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A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

BACKGROUND AND OBJECTIVES

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

METHODS

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

RESULTS

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

CONCLUSIONS

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Asthma is among the most prevalent chronic conditions in children, affecting almost 6 million children in the United States.1  In the most severe, uncontrolled cases, children with asthma experience disruptions to their everyday life, including missed school, unplanned emergency department (ED) visits, and hospitalizations. This results in increased healthcare costs and decreased quality of life and educational potential.2  The annual clinical and academic burden of childhood asthma results in approximately 10.5 million missed school days, 640 000 ED visits, and 157 000 hospitalizations.3 

Childhood asthma disproportionately affects children in low-income populations, inner-cities,2,4,5  and underrepresented minority populations.6,7  Black children (13.5%) are more likely to have current asthma than White (5.7%) children.8  Among Hispanic populations, the current childhood asthma prevalence is 8.0% and is even higher for a subset of Puerto Rican children (17.0%).9  Black children are 4 times more likely to have an asthma hospitalization and over 7 times increased risk to die of asthma when compared with White children.10  Additionally, children from low-income populations are more likely to visit the ED than affluent children.11  Black race, living in an urban residence, and poverty are attributable to 30% of the risk for asthma hospitalization.12 

The communities where children live have a significant impact on the social patterning of asthma inequities.13,14  Black and Hispanic children compared with White children disproportionately live in historically disinvested neighborhoods.1519  Major sources of air pollution, such as industrial facilities and major highways, which decrease the ambient air quality and exacerbate asthma symptoms, are found in low-income communities.2023  Inequities in air pollution exposure are more pronounced than inequities based on income when comparing underrepresented minorities to White populations.24 

Neighborhoods can also exacerbate asthma symptoms by exposure to poor indoor air quality, allergens, and type of housing.2527  Substandard, deteriorated housing found in low-income communities is associated with mold, pest infestation, and water damage.28  Safety concerns, such as community violence, may force children to stay indoors for longer periods of time, increasing potential for exposure to indoor sources of asthma triggers.29  Lack of quality transportation, available social services, and access to healthcare resources in the community is a barrier and can further prevent caregivers from appropriately managing their children’s asthma.29 

Community interventions may be a plausible solution to reduce childhood asthma exacerbations leading to ED visits and hospitalizations. Community interventions are strategies seeking to reduce adverse health outcomes in a population within a defined local context. It is important to understand the effectiveness of community interventions given spatial patterning of childhood asthma risk.13,3033  Children spend a vast majority of their time in their communities, including visiting family or friends, attending school, recreational centers, or other public places. Based on this premise and the community level inequities in exposure to in-home asthma triggers, there is a need to identify strategies affecting communities.

A seminal systematic review conducted by Chan and colleagues found significant associations between multicomponent community-based interventions (eg, interventions focusing on asthma self-management education, reduction of home environmental triggers, care coordination, school involvement, primary healthcare provider assessment, community support, and/or advocacy for policy changes) and reductions in childhood asthma severity.34  Their review found that most studies included interventions related to asthma self-management education, home environmental assessment, and care coordination; many were held in clinical settings.34  However, less is known about the impact of community interventions with multiple components compared with more expansive environmental changes affecting whole communities (eg, smoke-free legislature, traffic reduction models, and green housing) as it relates to the reduction of emergency healthcare utilization. Accordingly, this systematic review aimed to examine the broader scope of community interventions to evaluate evidence of their effectiveness for reducing childhood asthma exacerbations leading to ED visits and hospitalizations and provide a conceptual model to inform the implementation of future community interventions.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines35  to perform the systematic review. We developed a protocol and registered it with the International Prospective Register of Systematic Reviews (registration number: CRD42020196132), before conducting the review and writing the final report.

Five electronic databases (ScienceDirect, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PubMed, and the Cochrane Library) were used to search articles published from January 2010 to December 2021. We examined studies to see how effective community interventions are in reducing childhood asthma ED visits and hospitalizations. In each database we used search terms such as: (asthma AND [“community intervention” OR “community based” OR environment OR “evidence based” OR “patient education” OR “health education” OR “environmental justice” OR “collective action”] AND [hospitalization OR hospitalized OR inpatient OR emergency]). Our search strategy also comprised medical subject headings in addition to search terms related to childhood asthma ED visits and hospitalizations. To review our complete search strategy of database-specific search terms see the Supplemental Information. Additional studies were identified from hand searched reference sections.

Searches were limited to full-text articles published in the English language. Eligible studies included children with asthma who were exposed to community interventions. Community interventions comprised those that were place-based (eg, neighborhoods, zip codes, counties, etc), including those that were community-led (eg, community health workers [CHWs], local leaders, community partners, etc) and/or sociodemographic-based (eg, low-income, Black, Hispanic, etc). The main outcomes were childhood asthma ED visits and hospitalizations occurring after exposure to community interventions. Eligible study designs consisted of randomized controlled trials, longitudinal cohort, quasi-experimental design, natural experiment, or time series studies to examine the benefits and effectiveness of community interventions. There were no limitations for geographic location; all studies published worldwide were considered.

Searches excluded children with asthma exposed to no community interventions, community interventions in collaboration with drug therapies, and animal studies. Community interventions exclusively examining school or clinical settings were omitted as well as studies with only non-clinical outcomes. Though schools and clinics are important aspects of the community, recently published systematic reviews on school-based self-management,36  asthma education for school staff,37  school and community-based,38  and inpatient quality improvement39  interventions already exist. Though quality improvement studies did not clearly demonstrate effective reductions in asthma ED revisits or readmissions,39  school-based self-management interventions improved hospitalizations and ED visits.36  We made exceptions to our exclusion criteria for mobile community clinics that were located at schools as it is critical to identify methods of reducing barriers to care in underserved communities.

Titles and abstracts from each search engine were reviewed independently by 2 authors during the initial search. Eligible studies identified from the initial search were evaluated by 2 authors in the second phase for the full text review. Any disagreements between individual judgment were brought to the other co-authors for a discussion and resolved consensus for inclusion or exclusion. We abstracted data on study design, geographic location, study participants, sample size, type and description of community intervention, outcome measurements, and key results. A summary of findings is displayed in Table 1.

