Toby C. Lewis

Community action against asthma: examining the partnership process of a community-based participatory research project.

AbstractBACKGROUND: Community Action Against Asthma (CAAA) is a community-based participatory research (CBPR) project that assesses the effects of outdoor and indoor air quality on exacerbation of asthma in children, and tests household- and neighborhood-level interventions to reduce exposure to environmental asthma triggers. Representatives of community-based organizations, academia, an integrated health system, and the local health department work in partnership on CAAA’s Steering Committee (SC) to design and implement the project. OBJECTIVE: To conduct a process evaluation of the CAAA community-academic partnership. DESIGN: In-depth interviews containing open-ended questions were conducted with SC members. Analysis included established methods for qualitative data, including focused coding and constant comparison methods. SETTING: Community setting in Detroit, Michigan. PARTICIPANTS: Twenty-three members of the CAAA SC. MEASUREMENTS: Common themes identified by SC members relating to the partnership’s ability to achieve project goals and the successes and challenges facing the partnership itself. MAIN RESULTS: Identified partnership accomplishments included: successful implementation of a complex project, identification of children with previously undiagnosed asthma, and diverse participation and community influence in SC decisions. Challenges included ensuring all partners’ influence in decision-making, the need to adjust to “a different way of doing things” in CBPR, constraints and costs of doing CBPR felt by all partners, ongoing need for communication and maintaining trust, and balancing the needs of science and the community through intervention. CONCLUSIONS: CBPR can enhance and facilitate basic research, but care must be given to trust issues, governance issues, organizational culture, and costs of participation for all organizations involved.

Air pollution-associated changes in lung function among asthmatic children in Detroit

In a longitudinal cohort study of primary-school–age children with asthma in Detroit, Michigan, we examined relationships between lung function and ambient levels of particulate matter ≤ 10 μm and ≤ 2.5 μm in diameter (PM10 and PM2.5) and ozone at varying lag intervals using generalized estimating equations. Models considered effect modification by maintenance corticosteroid (CS) use and by the presence of an upper respiratory infection (URI) as recorded in a daily diary among 86 children who participated in six 2-week seasonal assessments from winter 2001 through spring 2002. Participants were predominantly African American from families with low income, and > 75% were categorized as having persistent asthma. In both single-pollutant and two-pollutant models, many regressions demonstrated associations between higher exposure to ambient pollutants and poorer lung function (increased diurnal variability and decreased lowest daily values for forced expiratory volume in 1 sec) among children using CSs but not among those not using CSs, and among children reporting URI symptoms but not among those who did not report URIs. Our findings suggest that levels of air pollutants in Detroit, which are above the current National Ambient Air Quality Standards, adversely affect lung function of susceptible asthmatic children.

Community Involvement in the Conduct of a Health Education Intervention and Research Project: Community Action Against Asthma

There is a need for more guidance on how to implement community-based participatory research, particularly on the roles of community members, throughout the process. This article focuses on how a Steering Committee, composed of representatives from community-based organizations, a local health department, an integrated health care system, and academia from the University of Michigan, participated in the design and implementation of a children’s asthma study in Detroit, Michigan: Community Action Against Asthma. In addition, this article focuses on the role of community members as data collectors, examining a variety of sophisticated data collection roles. A description and analysis of how community members shaped and participated in the project, the lessons learned, and recommendations for practitioners are also presented.

Particulate matter concentrations in residences: an intervention study evaluating stand‐alone filters and air conditioners

UNLABELLED This study, a randomized controlled trial, evaluated the effectiveness of free-standing air filters and window air conditioners (ACs) in 126 low-income households of children with asthma. Households were randomized into a control group, a group receiving a free-standing HEPA filter placed in the childs sleeping area, and a group receiving the filter and a window-mounted AC. Indoor air quality (IAQ) was monitored for week-long periods over three to four seasons. High concentrations of particulate matter (PM) and carbon dioxide were frequently seen. When IAQ was monitored, filters reduced PM levels in the childs bedroom by an average of 50%. Filter use varied greatly among households and declined over time, for example, during weeks when pollutants were monitored, filter use was initially high, averaging 84±27%, but dropped to 63±33% in subsequent seasons. In months when households were not visited, use averaged only 34±30%. Filter effectiveness did not vary in homes with central or room ACs. The study shows that measurements over multiple seasons are needed to characterize air quality and filter performance. The effectiveness of interventions using free-standing air filters depends on occupant behavior, and strategies to ensure filter use should be an integral part of interventions. PRACTICAL IMPLICATIONS Environmental tobacco smoke (ETS) increased particulate matter (PM) levels by about 14 μg/m3 and was often detected using ETS-specific tracers despite restrictions on smoking in the house as reported on questionnaires administered to caregivers. PM concentrations depended on season, filter usage, relative humidity, air exchange ratios, number of children, outdoor PM levels, sweeping/dusting, and presence of a central air conditioner (AC). Free-standing air filters can be an effective intervention that provides substantial reductions in PM concentrations if the filters are used. However, filter use was variable across the study population and declined over the study duration, and thus strategies are needed to encourage and maintain use of filters. The variability in filter use suggests that exposure misclassification is a potential problem in intervention studies using filters. The installation of a room AC in the bedroom, intended to limit air exchange ratios, along with an air filter, did not lower PM levels more than the filter alone.

