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The Final Report of the Asthma Health Outcomes Project Is Available Asthma Health Outcomes Project Asthma Programs with an Environmental Component: A Review of the Field and Lessons for Success December 2007 Contact Information Center for Managing Chronic Disease University of Michigan 109 Observatory Street Ann Arbor, MI 48109-2029 Phone: 734-763-1457 Fax: 734-763-7379 centerformanagingchronicdisease.org [email protected] This work was supported by grant XA-83042901 from the Indoor Environments Division of the US Environmental Protection Agency Introduction This report aims to answer the following questions important to all interested in control of asthma: (a) what kind of strategies have been implemented to help improve life for individuals with asthma; (b) what challenges do program providers face in implementing their interven- tions; (c) what are the factors that help make programs successful; and (d) to what extent are programs implementing the factors that have been associated with success? The report presents the results of data collection and analyses conducted by the Asthma Health Outcomes Project (AHOP) conducted through a cooperative agreement between the Center for Managing Chronic Disease, University of Michigan and the Indoor Environments Division of the US Environmental Protection Agency. It presents descriptive frequencies and qualitative data from 223 programs drawn from 532 identified worldwide that 1) focused on asthma, 2) included an environmental component, and 3) reported improvements in health outcomes. It also includes findings from a more detailed analysis of a subset (111) of these programs published in peer-reviewed journals. The report contains eight sections and four appendices: I. Executive Summary .......................................................................................................... 5 Provides a summary of the report II. Background ....................................................................................................................... 6 Describes the Asthma Health Outcomes Project and its objectives III. Methods ............................................................................................................................. 7 Explains the methods used for data collection and analysis IV. Programmatic Factors Associated with Health Outcomes .............................................. 12 Organized by programmatic themes, presents factors associated with health outcomes among the subgroup of programs reporting in peer-reviewed publications; presents the frequency of programs with these factors among the full data set of 223; and explores the qualitative experience of programs in implementing the factors associated with positive health outcomes A. Community Centered ................................................................................................ 12 B. Clinically Connected ................................................................................................. 15 C. Collaborative ............................................................................................................. 20 D. Responsive to Needs ................................................................................................. 23 E. Participants’ Socioeconomic Status ........................................................................... 28 F. Rigor of Evaluation .................................................................................................... 31 V. Program Planning for Specific Health Outcomes ........................................................... 35 Guides the use of AHOP findings organized by desired health outcomes VI. About the Programs ........................................................................................................ 37 Provides descriptive data from the subset of 223 programs and 6 brief case studies describing the breadth of programs www.CenterforManagingChronicDisease.org 3 VII. Unintended Impacts ........................................................................................................ 46 Discusses the unintended impacts of programs as described by respondents VIII. Conclusions ..................................................................................................................... 47 Provides conclusions to project findings Appendix A Acknowledgements AHOP Expert Panel and Team Appendix B Overviews of 223 Asthma Programs Brief narrative descriptions of each program Appendix C Descriptive Data Frequencies of peer-reviewed programs, those not peer-reviewed, and all 223 programs Appendix D Bibliography Publications related to the programs included in the quantitative analysis Program documents and reports are also available at www.AlliesAgainstAsthma.net/AHOP Executive Summar y To better understand what makes asthma programs successful, the Asthma Health Outcomes Project (AHOP) at the Center for Managing Chronic Disease, University of Michigan was created and funded under a cooperative agreement with the Indoor Environments Division of the US Environmental Protection Agency (EPA). A process was developed and implemented to identify asthma programs around the world that included an environmental component and have demonstrated a positive impact on asthma-related health outcomes. The aim was to identify the factors that are associated with success. Through a wide-reaching outreach campaign, AHOP identified 532 asthma programs worldwide, 223 of which reported completing an evaluation that demonstrated improvements in at least one asthma-related health outcome. Through telephone interviews, review of program documents, and examination of published literature, data were gathered for each program related to background, planning, design, administration, implementation, evaluation design, and findings. Initial analyses found significant variance among the type and quality of evaluations reported. To increase confidence in the findings, quantitative analyses focused on a subset of 111 programs that had reported results in peer-reviewed publications. Bivariate relationships between programmatic factors and health outcomes were analyzed with x2 statistics using Fisher’s exact tests (p<0.05). Odds ratios as estimates of the association between various program factors and health outcomes and 95 percent confidence intervals were obtained using unconditional logistic regression. This analysis identified significant differences among programs that utilized pre-post evaluation designs and those that used other designs, including randomized controlled trials (RCT). An additional analysis was therefore conducted among the 65 programs using RCT to confirm earlier results. Odds ratios for these associations were calculated to determine which associations were in the same direction as those in the preliminary findings. Results of these analyses suggest themes across programs that are more likely to report a positive impact on health outcomes. These are that programs were: • Community centered • Collaborative • Clinically connected • Responsive to need These themes were also evident in a qualitative analysis of program data. In highlighting the strengths and challenges of their programs, respondents discussed the importance of having close ties with the community, strong collaboration across organizations, being connected with clinical care providers, and shaping program activities to address participants’ needs. Analyses also demonstrated that programs faced significant challenges in working with low income populations and in implementing rigorous evaluations that fit with their goals and resources. Program documents, the Preliminary Field Report, and this final report can be found on the AHOP website, AlliesAgainstAsthma.net/AHOP. www.CenterforManagingChronicDisease.org 5 Background Asthma, a chronic inflammatory disease of the airways, is a major public health problem of increasing concern in the United States. According to the most recent data available, between 1980 and 1994 the prevalence of asthma increased 75% overall and 74% among children 5 to 14 years of age.1 Although since the late 1990s the prevalence has flattened in the U.S., two observations are salient. First, prevalence continues to be high, affecting 15.7 million Americans, including 6.5 million children younger than 18 years old.2 Second, flattening in the general population has not been observed in low income and minority communities. Indeed the burden of asthma in these hot spots is still increasing with prevalence as high as 25% reported in some areas3,4 In the past decade there have been significant advances in asthma management, giving most people with asthma the opportunity to live active and healthy lives. Recommendations for diagnosing and treating asthma have been translated by the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute (NHLBI) into guidelines for patient care and have been distributed widely. These guidelines emphasize not only quality medical care and support for patient management of symptoms, but also note that a reduction in exposure to environmental allergens such as house dust mites, cockroaches, animal dander, tobacco smoke, and mold can reduce the frequency and severity of asthma attacks for sensitized children.5 Despite these advances in understanding of the disease, many children continue to suffer with asthma. In response to the burden and prevalence of asthma, recent years have seen a proliferation of programs and services aimed at improving the health and quality of life of people
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