Community health worker support improves inhaler adherence in urban children with asthma
Key takeaways:
- Community health worker services were associated with improvements in inhaler technique, possession of inhaled corticosteroids and adherence compared with certified asthma educator services.
- Improvements in inhaler technique were sustained through 24 months among children who received community health worker services.
- Systemic and policy changes in health care are necessary to improve outcomes related to environmental exposures that trigger asthma.
Visits from a community health worker were associated with improved medication adherence and inhaler technique among urban children with asthma, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
However, changes in health care policy are needed to support sustainable improved outcomes for these children, the researchers wrote.
“This study was designed to try to reduce asthma health disparities,” Andrea A. Pappalardo, MD, FAAAAI, FACAAI, assistant professor of medicine and pediatrics at University of Illinois at Chicago, told Healio.
“Many factors contribute to asthma health disparities and result in urban low-income children being less likely to receive guideline-based asthma care,” she continued. “We know that self-management support can help, but how to implement self-management support in real-world settings was not clear.”
Study design and methods
The Asthma Action at Erie Trial recruited 223 children aged 5 to 16 years (average age, 9.4 years; standard deviation, 3) with uncontrolled asthma who attended a Federally Qualified Health Center in the Chicago area. Also, 85.2% of these patients were Hispanic and 44% were girls.
During the baseline assessment, researchers collected information about each child’s demographics, asthma symptoms and history, medication, inhaler technique, triggers, psychosocial factors and other data.
Data collection was repeated at each patient’s home at 6, 12 and 24 months and via telephone at 18 months. Monthly phone calls gathered updates about hospitalizations, ED and urgent care visits and oral corticosteroid bursts as well.
The researchers also hired and trained one certified asthma educator (AE-C) and two community health workers (CHWs) who all were bilingual in English and Spanish.
“The practical value of both CHWs and AE-Cs are known to those who have worked in the community asthma and allergy space for years,” Pappalardo said.
Within a month of enrollment and again at 6 months, the 108 children in the AE-C arm were offered an hour-long session at the health center that covered asthma symptoms, control, medications, adherence, technique, triggers, action plans and any concerns the caregiver or child had, with telephone follow-ups 2 weeks after each session.
The 115 children in the CHW arm were offered 10 visits mostly at home over 12 months. These visits focused on the same asthma topics, the researchers said, but were flexible to cover specific needs and include behavioral change plans, in addition to identifying triggers in the home and discussing how to change them.
The families in the CHW group had a median of seven visits (interquartile range, 4), whereas 49% of the AE-C group received no interventions, 29% had one session and 22% had two sessions. Costs included $74 per CHW visit and $135 per AE-C session.
Previous analysis of the trial’s findings indicated that the CHW and AE-C groups achieved similar results in asthma control, which Pappalardo called surprising because the CHWs had much more contact with families. The current analysis examined the intervention’s impacts on adherence, inhaler technique and trigger reduction in the home.
Study findings
At 6 months, the CHW group had a 9.8% (95% CI, 4.2%-15.32%) improvement in inhaler technique that was sustained after the end of the intervention. But the medication technique in the AE-C grew worse (P = .013), which resulted in a 13.4% difference (95% CI, 7.8%-18.9%) between the groups at 12 months. At 24 months, the difference was 10% (95% CI, 4.7%-15.3%), which the researchers called significant.
While 44.4% of children had an inhaled corticosteroid (ICS) at home at baseline, 56% of the CHW group and 35% of the AE-C group had an ICS at home at 12 months (OR = 2.39; 95% CI, 0.99-5.79), although this effect was not sustained at 24 months (OR = 1.52; 95% CI, 0.59-3.92).
In an adjusted model, the CHS group had improved ICS adherence at 12 months but the AE-C group did not, with a 16% (95% CI, 2.3%-29.7%) difference between the groups, although both arms were similar again at 24 months.
“This secondary analysis showed, as we expected, that the CHW intervention was associated with improved adherence to asthma therapies and better inhaler technique,” Pappalardo said.
“When we stopped the intervention, behaviors deteriorated, which suggests that continuing CHW services are needed to sustain medication adherence and correct inhaler technique,” she continued.
Except for improvements in exposures to strong odors in both the CHW group (OR = 0.25; 95% CI, 0.13-0.47) and AE-C group (OR = 0.38; 95% CI, 0.19-0.78) at 24 months, the researchers continued, there were no meaningful changes in trigger exposures in either group.
Although families do change triggers that they can control, the researchers noted, many triggers are related to housing, infrastructure and other factors beyond their control, requiring changes in public health at the systemic and policy level.
Still, the researchers said that CHW interventions linked directly to a medical system can improve the presence of and adherence to ICS treatment among children with asthma who live in urban settings. Replicating these results may be challenging, however.
“Many states have no formal certification for CHWs, making standardization difficult,” Pappalardo said. “Clinical groups should follow the best practices for CHW training and hiring, as described by the CHW Core Consensus Project.”
Reference:
- CHW Core Consensus Project. https://www.c3project.org/. Accessed Sept. 21, 2022.
- Martin MA, et al. Am J Public Health. 2021;doi:10.2105/AJPH.2021.306272.
For more information:
Andrea A. Pappalardo, MD, FAAAAI, FACAAI, can be reached at apappa2@uic.edu.