Identification of gaps in the diagnosis and treatment of childhood asthma using a community-based participatory research approach

The goal of this investigation was to use a community-based participatory research approach to develop, pilot test, and administer an asthma screening questionnaire to identify children with asthma and asthma symptoms in a community setting. This study was conducted as the recruitment effort for Community Action Against Asthma, a randomized trial of a household intervention to reduce exposure to environmental triggers of asthma and was not designed as a classic prevalence study. An asthma screening questionnaire was mailed and/or hand delivered to parents of 9,627 children, aged 5 to 11 years, in two geographic areas of Detroit, Michigan, with predominantly African American and Hispanic populations. Additional questionnaires were distributed via community networking. Measurements included parent report of their childs frequency of respiratory symptoms, presence of physician diagnosis of asthma, and frequency of doctor-prescribed asthma medication usage. Among the 3,067 completed questionnaires, 1,570 (51.2% of returned surveys, 16.3% of eligible population) were consistent with asthma of any severity and 398 (12.9% of returned surveys, 4.1% of eligible population) met criteria, for moderate-to-severe asthma. Among those meeting criteria for moderate-to-severe asthma, over 30% had not been diagnosed by a physician, over one half were not taking daily asthma medication, and one quarter had not taken any physician-prescribed asthma medication in the past year. Screening surveys conducted within the context of a community-based participatory research partnership can identify large numbers of children with undiagnosed and/or undertreated moderate-to-severe asthma. These children are likely to benefit from interventions to reduce morbidity and improve quality of life.

Levels and sources of volatile organic compounds in homes of children with asthma

UNLABELLED Many volatile organic compounds (VOCs) are classified as known or possible carcinogens, irritants, and toxicants, and VOC exposure has been associated with the onset and exacerbation of asthma. This study characterizes VOC levels in 126 homes of children with asthma in Detroit, Michigan, USA. The total target VOC concentration ranged from 14 to 2274 μg/m(3) (mean = 150 μg/m(3); median = 91 μg/m(3)); 56 VOCs were quantified; and d-limonene, toluene, p, m-xylene, and ethyl acetate had the highest concentrations. Based on the potential for adverse health effects, priority VOCs included naphthalene, benzene, 1,4-dichlorobenzene, isopropylbenzene, ethylbenzene, styrene, chloroform, 1,2-dichloroethane, tetrachloroethene, and trichloroethylene. Concentrations varied mostly due to between-residence and seasonal variation. Identified emission sources included cigarette smoking, solvent-related emissions, renovations, household products, and pesticides. The effect of nearby traffic on indoor VOC levels was not distinguished. While concentrations in the Detroit homes were lower than levels found in other North American studies, many homes had elevated VOC levels, including compounds that are known health hazards. Thus, the identification and control of VOC sources are important and prudent, especially for vulnerable individuals. Actions and policies to reduce VOC exposures, for example, sales restrictions, improved product labeling, and consumer education, are recommended. PRACTICAL IMPLICATIONS Total target VOC concentrations in the Detroit homes ranged from 14 to 2274 lg/m3, generally lower than found in earlier studies. However, a subset of houses had elevated concentrations, and levels of 1,4-dichlorobenzene, naphthalene, and benzene reached levels commensurate with excess individual cancer risks of 10(-2), 10(-3), and 10(-4), respectively. VOC concentrations varied mostly due to between-residence and season effects. The most important sources included cigarette smoking, vehicle-related emissions, building renovation, solvents, household products, and pesticides.

Macrophage/epithelial cell CCL2 contributes to rhinovirus-induced hyperresponsiveness and inflammation in a mouse model of allergic airways disease

