2000 Progress Report: A Community-Based Intervention to Reduce Environmental Triggers for Asthma Among Children (Asthma Intervention)

EPA Grant Number: R826710C003
Subproject: this is subproject number 003 , established and managed by the Center Director under grant R826710
(EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).

Center: Michigan Center for the Environment and Children’s Health
Center Director: Israel, Barbara A.
Title: A Community-Based Intervention to Reduce Environmental Triggers for Asthma Among Children (Asthma Intervention)
Investigators: Israel, Barbara A. , Brown, Randall , Keeler, Gerald J. , Lin, Xihong , Parker, Edith , Philbert, Martin , Remick, Daniel , Robins, Thomas
Institution: University of Michigan
EPA Project Officer: Hahn, Intaek
Project Period: January 1, 1998 through January 1, 2002
Project Period Covered by this Report: January 1, 1999 through January 1, 2000
Project Amount: Refer to main center abstract for funding details.
RFA: Centers for Children's Environmental Health and Disease Prevention Research (1998) RFA Text |  Recipients Lists
Research Category: Children's Health , Health Effects , Health

Objective:

The first specific aim of this household and neighborhood level community-based intervention research project is to reduce exposure of children to environmental contaminants within their homes and neighborhoods that trigger asthma, thereby improving asthma-related health status and reducing asthma-related medical care utilization. Asthmatic children will be identified through elementary school screenings and their parents will be asked to enroll in a household intervention in which outreach workers will visit each household 12 times in 2 years (9 times in the intensive first year, and 3 times in the second year). Outreach workers will work with the family to reduce indoor household exposure factors identified as excerbating asthma, such as cockroach mites, cat dander, environmental tobacco smoke, and mold. Each household will also be supplied with educational materials and other resources to reduce indoor asthma triggers such as vacuum cleaners, bedding covers, cleaning kits, and mats. In the neighborhood component of the intervention, community organizers will work with neighborhood groups on asthma awareness and reduction of environmental threats to children's respiratory health. The second specific aim is to conduct a randomized, staggered design community-based intervention to test the following hypotheses: (1) The household level intervention will improve asthma-related health status (and other mental and physical health outcomes), and increase behaviors to reduce home environmental hazards; (2) A neighborhood level intervention when combined with a household level intervention will provide an enhanced effect on the outcomes at the household level; (3) A less intensive household intervention following an initial intensive intervention will maintain similar level effects; and (4) A long-term neighborhood intervention, when combined with a household-level intervention, will result in greater intervention effects than a household level intervention with a short-term neighborhood component. The third specific aim is to conduct a process and context evaluation in addition to the outcome evaluation of both components of the intervention.

Progress Summary:

The Intervention and Exposure Cores of MCECH continue to have the same specific aims as stated in the proposal, but because the two are so integrated and have the same participants and current goals, their research teams and activities have been combined into one "meta"-project called: Community Action Against Asthma, or CAAA. A Steering Committee, which meets monthly and is comprised of the university and Detroit community partners involved in both projects, oversees and is directly involved in decision making and other activities regarding the implementation of the research protocol. A separate Research Work Group, comprised of the university-based faculty and staff for CAAA, oversees the technical aspects of research issues and works closely and in coordination with the CAAA Steering Committee.

There have been no changes in the specific aims. The asthma intervention core will test the ability of individually tailored interventions to reduce exposure to environmental contaminants and to improve asthma related health status. At the same time, the intervention will provide direct benefit to the children and families enrolled in the study. The central hypothesis being addressed in the asthma exposure core is that exposure to ambient air contaminants will aggravate the health status of asthmatic children largely through the potentiation of the adverse effects of common indoor air contaminants. Proving or refuting this hypothesis will lead to substantial advances in scientific knowledge and have a direct impact on public health recommendations.

The most critical element in the success of the project to date has been the establishment at the outset of a dynamic Steering Committee (SC) comprised of representatives from all of the partner organizations: Butzel Family Center, Community Health and Social Services, Inc. (CHASS Center), Detroit Health Department, Detroiters Working for Environmental Justice, Friends of Parkside, Henry Ford Health System, Kettering/Butzel Health Initiative, Latino Family Services, United Community Housing Coalition, Warren/Conner Development Coalition, and the University of Michigan Schools of Public Health and Medicine. The Detroit Public Schools also are collaborating with the project. The SC meets on at least a monthly basis. The SC has, through a process of consensus, been responsible for all major decisions regarding study design as well as numerous more specific decisions concerning, for example, recruitment strategies, wording of instruments, and hiring of personnel.

A screening questionnaire was distributed in the Fall of 1999 to identify children with asthma then ages 6 to 10. Over 7,500 questionnaires were successfully mailed and about 2,000 were distributed in elementary schools. A total of 3,342 screening questionnaires were completed and returned in 1999. Among the returned questionnaires, 1,655 (49.7 %) were consistent with probable or known asthma of any severity. Among these, 387 (11.5 % of the total returned) had probable or known moderate to severe asthma based on National Asthma Education and Prevention Program diagnostic guidelines and another 116 had mild persistent asthma severe enough for eligibility for the study. Calculated minimum population-based estimates of

figure 1

prevalence for any asthma (18.9 %) and moderate to severe asthma (4.4 %) substantially exceed national averages. Among those with known or probable moderate to severe asthma, over 30 percent had not been diagnosed by a physician, over one-half were not taking daily asthma medication, and approximately one-quarter had not taken any physician-prescribed asthma medication in the past 12 months.

