Asthma affects 3-4 million children under age 17 years, or roughly 6% of children in the U.S. The prevalence, morbidity and mortality of asthma increased substantially among children <18 years of age since the 1980's. Poor, minority, urban childen are affected disproportionately; the prevalence of asthma is 50% higher in African-American children than in Caucasians, and the likelihood of dying from asthma is 2-3 times greater among non-whites than among Caucasians. The economic costs of asthma are enormous, estimated at $6.2 billion in 1990. In spite of the availability of improved medications for the treatment of asthma, asthma remains the most common medical diagnosis for admission to the vast majority of children's hospitals across the country, and continues to account for a substantial fraction of total visits to emergency rooms, particularly for children from inner city, underserved communities. Asthma morbidity among poor inner city minority children is associated with multiple overlapping factors including low socioeconomic status, decreased accessibility to and decreased quality of health care services, increased exposure to environmental triggers and impaired psychosocial functioning. Acute exacerbations of asthma resulting in functional morbidity, emergency room treatment and hospitalization are largely preventable, especially if treatment of the disease is comprehensive, preventive and ongoing. Educational programs alone can effect improvement in patient knowledge and self-management skills but in general, have had little effect in reducing morbidity. To impact on morbidity, these programs must positively influence patient behavior/ compliance and must address improvements in the quality of health care services. Development and evaluation of cost-effective interventions targeted at high risk populations is essential. The objectives of the study are to evaluate risk factors for asthma morbidity in the local population and to test the hypothesis that a multi-component intervention (educational, behavioral, medical) can reduce asthma-related morbidity among high risk children with asthma. The multi component intervention is based on the current model that asthma is induced in genetically susceptible individuals by environmental and social factors. Appropriate medical and self-management is essential and can counterbalance these asthma-inducing factors, but its effectiveness is largely influenced by patient/caretaker compliance, understanding and acceptance of disease management and psychosocial factors that affect the local community of urban disadvantaged children. An asthma intervention must impact these compliance and psychosocial barriers to allow medical management to improve asthma morbidity and the intervention must be tailored to the target population. We believe our intervention, which addresses educational, behavioral and medical needs, effectively accomplishes these objectives. The principal aims of the study are (1) to evaluate the psychosocial, economic, medical and environmental risk factors contributing to asthma morbidity in the local community of urban, economically disadvantaged children with asthma, and (2) to develop, implement and evaluate a randomized, controlled multiple-component intervention of one year duration to reduce asthma morbidity in this population. Risk factors in the population are assessed by (1) the Children's Health Survey for Asthma (AAP), to obtain descriptive information about the patient and family, their knowledge about asthma and possible demographic, socioeconomic, psychosocial, behavioral and environmental risk factors; (2) assessment of the home environment for environmental and allergic exposures which may exacerbate asthma (in collaboration with the public health departments of Santa Clara, San Mateo and San Francisco counties); (3) measurement of sensitization to common allergic triggers by allergen skin testing and (4) assessment of salivary cotinine, a bioassay to determine environmental tobacco smoke exposure. The intervention focuses on (1) improving asthma self-management by children with asthma and their caretakers by means of individual and group asthma education, asthma hotline and case management, (2) changing individual behavior/ compliance through the use of a novel Supernintendo asthma video game and (3) improving quality of health care services through facilitated referral to an asthma specialist. The study group includes Spanish or English-speaking children age 5-12 years with moderate to severe asthma, currently receiving Medi-Cal benefits or with income equivalence, and who have not received asthma specialty care in the six months prior to enrollment. Study patients are seen at San Francisco General Hospital, Lucile Packard Children's Hospital or Santa Clara Valley Medical Center on several visits and transportation costs are reimbursed. Assessment of the intervention is conducted by face to face and phone interviews of subjects/ caretakers, self-administered surveys and symptom/ medication diaries; objective evaluation of pulmonary function testing, allergen skin testing and salivary cotinine; and surveillance of clinic, emergency department and hospital utilization. Targeted enrollment is 120 subjects to obtain a sample size of 48 subjects per group.
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