing triggers (e.g., HEPA vacuum cleaners and mattress encasings) were most effective at reducing in-home asthma triggers and improving asthma outcomes. Crocker et al. (2011) evaluated the impact of home-based environmental interventions on asthma-related outcomes across 23 studies (14 clinical trials; 9 pre/post studies) and found an overall median reductions of 0.8 symptom days over a 2-week period and reductions of 0.4
May/June 2014
hospitalizations per year, 0.2 ED visits per year, and 0.5 unscheduled physician office visits annually. Relatively little research has explored the role of registered nurses in environmentally focused asthma interventions. Tzeng, Chiang, Hsueh, Ma, and Fu (2010) implemented an intensive patientcentered education on home environmental control behaviors in a Taiwan clinic. Significant improvement in asthma signs and symptoms and lung function was reported. Krieger, Takaro, Song, Beaudet, and Edwards (2009) described an effective collaboration between clinic-based registered nurses and home-based CHWs. Nurses met with patients and their families in the clinic and educated them about asthma-control strategies using a personalized asthma management plan. The education was followed by in-home visits by CHWs who reinforced education topics, provided social support, and furnished asthma trigger-reducing supplies. Compared with clinic-based education, the addition of a CHW home visit produced significantly greater reductions in use of rescue medicine, activity limitation, and acute asthma exacerbations. Although the effectiveness of home-based asthma interventions has been well documented in the literature, most of the interventions have been implemented by CHWs. This study adds to the literature by exploring the role public health nurses can play in environmentally focused asthma interventions. The purpose of this study was to evaluate a Healthy Homes intervention for low-income families of children with asthma in an urban setting. We explored the impact of a Healthy Homes intervention on: (1) short-term and long-term measures of asthma severity; (2) caregiver QOL; (3) asthma trigger-related household activities; and (4) use of asthma management activities. The Healthy Homes intervention was conducted between January 2008 and December 2011 and was funded by a 3-year U.S. Department of Housing and Urban Development (HUD) grant. Personnel involved were staff from the health department serving Columbus, Ohio (population 787,033) (United States Census Bureau, 2012). Participants were referred to the program by the local children’s hospital, physicians’ offices, social workers, school nurses, community-based organizations, and word of mouth. Following enrollment in the program, a registered sanitarian completed a home assessment to identify asthma
Sweet et al.: Impact of a Home-Based Asthma Intervention triggers and safety hazards. Asthma-related home issues assessed included moisture and mold, ventilation, type of flooring, pests, pets, tobacco smoke, fragrances and other sources of volatile organic chemicals, general cleanliness, and the presence of clutter. Home assessment data were recorded using a tool developed for the program consisting of a checklist and space for narrative comments. The home assessment was followed by a home education visit by the program Public Health Nurse (PHN) or the health educator (who was also a student nurse in an Associate Degree registered nursing program). Both the PHN and health educator provided comprehensive education that included disease-specific mediation and symptom management information in addition to asthma trigger management recommendations. The PHN trained the health educator, and her visits were similar to those of the PHN in terms of content and approach. All project staff completed the National Center for Healthy Housing’s Healthy Homes Practitioner Course and the American Lung Association of Ohio’s Asthma Educator course. The PHN is also a Certified Asthma Educator (AE-C®). Participants were given educational materials consisting of a “Healthy Homes Action Plan” binder. The action plan contained information on asthma and recommendations for reducing asthma triggers and safety hazards in the home based on results of the home assessment. During the education visit, the “Healthy Homes Action Plan” was reviewed with the caregiver using verbal instruction and demonstration. Caregiver understanding of the child’s medications, medication administration, signs and symptoms of asthma exacerbation, and signs of asthma emergency were reviewed. Participants also received bedding supplies (allergen-proof encasings for mattress, box spring, and pillows), a HEPA vacuum cleaner, a cleaning kit (mop and bucket, Murphy® Oil Soap, vinegar, baking soda, a spray bottle, and a scrub pad), a rubber door mat, a humidity monitor, and, in cases of significant moisture problems, a dehumidifier. Safety supplies were provided based on client need and included nonslip strips for bathtubs, window locks, child gates, and plug covers. Clients with active roach infestations received boric acid powder with an applicator and food storage containers. In homes with structural issues contributing to mold and moisture or safety hazards, physical
245
intervention services were provided through a community action agency. Physical interventions included but were not limited to cleaning/repairing gutters and downspouts, re-grading soil around foundations, venting dryers, installing/repairing bathroom vents, fixing/installing handrails, and removing mold. Mold was removed following mold remediation guidelines developed by the New York City Department of Health and Mental Hygiene, Bureau of Environmental and Occupational Disease Epidemiology (2008). Grant funds could not be used to replace roofs, address broken furnaces or central air conditioners, or abate lead hazards; in some cases, program staff was able to collaborate with other agencies that had capacity and funding to address these issues. Property owners were responsible for addressing any housing code violations. With the occupant’s permission, unmitigated code violations were referred to the local code enforcement agency. Physical intervention services and integrated pest control services were provided in single family homes, duplexes, and townhomes, but were not provided in multiunit apartment buildings. For physical issues identified in an apartment, the program provided the property owner with a letter detailing recommended actions. A licensed pest control operator provided integrated pest management for roaches and rodents using the least toxic control method (baits, exclusion, and traps). For bedbugs, conventional pesticides were applied in cracks and crevices. The education visit was followed by one or two in-home follow-up visit(s) at 2 and 4 weeks following the education visit and one or two follow-up phone calls. If issues arose beyond the scope of the program (e.g., threat of eviction, parent mental health concerns, or difficulty paying utility bills), participants were referred to social service agencies.
