The following paper is a critical appraisal of a journal entry that appears in the Social Science & Medicine journal, published in 2006. The authorship of A community-based participatory research study of multifaceted in-home environmental interventions for pediatric asthmatics in public housing is a highly qualified of five authors. Jonothan Levy, Junenette Peters, and Jane Clougherty represent Harvard School of Public Health and Doug Brugge and Shawnette Saddler represent Tufts University School of Medicine (Levy, Brugge, Peters, Clougherty, & Saddler, 2006). The researchers tackle an important issue, as is evident by statistics. In 2009, 14% of US American children had ever been diagnosed with asthma, and 10% still have it. Of the 10 million U.S. children, children in poor families are diagnosed disproportionately more often than children in families that were not poor (Bloom, Cohen, & Freeman, 2009).
The purpose of this study is to gain better understanding into the effectiveness of integrated pest management (IPM) on controlling and minimizing pediatric asthma symptoms. The researchers focus on areas of urban and low-income housing due to the prevalence of pest-infestation in such corresponding areas. The study aims to analyze the interactivity of risk factors and their effect on long-term health outcomes. Therefore, an attempt is made to draw correlational data with the aforementioned factors and aggravation of asthmatic symptoms. The findings of this study are to be used in combination with other studies as part of a Healy Public Housing Initiative (Levy et al., 2006).
This study is based on a community-based participatory research intervention study. The subjected community is a combination of public housing developments located in Boston, Massachusetts, USA. Two of three housing developments have undergone renovations, whereas one (West Broadway or WeB) has not. The sample size includes fifty children between the ages of 4-17, all of who suffer from asthmatic symptoms. The intervention process includes support from trained community health advocates and more prominently IPM, cleaning, and educational assistance. The health instruments for collection and analyses include enrollment questionnaires, longitudinal health data collection, allergy testing and allergen sampling, medication evaluation, environmental interventions, asthma education/ case management, and statistical analyses. Successfully completed interventions provide detailed data on contribution of environmental, medical, social factors on health outcomes (Levy et al., 2006).
Notable results include significance in symptom reduction of children at WeB, compared to those in the other two renovated areas. At WeB (the only non-renovated development), 95% of children experienced improvement with a mean symptom reduction score from 2.7 to 0.8. Post-intervention data shows a decrease in three prominent categories including wheezing and coughing, slowing down or stopping play, and waking at night. Allergy testing shows that 77% of the children were affected by tested allergens, especially cockroaches and dust mites. These findings were especially significant as only 6% reported these allergies pre-intervention. The intervention also saw an increase in use of peak flow meters, which were provided by the study. In aggregate, the study proved that pest management and allergen reduction provide positive health outcomes on the multifactorial phenomena that is urban pediatric asthma. In regards to a major concern of the study, which is to improve long-term reduction, it was found that the rate of improvement slowed down significantly after the first 5 months of post-intervention (Levy et al., 2006).
This study used bundled interventions in order to maximize the effectiveness of the research. Focusing on individual rather than bundled interventions can provide more insights on the specific problem area. However, seeing as bundled interventions provide for more effective treatment, especially in the case of the multifactorial nature of asthma, this study can be easily justified as it longitudinally focuses on bundled interventions. The ability to conduct this study using longitudinal research made it possible to infer health outcomes for multiple combinations of risk factors. Moreover, the longitudinal nature this study provides more insight on long-term exposure reduction. This is especially important given the relative uncertainty experienced in past studies of dust mite control, air filtration, and HEPA vacuums.
This study demonstrates its importance by confirming the degree of difficulty in determining long-term symptom reduction techniques for asthmatic children. Even with months of pre-study data collection and post-study data collection, long-term reduction slowed. This indicates to future researchers that while the intervention methods used in this study are effective in the short-term, there must be new experimentation conducted, which focuses on continuous improvement.
As it is mentioned in the study, it is not easy to design CBPR studies that can serve a purpose for both the community and the researchers. The study concludes that involvement of community members in this study has probably provided participants with a larger network for social support. However, the lack of implementation of a control population and post-study data relevant to this assumption leave it just an assumption.
The data collected pertained to a misrepresentative group of subjects. Of the 50 children who completed the study successfully, 98% were of Hispanic and African American origin, with the former comprising a 70% majority. Although these two groups are more susceptible to asthma, the ratio of the sample size to the population is disproportionate (“Non-Hispanic black children were more likely to have ever been diagnosed with asthma (22%) or to still have asthma (17%) than Hispanic children (13% and 8%) or non-Hispanic white children (12% and 8%)” (Bloom et al., 2009). This could possibly be attributed to a lack of thoroughness in data collection, seeing as the initial sample size was 78, where 28 participants were lost to follow up and questionnaire error. While these losses are bound to occur, the size of the loss in this case is rather high. It is possible that the additional subject would have provided more diverse results and therefore altered the implications of the study.
Lack of thoroughness could also have been a contributor to the fact that the study was not able to assess the degree to which prescribed medications were used properly and that the perception of caregivers regarding medication adequacy did not change, even though, based on persistent/ intermittent asthma level criteria, only 32% of children were adequately medicated.
RECOMMENDATIONS FOR FUTURE RESEARCH
In conclusion, CBPR intervention studies provide a unique perspective to the area of pediatric asthma research. If properly executed, studies such as this one can greatly contribute to long-term symptom reduction of asthmatic children. It is recommended that future research should focus on the contribution levels of environmental and social factors in asthma intervention programs, and the means by which these factors are synergized. If possible, a control group would be beneficial to any subsequent related research. It is advisable that further CBPR studies are conducted as this type of study has the ability to simultaneously educated more than one important stakeholder about relatively significant matters, the stakeholders being health professionals, researchers, scientists, caregivers and patients. Future research would make the most sense where an appropriate budget is allocated. A more substantial budget would allow for an increase in sample size, providing more accurate results. Furthermore, partial budget allocation can be used as an incentive for community members to participate in control group studies.
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Bloom, B., Cohen, R.A., & Freeman, G. (2009). U.s. children: national health interview survey, 2009. Vital and Health Statistics, 10(247), Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_247.pdf
Levy, J.I., Brugge, D., Peters, J.L., Clougherty, J.E., & Saddler, S.S. (2006). A community-based participatory research study of multifaceted in-home environmental interventions for pediatric asthmatics in public housing. Social Science & Medicine , 63. Retrieved from http://www.healthyhomestraining.org/ipm/spengler_journal_1.pdf