TABLE 1

Systematic Review Summary of Findings

CitationStudy DesignStudy LocationSample SizeAge, yRace and EthnicityExposureIntervention DescriptionOutcomeKey Findings
Care coordination in communities 
 Clark et al 201342  Retrospective cohort study Multiple cities 12 361 children with the intervention and 14 475 children in the comparison group 2–18 63% Black, 17% Hispanic, and 11% White Allies Against Asthma community coalitions in low-income communities Improvements in care coordination and standardization of clinical care, home environmental conditions, and increased opportunities for families to learn asthma management techniques. Specific strategies used varied in response to the features of the community in which it was being implemented. Asthma-related ED visits, urgent care visits, and hospitalizations At any point during the study period, the hazard for an ED visit, urgent care visit, or hospitalization was 7% (P <.02) greater for children in the non-allies communities compared with those with no enrollment gap in the intervention communities. 
 Coughey et al 201043  Quasi-experimental study Philadelphia, Pennsylvania 59 children with a matched sample of 236 children 3–12 84.4% Black, 6.7% Hispanic, 6.7% White, and 2.2% other or refused Child Asthma Link Line (CALL) Telephone-based program which provided asthma education to childhood asthma caregivers and linked them with other community-based medical, educational, and social services based on responses to an intake assessment. Asthma-related ED visits, hospitalizations, and doctor visits CALL group was significantly less likely to have a follow-up hospitalization than the matched sample group, with a CMH statistic of 5.38 (P = .02), and significantly more likely to have a doctor visit than the matched sample group, with a CMH statistic of 4.01 (P = .045). There was a significant difference between CALL participants with ≥2 ED visits at baseline and the likelihood for a follow-up ED visit (33.3%) compared with the matched sample (62.1%) (CMH = 4.00, P = .046). 
 Findley et al 201144  Pre and post intervention Chicago, Illinois; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; San Juan, Puerto Rico 724 children: Chicago: 176, Los Angeles: 201, New York: 68, Philadelphia: 161, San Juan: 118 Average: Chicago: 8.2, Los Angeles: 9.8, New York: 6.0, Philadelphia: 7.5, San Juan: 5.5 Chicago: 100% Black; Los Angeles: 70% Hispanic, 22% Black, 8% other; New York: 91% Hispanic, 9% Black; Philadelphia: 85% Black, 11% Hispanic, 4% other; San Juan: 100% Hispanic Merck Childhood Asthma Network (MCAN) Care Coordination Programs for medically underserved, low-income communities: Los Angeles Unified School District Asthma Program, Community Asthma Prevention Program of Children’s Hospital of Philadelphia and Child Asthma Link Line, La Red de Asma Infantil, Addressing Asthma in Englewood Project, and Washington Heights and Inwood Network for Asthma CHWs or nurse led care coordination model which incorporates culturally competent asthma education, home environmental trigger reduction, healthcare system facilitation, social service referrals, and social support. Implementation varied for each site. Asthma-related ED visits, hospitalizations, and missed school days ED visits decreased by 36% to 63% and hospitalizations declined by 26% to 78% across each intervention site (P = .01). Also 78% to 89% of children had a reduction in missed school days (P = .01). 
Janevic et al 201645  Pre and post intervention Chicago, Illinois; Los Angeles, California; Philadelphia, Pennsylvania; San Juan, Puerto Rico 805 children: Chicago: 134, Los Angeles: 232, Philadelphia: 254, San Juan: 185 18 and younger 50.4% Black, 42.1% Hispanic, 1.7% White, 5.3% other MCAN Care Coordination Programs, phase II for medically underserved, low-income communities: Los Angeles Unified School District Asthma Program, Children’s Hospital of Philadelphia Asthma Care Navigator Program, La Red de Asma Infantil, and Addressing Asthma in Englewood Project Medical-social care model which utilizes asthma care coordinators to deliver culturally relevant asthma education, connect families with health and social services, and facilitate communication between families and physicians. Asthma care coordinators are nurses, CHWs, or health educators. Implementation varied for each site. Asthma-related ED visits and hospitalizations The RR of having 1 or more ED visits were 0.63 (95% CI: 0.45 to 0.89), taking into account a baseline of at least 1 ED visit. The RR of having 1 or more hospitalizations was 0.69 (95% CI: 0.47 to 1.01), considering a baseline of at least 1 hospitalization. 
 Lara et al 201346  Pre and post intervention San Juan, Puerto Rico 117 children Under 18 100% Hispanic La Red de Asma Infantil clinic and home-based intervention in 2 housing projects Adaptation of Yes We Can and Inner-City Asthma Study interventions involving home assessment, “Safe Sleeping Zone module” visit, home-based education, and CHW home visits. Led by multidisciplinary team of physician, community nurse or coordinator, and CHWs. Asthma-related ED visits, hospitalizations, and cost-benefit analysis There was a >60% decrease in preventable hospitalizations from 35.9% to 13.7% (P <.001) after implementation of the intervention. There was about 50% decrease in preventable ED visits from 82.1% to 45.3% (P <.001). The average simulated costs for ED visits and hospitalizations were reduced by $5913 (SD: $1888), which is a 45% decrease. 
 Mansfield et al 201147  Pre and post intervention Chicago, Illinois; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; San Juan, Puerta Rico 724 children: Chicago: 176, Los Angeles: 201, New York: 68, Philadelphia: 161, San Juan: 118 19 and younger 50% Black, 44% Hispanic, 2% White, 1% other MCAN Care Coordination Programs Phase I, for medically underserved, low-income communities Care coordination model which encompasses asthma management education, dissemination of asthma awareness in the community, physician education, and school management to improve asthma outcomes. Implementation varied for each site. Asthma-related ED visits, hospitalizations, and missed school days The amount of average ED visits reduced from 1.90 (SD = 2.96) to 0.80 (SD = 1.80). Average hospitalizations decreased from 0.48 (SD = 1.23) to 0.28 (SD = 1.18). The average of missed school days decreased from 7.31 (SD = 9.41) to 3.16 (SD = 6.80). All findings are significant (P ≤.01). 
 Peretz et al 201248  Pre and post intervention New York, New York 472 families Child age range unspecified Race not specified Washington Heights and Inwood Network for Asthma Program serving low-income communities Community, academic, and hospital partnership for care coordination where CHWs provide culturally appropriate comprehensive asthma management education and support to families, including home environmental assessments, trigger reduction strategies, and clinical and social referrals. Asthma-related ED visits, hospitalizations, and missed school days Children who received the intervention had a 63% decrease in overnight hospital visits, 52% decrease in ED visits, and a 42% decrease in missed school days. All findings were statistically significant (P <.001). 
 Woods et al 201249  Pre and post intervention Boston, Massachusetts 283 children 2–18 52.3% Hispanic, 39.6% Black, 8.1% Other Community Asthma Initiative (CAI) for low-income communities CAI is governed by a community and family advisory board and is a combination of (1) nurse case management and care coordination; (2) nurse supervised CHW home visits for asthma education, environmental assessments, and remediation; and (3) referrals to an Integrated Pest Management exterminator or Inspectional Service. Asthma-related ED visits, hospitalizations, missed school, and caregiver workdays, and cost-benefit analysis There were reductions in hospitalizations (84.8%), ≥1 ED visits (68.0%), missed caregiver workdays (49.7%), and missed school days (41.0%). All statistics were significant (P <.0001). In a separate analysis of the CAI intervention (N = 102) and a demographically similar comparison group (N = 559), there were significant reductions in emergency healthcare costs (P <.0001) and a return on investment of 1.46. 
Policy and environmental changes affecting communities 
 Croghan et al 201550  Retrospective cohort study Olmsted County, Minnesota 1531 children Under 18 Race not specified Smoke-free legislation Smoke-free law enacted on October 1, 2007, covering all workplaces, including bars and restaurants. Asthma-related ED visits Children experienced a decline in ED visits for asthma after implementation of the smoke-free legislation (RR = 0.751; 95% CI: 0.595 to 0.947; P = .015). The increasing trend in ED visits which was present before the implementation of the smoke-free law was no longer present after it was enacted. 
 Gaudreau et al 201351  Ecological observational time series study Prince Edward Island, Canada Child sample size not specified Under 15 Race not specified Smoke-free legislation Smoke-free law enacted on June 1, 2003, banning smoking in all public places and workplaces with additional amendments for smoking on school grounds. Asthma-related hospitalizations No significant changes were found in hospital admission rates for respiratory diseases, including childhood asthma after the smoking ban. There was a non-significant change of 1.11 in mean monthly admission rates (95% CI: 0.63 to 1.95; P = .71) for child asthma. 
 Landers 201652  Pre and post, non-equivalent control group design Multiple counties, United States Child sample size not specified Child age not specified Race not specified Smoke-free legislation County level smoke-free laws across 12 states. Laws were enacted between 2003 and 2008. Asthma-related hospital discharges County smoke free laws had a statistically significant reduction in childhood asthma hospital discharges (b = −1.32; P <.05). 
 Lantz et al 201853  Pre and post intervention Detroit, Michigan 126 982 children split into 3 groups based on asthma severity (1) children with asthma, (2) asthma ED visit in past year, and (3) asthma hospitalization last year Under 18 Race not specified “Pay for Success” financing multicomponent home-based demonstration project in a Medicaid population A home assessment, followed by moderate remediation for environmental triggers, home-based education, and case management with a trained professional to improve asthma. Asthma-related ED visits, hospitalizations, and cost-benefit analysis For Groups 1 and 2, a decrease in ED visits from 5153 to 1334 and in hospital admissions from 609 to 153 is expected with the intervention. For group 3, there is expected to be a drop from 719 to 186 ED visits, and 609 to 153 hospital admissions with the intervention. Possible significant savings for group 2 are $1.4 million for the federal Medicaid and $634 000 for the state Medicaid programs. For group 3, potential significant savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid are expected. 
 Lopez et al 201554  Pre and post intervention East Harlem, New York 60 children Under 18 51.7% Black, 36.7% Hispanic, 6.7% Multiracial, 5.0% Unreported Controlling Asthma through Home Remediation (CAHR), a program of LSA Family Health Service for children living in public housing CAHR provides CHW-led comprehensive case management, housing assessment and remediation, asthma education, and advocacy to improve building conditions from the Housing Authority. Asthma-related ED visits, urgent care visits, and hospitalizations Average ED or urgent care visits decreased from 2.98 (SD = 4.39) to 1.18 (SD = 1.72) P = .001. Average hospitalizations were reduced from 0.42 (SD = 0.89) to 0.15 (SD = 0.44) P = .004. 
