Objective: Describe the development and preliminary impact of CAMP Air, a web-based intervention for adolescents with uncontrolled asthma. Materials and Methods: CAMP Air was developed using an iterative process with input from stakeholders and incorporating usability testing results (n = 14 adolescents). To test CAMP Air's initial impact, 61 adolescents from two New York City public high schools (n = 37) and from clinics, community-based organizations, and third-party recruitment services (i.e., community sample; n = 24) were enrolled in a randomized pilot trial. Participants were randomized to CAMP Air (n = 30) or information-and-referral control intervention (n = 31). A point-person worked with school participants to complete CAMP Air. Results: CAMP Air participants were satisfied with the intervention and its value for supporting self-management, completing on average 6 of 7 modules. Relative to controls, CAMP Air participants demonstrated significantly improved asthma knowledge, asthma control, night wakening and school absences, and less risk for urgent care visits. Adolescents enrolled in schools completed more modules and had significantly fewer nights woken and school absences than community enrollees. Conclusion: CAMP Air improves asthma outcomes among adolescents with uncontrolled asthma. Practice Implications: A web-based intervention CAMP Air is a promising intervention. When a point-person works with adolescents, CAMP Air's access and impact are improved. (C) 2020 Elsevier B.V. All rights reserved.

BACKGROUND:Humans are ubiquitously exposed to flame retardants, including organophosphate esters (OPEs), through direct contact with consumer products or exposure through household dust. Children are at increased risk because of their proximity to dust, hand-to-mouth activity, and the importance of childhood as a critical period in neurodevelopment.OBJECTIVES:To quantify differences in exposure levels between mothers and children (three to six years of age), we analyzed urinary metabolites of OPEs. We additionally assessed the ability of silicone wristbands (measuring ambient exposure) to predict urinary metabolite concentrations.METHODS:We selected 32 mother and child dyads from an existing cohort. Participants provided baseline urine samples and wore wristbands for one week. After the first week, they returned their wristbands and provided a second urine sample. During the second week, participants wore a second wristband that they returned at the end of week two with a third and final urine sample.RESULTS:We found significantly higher levels of bis(1,3-dichloro-2-propyl) phosphate (BDCIPP) (p < 0.001) and lower levels of bis(1-chloro-2-isopropyl) 1-hydroxy-2-propyl phosphate (BCIPHIPP) (p < 0.001) in children's urine samples compared to mothers' samples at baseline. We found that triphenylphosphate (TPHP), tris(1,3-dichloroisopropyl) phosphate (TDCIPP), and tris(1-chloro-2-propyl) phosphate (TCIPP) measured in wristbands predicted their respective metabolite levels in urine.CONCLUSION:Children had higher levels than mothers for two of six flame retardant metabolites measured in urine. Generally, wristband measurements positively predicted internal dose. As little is known about the health effects of OPEs on child development, future research is needed to determine the impact of differential exposure.

Objective: Adverse cross-cultural interactions are a persistent problem within medicine impacting minority patients' use of services and health outcomes. To test whether 1) enhancing the evidence-based Physician Asthma Care Education (PACE), a continuing medical education program, with cross cultural communication training (PACE Plus) would improve the asthma outcomes of African American and Latino/Hispanic children; and 2) whether PACE is effective in diverse groups of children. Methods: A three-arm randomized control trial was used to compare PACE Plus, PACE, and usual care. Participants were primary care physicians (n = 112) and their African American or Latino/Hispanic pediatric patients with persistent asthma (n = 867). The primary outcome of interest included changes in emergency department visits for asthma overtime, measured at baseline, and 9 and 21 months following the intervention. Other outcomes included hospitalizations, asthma symptom experience, caregiver asthma-related quality of life, and patient-provider communication measures. Results: Over the long term, PACE Plus physicians reported significant improvements in confidence and use of patient-centered communication and counseling techniques (p < 0.01) compared to PACE physicians. No other significant benefit in primary and secondary outcomes was observed in this trial. Conclusion: PACE Plus did not show significant benefit in asthma-specific clinical outcomes. More trials and multi-component strategies continue to be needed to address complex risk factors and reduce disparities in asthma care.