Human rhinovirus (HRV) infections lead to exacerbations of lower airways disease in asthmatic patients but not in healthy individuals. However, underlying mechanisms remain to be completely elucidated. We hypothesized that the Th2-driven allergic environment enhances HRV-induced CC chemokine production, leading to asthma exacerbations. Ovalbumin (OVA)-sensitized and -challenged mice inoculated with HRV showed significant increases in the expression of lung CC chemokine ligand (CCL)-2/monocyte chemotactic protein (MCP)-1, CCL4/macrophage inflammatory protein (MIP)-1β, CCL7/MCP-3, CCL19/MIP-3β, and CCL20/MIP3α compared with mice treated with OVA alone. Inhibition of CCL2 with neutralizing antibody significantly attenuated HRV-induced airways inflammation and hyperresponsiveness in OVA-treated mice. Immunohistochemical stains showed colocalization of CCL2 with HRV in epithelial cells and CD68-positive macrophages, and flow cytometry showed increased CCL2(+), CD11b(+) cells in the lungs of OVA-treated, HRV-infected mice. Compared with lung macrophages from naïve mice, macrophages from OVA-exposed mice expressed significantly more CCL2 in response to HRV infection ex vivo. Pretreatment of mouse lung macrophages and BEAS-2B human bronchial epithelial cells with interleukin (IL)-4 and IL-13 increased HRV-induced CCL2 expression, and mouse lung macrophages from IL-4 receptor knockout mice showed reduced CCL2 expression in response to HRV, suggesting that exposure to these Th2 cytokines plays a role in the altered HRV response. Finally, bronchoalveolar macrophages from children with asthma elaborated more CCL2 upon ex vivo exposure to HRV than cells from nonasthmatic patients. We conclude that CCL2 production by epithelial cells and macrophages contributes to HRV-induced airway hyperresponsiveness and inflammation in a mouse model of allergic airways disease and may play a role in HRV-induced asthma exacerbations.

Sources, concentrations, and risks of naphthalene in indoor and outdoor air

UNLABELLED Naphthalene is a ubiquitous pollutant, and very high concentrations are sometimes encountered indoors when this chemical is used as a pest repellent or deodorant. This study describes the distribution and sources of vapor-phase naphthalene concentrations in four communities in southeast Michigan, USA. Outdoors, naphthalene was measured in the communities and at a near-road site. Indoors, naphthalene levels were characterized in 288 suburban and urban homes. The median outdoor concentration was 0.15 μg/m(3), and a modest contribution from rush-hour traffic was noted. The median indoor long-term concentration was 0.89 μg/m(3), but concentrations were extremely skewed and 14% of homes exceeded 3 μg/m(3), the chronic reference concentration for non-cancer effects, 8% exceeded 10 μg/m(3), and levels reached 200 μg/m(3). The typical excess individual lifetime cancer risk was about 10(-4) and reached 10(-2) in some homes. Important sources include naphthalenes use as a pest repellent and deodorant, migration from attached garages and, to lesser extents, cigarette smoke and vehicle emissions. Excessive use as a repellent caused the highest concentrations. Naphthalene presents high risks in a subset of homes, and policies and actions to reduce exposures, for example, sales bans or restrictions, improved labeling, and consumer education, should be considered. PRACTICAL IMPLICATIONS Long-term average concentrations of naphthalene in most homes fell into the 0.2-1.7 μg/m(3) range reported as representative in earlier studies. The highly skewed distribution of concentrations results in a subset of homes with elevated concentrations and health risks that greatly exceed US EPA and World Health Organization (WHO) guidelines. The most important indoor source is the use of naphthalene as a pest repellant or deodorant; secondary sources include presence of an attached garage, cigarette smoking, and outdoor sources. House-to-house variation was large, reflecting differences among the residences and naphthalene use practices. Stronger policies and educational efforts are needed to eliminate or modify indoor usage practices of this chemical.

Air pollution and respiratory symptoms among children with asthma: Vulnerability by corticosteroid use and residence area

RATIONALE Information on how ambient air pollution affects susceptible populations is needed to ensure protective air quality standards. OBJECTIVES To estimate the effect of community-level ambient particulate matter (PM) and ozone (O) on respiratory symptoms among primarily African-American and Latino, lower-income asthmatic children living in Detroit, Michigan and to evaluate factors associated with heterogeneity in observed health effects. METHODS A cohort of 298 children with asthma was studied prospectively from 1999 to 2002. For 14days each season over 11 seasons, children completed a respiratory symptom diary. Simultaneously, ambient pollutant concentrations were measured at two community-level monitoring sites. Logistic regression models using generalized estimating equations were fit for each respiratory symptom in single pollutant models, looking for interactions by area or by corticosteroid use, a marker of more severe asthma. Exposures of interest were: daily concentrations of PM<10μm, <2.5μm, and between 10 and 2.5μm in aerodynamic diameter (PM, PM, and PM respectively), the daily 8-hour maximum concentration of O (8HrPeak), and the daily 1-hour maximum concentration of O (1HrPeak). RESULTS Outdoor PM, PM, 8HrPeak, and 1HrPeak O concentrations were associated with increased odds of respiratory symptoms, particularly among children using corticosteroid medication and among children living in the southwest community of Detroit. Similar patterns of associations were not seen with PM. CONCLUSIONS PM and O at levels near or below annual standard levels are associated with negative health impact in this population of asthmatic children. Variation in effects within the city of Detroit and among the subgroup using steroids emphasizes the importance of spatially refined exposure assessment and the need for further studies to elucidate mechanisms and effective risk reduction interventions.

Nasal cytokine responses to natural colds in asthmatic children

The mechanisms by which viruses induce asthma exacerbations are not well understood.