 Norton and Brown 201455  Pre and post intervention Baltimore, Maryland 139 children 2–14 93.4% Black, 5.8% White, 0.8% American, Indian and Alaskan Native Green and Healthy Homes Initiative for low-income communities Home asthma education combined with environmental control practices taken from healthy homes, weatherization, energy efficiency, and lead hazard reduction projects. Asthma-related ED visits, hospitalizations, doctor visits, and missed school and caregiver workdays Intervention participants had a 65.5% reduction in hospitalizations and a 27.7% reduction in ED visits. The mean difference in hospitalizations postintervention was 0.239 (SD = 0.824), and the mean difference in ED visits was 0.261 (SD = 1.250). There was also a 37% reduction in missed caregiver workdays, 27% reduction in missed school days, 26% reduction in doctor calls, and 22% reduction in doctor visits. All findings were statistically significant (P <.02). 
 Peel et al 201056  Interrupted time-series study Atlanta, Georgia 9044 children 18 and younger 55.2% White, 36.3% Black, 6.0% other, 2.5% Hispanic Traffic reduction campaign during the 1996 Olympic Games Promotion of public transportation, increased availability of public transportation, promotion of alternative work hours and telecommuting to reduce traffic. Asthma-related ED visits, traffic counts, and ambient air pollution There were no significant reductions observed in ED visits for childhood asthma patients (RR = 0.953; 95% CI: 0.650 to 1.399). Morning traffic count was reduced by up to 20%. Eight-hour maximum ozone concentrations and 1-h maximum CO concentrations were reduced by 30%. One-hour maximum NO2, and the average 24-h PM10 concentrations had non-significant reductions ranging from 5% to 17%. 
 Sajjadi and Bridgman 201157  Interrupted time-series study Lower Hunter Region, Australia Child sample size not specified 14 and younger Race not specified Closure of large local steel works industry, Broken Hill Proprietary (BHP) Closure of BHP, the principal source of particulate matter and other air pollutants in the area. Asthma-related hospitalizations The hospital admission rate for children in the Lower Hunter Region with asthma decreased 30.3% after the closing of BHP, from 1.795 to 1.252 (P = .004). 
Home-based interventions in communities 
 Breysse et al 201458  Quasi-experimental study King County, Washington 34 families with the intervention and 68 families from a historical comparison group 3–17 Intervention group: 47% Hispanic, 18% Black, 21% Vietnamese, 6% Other Asian, Pacific Islander, 6% White, 3% other or unreported; comparison group: 46% Hispanic, 16% Black, 12% Vietnamese, 10% Other Asian Pacific Islander, 9% White, 7% other or unreported Highline Communities Healthy Homes Project in low-income communities Community health worker (CHW) home education program with the addition of weatherization-plus-health interventions for low-income communities. Asthma-related urgent clinical care (ED visit, hospitalization, or unscheduled clinic visit) Children in the intervention group had larger reductions in asthma outcomes when compared with the historical comparison group. There was a 31.7% reduction in average urgent clinical care in the past year among the intervention group (CI: −47.8 to −15.5; P = .01) and a 23.6% reduction in the comparison group (CI: −36.5 to −10.7; P = .003). However, these findings were not statistically significant across study groups. 
 Campbell et al 201559  Randomized parallel group trial King County, Washington 182 with the intervention and 191 in the control group 3–17 62.2% Hispanic, 15.3% Black, 8.8% White, 5.4% multiracial, 4.8% Asian and Pacific Islander, 3.5% other Healthy Homes program for Medicaid population CHW home visit program with asthma education, support, service coordination, self-management practices, home environmental assessment, and cleaning supplies. The control group received usual care including asthma education and resources. Asthma-related urgent healthcare utilization (ED visits, hospitalizations, unscheduled clinic visits) and cost-benefit analysis Among the intervention group there were 1.31 fewer urgent healthcare utilization events in the past year (CI: −2.10 to −0.52; P = .001) when compared with the control group. Researchers observed a 1.90 return of investment. 
 Largo et al 201160  Pre and post intervention Lansing, Michigan 243 families Under 18 38.7% Black, 27.6% White, 25.9% multiracial, 10.3% Hispanic, 2.1% other, 5.8% unreported Healthy Homes University (HHU) program for low-income communities HHU is a home environmental and asthma education intervention. It includes asthma trigger reduction and injury prevention education, as well as products and services to reduce exposure for asthma triggers. Asthma-related ED visits, hospitalizations, unscheduled doctor’s visits, and missed school days There was a 68% decrease for hospitalizations, 53% reduction for ED visits, and 48% decrease for unscheduled visits to a healthcare provider after 6 mo. HHU participants also experienced a 71% decline in missed school says. All findings were statistically significant (P <.0001). 
 Mankikar et al 201661  Pre and post intervention Southeastern, Pennsylvania 150 families with 359 children Under 18 67.7% Black, 58.2% Hispanic, 20.8% White, 6.9% other, 1.5% multiracial, 1.5% Pacific Islander, 0.8% Asian, 0.8% Native American Southeastern Pennsylvania Lead and Healthy Homes Program (SPLHHP) for low-income communities SPLHHP incorporates CHW, environmental health professional, or nurse-led healthy home assessment, home environmental hazard exposure education, asthma prevention and management education, healthy homes supplies, and referrals. Asthma-related ED visits, hospitalizations, and doctor visits After participating in SPLHHP, participants experienced statistically significant decreases in 3-mo rate hospitalizations (Z = −4.639, P <.001), doctor visits (Z = −2.579, P = .010), and a non-significant reduction in ED visits (Z = −1.777, P = .076). 
 Sweet et al 201362  Pre and post intervention Columbus, Ohio 115 children Under 18 71.8% Black, 16.7% White, 6.4% other, 5.1% Hispanic Healthy Homes intervention for low-income communities Public health nurse, health educator, and registered sanitarian provide home-based asthma education; home assessment of asthma triggers and safety hazards; cleaning supplies; and physical home interventions such as mold abatement, ventilation repair, and pest control. Asthma-related ED visits, hospitalizations, and missed school and caregiver workdays Healthy home intervention children experienced significant reductions in ED visits by a mean of 0.67 visits (P <.01) over the past 3 mo. They also had 3.4 fewer missed school days (P <.01) and caregivers had 2.6 fewer missed work days (P = .04) over the past 6 mo. Teductions in hospitalizations from 6.24 (SD = 12.82) to 2.81 (SD = 5.94) over the past 3 mo were not significant (P = .33). 
 Turyk et al 201363  Pre and post intervention Chicago, Illinois 218 children 18 and younger 100% Black Addressing Asthma in Englewood Project, Phase I Community health educator led program which incorporates asthma management education, school screenings, customized low-cost home remediation, provider education, and social and medical referrals Asthma-related ED visits, urgent care visits, hospitalizations, and missed school and caregiver workdays ED visits declined from 46.8% at baseline to 23.9%. Urgent care visits were reduced from 46.1% to 19.4%. Hospitalizations decreased from 15.6% to 4.6%. The amount of missed school days and caregiver workdays also declined. All findings were significant (P <.0001). 
Community-based health services 
 Eakin et al 201164  Randomized controlled trial Baltimore, Maryland 322 children 2–6 97% Black, Breathmobile only, Facilitated Asthma Communication Intervention (FACI) only, both Breathmobile plus FACI, or standard care for low-income communities The Breathmobile is a mobile asthma clinic that delivers asthma screening, evaluation, and treatment services to children at their schools. FACI is a home-based program for asthma education and increased patient-provider communication. Asthma-related ED visits and hospitalizations There was an increase of 0.61 among the FACI only group in the mean number of ED visits at 6 mo (P = .01). There was a non-significant 83% decrease in mean hospitalizations at 6 mo for the Breathmobile plus FACI group (P = .08). However, none of these trends were maintained after 1 y of follow up. 
 Martin et al 202165  Randomized comparative effectiveness trial Cook County, Illinois 223 children 5–16 85.2% Hispanic, 28.4% White, 17.6% Black Asthma Action at Erie Trial with CHW home visits or certified asthma educator (AE-C) clinical sessions for low-income communities CHWs and AE-Cs share the same asthma self-management education, support, and action plans. CHWs and AE-Cs do not provide home environmental remediation equipment. Asthma-related ED visits, urgent care visits, and hospitalizations ED visits or hospitalizations were lower in the CHW group compared with the AE-C group at 24 mo (OR = 0.35; 95% CI: 0.14 to 0.88). The odds for urgent care visits were also lower for the CHW group (OR = 0.52; 95% CI: 0.27 to 1.01). 
 Morphew and Galant 201966  Retrospective cohort study Orange County, California 1204 children split into 4 groups (normal BMI, overweight, obese, morbidly obese) 3–18 90.3% Hispanic Children’s Hospital of Orange County Children’s Breathmobile Program in underserved areas with low-income Community-based mobile asthma clinic used to deliver culturally compatible clinical care to children in their communities and maintain continuity with care providers. Asthma-related ED visits, hospitalizations, and missed school days About 80% of children with moderate to severe asthma, and across all BMI categories, attained well-controlled asthma in 3 mo. All BMI categories saw reductions in ED visits and hospitalizations (P <.001). The likelihood that a patient would need an ED visit was reduced by 50% to 60%. The probability that a child would need to be hospitalized was reduced by at least 68%, with higher rates of reduction for children with normal BMI (81.2%). The number of missed school days decreased from a mean of 5 d to 1 per year across BMI categories (P <.001). 
 Naar et al 201867  Randomized controlled trial (location not specified) USA 167 children 12–16 100% Black Multisystemic Therapy–Health Care (MST-HC) or in-home family support program for Black adolescents MST-HC is a home and community-based treatment which uses cognitive behavioral therapy to address barriers for poor self-management of asthma. MST-HC includes skills training, behavioral therapy, family therapy, patient-provider communication training, and school communication training. Delivery of service is at home, school, doctor’s office, or community center. The family support group is a home customized family counseling program. Asthma-related ED visits and hospitalizations The MST-HC group had fewer hospitalizations compared with the family support comparison group (b = −0.882; P = .04; IRR = 0.414; 95% CI: 0.175 to 0.978). ED visit reductions from the MST-HC group had no difference compared with the family support group (b = −0.126; P = .63). ED visits in the MST-HC group decreased from 1.15 to 0.83, and ED visits in the family support group decreased from 1.19 to 0.87. 