Methods Design and sample This one-group pretest/posttest evaluation study used a convenience sample of children with asthma and their caregivers enrolled in the Columbus (Ohio) Public Health Department’s “Healthy Homes Program” (n = 115). Eligibility for the program required that families reside in Columbus and have a family income at or below 80% of median income
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in Franklin County (Ohio) ($54,900 for a family of four). Families also had to meet one of the following criteria: (a) one or more children in the household under the age of 18 (at the time of recruitment) with physician-diagnosed asthma; (b) parent with physician-diagnosed asthma with a child less than 6 years of age; or (c) a pregnant woman in the household with physician-diagnosed asthma. Only participants who met criteria (a) were included in this evaluation. Only participants who received an education visit had at least one follow-up visit, and completed baseline and 6-month follow-up surveys were included in this study. Baseline questionnaires were administered verbally by the sanitarian during the initial in-home assessment; 6-month follow-up questionnaires were administered over the phone by the PHN or health educator. This study was approved by both the Ohio Department of Health’s Institutional Review Board (IRB) and The Ohio State University IRB.
Measures Assessment tools were developed for a prior HUDfunded Healthy Homes intervention at the city health department (Polivka, Chaudry, Crawford, Bouton, & Sweet, 2011). The assessment recorded the child’s race/ethnicity and age and the caregiver’s relationship with the child, education, and employment status. Short-term indicators of asthma severity were recorded as number of days (0–14) asthma episodes had occurred over the previous 2-week time period: days with asthma symptoms, nighttime awakenings, days the child used his/her quick relief medication, and days the child’s activity was limited due to asthma. Long-term indicators were ED visits, hospitalizations, days of missed school, and caregiver missed work days. Self-reported ED visits and hospitalizations were assessed over the 3 months prior to the date the survey was conducted; days of missed school and caregiver missed work days were assessed over the prior 6 months. Caregiver QOL was assessed using nine questions about how often (4 = none of the time; 1 = all of the time) in the last 2 weeks child’s asthma affected the caregiver’s normal activities and emotional well-being. Questions were adapted from a 13-item questionnaire developed by Juniper et al. (1996). Each item was assessed individually and considered as an indicator of caregiver QOL; a
May/June 2014
summary score was not calculated. Cronbach’s alpha for the 9 QOL items used was .74. Caregiver trigger-related household activities assessed were indoor smoking, use of allergen-proof encasings, moisture ventilation in the bathroom, and use of fragrance-free cleaning products. Indoor smoking was recorded as one of the three statements: (1) “there are no rules about smoking in my home,” (2) “smoking is only allowed in some rooms of my home,” or (3) “smoking is not allowed anywhere in my home.” Caregivers were asked whether or not allergen-proof encasings were used on their asthmatic child’s pillow, mattress, or box spring (yes/no). Use of fragrance-free cleaning products was assessed by asking the caregiver how often they used these products; and how often a bathroom fan or open window was used while showering. Responses were recorded as “always,” “sometimes,” or “never.” Asthma management activities were assessed by asking the caregiver whether their child used a spacer with their inhaler and whether there was an asthma action plan (yes/no).
