Consideration of Public Health Strategies for Asthma Care

Speakers discussed public health strategies for targeting the indoor environment as an intervention for asthma care during a session at the AAAAI Annual Meeting.

Matthew Perzanowski, PhD, of Columbia University in New York, began by talking about the need for community-level interventions. He discussed a 2002 study by Rauh et al published in Environmental Health Perspectives that found that indoor household allergen levels are related to degree of household disrepair, after adjusting for individual family attributes, suggesting that social-structural aspects of housing may be appropriate targets for public health interventions designed to reduce allergen exposure. Dr. Perzanowski said the ability to remediate structural problems in low-income urban homes is often not possible for the individual. “We need to reframe this as a public health issue instead of interventions,” he said.

A 2016 study by Shelef et al published in the Journal of Allergy and Clinical Immunology showed that stakeholder engagement was important in developing patient-centered a pediatric asthma intervention. This incorporated the perspectives of parents of children with asthma; local providers of community-based medical, legal, and social services; and national experts in asthma research methodology and implementation. Stakeholder engagement was a useful framework for developing an intervention that was acceptable and relevant to our target population. “This approach might have unique benefits in underserved populations, leading to sustainable improvement in health outcomes and reduced disparities,” the authors concluded.

“There are important challenges in individual-level interventions,” Dr. Perzanowski said. “That’s why I think community-level interventions can really help” to reduce combustion exposure, invoke resident smoking bans, and take legal action to force landlords to address things such as mold and holes. “Involve the community for more effective outcomes,” he concluded.

Felicia A. Rabito, PhD, MPH, of Tulane University in Louisiana, debated the usefulness of single versus multicomponent interventions for asthma disease improvement. The National Asthma Education and Prevention Program Expert Panel Report-3 recommends a multicomponent approach, and clinical guidelines recommend pharmacologic and nonpharmacologic interventions.

“Asthma is a complex, multifactorial disease,” she said. “There are many risk factors for this disease and exacerbations.” Many multicomponent interventions focus on indoor allergens, although “We know that it’s not just indoor allergens that are risk factors for exacerbations,” said Dr. Rabito, as exposures occurromg both in and out of home affect asthma. So, she asked, “Is reducing indoor allergen triggers a reasonable approach to asthma management?”

There is strong preliminary evidence that suggests targeting single exposures using a single intervention—particularly for cockroach and mouse allergens—may be an effective approach to improve asthma morbidity, she said. There is a lack of data on single-intervention approaches to most of the other allergens and interventions for asthma. If exposure levels are not significantly reduced, health benefits cannot be expected, she said. Allergen exposure and sensitization patterns vary widely between subpopulations, so there are concerns regarding generalizability of any study findings.

“Perhaps it’s time to update our guidelines,” she said. “I think single-intervention approaches warrant more research.”

Tyra Bryant-Stephens, MD, of the Children’s Hospital of Philadelphia in Pennsylvania, concluded by discussing public health research and dissemination of data to the public.

“Why does it take so long for research to reach the public?” she asked, noting some reasons:

  • Disconnect between researchers and decision makers, clinicians, and community residents
  • Lack of involvement of end-users in research design and implications
  • Cost of interventions
  • Nongeneralizability of research

She pointed to the need for community-based participatory research. “It’s not a pill study, it’s not tidy, but it’s necessary,” said Dr. Bryant-Stephens. “As clinicians, we tend to think of improved health outcomes, but for the community, it’s more about the social change.”

Dr. Bryant-Stephens then discussed a 2015 paper by Bodison et al published in Clinical and Translational Science that looked at problems of data dissemination to the community and identified key barriers, including:

  • Community stakeholders have little input to identifying the problem
  • Key stakeholders are not included in the development of the research
  • Cultural differences and health disparities limit community engagement
  • Dissemination of research findings seldom reach or are meaningful to the community being studied

A 2016 article by McDavitt et al published in Preventing Chronic Disease identified engagement tactics, calling for dissemination as a dialogue through:

  • Incorporating dissemination into project aims
  • Processing for community dissemination, including planning, outreach, content development, interactive presentations, and follow-up
  • Beginning with sharing findings with the community partners
  • Allowing community partners to interpret and identify what should be disseminated
  • Creating a flexible dissemination plan
  • Tailoring presentations to each community group and establishing a point person to serve as a community liaison
  • Conducting pre-meetings with a gatekeeper

It is important to use various media tools to disseminate messages, including social media, newspapers, and church bulletins, she said.

In terms of recruiting community partners, Dr. Bryant-Stephens shared what she and her team learned:

  • Get off your campus
  • Target community-based organizations that have a vested interest
  • Ask them to think about how the research topic will impact them
  • Ask for ideas
  • Invite them to be part of the research team

She pointed to the website for their Community Asthma Prevention Program (chop.edu/centers-programs/community-asthma-prevention-program-capp), which offers free asthma education classes in familiar environments, such as schools, churches, daycare centers, and community centers. The website includes referral forms, housing assessment forms, and more information for the community