CitationStudy DesignStudy LocationSample SizeAge, yRace and EthnicityExposureIntervention DescriptionOutcomeKey Findings
Care coordination in communities 
 Clark et al 201342  Retrospective cohort study Multiple cities 12 361 children with the intervention and 14 475 children in the comparison group 2–18 63% Black, 17% Hispanic, and 11% White Allies Against Asthma community coalitions in low-income communities Improvements in care coordination and standardization of clinical care, home environmental conditions, and increased opportunities for families to learn asthma management techniques. Specific strategies used varied in response to the features of the community in which it was being implemented. Asthma-related ED visits, urgent care visits, and hospitalizations At any point during the study period, the hazard for an ED visit, urgent care visit, or hospitalization was 7% (P <.02) greater for children in the non-allies communities compared with those with no enrollment gap in the intervention communities. 
 Coughey et al 201043  Quasi-experimental study Philadelphia, Pennsylvania 59 children with a matched sample of 236 children 3–12 84.4% Black, 6.7% Hispanic, 6.7% White, and 2.2% other or refused Child Asthma Link Line (CALL) Telephone-based program which provided asthma education to childhood asthma caregivers and linked them with other community-based medical, educational, and social services based on responses to an intake assessment. Asthma-related ED visits, hospitalizations, and doctor visits CALL group was significantly less likely to have a follow-up hospitalization than the matched sample group, with a CMH statistic of 5.38 (P = .02), and significantly more likely to have a doctor visit than the matched sample group, with a CMH statistic of 4.01 (P = .045). There was a significant difference between CALL participants with ≥2 ED visits at baseline and the likelihood for a follow-up ED visit (33.3%) compared with the matched sample (62.1%) (CMH = 4.00, P = .046). 
 Findley et al 201144  Pre and post intervention Chicago, Illinois; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; San Juan, Puerto Rico 724 children: Chicago: 176, Los Angeles: 201, New York: 68, Philadelphia: 161, San Juan: 118 Average: Chicago: 8.2, Los Angeles: 9.8, New York: 6.0, Philadelphia: 7.5, San Juan: 5.5 Chicago: 100% Black; Los Angeles: 70% Hispanic, 22% Black, 8% other; New York: 91% Hispanic, 9% Black; Philadelphia: 85% Black, 11% Hispanic, 4% other; San Juan: 100% Hispanic Merck Childhood Asthma Network (MCAN) Care Coordination Programs for medically underserved, low-income communities: Los Angeles Unified School District Asthma Program, Community Asthma Prevention Program of Children’s Hospital of Philadelphia and Child Asthma Link Line, La Red de Asma Infantil, Addressing Asthma in Englewood Project, and Washington Heights and Inwood Network for Asthma CHWs or nurse led care coordination model which incorporates culturally competent asthma education, home environmental trigger reduction, healthcare system facilitation, social service referrals, and social support. Implementation varied for each site. Asthma-related ED visits, hospitalizations, and missed school days ED visits decreased by 36% to 63% and hospitalizations declined by 26% to 78% across each intervention site (P = .01). Also 78% to 89% of children had a reduction in missed school days (P = .01). 
Janevic et al 201645  Pre and post intervention Chicago, Illinois; Los Angeles, California; Philadelphia, Pennsylvania; San Juan, Puerto Rico 805 children: Chicago: 134, Los Angeles: 232, Philadelphia: 254, San Juan: 185 18 and younger 50.4% Black, 42.1% Hispanic, 1.7% White, 5.3% other MCAN Care Coordination Programs, phase II for medically underserved, low-income communities: Los Angeles Unified School District Asthma Program, Children’s Hospital of Philadelphia Asthma Care Navigator Program, La Red de Asma Infantil, and Addressing Asthma in Englewood Project Medical-social care model which utilizes asthma care coordinators to deliver culturally relevant asthma education, connect families with health and social services, and facilitate communication between families and physicians. Asthma care coordinators are nurses, CHWs, or health educators. Implementation varied for each site. Asthma-related ED visits and hospitalizations The RR of having 1 or more ED visits were 0.63 (95% CI: 0.45 to 0.89), taking into account a baseline of at least 1 ED visit. The RR of having 1 or more hospitalizations was 0.69 (95% CI: 0.47 to 1.01), considering a baseline of at least 1 hospitalization. 
 Lara et al 201346  Pre and post intervention San Juan, Puerto Rico 117 children Under 18 100% Hispanic La Red de Asma Infantil clinic and home-based intervention in 2 housing projects Adaptation of Yes We Can and Inner-City Asthma Study interventions involving home assessment, “Safe Sleeping Zone module” visit, home-based education, and CHW home visits. Led by multidisciplinary team of physician, community nurse or coordinator, and CHWs. Asthma-related ED visits, hospitalizations, and cost-benefit analysis There was a >60% decrease in preventable hospitalizations from 35.9% to 13.7% (P <.001) after implementation of the intervention. There was about 50% decrease in preventable ED visits from 82.1% to 45.3% (P <.001). The average simulated costs for ED visits and hospitalizations were reduced by $5913 (SD: $1888), which is a 45% decrease. 
 Mansfield et al 201147  Pre and post intervention Chicago, Illinois; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; San Juan, Puerta Rico 724 children: Chicago: 176, Los Angeles: 201, New York: 68, Philadelphia: 161, San Juan: 118 19 and younger 50% Black, 44% Hispanic, 2% White, 1% other MCAN Care Coordination Programs Phase I, for medically underserved, low-income communities Care coordination model which encompasses asthma management education, dissemination of asthma awareness in the community, physician education, and school management to improve asthma outcomes. Implementation varied for each site. Asthma-related ED visits, hospitalizations, and missed school days The amount of average ED visits reduced from 1.90 (SD = 2.96) to 0.80 (SD = 1.80). Average hospitalizations decreased from 0.48 (SD = 1.23) to 0.28 (SD = 1.18). The average of missed school days decreased from 7.31 (SD = 9.41) to 3.16 (SD = 6.80). All findings are significant (P ≤.01). 
 Peretz et al 201248  Pre and post intervention New York, New York 472 families Child age range unspecified Race not specified Washington Heights and Inwood Network for Asthma Program serving low-income communities Community, academic, and hospital partnership for care coordination where CHWs provide culturally appropriate comprehensive asthma management education and support to families, including home environmental assessments, trigger reduction strategies, and clinical and social referrals. Asthma-related ED visits, hospitalizations, and missed school days Children who received the intervention had a 63% decrease in overnight hospital visits, 52% decrease in ED visits, and a 42% decrease in missed school days. All findings were statistically significant (P <.001). 
 Woods et al 201249  Pre and post intervention Boston, Massachusetts 283 children 2–18 52.3% Hispanic, 39.6% Black, 8.1% Other Community Asthma Initiative (CAI) for low-income communities CAI is governed by a community and family advisory board and is a combination of (1) nurse case management and care coordination; (2) nurse supervised CHW home visits for asthma education, environmental assessments, and remediation; and (3) referrals to an Integrated Pest Management exterminator or Inspectional Service. Asthma-related ED visits, hospitalizations, missed school, and caregiver workdays, and cost-benefit analysis There were reductions in hospitalizations (84.8%), ≥1 ED visits (68.0%), missed caregiver workdays (49.7%), and missed school days (41.0%). All statistics were significant (P <.0001). In a separate analysis of the CAI intervention (N = 102) and a demographically similar comparison group (N = 559), there were significant reductions in emergency healthcare costs (P <.0001) and a return on investment of 1.46. 
Policy and environmental changes affecting communities 
 Croghan et al 201550  Retrospective cohort study Olmsted County, Minnesota 1531 children Under 18 Race not specified Smoke-free legislation Smoke-free law enacted on October 1, 2007, covering all workplaces, including bars and restaurants. Asthma-related ED visits Children experienced a decline in ED visits for asthma after implementation of the smoke-free legislation (RR = 0.751; 95% CI: 0.595 to 0.947; P = .015). The increasing trend in ED visits which was present before the implementation of the smoke-free law was no longer present after it was enacted. 
 Gaudreau et al 201351  Ecological observational time series study Prince Edward Island, Canada Child sample size not specified Under 15 Race not specified Smoke-free legislation Smoke-free law enacted on June 1, 2003, banning smoking in all public places and workplaces with additional amendments for smoking on school grounds. Asthma-related hospitalizations No significant changes were found in hospital admission rates for respiratory diseases, including childhood asthma after the smoking ban. There was a non-significant change of 1.11 in mean monthly admission rates (95% CI: 0.63 to 1.95; P = .71) for child asthma. 
 Landers 201652  Pre and post, non-equivalent control group design Multiple counties, United States Child sample size not specified Child age not specified Race not specified Smoke-free legislation County level smoke-free laws across 12 states. Laws were enacted between 2003 and 2008. Asthma-related hospital discharges County smoke free laws had a statistically significant reduction in childhood asthma hospital discharges (b = −1.32; P <.05). 
 Lantz et al 201853  Pre and post intervention Detroit, Michigan 126 982 children split into 3 groups based on asthma severity (1) children with asthma, (2) asthma ED visit in past year, and (3) asthma hospitalization last year Under 18 Race not specified “Pay for Success” financing multicomponent home-based demonstration project in a Medicaid population A home assessment, followed by moderate remediation for environmental triggers, home-based education, and case management with a trained professional to improve asthma. Asthma-related ED visits, hospitalizations, and cost-benefit analysis For Groups 1 and 2, a decrease in ED visits from 5153 to 1334 and in hospital admissions from 609 to 153 is expected with the intervention. For group 3, there is expected to be a drop from 719 to 186 ED visits, and 609 to 153 hospital admissions with the intervention. Possible significant savings for group 2 are $1.4 million for the federal Medicaid and $634 000 for the state Medicaid programs. For group 3, potential significant savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid are expected. 
 Lopez et al 201554  Pre and post intervention East Harlem, New York 60 children Under 18 51.7% Black, 36.7% Hispanic, 6.7% Multiracial, 5.0% Unreported Controlling Asthma through Home Remediation (CAHR), a program of LSA Family Health Service for children living in public housing CAHR provides CHW-led comprehensive case management, housing assessment and remediation, asthma education, and advocacy to improve building conditions from the Housing Authority. Asthma-related ED visits, urgent care visits, and hospitalizations Average ED or urgent care visits decreased from 2.98 (SD = 4.39) to 1.18 (SD = 1.72) P = .001. Average hospitalizations were reduced from 0.42 (SD = 0.89) to 0.15 (SD = 0.44) P = .004. 