Analytic strategy Demographic data were analyzed using descriptive statistics. Pre- and postintervention comparison of asthma severity data and caregiver QOL were compared using Wilcoxon tests for nonparametric paired samples. Comparison of asthma triggerrelated household activities and asthma management activities at baseline and follow-up was compared using McNemar’s test. A p-value of
POPULATIONS
AT
RISK ACROSS
THE
LIFESPAN: PROGRAM EVALUATIONS
The Impact of an Urban Home-Based Intervention Program on Asthma Outcomes in Children Laura L. Sweet, M.S.N., R.N.,1 Barbara J. Polivka, Ph.D., R.N.,2 Rosemary V. Chaudry, Ph.D., M.P.H., P.H.C.N.S.-B.C.,3 and Philip Bouton, B.A.1 1 3
Columbus Public Health, Healthy Homes Program, Columbus, Ohio; 2School of Nursing, University of Louisville, Louisville, Kentucky; and Delaware General Health District, Delaware, Ohio
Correspondence to: Laura Sweet, Columbus Public Health, 240 Parsons Ave., Columbus, OH 43215. E-mail: [email protected]
ABSTRACT Objectives: This program evaluation examines the outcomes of a multicomponent urban home-based asthma program implemented through a city health department in a large Midwestern city. The purpose of the program was to improve asthma outcomes by controlling indoor asthma triggers in the home environment. Design and Sample: This was a pre-post evaluation study. Participants received home-based education from a public health nurse or a health educator, cleaning and other supplies, and physical home interventions such as mold abatement and pest control. Asthma outcomes, caregiver quality of life, trigger-related activities, and asthma management activities at baseline and 6 months following the intervention were evaluated using survey data. A total of 115 participants for whom baseline and follow-up data were available were included in this analysis. Measures: This study used parent self-reported quantitative and qualitative data which were collected through baseline and follow-up surveys administered by program staff. Results: Significant reduction in asthma symptom days, nighttime awakenings, days with activity limitation, and albuterol use were observed. Emergency department visits, missed school days, and caregiver missed work days also were significantly reduced, and caregiver quality of life improved. Conclusions: This multifaceted home-based intervention decreased asthma triggers and improved asthma outcomes in children, and improved the quality of life of their caregivers. Key words: asthma, environmental health, program evaluation, urban health.
Background Asthma—the most common chronic childhood disease—affects approximately 7.1 million children in the United States. Childhood asthma contributes to missed school days and reduced quality of life (QOL) (Akinbami, Moorman, & Liu, 2011). The burden of childhood asthma falls disproportionately on children in low-income households and children who are African American (Bloom, Cohen, & Freeman, 2010). In 2009, 14% of children in lowincome households had asthma, compared with 8% of children in middle or upper income households. Furthermore, 17% of African American children had
asthma compared with 8% of White and Hispanic children. Causes of increased prevalence of asthma in low income, urban dwelling, and African American populations remain unclear (Gern, 2010). Factors that may be associated with asthma disparities include poor nutrition, maternal stress, exposure to pollution, and adverse homes environmental conditions (e.g., indoor dampness, inadequate ventilation, and pest infestation). In addition to exacerbating asthma symptoms, certain indoor aeroallergens and pollutants—including cigarette smoke, dust mite allergen, and mold—increase
243
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the likelihood of children to develop asthma (Institute of Medicine [IOM], 2000; Reponen et al., 2012). Several studies examined whether home-based interventions designed to reduce indoor asthma triggers improved asthma outcomes. Interventions typically involve multiple in-home education visits and provision of supplies and may also include physical interventions such as mold abatement or pest control. In most cases, the educational interventions were provided by a community health worker (CHW), focused on reducing asthma triggers, and included little or no clinical content. Supplies provided varied; items most often provided were mattress and pillow allergen encasings, vacuums with High Efficiency Particulate Air (HEPA) filters, HEPA air purifiers, and integrated pest management supplies (Bryant-Stephens, Kurian, Guo, & Zhao, 2009; Evans et al., 1999; Eggleston et al., 2005; Krieger, Takaro, Song, & Weaver, 2005; Kercsmar et al., 2006; Morgan et al., 2004; Postma, Karr, & Kieckhefer, 2009; Primomo, Johnston, DiBiase, Nodolf, & Noren, 2006). Studies have consistently shown a decrease in days with asthma symptoms following home-based environmentally focused interventions. Impact on health care utilization is more variable. Not all studies showed a reduction in ED visits and not all showed reduction in hospitalizations (BryantStephens et al., 2009; Eggleston et al., 2005; Evans et al., 1999; Kercsmar et al., 2006; Krieger et al., 2005; Morgan et al., 2004; Primomo et al., 2006). Several studies cited above were randomized controlled trials (Eggleston et al., 2005; Evans et al., 1999; Kercsmar et al., 2006; Krieger et al., 2005; Morgan et al., 2004); others were quasiexperimental (Bryant-Stephens et al., 2009; Primomo et al., 2006). Wu and Takaro (2007) reviewed 15 randomized clinical trials published from 1992 to 2006. They concluded that interventions combining education with mechanical methods of removing triggers (e.g., HEPA vacuum cleaners and mattress encasings) were most effective at reducing in-home asthma triggers and improving asthma outcomes. Crocker et al. (2011) evaluated the impact of home-based environmental interventions on asthma-related outcomes across 23 studies (14 clinical trials; 9 pre/post studies) and found an overall median reductions of 0.8 symptom days over a 2-week period and reductions of 0.4
May/June 2014