OBJECTIVE:The aim of this study was to identify the educational needs of inner-city children with persistent asthma and their caregivers who utilize the emergency department (ED) for asthma care as well as determine their guideline adherence, factors associated with ED use, and comfort with computers.METHODS:Cross-sectional survey of children aged 2 to 18 years with previous diagnosis of asthma presenting with asthma-related complaints or acute asthma exacerbations to an urban pediatric ED. Data on demographics, families' response to acute asthma, approach to asthma prevention, access to care, educational topics of interest, and sources of health information were collected.RESULTS:Of approximately 1500 asthma-related visits, 218 caregivers were approached, and 200 completed the survey. In the past 12 months, 31% had experienced at least 1 asthma-related hospitalization, and 55.5% had had at least 3 ED visits. Although 184 (92.9%) of 198 caregivers were able to identify a primary physician, 37% reported they were more likely to take their child to the ED in response to acute asthma during the day as opposed to their physician (17%). Approximately half of patients were not on any preventive medication, with 57% not having had received an Asthma Action Plan. Caregivers expressed the most interest in learning about long-term controller medications (44.2%), use of metered dose inhalers or nebulizers (44.2%), and trigger avoidance (35.2%). Most caregivers (approximately 68%) reported ease of use with computers and the Internet.CONCLUSION:There was discordance between caregivers' reports of primary care provider teaching on asthma management and the use of the controller medications and possession of the Asthma Action Plans for persistent asthma. Education could focus on caregiver concerns of the safety and benefits of the controller medications.

Background Polybrominated diphenyl ethers (PBDEs) have been largely replaced by organophosphate flame retardants (OPFRs) and alternative brominated flame retardants (Alt-BFRs) to meet flammability requirements. Humans are ubiquitously exposed to some variety of flame retardants through contact with consumer products directly or through household dust. Objectives To evaluate the effectiveness of house cleaning and hand washing practices to reduce exposure to flame retardants, we measured concentrations in dermal hand wipes and urinary metabolites before and after assignment to two consecutive interventions. Methods We selected 32 mother and child dyads from an existing cohort. This analysis focuses on mothers. Participants provided baseline measurements (urine, hand wipes, and questionnaires) and were then assigned for 1 week to either a house cleaning (including instruction on proper technique and cleaning supplies) or hand washing (including instruction on proper technique and soaps) intervention arm. For the second week, participants were assigned to the second intervention in addition to their initial assignment, thus all subjects both washed their hands and cleaned according to the intervention guidelines during week 2. We collected measurements at the end of weeks 1 and 2. Results We found reductions in urinary analytes after week 1 of house cleaning (BCIPHIPP and ip-DPHP), week 1 of hand washing (BCIPP, BCIPHIPP, and tbutyl-DPHP), and week 2 of combined interventions (BCIPHIPP and tbutyl-DPHP), compare to baseline. We found no significant decline in hand wipes in the entire sample but did find reductions after week 1 of house cleaning (BDE 209), week 1 of hand washing (TCEP), and week 2 of combined interventions (TDCIPP and BDE 209) in women with exposure above the median at baseline (verified through simulations). Conclusions Exposure to individual flame retardants was reduced by about half, in some cases, by 1 week of increased hand washing, house cleaning to reduce dust, or combined activities.

Objective: Exercise-induced wheeze (EIW) has been found to be associated with asthma-related urgent care in school-aged children. Despite asthma's high prevalence and morbidity among adolescents, this association has not been examined in adolescents. We tested the association of EIW and other asthma symptoms to asthma-related ED visits and hospitalizations in urban adolescents with probable asthma. We hypothesized that EIW would be associated with urgent care. Methods: In this cross-sectional study 30,467 high school students (mean age = 16.0) from 49 NYC schools completed two brief validated measures, one assessing probable asthma and the other the frequency of six asthma symptoms over the past year. Adolescents also reported if in the past year they had an asthma-related ED visit or hospitalization. Analyses presented here included students with probable asthma (n = 9149). Using logistic regression, we modeled each asthma symptom as a function of ED visits and hospitalizations adjusting for sex, age, race/ethnicity and asthma severity. Multivariable models included all symptoms to account for the potential interaction between symptoms. Results: Among adolescents with probable asthma, EIW was associated with ED visits and hospitalizations. In multivariable models wheeze without a cold, chest tightness, night wakening, but not EIW, were significantly associated with both ED visits and hospitalizations. Conclusions: Unlike findings with younger children, EIW does not appear to be associated with ED visits and hospitalizations among urban adolescents with probable asthma. Instead, symptoms, such as chest tightness and night wakening, appear to be important at identifying adolescents at risk for asthma-related urgent care.