 Norton and Brown 201455  Pre and post intervention Baltimore, Maryland 139 children 2–14 93.4% Black, 5.8% White, 0.8% American, Indian and Alaskan Native Green and Healthy Homes Initiative for low-income communities Home asthma education combined with environmental control practices taken from healthy homes, weatherization, energy efficiency, and lead hazard reduction projects. Asthma-related ED visits, hospitalizations, doctor visits, and missed school and caregiver workdays Intervention participants had a 65.5% reduction in hospitalizations and a 27.7% reduction in ED visits. The mean difference in hospitalizations postintervention was 0.239 (SD = 0.824), and the mean difference in ED visits was 0.261 (SD = 1.250). There was also a 37% reduction in missed caregiver workdays, 27% reduction in missed school days, 26% reduction in doctor calls, and 22% reduction in doctor visits. All findings were statistically significant (P <.02). 
 Peel et al 201056  Interrupted time-series study Atlanta, Georgia 9044 children 18 and younger 55.2% White, 36.3% Black, 6.0% other, 2.5% Hispanic Traffic reduction campaign during the 1996 Olympic Games Promotion of public transportation, increased availability of public transportation, promotion of alternative work hours and telecommuting to reduce traffic. Asthma-related ED visits, traffic counts, and ambient air pollution There were no significant reductions observed in ED visits for childhood asthma patients (RR = 0.953; 95% CI: 0.650 to 1.399). Morning traffic count was reduced by up to 20%. Eight-hour maximum ozone concentrations and 1-h maximum CO concentrations were reduced by 30%. One-hour maximum NO2, and the average 24-h PM10 concentrations had non-significant reductions ranging from 5% to 17%. 
 Sajjadi and Bridgman 201157  Interrupted time-series study Lower Hunter Region, Australia Child sample size not specified 14 and younger Race not specified Closure of large local steel works industry, Broken Hill Proprietary (BHP) Closure of BHP, the principal source of particulate matter and other air pollutants in the area. Asthma-related hospitalizations The hospital admission rate for children in the Lower Hunter Region with asthma decreased 30.3% after the closing of BHP, from 1.795 to 1.252 (P = .004). 
Home-based interventions in communities 
 Breysse et al 201458  Quasi-experimental study King County, Washington 34 families with the intervention and 68 families from a historical comparison group 3–17 Intervention group: 47% Hispanic, 18% Black, 21% Vietnamese, 6% Other Asian, Pacific Islander, 6% White, 3% other or unreported; comparison group: 46% Hispanic, 16% Black, 12% Vietnamese, 10% Other Asian Pacific Islander, 9% White, 7% other or unreported Highline Communities Healthy Homes Project in low-income communities Community health worker (CHW) home education program with the addition of weatherization-plus-health interventions for low-income communities. Asthma-related urgent clinical care (ED visit, hospitalization, or unscheduled clinic visit) Children in the intervention group had larger reductions in asthma outcomes when compared with the historical comparison group. There was a 31.7% reduction in average urgent clinical care in the past year among the intervention group (CI: −47.8 to −15.5; P = .01) and a 23.6% reduction in the comparison group (CI: −36.5 to −10.7; P = .003). However, these findings were not statistically significant across study groups. 
 Campbell et al 201559  Randomized parallel group trial King County, Washington 182 with the intervention and 191 in the control group 3–17 62.2% Hispanic, 15.3% Black, 8.8% White, 5.4% multiracial, 4.8% Asian and Pacific Islander, 3.5% other Healthy Homes program for Medicaid population CHW home visit program with asthma education, support, service coordination, self-management practices, home environmental assessment, and cleaning supplies. The control group received usual care including asthma education and resources. Asthma-related urgent healthcare utilization (ED visits, hospitalizations, unscheduled clinic visits) and cost-benefit analysis Among the intervention group there were 1.31 fewer urgent healthcare utilization events in the past year (CI: −2.10 to −0.52; P = .001) when compared with the control group. Researchers observed a 1.90 return of investment. 
 Largo et al 201160  Pre and post intervention Lansing, Michigan 243 families Under 18 38.7% Black, 27.6% White, 25.9% multiracial, 10.3% Hispanic, 2.1% other, 5.8% unreported Healthy Homes University (HHU) program for low-income communities HHU is a home environmental and asthma education intervention. It includes asthma trigger reduction and injury prevention education, as well as products and services to reduce exposure for asthma triggers. Asthma-related ED visits, hospitalizations, unscheduled doctor’s visits, and missed school days There was a 68% decrease for hospitalizations, 53% reduction for ED visits, and 48% decrease for unscheduled visits to a healthcare provider after 6 mo. HHU participants also experienced a 71% decline in missed school says. All findings were statistically significant (P <.0001). 
 Mankikar et al 201661  Pre and post intervention Southeastern, Pennsylvania 150 families with 359 children Under 18 67.7% Black, 58.2% Hispanic, 20.8% White, 6.9% other, 1.5% multiracial, 1.5% Pacific Islander, 0.8% Asian, 0.8% Native American Southeastern Pennsylvania Lead and Healthy Homes Program (SPLHHP) for low-income communities SPLHHP incorporates CHW, environmental health professional, or nurse-led healthy home assessment, home environmental hazard exposure education, asthma prevention and management education, healthy homes supplies, and referrals. Asthma-related ED visits, hospitalizations, and doctor visits After participating in SPLHHP, participants experienced statistically significant decreases in 3-mo rate hospitalizations (Z = −4.639, P <.001), doctor visits (Z = −2.579, P = .010), and a non-significant reduction in ED visits (Z = −1.777, P = .076). 
 Sweet et al 201362  Pre and post intervention Columbus, Ohio 115 children Under 18 71.8% Black, 16.7% White, 6.4% other, 5.1% Hispanic Healthy Homes intervention for low-income communities Public health nurse, health educator, and registered sanitarian provide home-based asthma education; home assessment of asthma triggers and safety hazards; cleaning supplies; and physical home interventions such as mold abatement, ventilation repair, and pest control. Asthma-related ED visits, hospitalizations, and missed school and caregiver workdays Healthy home intervention children experienced significant reductions in ED visits by a mean of 0.67 visits (P <.01) over the past 3 mo. They also had 3.4 fewer missed school days (P <.01) and caregivers had 2.6 fewer missed work days (P = .04) over the past 6 mo. Teductions in hospitalizations from 6.24 (SD = 12.82) to 2.81 (SD = 5.94) over the past 3 mo were not significant (P = .33). 
 Turyk et al 201363  Pre and post intervention Chicago, Illinois 218 children 18 and younger 100% Black Addressing Asthma in Englewood Project, Phase I Community health educator led program which incorporates asthma management education, school screenings, customized low-cost home remediation, provider education, and social and medical referrals Asthma-related ED visits, urgent care visits, hospitalizations, and missed school and caregiver workdays ED visits declined from 46.8% at baseline to 23.9%. Urgent care visits were reduced from 46.1% to 19.4%. Hospitalizations decreased from 15.6% to 4.6%. The amount of missed school days and caregiver workdays also declined. All findings were significant (P <.0001). 
Community-based health services 
 Eakin et al 201164  Randomized controlled trial Baltimore, Maryland 322 children 2–6 97% Black, Breathmobile only, Facilitated Asthma Communication Intervention (FACI) only, both Breathmobile plus FACI, or standard care for low-income communities The Breathmobile is a mobile asthma clinic that delivers asthma screening, evaluation, and treatment services to children at their schools. FACI is a home-based program for asthma education and increased patient-provider communication. Asthma-related ED visits and hospitalizations There was an increase of 0.61 among the FACI only group in the mean number of ED visits at 6 mo (P = .01). There was a non-significant 83% decrease in mean hospitalizations at 6 mo for the Breathmobile plus FACI group (P = .08). However, none of these trends were maintained after 1 y of follow up. 
 Martin et al 202165  Randomized comparative effectiveness trial Cook County, Illinois 223 children 5–16 85.2% Hispanic, 28.4% White, 17.6% Black Asthma Action at Erie Trial with CHW home visits or certified asthma educator (AE-C) clinical sessions for low-income communities CHWs and AE-Cs share the same asthma self-management education, support, and action plans. CHWs and AE-Cs do not provide home environmental remediation equipment. Asthma-related ED visits, urgent care visits, and hospitalizations ED visits or hospitalizations were lower in the CHW group compared with the AE-C group at 24 mo (OR = 0.35; 95% CI: 0.14 to 0.88). The odds for urgent care visits were also lower for the CHW group (OR = 0.52; 95% CI: 0.27 to 1.01). 
 Morphew and Galant 201966  Retrospective cohort study Orange County, California 1204 children split into 4 groups (normal BMI, overweight, obese, morbidly obese) 3–18 90.3% Hispanic Children’s Hospital of Orange County Children’s Breathmobile Program in underserved areas with low-income Community-based mobile asthma clinic used to deliver culturally compatible clinical care to children in their communities and maintain continuity with care providers. Asthma-related ED visits, hospitalizations, and missed school days About 80% of children with moderate to severe asthma, and across all BMI categories, attained well-controlled asthma in 3 mo. All BMI categories saw reductions in ED visits and hospitalizations (P <.001). The likelihood that a patient would need an ED visit was reduced by 50% to 60%. The probability that a child would need to be hospitalized was reduced by at least 68%, with higher rates of reduction for children with normal BMI (81.2%). The number of missed school days decreased from a mean of 5 d to 1 per year across BMI categories (P <.001). 
 Naar et al 201867  Randomized controlled trial (location not specified) USA 167 children 12–16 100% Black Multisystemic Therapy–Health Care (MST-HC) or in-home family support program for Black adolescents MST-HC is a home and community-based treatment which uses cognitive behavioral therapy to address barriers for poor self-management of asthma. MST-HC includes skills training, behavioral therapy, family therapy, patient-provider communication training, and school communication training. Delivery of service is at home, school, doctor’s office, or community center. The family support group is a home customized family counseling program. Asthma-related ED visits and hospitalizations The MST-HC group had fewer hospitalizations compared with the family support comparison group (b = −0.882; P = .04; IRR = 0.414; 95% CI: 0.175 to 0.978). ED visit reductions from the MST-HC group had no difference compared with the family support group (b = −0.126; P = .63). ED visits in the MST-HC group decreased from 1.15 to 0.83, and ED visits in the family support group decreased from 1.19 to 0.87. 

