Margaret Wilkin

Policy and system change and community coalitions: outcomes from allies against asthma.

OBJECTIVES We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their childs asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Improvements in health care use associated with community coalitions: Long-term results of the allies against asthma initiative

OBJECTIVES We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Food & Community: the cross-site evaluation of the W.K. Kellogg Food & Fitness community partnerships

This article describes the collaborative development of the cross-site evaluation of the Food & Fitness initiative. Evaluators and community partners together created a multi-site evaluation to document similarities and unique aspects across the work in the nine participating communities. The evaluation includes measures of partner engagement, resources, processes, and outcomes of achieving systems and policy change, and impact of the work in vulnerable communities. Inherent in and critical to the evaluation is a process for providing feedback to communities and stakeholders. Pioneering ways to assess the process of achieving systems and policy change and the impact of this work on children and families, the Food & Fitness cross-site evaluation is creating a picture of the collective accomplishments of these community partnerships, which are doing innovative work related to equity around food access and the built environment.

Pediatric Asthma Care Coordination in Underserved Communities: A Quasiexperimental Study

OBJECTIVES To assess the effect of care coordination on asthma outcomes among children in underserved urban communities. METHODS We enrolled children, most of whom had very poorly or not well-controlled asthma, in medical-social care coordination programs in Los Angeles, California; Chicago, Illinois; Philadelphia, Pennsylvania; and San Juan, Puerto Rico in 2011 to 2014. Participants (n = 805; mean age = 7 years) were 60% male, 50% African American, and 42% Latino. We assessed asthma symptoms and health care utilization via parent interview at baseline and 12 months. To prevent overestimation of intervention effects, we constructed a comparison group using bootstrap resampling of matched control cases from previous pediatric asthma trials. RESULTS At follow-up, intervention participants had 2.2 fewer symptom days per month (SD = 0.3; P < .01) and 1.9 fewer symptom nights per month (SD = 0.35; P < .01) than did the comparison group. The relative risk in the past year associated with the intervention was 0.63 (95% confidence interval [CI] = 0.45, 0.89) for an emergency department visit and 0.69 (95% CI = 0.47, 1.01) for hospitalization. CONCLUSIONS Care coordination may improve pediatric asthma symptom control and reduce emergency department visits. POLICY IMPLICATIONS Expanding third-party reimbursement for care coordination services may help reduce pediatric asthma disparities.

Policy and System Change and Community Coalitions Outcomes From Allies Against Asthma

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child’s asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Sustaining School‐Based Asthma Interventions Through Policy and Practice Change

BACKGROUND Schools are an ideal setting for implementation of asthma interventions for children; however, sustaining school-based programs can be challenging. This study illustrates policy and practice changes brought about through the Childhood Asthma Linkages in Missouri (CALM) program to sustain such programs. METHODS Researchers analyzed caregiver-reported quantitative data regarding asthma-related outcomes in preintervention and postintervention surveys and qualitative data regarding sustainability efforts in schools reported by CALM grantees. A grounded theory approach was used to identify key concepts and themes that emerged. RESULTS In 330 children, significant improvements were seen in asthma symptoms, rescue inhaler use, health care utilization, school absenteeism, and activity limitations. Overall, 27 school-based policy and practice changes supporting program sustainability were reported, with policy changes most often concerning the assessment and/or monitoring of children with asthma in the school setting, and practice changes most often regarding institution of regular asthma education programs for students and school personnel. CONCLUSIONS Sustaining school-based asthma programs is challenging, but can be realized through the participation of diverse partners in enacting policy and practice changes that support the institutionalization of programs into the day-to-day processes of the schools.

The Extent and Patterns of Multiple Chronic Conditions in Low-Income Children

Background and objectives. Little is known about the magnitude of multiple chronic conditions (MCC) in children. This study describes the prevalence of and patterns of comorbidities in children receiving Medicaid assistance. Methods. Diagnoses from 5 years of Medicaid claims data were reviewed and identified 128 044 children with chronic conditions. The relationship between comorbidities and significant urgent health care events was analyzed using logistic regression modeling. Results. More than 15 000 children (12%) had claims for more than 1 condition. The most frequent combination was asthma and allergic rhinitis. Significant health care events ranged from 18% to 51% in children, and the odds of having a significant event increased with each additional condition. Those with ≥4 conditions had 4.5 times the odds of a significant event compared with those with 1 condition (P < .0001). Conclusion. MCC are prevalent in low-income children and are associated with greater risk for urgent health care use.

Moving toward and beyond equity: the Food & Fitness approach to increasing opportunities for health in communities

Through creating avenues for authentic civic engagement of individuals living in vulnerable communities, the Food & Fitness community partnerships have actualized innovative ways to change the trajectory of health outcomes in neighborhoods across the United States. Working to increase the availability of healthy, locally grown food and opportunities for physical activity in communities that have suffered from years of disinvestment, the partnerships have moved toward and beyond merely bridging the equity gap.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest

Abstract Objective: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. Methods: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. Results: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). Conclusion: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.