More than four million people with asthma live outside of urban areas. Most of these patients are seen in primary care settings where their asthma is often inadequately managed, representing a significant gap in care. Health disparities for rural children with asthma include poverty, limited access to specialty care, and environmental challenges including high levels of outdoor and indoor air pollution exposure. We propose to develop a comprehensive Asthma Care Implementation Program (ACIP) to improve care for rural children with asthma. This project will bring together investigators from the University of Arizona and National Jewish Health to 1) engage four communities in rural southwestern Colorado and northern Arizona to build a successful collaboration; and 2) conduct a randomized pragmatic trial of a community rural pediatric asthma program. In the first (U34) phase, we will build on initial community outreach efforts conducted in 2014 with over 50 healthcare providers and critical access hospitals in the 25,000 mile Four Corners region (including the Southern Ute, Ute Mountain Ute, and Navajo Nation Reservations). During the initial engagement phase, we will solidify relationships and assess community needs with stakeholders including parents, community leaders, hospital administrators, schools, and providers. In the second (U01) phase, we will employ a stepped wedge, randomized trial design to test the capacity of the ACIP to improve asthma care and outcomes with four integrated interventions: 1) the medical care component will include comprehensive training of PCPs and hospital staff in evidence-based pediatric asthma management; 2) the home component will address community concerns about air quality and determine potential methods to measure and reduce environmental risks to children with asthma; 3) the community component will include a school-based program to identify undiagnosed asthma, provide education, and facilitate communication between school, family, and provider; and 4) the family component will connect families with all of the above including care coordination, education, and other forms of assistance such as transportation or low-cost medication. The final trial will be modified in accord with stakeholder input during the engagement phase and evaluated within the RE-AIM framework. We believe that the intervention could serve as a model for implementation of strategies to improve asthma care among children in rural settings, including those living on Native American reservations.

Public Health Relevance

Ten percent of children have asthma. Many of them live in rural areas where access to specialty care is limited and exposure to wind, agricultural particulates, biomass heating, and large coal-powered power plants create increased risks. This project seeks to implement a community-based program to provide improved care to children living in rural areas of the southwest United States including Native American reservations.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Clinical Planning Grant Cooperative Agreement (U34)
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Special Emphasis Panel (ZHL1-CSR-J (S1))
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Freemer, Michelle M
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National Jewish Health
United States
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Lowe, Ashley A; Bender, Bruce; Liu, Andrew H et al. (2018) Environmental Concerns for Children with Asthma on the Navajo Nation. Ann Am Thorac Soc 15:745-753