Abbreviations: BMI, body mass index; CMH, Cochran-Mantel-Haenszel; IRR, incidence rate ratio; NO2, nitrogen dioxide; OR, odds ratio; PM10, particulate matter smaller than 10 µm; SD, standard deviation.

Two authors assessed the eligible studies for risk of bias to describe the quality of the body of evidence. For the randomized controlled trials, we used the Cochrane Risk of Bias tool for randomized trials version 2 and its associated version for cluster randomized trials.40  The Cochrane Risk of Bias tool for randomized trials version 2 examines 5 domains of bias: (1a) bias arising from the randomization process, (1b) bias arising from the timing of identification or recruitment of participants, (2) bias caused by deviations from the intended interventions, (3) bias caused by missing outcome data, (4) bias in measurement of the outcome, and (5) bias in selection of the reported result.40  Individual domains and an overall score were graded with low, some concerns, or high risk of bias. For the remaining non-randomized controlled trials, we used the Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I).41  This tool included 7 domains of bias: (1) bias caused by confounding, (2) bias in selection of participants into the study, (3) bias in classification of interventions, (4) bias caused by deviations from intended interventions, (5) bias caused by missing data, (6) bias in measurement of outcomes, and (7) bias in selection of the reported result.41  Domain and overall scores for the ROBINS-I yielded low, moderate, critical, serious, or missing or unclear risk of bias.

We identified 1816 records and an additional 40 records from hand searched reference sections. We reviewed 74 records for full text review and 48 were removed. We identified 26 records that met our inclusion criteria for the final report (Fig 1). Because of the heterogeneous nature of the identified community interventions from eligible studies, a meta-analysis could not be performed.

FIGURE 1

Literature search results on community interventions for reducing childhood asthma ED visits and hospitalizations. Publications from PubMed, ScienceDirect, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science, and hand searched references from 2010 to 2021 were examined for childhood asthma community interventions. Out of 1816 records identified, 74 full text records were assessed for eligibility, and 26 publications met the inclusion criteria.

FIGURE 1

Literature search results on community interventions for reducing childhood asthma ED visits and hospitalizations. Publications from PubMed, ScienceDirect, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science, and hand searched references from 2010 to 2021 were examined for childhood asthma community interventions. Out of 1816 records identified, 74 full text records were assessed for eligibility, and 26 publications met the inclusion criteria.