Rationale: Asthma clinical guidelines suggest written asthma action plans are essential for improving self-management and outcomes.Objectives: To assess the efficacy of written instructions in the form of a written asthma action plan provided by subspecialist physicians as part of usual asthma care during office visits.Methods: A total of 407 children and adults with persistent asthma receiving first-time care in pulmonary and allergy practices at 4 urban medical centers were randomized to receive either written instructions (n = 204) or no written instructions other than prescriptions (n = 203) from physicians.Measurements and Main Results: Using written asthma action plan forms as a vehicle for providing self-management instructions did not have a significant effect on any of the primary outcomes: (1) asthma symptom frequency, (2) emergency visits, or (3) asthma quality of life from baseline to 12-month follow-up. Both groups showed similar and significant reductions in asthma symptom frequency (daytime symptoms [P < 0.0001], nocturnal symptoms [P < 0.0001], p-agonist use [P < 0.0001]). There was also a significant reduction in emergency visits for the intervention (P < 0.0001) and control (P < 0.0006) groups. There was significant improvement in asthma quality-of-life scores for adults (P < 0.0001) and pediatric caregivers (P < 0.0001).Conclusions: Our results suggest that using a written asthma action plan form as a vehicle for providing asthma management instructions to patients with persistent asthma who are receiving subspecialty care for the first time confers no added benefit beyond subspecialty-based medical care and education for asthma.

Objective. Peers can play a critical role in asthma management, with attitudes toward friends with asthma hindering or supporting self-management. We explored minors' attitudes toward peers with asthma, testing if attitudes varied by grade, sex, asthma knowledge, and asthma status. Methods. Three hundred and eighty-one students in grades 5-11 (51% female; 51% White, non-Hispanic; 12% with asthma) read five vignettes about peers with asthma, and rated the characters on 10 adjective pairs (e. g., afraid/brave and sad/happy). Three vignettes portrayed an aspect of uncontrolled asthma (asthma-related school absence, asthma-related limited physical activity, and asthma-related school nurse visit). One vignette depicted controlled asthma; one described taking medication publically. We computed a total attitude score for each vignette and a mean attitude score across the three uncontrolled vignettes. Linear regression analyses tested the effect of each predictor (grade, sex, asthma knowledge, and asthma status) on attitudes, as well as the interaction of asthma status with the remaining three predictors. Results. Grade was the most robust predictor. Participants in higher grades tended to have more favorable attitudes toward peers with asthma, except for the controlled asthma vignette where participants in lower grades had more favorable attitudes. There were significant interactions between grade and asthma status for the stop-running-and-taking-medication- publically vignettes: among those with asthma, participants in higher grades had more favorable attitudes. Sex interacted with asthma status for the overall uncontrolled, absence, and stop-running vignettes; among those with asthma, girls had more favorable attitudes. Conclusion. With increased grade, minors have better attitudes toward peers with asthma. Living with asthma may normalize asthma. Clinicians can use grade-specific findings to counsel patients.

OBJECTIVES:To use the children's sleep habits questionnaire (CSHQ) to characterize sleep problems in a group of 5- to 6-year-old minority children living in urban communities and to compare our findings with data from 5- to 6-year-old children in the original CSHQ validation study.METHODS:A cross-sectional study design was used to collect sleep data from parents using the CSHQ.RESULTS:The CSHQ was completed by 160 parents; 150 (94%) scored ≥41, indicating a sleep problem. The prevalence of having sleep problems for our minority community sample was significantly higher than the original community sample (94% vs. 23%, P < .001). The minority sample also had significantly higher mean total CSHQ scores (51.5 vs 37.9, P < .001) and higher scores across all 8 subscales of the CSHQ (P < .001 for all comparisons).CONCLUSIONS:The results suggest that sleep problems may be more prevalent in urban, early-school-aged minority children than previously reported.

Introduction. Youth as young as 11 are given responsibility to manage their asthma. Yet, little is known regarding early adolescents' asthma self-management behaviors. This study characterizes urban early adolescents' asthma self-management behaviors and perceived responsibility to manage asthma, exploring demographic differences and examining the relationship between asthma responsibility and disease management. Methods. About 317 Hispanic and African American/Black early adolescents (mean age = 12.71) with persistent, uncontrolled asthma reported prevention and symptom management steps, and responsibility for asthma care. We used Poisson, cumulative logistic, logistic, and linear mixed-effects regression models to assess the relationships among demographic predictors, prevention and management behaviors, and responsibility for asthma care. Results. Fifty percent took 7-9 prevention steps; few saw physicians when asymptomatic or took daily medication. When symptomatic, 92% used medication to treat symptoms and 56% sought medical attention. Controlling for asthma responsibility, fewer older youth reported observing how they feel when asthma is likely to start, observing symptom changes, or asking for help. More boys reported taking medication daily or upon trigger exposure. Controlling for age, gender, and race/ethnicity, those reporting more asthma responsibility were less likely to report taking management steps, seeking preventive care, asking for help, or going to a doctor/hospital for their asthma. Conclusions. Early adolescents' asthma self-management is suboptimal. With increasing age, they are less observant regarding their asthma and less likely to seek help. Although they perceive themselves to have greater responsibility for managing their asthma, early adolescents do less to care for their asthma, suggesting they are being given responsibility for asthma care prematurely.

