Asthma: Home-Based Multi-Trigger, Multicomponent Environmental Interventions Children and Adolescents with Asthma
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends the use of home-based multi-trigger, multicomponent interventions with an environmental focus for children and adolescents with asthma based on strong evidence of effectiveness in improving overall quality of life and productivity, specifically:
- Improving asthma symptoms
- Reducing the number of school days missed due to asthma
The full CPSTF Finding and Rationale Statement and supporting documents for Asthma: Home-Based Multi-Trigger, Multicomponent Environmental Interventions Children and Adolescents with Asthma are available in The Community Guide Collection on CDC Stacks.
Intervention
Home-based multi-trigger, multicomponent interventions with an environmental focus for persons with asthma aim to reduce exposure to multiple indoor asthma triggers (allergens and irritants). These interventions involve home visits by trained personnel to conduct two or more activities. The programs in this review conducted environmental activities that included:
- Assessment of the home environment
- Changing the indoor home environment to reduce exposure to asthma triggers
- Education about the home environment
Most programs also included one or more of the following additional non-environmental activities:
- Training and education to improve asthma self-management
- General asthma education
- Social services and support
- Coordinated care for the asthma client
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 22 studies (search period 1966 – February 2008). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to asthma control.
Study Characteristics
The following characteristics describe studies used in systematic reviews of home-based multi-trigger, multicomponent environmental interventions for adults and for children and adolescents.
- Of the 23 included studies, 20 studies evaluated interventions targeting homes in which only children or adolescents had asthma; one study exclusively targeted adults; and two studies targeted children and adults (results of these last two studies were included both in the child and adult analyses).
- The number of participants in the studies ranged from 18 to 1033, with a median number of 104 participants (interquartile interval [IQI]: 64–274).
- Follow-up periods ranged from 1 month to 48 months, with a median follow-up period of 12 months (IQI: 12–18 months).
- Education focus ranged from primarily environmental education to primarily asthma self-management education, including monitoring asthma symptoms and the use of asthma management plans.
- Most studies focused equally on both environmental and self-management education.
- Two studies (9%) focused only on remediation and did not have an educational component.
- Fourteen studies were tailored based on exposure to asthma triggers in the home; of these, seven also included specific allergen sensitivities in tailoring the intervention.
- Number of home visits was one (3 studies), two to seven (15 studies), and eight or more (5 studies).
- Home visits were made exclusively by community health workers (6 studies), nurses (5 studies), respiratory therapists (2 studies), physicians (2 studies), social workers (1 study), housing officers (1 study), environmental educators (1 study), and trained sanitarians (1 study). Or they were conducted by mixed teams of community health workers and nurses (2 studies), social worker, nurse, and respiratory therapist (1 study), and research assistant and pest control professional (1 study).
Summary of Results
Twenty-two studies qualified for the effectiveness review.
- Asthma symptom days: median decrease of 21 days per year (6 studies)
- School days missed: median decrease of 12 days per year (5 studies)
- Acute healthcare visits: combined median decrease of 0.57 visits per year (10 studies)
- Hospitalizations: median decrease of 0.4 hospitalizations per year
- Emergency department visits: median decrease of 0.2 visits per year
- Unscheduled office visits: median decrease of 0.5 visits per year
- Pulmonary function: overall, no significant improvement (7 studies)
Summary of Economic Evidence
The Task Force finds that home-based multi-trigger, multicomponent interventions with a combination of minor or moderate environmental remediation with an educational component provide good value for the money invested based on improvement in symptom free days and savings from averted costs of asthma care and improvement in productivity.
Thirteen studies described in fourteen papers qualified for the economic review. All numbers are in $2007 US dollars.
- Program cost per participant: $231 to $14,858 (13 studies)
- Interventions with major environmental remediation: $3,796 to $14,858 (3 studies)
- Interventions with minor to moderate remediation and an educational component: $231 to $1,720 (10 studies)
- Six studies with minor to moderate remediation demonstrated that these interventions provide good value for money invested based on substantial returns for money invested and a cost per symptom free day that is below the standard cut-off for what is considered cost-effective in the literature.
