The National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH), has awarded four grants to improve outcomes for children in communities with especially high rates of childhood asthma.
These grants—for Philadelphia, PA; Richmond, VA; the greater Providence, RI area; and in three agencies on the Navajo Nation reservation—represent an important milestone in the implementation of the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities, according to NHLBI’s program officer Michelle M. Freemer, M.D., MPH.
“The critical aspects of this program are to provide comprehensive and integrated care for children in all spheres of their lives and to create programs that will be sustainable even after the grant support ends,” said Dr. Freemer. “That way it can impact disparities in the long run.”
The disparities among children with asthma in the United States are stark. Among white children, 8.2 percent have asthma, compared to 16 percent of African American children, 10.7 percent of American Indian and Alaska Native children, and 7.9 percent of Hispanic children overall (though the rate among Puerto Rican children is 16.5 percent).
To address the research needs that would tackle these disparities, investigators participating in this grant program collaborated with others in their communities to create an Asthma Care Implementation Program (ACIP). The ACIP helps coordinate the work of those who contribute to the care of children with asthma—medical care professionals, families, home environment, and the community, explained Freemer.
Each of the ACIPs will be based in communities that have some of the highest rates of asthma.
In 2015, the most recent year for rankings, Richmond, Virginia, was the second worst metro area with asthma according to the Asthma and Allergy Foundation of America. In the Navajo Nation, asthma rates are two to three times higher than in the general population. Rhode Island has the seventh-highest child asthma rate among ranked states; in the high-poverty core cities of Greater Providence, children with asthma are also much more likely to be chronically absent from school. In Philadelphia County the prevalence of asthma is 19 percent, almost double the state’s 10 percent average.
Investigators Bruce Bender, Ph.D., and Lynn Gerald, Ph.D., will work with the Navajo Nation in three participating agencies in Arizona – Fort Defiance, Chinle, and Tuba City. The prevalence of asthma among children on the Navajo Nation is two to three times that of the general population, with barriers to care that include poverty, environmental pollutants, and long travel distances to resources.
Working alongside their Navajo partners, the researchers will combine two previously tested programs—one focused on training providers and one on school-based education and monitoring—to build a comprehensive, integrated, team-based ACIP to meet the identified needs of the communities.
The clinical trial will be pragmatic, leveraging data collected for the Indian Health Service (IHS) database during the routine care process. The trial also will include interviews with 300 families, each with a child who has asthma, and key informant interviews with care providers, including health care providers, school teachers, and nurses.
The results will be shared with multiple organizations, including local chapter houses and other agencies and reservations.
For two decades, the Community Asthma Prevention Program (CAPP) has used community health workers to improve asthma outcomes of children in Philadelphia. Tyra Bryant-Stephens, M.D., the lead investigator, established a network of stakeholders with representation from public housing, the health care sector, the community, and schools, to build on the foundation set by CAPP and address the needs of West Philadelphia in WEPACC. The project will use health workers to deliver sustainable patient-centered, evidence-based interventions to school-aged children (ages 6-12 years) with asthma.
Approximately 600 asthmatic children from three inner-city primary care clinics will be randomly assigned to one of four study groups: primary care community health workers, school community health workers, a combined group of primary care and school community health workers, or a control group. They all will be followed for one year.
To make sure the program is sustainable, investigators also plan to examine the cost-effectiveness associated with the intervention and implementation strategies.
Health and environment experts consistently identify Richmond as one of the most challenging places to live for people with asthma. Observing the lack of a comprehensive, community-engaged asthma care program for children at highest risk for poor asthma outcomes, Robin Everhart., M.D., and her team conducted a year-long community-needs assessment. The resulting program, RVA Breathes, includes family-based, asthma self-management education delivered by community health workers who are parents of children with asthma. It also features home environmental remediation and a school-based component of care, interventions that capitalize on existing resources and relationships among stakeholders in Richmond.
The findings from this trial are expected to allow for dissemination and implementation of RVA Breathes as a sustainable program in the Richmond area.