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Community interventions were arranged into 4 categories: (1) care coordination in communities (n = 8),4249  (2) policy and environmental changes affecting communities (n = 8),5057  home-based interventions in communities (n = 6),5863  and community-based health services (n = 4).6467  However, there is some overlap in services as many studies included an aspect of interventions in the home as a core activity. Sources for the main outcomes include electronic health records (n = 4),50,51,57,66  medical claims (n = 5),42,43,52,53,56  and caregiver self-reports (n = 14).44,45,4749,54,55,5861,6264  Three studies used both electronic health records and self-reports.46,65,67  Community interventions were held in majority Black and Hispanic populations for 19 out of the 20 publications that reported racial demographics.4247,49,54,55,5867  There was 1 study conducted in Canada51  and 1 in Australia.57  The remaining were across all 4 regions of the United States, including Puerto Rico.

Eight studies investigated the relationship between care coordination and reduction of emergency healthcare utilization.4249  Seven care coordination models significantly reduced both ED visits and hospitalizations.4244,4649  Five care coordination studies were affiliated with the Merck Childhood Asthma Network (MCAN),4448  a coordination model incorporating culturally relevant asthma education, dissemination of asthma awareness in the community, and physician education. MCAN programs employed asthma care coordinators to connect families with health and social services and facilitate communication between families, physicians, and schools. Asthma care coordinators were nurses, CHWs or health educators. According to a cross site evaluation of MCAN programs, ED visits decreased by 36% to 63% and hospitalizations declined by 26% to 78% (P = .01).44  The remaining 3 care coordination studies were the Community Asthma Initiative (CAI),49  Child Asthma Link Line,43  and the Allies Against Asthma community coalitions.42  Care coordination programs engaged community collaboration with healthcare, government, and academic partnerships. Stakeholders included representation from community members, families with asthma, community-based organizations, CHWs, healthcare agencies, clinical practices, Medicaid managed care organizations, academic leaders, and the government.

We found 8 studies related to policy and environmental changes. Three studies assessed the impact of policies focusing on home environmental trigger reduction in low-income communities and illustrated favorable reductions in emergency healthcare utilization.5355  The first study was the Green and Healthy Homes Initiative, an environmental justice project in partnership with the US Department of Energy and Environment. Green and Healthy Homes Initiative was designed to combat the shortage of affordable quality housing in low-income communities. Comprehensive environmental home assessments were performed to improve poor quality housing. Investigators found evidence of a 65.5% reduction in hospitalizations and a 27.7% reduction in ED visits for children with asthma (P <.02).55  The second study was the Controlling Asthma through Home Remediation (CAHR) program. CAHR had a unique relationship with community-based organizations. In addition to reducing emergency healthcare utilization, they successfully advocated for systemic changes in the regulation and enforcement of maintenance and repairs with the New York City Housing Authority.54  Lastly, Lantz and colleagues predicted a Medicaid population of 7619 children with asthma in a United States Midwestern city would avert 1334 annual ED visits and 153 hospital admissions for a potential “Pay for Success” multicomponent environmental home-based demonstration project.53  Potential significant savings for children with an ED visit in the last year are $1.4 million for the federal Medicaid and $634 000 for the state Medicaid programs. For children with a hospitalization in the last year, possible savings of $2.8 million to federal Medicaid and $1.3 million to state Medicaid are expected.53 

Three studies investigated the influence of smoke-free laws including all public places (eg, workplaces, restaurants, and school grounds).5052  There were mixed results on the effect of smoke-free laws on emergency healthcare utilization. Croghan and colleagues discovered a reduction in ED visits (risk ratio [RR] = 0.751, 95% confidence interval [CI]: 0.595 to 0.947, P = .015)50  and Landers found reductions in hospital discharges after the enactment of county smoke-free laws across 12 states (b = −1.32; P <.05).52  Gaudreau and colleagues found no significant changes in hospital admissions after a smoking ban.51  Only 3 studies that assessed the impact of county-level smoke-free laws (or an international equivalent that matched the average size of a US county) met our inclusion criteria. Although there is a wealth of evidence supporting the reductions of asthma hospital admissions, discharges, or ED visits in larger settings, we omitted studies with exclusive statewide or nationwide settings.6871 

There were mixed findings from 2 air pollution reduction strategies.56,57  After the closure of a local steel industry, childhood asthma hospital admissions significantly decreased by 30.3% (P = .004).57  Peel and colleagues investigated a traffic reduction strategy and observed up to a 20% decrease in morning traffic counts. They found a 30% decrease in associated 8-hour maximum ozone concentrations and a 30% reduction in 1-hour maximum carbon monoxide concentrations. Although there were decreased traffic counts and air pollutants, there was no impact on childhood asthma ED visits.56  However, Friedman and colleagues previously studied the same traffic reduction strategy and found 11.1% decrease in daily acute care visits for childhood asthma.72  The differential findings may be attributed to the available data sources.

Six studies focused on the impact of home-based interventions in predominately Black and Hispanic, low-income communities.5863  These studies employed CHWs, environmental health professionals, community nurses, or other health educators for home visit programs to conduct healthy home assessments and identify asthma triggers. They also provided comprehensive asthma education, healthy home supplies, and arranged weatherization, remediation, mold abatement, and pest control. The objective was to reduce exposure to cockroaches, dust mites, mold, and tobacco smoke. Simultaneous implementation of care coordination and home-based interventions resulted in fewer missed daycare or school days44,4749  and missed caregiver workdays.60,62,63  Though there is evidence in the literature to support the impact of home-based interventions,73,74  only half of the home-based interventions resulted in significant decreases to both asthma ED visits and hospitalizations.59,60,63  Most notably in the Healthy Homes University program, there was a 68% decrease for hospitalizations, 53% reduction for ED visits, and 48% decrease for unscheduled visits to a healthcare provider (P <.0001).60 

We found 4 community-based health services interventions. Researchers for 2 studies sought to improve access to healthcare. Both analyzed the impact of Breathmobiles, mobile asthma clinics that deliver asthma screening, evaluation, and treatment services to children and maintained continuity with healthcare providers.64,66  Breathmobiles reduced barriers to healthcare and economic concerns but yielded mixed findings to reduce emergency healthcare utilization. For example, Eakin and colleagues found no significant decline in ED visits for children randomized to a Breathmobile plus home-based program in the inner-city of Baltimore.64  However, Morphew and colleagues found Breathmobile participants in Orange County, California were 50% to 60% less likely to need an ED visit (P <.001) and had 68% reduction in hospitalizations (P <.001). The intervention improved health outcomes among children with asthma and comorbid conditions, including obesity.66 

Two studies investigated the difference in the effectiveness of delivering interventions across various settings.65,67  Martin and colleagues compared the difference between CHW-delivered asthma management, support, and education in the home setting to a certified asthma educator with the same content in a clinical setting. ED visits and hospitalizations were lower in the CHW group, but emergency care visit reductions were not significant.65  Naar and colleagues evaluated cognitive behavioral therapy to address barriers for poor self-management of asthma at any location (eg, home, school, and community center). The effect of this intervention was compared with an in-home family therapy and support model. Participants that received the cognitive behavioral therapy at a setting of their choice had fewer hospitalizations, but they did not experience a significant decline in ED visits.67 

The risk of bias for community interventions ranged from moderate to critical for non randomized studies. Out of 22 non-randomized studies, 16 had serious risk of bias.42,43,47,49,50,5258,63,66  Most of the serious risk is attributed to bias from measurement of outcomes, which is accredited to self-reported outcomes, and bias from confounding. Five studies had a critical risk of bias,45,51,6062  which is also attributed to confounding. Childhood asthma is exacerbated by risk factors difficult to control in statistical analyses (eg, exposure to outdoor air pollutants and seasonal trends). Most investigators did not support their findings by exploring potential confounding exposure to secondhand smoke, seasonality, or change in medication use. The risk of bias ranged from some concerns to high concerns for randomized studies. Three out of 4 randomized controlled trials had a high risk of bias,59,64,65  which is mainly attributed to bias caused by deviations from the intended intervention.64,65  For more details on the risk of bias assessment, see the Supplemental Information.