In 2005, local leaders in New York City developed the Washington Heights/Inwood Network for Asthma Program to address the burden of asthma in their community. Bilingual community health workers based in community organizations and the local hospital provided culturally appropriate education and support to families who needed help managing asthma. Families participating in the yearlong care coordination program received comprehensive asthma education, home environmental assessments, trigger reduction strategies, and clinical and social referrals. Since 2006, 472 families have enrolled in the yearlong program. After 12 months, hospitalizations and emergency department visits decreased by more than 50%, and caregiver confidence in controlling the child's asthma increased to nearly 100%. Key to the program's success was the commitment and involvement of community partners from program inception to date.

Objective: To describe and test the feasibility of asthma self-management for adolescents with undiagnosed asthma (ASMA-Undx), an 8-week school-based intervention for urban adolescents comprised of three group and five individual coaching sessions, and academic detailing for their primary care providers (PCPs).Methods: Thirty high school students (mean age 15.9; 92% female; 72% Latino/a) who reported symptoms of persistent asthma, but no diagnosis were randomized to ASMA-Undx or a no-treatment control group. Interviews were conducted pre- and post-intervention.Results: All intervention students participated in the three group sessions; 64% received all five individual coaching sessions. Academic detailing telephone calls made by a pediatric pulmonologist reached 83% of the students' PCPs. Relative to controls, a significantly greater proportion of ASMA-Undx students were diagnosed (79% versus 6%, respectively), and prescribed asthma medication (57% versus 6%, respectively). Barriers to diagnosis and treatment included students' and parents' lack of knowledge about asthma.Conclusion: ASMA-Undx is a feasible and promising intervention to assist urban adolescents with undiagnosed asthma obtain a diagnosis and treatment.Practice implications: ASMA-Undx has the potential to reach many adolescents because it is school-based. It can serve as a model for interventions targeting other pediatric illnesses. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

RATIONALE:Asthma prevalence and morbidity are especially elevated in adolescents, yet few interventions target this population.OBJECTIVES:To test the efficacy of Asthma Self-Management for Adolescents (ASMA), a school-based intervention for adolescents and medical providers.METHODS:Three hundred forty-five primarily Latino/a (46%) and African American (31%) high school students (mean age = 15.1 yr; 70% female) reporting an asthma diagnosis, symptoms of moderate to severe persistent asthma, and asthma medication use in the last 12 months were randomized to ASMA, an 8-week school-based intervention, or a wait-list control group. They were followed for 12 months.MEASUREMENTS AND MAIN RESULTS:Students completed bimonthly assessments. Baseline, 6-month, and 12-month assessments were comprehensive; the others assessed interim health outcomes and urgent health care use. Primary outcomes were asthma self-management, symptom frequency, and quality of life (QOL); secondary outcomes were asthma medical management, school absences, days with activity limitations, and urgent health care use. Relative to control subjects, ASMA students reported significantly: more confidence to manage their asthma; taking more steps to prevent symptoms; greater use of controller medication and written treatment plans; fewer night awakenings, days with activity limitation, and school absences due to asthma; improved QOL; and fewer acute care visits, emergency department visits, and hospitalizations. In contrast, steps to manage asthma episodes, daytime symptom frequency, and school-reported absences did not differentiate the two groups. Most results were sustained over the 12 months.CONCLUSIONS:ASMA is efficacious in improving asthma self-management and reducing asthma morbidity and urgent health care use in low-income urban minority adolescents.