- Cost-benefit studies show a return of $5.3 to $14.0 for each dollar invested (3 studies)
- Cost-effectiveness studies show a cost of $12 to $57 per additional symptom free day (3 studies)
- The majority of studies in the economic review were interventions for children with asthma, and studies that included adults also included children.
Applicability
Based on results of the systematic review, interventions should be applicable across a broad range of settings and asthma populations.
Reviewed interventions were conducted:
- Mostly in the homes of U.S. urban minority children
- By a wide range of organizations including state and local health departments, health care systems, and community organizations
- By a wide range of trained personnel including community health workers (most common), nurses, respiratory therapists, social workers, and physicians
Evidence Gaps
The following outlines evidence gaps for home-based multi-trigger, multicomponent environmental interventions for adults and for children and adolescents.
Effectiveness. The effectiveness of home-based multi-trigger, multi-component interventions has been established. Important questions still remain regarding the intervention composition and intensity as well as effectiveness in different settings and populations. Some of these questions include:
- What are the independent contributions of particular intervention components to overall intervention effectiveness? Which components are the most important for inclusion in this intervention?
- What is the required intensity (number of home visits, intensity of remediation, intensity of education) needed for an effective home intervention program?
- How does household member smoking impact the effects of this intervention? Should smoking cessation counseling be a necessary component of all home-based environmental interventions for asthma?
Applicability. This intervention has been studied most in low-income, urban minority populations but is most likely effective in most settings and populations. The following questions remain about the applicability of this intervention in various settings and populations:
- How effective is this intervention in adult populations?
- Are there differences in intervention effectiveness between children and adolescents?
- How effective is this intervention in rural populations?
- Is this intervention more effective in participants with more severe asthma symptoms?
- How does the type of dwelling (apartment, duplex, single family home) impact the effectiveness of the intervention?
Implementation. This intervention has been implemented in a variety of ways. However, questions still remain as to what is the most effective and cost-effective way to implement this intervention in a “real-world setting.” These questions include:
- How should this intervention be integrated in the health care system to ensure appropriate access and sustainability?
- Which asthma patients should this intervention target?
- Who are the most effective intervention implementers (CHW, nurses respiratory therapist, etc.) and does this change depending on intervention setting?
Implementation Considerations and Resources
- Home-based environmental interventions in the community may combine asthma-related interventions with other health interventions, such as teaching lead-poisoning prevention and offering vaccinations during the home visit. It is not known, however, whether taking the focus away from asthma would make the primary intervention objective less effective.
- These interventions provide an effective way to target two of the four components considered essential to effective asthma management, according to the NAEPP Expert Panel Report Guidelines for the Diagnosis and Management of Asthma (EPR-3): (1) provision of self-management education for a partnership in asthma care; and (2) reduced exposure to indoor environmental triggers.
- The literature indicates that it is beneficial to hire and train community health workers to implement this intervention for the purpose of reaching out to primarily low-income, ethnic minority populations. Community health workers play an essential role in the implementation of interventions, bridging the gaps between underserved populations and researchers.
- The literature strongly suggests that environmental tobacco smoke be considered at the same level of importance as other asthma triggers and be an integral part of the standard environmental assessment, education, and evaluation components in home-based environmental interventions.
- The review team noted that remediation, particularly major remediation, can be very expensive for either the study or the participant. In addition, remodeling may increase triggers such as dust and volatile organic compounds and worsen asthma and allergies.
- Included studies noted the following barriers to implementation: reluctance of families to accept home visits, inability to maintain follow-up due to a transient population, difficulty scheduling appointments, and poor compliance with recommendations.
- Included studies cited the following additional benefits of these interventions: improved caregiver support, quality of life, family relationships, energy efficiency, communication between caregivers and physicians, and relationships between healthcare providers and the community.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.