We identified 26 community intervention publications designed to reduce childhood asthma ED visits or hospitalizations. The majority were in the care coordination (n = 8)4249  and policy and environmental changes domain (n = 8).5057  Both domains have the most promising impact on emergency healthcare utilization. Seven care coordination studies,4244,4649  and 5 policy and environmental change studies were significantly associated with a reduction in both ED visits and hospitalizations.50,52,54,55,57  Our findings provide examples of strategies that may be effective to treat asthma on a community level. Poor environmental conditions, particularly in historically disinvested communities, increase the risk for asthma ED visits and hospitalizations.75  It is well documented that underrepresented minorities, urban residence, and low income are associated with childhood asthma. As with many social and environmental determinants of health, the burden of air pollution and substandard housing falls disproportionately on racial and ethnic minorities.6  Interventions that cover entire communities may be more efficient in reducing asthma ED visits and hospitalizations.

The framework in Fig 2 illustrates a conceptual model of the relationship between community interventions and reductions in childhood asthma ED visits and hospitalizations. The figure displays pathways from community intervention domains to intermediate outcomes affecting caregiver quality of life, home environmental triggers, access to healthcare, and asthma management. There are 3 types of pathways: studies with all significant findings, majority of studies with significant results (at least two-thirds of studies), and studies with mixed significant findings (less than two-thirds of studies) for both outcomes. The conceptual model indicates that care coordination interventions and policy and environmental changes have the most impact on emergency healthcare utilization reduction. All care coordination interventions that measured quality of life (QoL) improved caregiver QoL. There is strong evidence, despite minimal variability, that care coordination programs increased access to healthcare and reduced home environmental triggers. Policies and environmental changes affecting communities were also effective in decreasing outdoor air pollution and home environmental triggers. There is some ambiguity in the home-based interventions domain, although they did increase caregiver QoL. The community-based health services domain also displayed mixed findings and may be an opportunity for further research.

FIGURE 2

Conceptual model of community interventions for reducing childhood asthma ED visits and hospitalizations. Community interventions are separated into 4 domains: community-based health services, care coordination, home-based, and policy and environmental changes. Pathways with dashed arrows signify mixed results or majority significant findings and smooth arrows illustrate significant associations for both emergency department visits and hospitalization reductions. See Table 1. for a full description of study characteristics with intervention components. CHW, community health worker; ED, emergency department; PCP, primary care physicians.

FIGURE 2

Conceptual model of community interventions for reducing childhood asthma ED visits and hospitalizations. Community interventions are separated into 4 domains: community-based health services, care coordination, home-based, and policy and environmental changes. Pathways with dashed arrows signify mixed results or majority significant findings and smooth arrows illustrate significant associations for both emergency department visits and hospitalization reductions. See Table 1. for a full description of study characteristics with intervention components. CHW, community health worker; ED, emergency department; PCP, primary care physicians.

Close modal

Despite the heterogeneity across community intervention domains, the underlying commonality was community engagement. There are many community risks and barriers that prevent caregivers from managing their children’s asthma. This knowledge is imperative for designing effective interventions for communities. It will allow for pathways to build community ownership and integration to dismantle the barriers. Community members in low-income neighborhoods are all too familiar with the exposure to air pollutants, community violence, and poor-quality housing. When they form partnerships to execute an intervention, it may elicit trust in caregivers of children with asthma. This may further increase adherence to community interventions. It is easier to accept assistance from CHWs in a shared community with strong ties.76  Trust is enhanced when interventions are designed to fit the unique needs of the defined community, implemented by members who share residence in the community,44  and speak the same language. Community collaboration to codesign, implement, and evaluate intervention design is a unique component for effective community interventions. Encouraging early involvement of community partners, as well as a unique partnership with CHWs is a key to success.48  Comprehensive asthma education, evaluation, and treatment offered with culturally and linguistically appropriate communication further addressed barriers to adherence and generated better asthma management from caregivers.49 

Most of the community interventions identified were conducted in predominately Black or Hispanic populations. Similar to findings from Postma and colleagues’ systematic review on CHW-led interventions77  and Chan and colleagues’ systematic review on multicomponent community-based interventions,32  the focus of our findings were in underrepresented minority communities. Our findings provide evidence for models that are reproducible in similar low-income communities with comparable racial composition in the United States. This could potentially reduce racial inequities. Community intervention strategies to decrease asthma morbidity from these studies may not be generalizable to other racial groups or affluent populations. This systematic review highlights the substantial role that community interventions play in Black and Hispanic populations as a window of actionable opportunity. The built environment, racial segregation, and housing inequities are a result of historical structural racism, which contribute to the asthma inequities.75  However, studies assessing community interventions focusing on the historical context of structural racism remain scarce. Future studies require quantitative and qualitative approaches that provide more geographic context of neighborhoods to understand the varying lived experiences of underrepresented minority children from White children with asthma.

The strengths of this systematic review include a comprehensive search using 5 databases, hand searched reference sections, and an assortment of search terms for community interventions. We also targeted a variety of community interventions to promote change based on the needs of the community. Rather than limit our search to only CHW delivered interventions,7779  or multicomponent community-based interventions,32  we expanded the scope to gather studies reporting on expansive environmental changes in communities. Although we primarily analyzed asthma hospitalizations and ED visits as the main outcomes of interest, there were other co-benefits. Select community interventions found additional reductions in missed daycare or school days (n = 9),44,4749,55,60,62,63,66  and missed caregiver workdays (n = 4).49,55,62,63  To measure QoL the majority of studies that assessed QoL used the Pediatric Asthma Caregiver’s Quality of Life instrument.80  Out of 8 studies that measured caregiver QoL or self-efficacy, 6 studies showed improvements.44,47,48,58,59,62 

Our systematic review had several limitations. Our broad inclusion criteria for community interventions limited our ability to conduct a complete analysis. Because of the heterogeneity in community interventions, we could not synthesize our findings into a meta-analysis. Limitations in the risk of bias assessment exist as many of the intervention studies were single arm studies and had no comparison group. The majority of studies had a serious risk of bias (n = 16).4244,47,49,50,5258,63,66  This is indicative of some problems in the study designs but does not mean the studies are too problematic to yield useful results.41  Though Cochrane is the gold standard for systematic reviews, their ROBINS-I is generally designed for comparative studies.

The target population of this systematic review consisted of children with asthma. Other studies that analyzed all ages but did not report separate results for children were omitted from the final report.8186  Though we did not restrict our inclusion criteria to any specific geographic location, most studies were conducted in the United States. Findings may not be reproducible in communities outside of the United States, particularly in countries with minimal racial and socioeconomic inequities and countries with universal healthcare. It is possible that our refined search for full text availability in peer-reviewed journals, publications from 2010 to 2021, and articles issued in the English language limited our findings and potentially omitted relevant studies. We are confident that the 26 publications included in our final report serve as a representative sample of the most recent community interventions for childhood asthma ED visits and hospitalizations.

This systematic review found significant associations between community interventions and the reduction of emergency healthcare utilization, suggesting a protective effect for the most uncontrolled and severe cases of childhood asthma. Though there are persistent racial inequities in childhood asthma exacerbations leading to ED visits and hospitalizations, our research adds evidence of successful community interventions in predominately underrepresented minority communities.

We thank Vivian McCallum, MLS (User Services Librarian, Cleveland Health Sciences Library, Case Western Reserve University), who assisted with the development of the search strategy; and the anonymous reviewers for providing constructive feedback that helped improve the quality of our manuscript.

Dr Gill coordinated data collection, developed the research question, search strategy, and study protocol, conducted the title, abstract, and full text review, performed the risk of bias assessment, and drafted the initial manuscript for the systematic review; Ms Shah conducted the title, abstract, and full text review, performed the risk of bias assessment, and reviewed and revised the manuscript; Dr Lee and Mrs Sommer developed the research question, search strategy, and study protocol, conducted the title and abstract review, and reviewed and revised the manuscript; Drs Ross and Bole critically assessed the content with expert analysis and reviewed and revised the manuscript; Dr Freedman developed the research question, search strategy, study protocol, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Research reported in this article was funded through a grant from the S. Livingston Mather Charitable Trust and the Mary Ann Swetland Center for Environmental Health Endowment. The funders had no role in the design and conduct of the systematic review.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.

CAHR

controlling asthma through home remediation

CHW

community health worker

CI

confidence interval

ED

emergency department

MCAN

Merck Childhood Asthma Network

QoL

quality of life

ROBINS-I

risk of bias in non-randomized studies – of interventions

RR

risk ratio

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