Background. Although schools are an important setting for asthma care in youth, teachers’ asthma knowledge and symptom management is poor. This study investigated the knowledge, prevention and management behaviors, and communication regarding asthma of teachers of low-income, ethnic minority students. It was hypothesized that relative to colleagues whose students did not have active asthma (i.e., did not have symptoms during the day), teachers of students with active asthma would have better asthma knowledge and that more would take asthma prevention steps and communicate with parents and school nurses. Methods. Drawing from 25 elementary schools in New York City, 320 pre-Kindergarten through 5th grade classroom teachers with at least one student with asthma completed measures assessing their asthma knowledge, steps taken to manage asthma, communication with the school nurse or parents, information they received about asthma, and whether or not they had at least one student in their class experience asthma symptoms. t test and chi-square were used to test hypotheses. Results. Asthma knowledge varied among teachers. Most could identify potential triggers, yet few knew that medication taken prior to exercise could prevent symptoms and that students with asthma need not avoid exercise. Communication between teachers and school nurses and between teachers and parents was lacking. Relative to colleagues whose students did not have active asthma, teachers whose students had active asthma had better asthma knowledge, more took steps to prevent students from having asthma symptoms, communicated with parents, and more initiated communication with the nurse. Conclusions. Teachers’ knowledge about asthma and asthma management is limited, especially among those whose students did not have active asthma. Teachers respond reactively to students who have symptoms in class by increasing prevention steps and communications with parents and the school nurse. A more proactive approach to managing asthma in schools is warranted.

Background Cockroaches and mice, which are common in urban homes, are sources of allergens capable of triggering asthma symptoms. Traditional pest control involves the use of scheduled applications of pesticides by professionals as well as pesticide use by residents. In contrast, integrated pest management (IPM) involves sanitation, building maintenance, and limited use of least toxic pesticides. Objectives We implemented and evaluated IPM compared with traditional practice for its impact on pests, allergens, pesticide use, and resident satisfaction in a large urban public housing authority. Methods We assigned IPM or control status to 13 buildings in five housing developments, and evaluated conditions at baseline, 3 months, and 6 months in 280 apartments in Brooklyn and Manhattan, in New York City (New York). We measured cockroach and mouse populations, collected cockroach and mouse urinary protein allergens in dust, and interviewed residents. All statistical models controlled for baseline levels of pests or allergens. Results Compared with controls, apartments receiving IPM had significantly lower counts of cockroaches at 3 months and greater success in reducing or sustaining low counts of cockroaches at both 3 and 6 months. IPM was associated with lower cockroach allergen levels in kitchens at 3 months and in beds and kitchens at 6 months. Pesticide use was reduced in IPM relative to control apartments. Residents of IPM apartments also rated building services more positively. Conclusions In contrast to previous IPM studies, which involved extensive cleaning, repeat visits, and often extensive resident education, we found that an easily replicable single IPM visit was more effective than the regular application of pesticides alone in managing pests and their consequences.

BACKGROUND:Patient-provider communication is essential for high-quality asthma care. The objective of this study was to assess the potential relationship of language barriers with outcomes of inner-city asthmatics. RESEARCH DESIGN:We interviewed a prospective cohort of 318 adults with persistent asthma receiving care at 2 large inner-city clinics. Patients were classified into 3 groups according to their English proficiency; non-Hispanics (all native English speakers), Hispanics proficient in English, and Hispanics with limited English proficiency. Data on asthma control (Asthma Control Questionnaire), resource utilization, and asthma-related quality of life (Asthma Quality of Life Questionnaire) were collected at 1 and 3 months of enrollment. Univariate and multiple regression analyses were used to compare asthma morbidity and quality of life according to the patients' level of English proficiency. RESULTS:Overall, 44% of patients were non-Hispanics, 38% were Hispanics proficient in English, and 18% were Hispanics with limited English proficiency. Unadjusted, stratified, and multivariate analyses showed a significant association between limited proficiency and poorer asthma control, increased resource utilization, and lower quality of life scores after controlling for potential confounders (P < 0.05 for all comparisons). Additionally, limited English proficiency was associated with increased worries about side effects or becoming addicted to inhaled corticosteroids, beliefs that asthma is an acute disease, decreased self-efficacy, and lower adherence rates. CONCLUSIONS:Inner-city asthmatics with limited English proficiency have significantly poorer asthma control, higher rates of resource utilization, and a lower quality of life. Further research is necessary to understand the mechanisms underlying this association.

Asthma is prevalent in school-age children and contributes to school absenteeism and limitation of activity. There is a sizable literature on school-based interventions for asthma that attempt to identify children with asthma and improve outcomes. The purpose of this review is to describe and discuss limitations of screening tools and school-based asthma interventions. Identification of children with asthma may be appropriate in schools located in districts with a high prevalence of children experiencing significant morbidity and a high prevalence of undiagnosed asthma, provided there is access to high-quality asthma care. We review strategies for improving access to care, for teaching self-management skills in schools, and for improving school personnel management skills. Although studies indicate that school-based programs have the potential to improve outcomes, competing priorities in the educational system present challenges to their implementation and emphasize the need for practical, targeted, and cost-effective strategies.