hospitalizations per year, 0.2 ED visits per year, and 0.5 unscheduled physician office visits annually. Relatively little research has explored the role of registered nurses in environmentally focused asthma interventions. Tzeng, Chiang, Hsueh, Ma, and Fu (2010) implemented an intensive patientcentered education on home environmental control behaviors in a Taiwan clinic. Significant improvement in asthma signs and symptoms and lung function was reported. Krieger, Takaro, Song, Beaudet, and Edwards (2009) described an effective collaboration between clinic-based registered nurses and home-based CHWs. Nurses met with patients and their families in the clinic and educated them about asthma-control strategies using a personalized asthma management plan. The education was followed by in-home visits by CHWs who reinforced education topics, provided social support, and furnished asthma trigger-reducing supplies. Compared with clinic-based education, the addition of a CHW home visit produced significantly greater reductions in use of rescue medicine, activity limitation, and acute asthma exacerbations. Although the effectiveness of home-based asthma interventions has been well documented in the literature, most of the interventions have been implemented by CHWs. This study adds to the literature by exploring the role public health nurses can play in environmentally focused asthma interventions. The purpose of this study was to evaluate a Healthy Homes intervention for low-income families of children with asthma in an urban setting. We explored the impact of a Healthy Homes intervention on: (1) short-term and long-term measures of asthma severity; (2) caregiver QOL; (3) asthma trigger-related household activities; and (4) use of asthma management activities. The Healthy Homes intervention was conducted between January 2008 and December 2011 and was funded by a 3-year U.S. Department of Housing and Urban Development (HUD) grant. Personnel involved were staff from the health department serving Columbus, Ohio (population 787,033) (United States Census Bureau, 2012). Participants were referred to the program by the local children’s hospital, physicians’ offices, social workers, school nurses, community-based organizations, and word of mouth. Following enrollment in the program, a registered sanitarian completed a home assessment to identify asthma
Sweet et al.: Impact of a Home-Based Asthma Intervention triggers and safety hazards. Asthma-related home issues assessed included moisture and mold, ventilation, type of flooring, pests, pets, tobacco smoke, fragrances and other sources of volatile organic chemicals, general cleanliness, and the presence of clutter. Home assessment data were recorded using a tool developed for the program consisting of a checklist and space for narrative comments. The home assessment was followed by a home education visit by the program Public Health Nurse (PHN) or the health educator (who was also a student nurse in an Associate Degree registered nursing program). Both the PHN and health educator provided comprehensive education that included disease-specific mediation and symptom management information in addition to asthma trigger management recommendations. The PHN trained the health educator, and her visits were similar to those of the PHN in terms of content and approach. All project staff completed the National Center for Healthy Housing’s Healthy Homes Practitioner Course and the American Lung Association of Ohio’s Asthma Educator course. The PHN is also a Certified Asthma Educator (AE-C®). Participants were given educational materials consisting of a “Healthy Homes Action Plan” binder. The action plan contained information on asthma and recommendations for reducing asthma triggers and safety hazards in the home based on results of the home assessment. During the education visit, the “Healthy Homes Action Plan” was reviewed with the caregiver using verbal instruction and demonstration. Caregiver understanding of the child’s medications, medication administration, signs and symptoms of asthma exacerbation, and signs of asthma emergency were reviewed. Participants also received bedding supplies (allergen-proof encasings for mattress, box spring, and pillows), a HEPA vacuum cleaner, a cleaning kit (mop and bucket, Murphy® Oil Soap, vinegar, baking soda, a spray bottle, and a scrub pad), a rubber door mat, a humidity monitor, and, in cases of significant moisture problems, a dehumidifier. Safety supplies were provided based on client need and included nonslip strips for bathtubs, window locks, child gates, and plug covers. Clients with active roach infestations received boric acid powder with an applicator and food storage containers. In homes with structural issues contributing to mold and moisture or safety hazards, physical
245
intervention services were provided through a community action agency. Physical interventions included but were not limited to cleaning/repairing gutters and downspouts, re-grading soil around foundations, venting dryers, installing/repairing bathroom vents, fixing/installing handrails, and removing mold. Mold was removed following mold remediation guidelines developed by the New York City Department of Health and Mental Hygiene, Bureau of Environmental and Occupational Disease Epidemiology (2008). Grant funds could not be used to replace roofs, address broken furnaces or central air conditioners, or abate lead hazards; in some cases, program staff was able to collaborate with other agencies that had capacity and funding to address these issues. Property owners were responsible for addressing any housing code violations. With the occupant’s permission, unmitigated code violations were referred to the local code enforcement agency. Physical intervention services and integrated pest control services were provided in single family homes, duplexes, and townhomes, but were not provided in multiunit apartment buildings. For physical issues identified in an apartment, the program provided the property owner with a letter detailing recommended actions. A licensed pest control operator provided integrated pest management for roaches and rodents using the least toxic control method (baits, exclusion, and traps). For bedbugs, conventional pesticides were applied in cracks and crevices. The education visit was followed by one or two in-home follow-up visit(s) at 2 and 4 weeks following the education visit and one or two follow-up phone calls. If issues arose beyond the scope of the program (e.g., threat of eviction, parent mental health concerns, or difficulty paying utility bills), participants were referred to social service agencies.