Of the 503 initially considered eligible for the study, approximately 30 were excluded because of living or having moved to an address outside of the target area. Of the remaining approximately 470 eligible children, 302 have been successfully enrolled into at least one aspect of the study (skin testing, baseline questionnaire, and/or first seasonal intensive data collection). Most of those not yet enrolled have proved difficult to contact by phone or mail. Fewer than 20 families have refused participation.

Other important steps accomplished in 1999-2000 include:

  • Development and pilot testing of written instruments in both English and Spanish including the screening questionnaire, adult (caregiver) questionnaire, child questionnaire, a household environmental checklist, and a neighborhood environmental checklist.
  • Elaboration of study protocols for skin test "fairs", training on use of the Airwatch airway monitor and symptom diary, administration of adult and children baseline questionnaires, completion of household and neighborhood environmental checklists, collection of household dust for allergen analysis, and measurement of personal and indoor household PM levels.
  • Hiring and training of staff from the community to serve as interviewers, air monitor and diary trainers, environmental checklist administrators, household dust collectors, and community environmental specialists ("CESs", or Outreach Workers).
  • Allergen skin testing of 272 children at 17 skin test "fairs".
  • Completion with 279 of the 302 participating families of the adult baseline questionnaires, household walk-through, and household dust collection for allergen analysis.
  • Participation by 205 families in the first 2-week intensive seasonal assessment through daily use of airway monitors and diaries, and, in a subset of about 80 households, measurement of vapor phase nicotine.
  • Installation of two tapered element oscillating microbalance instruments (TEOMs), for continuous measurement of ambient PM, on the rooftops of two Detroit elementary schools.
  • Development and production of customized indoor air sampling pump units, which were used to collect PM levels in each of the two elementary schools and in participant households during the first 2-week intensive seasonal assessment.
  • Creation and distribution of a newsletter for households participating in the study.
  • Distribution of vacuum cleaners and mattress and pillow covers to all wave one study participants as part of the intervention, and development of personalized plans for each of the households in wave one.
  • Participation by project faculty and staff in a 2-day training on Integrated Pest Management conducted by the Michigan Department of Agriculture, with plans underway to begin working with Abell Pest Management Services as part of the intervention.
  • Establishment of a Dissemination Committee, comprised of university and community representatives, to make information about the work of the project known to Detroit and the academic community. The Committee has developed a protocol consisting of guidelines for dissemination activities (including authorship on articles and on presentations, participation at national conferences, and promotion of project activities and findings within the Detroit community).

Results of Allergen Skin Testing. Based on preliminary analyses, the proportion of children with positive response to skin prick testing for each allergen is shown below:

Roach
Mite
Cat
Dog
Mouse
Rat
Ragweed
Grass
Alternaria
35%
54%
44%
33%
27%
33%
43%
51%
34%

The substantial proportion of children positive for allergens of outdoor origin (ragweed, grass, and Alternaria) was somewhat unexpected, and may have important implications for the customization of intervention strategies beyond those that were already envisioned for children allergic to roach and dust mite.

Future Activities:

The intervention activities as described above for the wave one families will continue during the 2000-2001 year. In March 2001, families who have been randomized into wave two will begin to receive their intervention. In addition, the neighborhood-level community awareness and mobilization campaign will begin in the upcoming year. This phase of the intervention will include educational events on environmental triggers for asthma, working with neighborhood block clubs and associations, advocacy for families attempting to adopt new health behaviors, assisting with housing issues, and organizing and conducting activities to reduce physical environmental hazards in their neighborhoods. Air monitoring activities, as described above, will be ongoing throughout the upcoming year.

We will continue our investigations as planned. We should have completed our complete characterization of the most model within the next 6 months. We will then begin to assay for the pathogenic factors.

Publications and Presentations:

Refer to the main center 2000 Progress Report.

Journal Articles:

No journal articles submitted with this report: View all 3 publications for this subproject

Supplemental Keywords:

asthma, ambient air, indoor air, exposure, health effects, children, stressor, pathogens, community-based, social science, pathology, monitoring, Detroit. Children, health, asthma, exposure, home, indoor air, inner city, cockroach, chemokines, allergen., RFA, Health, Scientific Discipline, Air, Environmental Chemistry, Health Risk Assessment, Risk Assessments, Susceptibility/Sensitive Population/Genetic Susceptibility, Allergens/Asthma, Children's Health, genetic susceptability, indoor air, Biology, asthma, dust mite, health effects, sensitive populations, school based study, asthma triggers, dust mites, dander, environmental triggers, community-based intervention, airway disease, exposure, second hand smoke, biological response, children, household, Human Health Risk Assessment, airway inflammation, human exposure, inhalation, assessment of exposure, childhood respiratory disease, mold, cigarette smoke, epidemeology, environmentally caused disease, environmental health hazard, environmental tobacco smoke, indoor air quality, tobacco smoke, dust , allergic response, allergen, disease, exposure assessment, human health risk, indoor environment, respiratory, toxics, cockroaches

Relevant Websites:

http://www.sph.umich.edu/urc/ Exit

Progress and Final Reports:

Original Abstract
  • 1998
  • 1999 Progress Report
  • Final

  • Main Center Abstract and Reports:

    R826710    Michigan Center for the Environment and Children’s Health

    Subprojects under this Center: (EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
    R826710C001 Indoor and Outdoor Air Contaminant Exposures and Asthma Aggravation Among Children (Asthma Exposure)
    R826710C002 Chemokines in the Pathogenesis of Asthma (Asthma Chemokines)
    R826710C003 A Community-Based Intervention to Reduce Environmental Triggers for Asthma Among Children (Asthma Intervention)