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Asthma: Home-Based Multi-Trigger, Multicomponent Environmental Interventions – Children and Adolescents with Asthma

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What the Task Force Found

About The Systematic Review

The Task Force 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 Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to asthma control.

Context

There is no information for this section.

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
  • 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
    • Community organizations
  • By a wide range of trained personnel including:
    • Community health workers (most common)
    • Nurses
    • Respiratory therapists
    • Social workers
    • Physicians

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified 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 insure appropriate access and sustainability?
  • Which asthma patients should this intervention target?
  • Who are the most effective intervention implementers (community health workers, nurses, respiratory therapists, etc.) and does this change depending on intervention setting?

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).

 

Publications

Wilce MA, Garbe PL. Evaluating home-based, multicomponent, multi-trigger interventions: your results may vary. American Journal of Preventive Medicine. 2011;41(2S1):S52–4.
Sever ML, Salo PM, Haynes AK, Zeldin DC. Inner-city environments and mitigation of cockroach allergen. American Journal of Preventive Medicine. 2011;41(2S1):S55–6.
Murphy JS, Sandel MT. Asthma and social justice: how to get remediation done. American Journal of Preventive Medicine. 2011;41(2S1):S57–8.
Krieger JW, Philby ML, Brooks MZ. Better home visits for asthma: lessons learned from the Seattle–King County asthma program. American Journal of Preventive Medicine. 41(2S1):S48.
Atherly AJ. The economic value of home asthma interventions. 2011;41(2S1):S59-61.
Crocker DD, Hopkins D, Kinyota S, Dumitru G, Herman E, Ligon C. A systematic review of home-based multi-trigger multi-component environmental interventions to reduce asthma morbidity. Journal of Allergy and Clinical Immunology. 2009;123(S20). Available at: http://www.jacionline.org/article/S0091-6749(08)02513-X/abstract.
Task Force on Community Services. Recommendations from the Task Force on Community Preventive Services to decrease asthma morbidity through home-based, multi-trigger, multicomponent interventions. American Journal of Preventive Medicine. 2011;41(2S1):S1-4.
Nurmagambetov TA, Barnett SBL, Jacob V, et al. Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. American Journal of Preventive Medicine. 2011;41(2S1):S33-47.
Crocker DD, Kinyota S, Dumitru GG, et al. Effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic review. American Journal of Preventive Medicine. 2011;41(2S1):S5-32.

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