Methods Design and sample This one-group pretest/posttest evaluation study used a convenience sample of children with asthma and their caregivers enrolled in the Columbus (Ohio) Public Health Department’s “Healthy Homes Program” (n = 115). Eligibility for the program required that families reside in Columbus and have a family income at or below 80% of median income
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in Franklin County (Ohio) ($54,900 for a family of four). Families also had to meet one of the following criteria: (a) one or more children in the household under the age of 18 (at the time of recruitment) with physician-diagnosed asthma; (b) parent with physician-diagnosed asthma with a child less than 6 years of age; or (c) a pregnant woman in the household with physician-diagnosed asthma. Only participants who met criteria (a) were included in this evaluation. Only participants who received an education visit had at least one follow-up visit, and completed baseline and 6-month follow-up surveys were included in this study. Baseline questionnaires were administered verbally by the sanitarian during the initial in-home assessment; 6-month follow-up questionnaires were administered over the phone by the PHN or health educator. This study was approved by both the Ohio Department of Health’s Institutional Review Board (IRB) and The Ohio State University IRB.
Measures Assessment tools were developed for a prior HUDfunded Healthy Homes intervention at the city health department (Polivka, Chaudry, Crawford, Bouton, & Sweet, 2011). The assessment recorded the child’s race/ethnicity and age and the caregiver’s relationship with the child, education, and employment status. Short-term indicators of asthma severity were recorded as number of days (0–14) asthma episodes had occurred over the previous 2-week time period: days with asthma symptoms, nighttime awakenings, days the child used his/her quick relief medication, and days the child’s activity was limited due to asthma. Long-term indicators were ED visits, hospitalizations, days of missed school, and caregiver missed work days. Self-reported ED visits and hospitalizations were assessed over the 3 months prior to the date the survey was conducted; days of missed school and caregiver missed work days were assessed over the prior 6 months. Caregiver QOL was assessed using nine questions about how often (4 = none of the time; 1 = all of the time) in the last 2 weeks child’s asthma affected the caregiver’s normal activities and emotional well-being. Questions were adapted from a 13-item questionnaire developed by Juniper et al. (1996). Each item was assessed individually and considered as an indicator of caregiver QOL; a
May/June 2014
summary score was not calculated. Cronbach’s alpha for the 9 QOL items used was .74. Caregiver trigger-related household activities assessed were indoor smoking, use of allergen-proof encasings, moisture ventilation in the bathroom, and use of fragrance-free cleaning products. Indoor smoking was recorded as one of the three statements: (1) “there are no rules about smoking in my home,” (2) “smoking is only allowed in some rooms of my home,” or (3) “smoking is not allowed anywhere in my home.” Caregivers were asked whether or not allergen-proof encasings were used on their asthmatic child’s pillow, mattress, or box spring (yes/no). Use of fragrance-free cleaning products was assessed by asking the caregiver how often they used these products; and how often a bathroom fan or open window was used while showering. Responses were recorded as “always,” “sometimes,” or “never.” Asthma management activities were assessed by asking the caregiver whether their child used a spacer with their inhaler and whether there was an asthma action plan (yes/no).
Analytic strategy Demographic data were analyzed using descriptive statistics. Pre- and postintervention comparison of asthma severity data and caregiver QOL were compared using Wilcoxon tests for nonparametric paired samples. Comparison of asthma triggerrelated household activities and asthma management activities at baseline and follow-up was compared using McNemar’s test. A p-value of
