YES WE CAN Children’s Asthma Program

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

YES WE CAN Children’s Asthma Program: Success Stories

Clinical

• A 30-month old African American boy living in public housing with his single mother was in urgent care in December 2003 with severe persistent asthma. The allergy skin prick test showed the boy to be allergic to egg whites, soy, and oranges in addition to mold, dogs, cats, and Arizona Cypress trees. The mother learned to administer medications as prescribed and to decrease the child’s exposure to potential triggers. The child exhibited no symptoms in early March 2004.
• A 10-year-old Latina girl experienced numerous asthma episodes, primarily exercise-induced, prior to enrolling in YES WE CAN. After graduating from the program, she is fully active in sports and her symptoms are under control.
• A 5-year-old Latina girl in kindergarten experienced several asthma episodes associated with upper respiratory infections. Appropriate medications, the avoidance of triggers, and a flu shot ended the episodes for the child. The mother reports that her daughter’s asthma is much better controlled as they follow the asthma program.
• An 11-year-old Latino boy experienced numerous ED visits and a hospital stay for asthma before being referred to YES WE CAN. The boy is allergic to dog and cat dander, pollen and grasses, dust mites, and cypress trees and is affected by changes in the weather. Adherence to the medications and a change to a more environmentally healthy residence have resulted in improved asthma control.
• A 6-year-old Latino boy and his 2-year-old sister were both frequently sick with asthma. They were allergic to mold, pollen, dust mites, grass pollen, and cypress trees. The 2-year-old was also admitted to the hospital with asthma in late 2003. Strict adherence to the prescribed asthma medication procedures and some remedial environmental actions in the home (mold removal, use of mite-impermeable mattress and pillow covers) have resulted in both children being free of serious illness from asthma since being enrolled in YES WE CAN.

Environmental

• An undocumented Latino immigrant family had a 4-year-old boy with asthma. The SFGH records showed the child had three ED visits in frequent succession; all billing records indicated diagnoses of pneumonia. The boy also visited the ED another 13 times for asthma and 4 additional times for upper respiratory infections. Finally, in March of 2002, the child was hospitalized for four days with pneumonia. The family had refused any home visits because they worried about being reported to the immigration authorities. However, later that same year, the boy was scheduled for a visit to the YES WE CAN asthma clinic at SFGH. The child maintained monthly check-ups with the clinic. The family finally agreed to a home visit following the visit to the clinic. The home visits revealed the presence of an old carpet. The CHW recommended carpet removal and helped the family write a letter in English to the landlord requesting removal of the carpet. This request was followed up with a similar request letter from the YES WE CAN clinician. The carpet was removed and the child, on the appropriate asthma medications, improved dramatically. By early fall of 2003, the child met all criteria for graduation from the YES WE CAN program.
• A 2-year-old Latina girl was admitted to the hospital in October 2003 for a 3-day stay. The child’s diagnosis included pneumonia and a positive culture for respiratory syncytial virus, common in young children with asthma. During the hospitalization, the inpatient medical staff did not formally diagnose the child, and she was sent home with only albuterol and a spacer. A medical resident on the inpatient floor alerted staff in the YES WE CAN asthma clinic about the girl. The family was referred to the CHW for a home visit in October 2003. The CHW learned that the family was on a 4-month waiting list for a specialty asthma clinic appointment and was looking for more affordable housing. The family lacked medical insurance, but wanted to get help for their child. A YES WE CAN clinic appointment was not available until late December 2003. In early December, however, the child visited the Urgent Care Center at SFGH with severe asthma symptoms, and was admitted to the hospital for three days. A medical resident called the YES WE CAN asthma clinic. The child was scheduled for an emergency clinic appointment the day of her discharge from the hospital. The child was prescribed both a controller medication and rescue medication. The family and the child were instructed on proper use of the medications, and the child’s symptoms soon subsided. At the local housing clinic, the family was given a referral for housing. They were able to relocate to a larger, sunnier, less humid, noncarpeted, and more affordable apartment in San Mateo County.
• An African American family living in public housing had a 6-year-old child who had asthma. Mold and mildew growth covered part of the ceiling and walls in the kitchen and the living room closet of the family’s home. The CHW wrote a letter to the San Francisco Housing Authority on behalf of the family, describing the mold and mildew conditions that were detrimental to the child’s health. The housing authority conducted an inspection and agreed to make repairs, including repairing the roof, cleaning the moldy areas, and repainting the affected rooms. These actions stopped the leaks, eradicated the mold, and reduced the boy’s asthma symptoms.
• A Latino family lived in substandard housing in the Mission district with two children with asthma; a boy aged 11 years and a girl aged 5 years. Environmental problems in the apartment included mold on the bedroom walls and ceiling. There were leaks in the roof, dampness in the living room area, and old carpeting. The family’s requests for repairs just brought harassment from the landlord. The mother shared her frustrations about the housing conditions with the CHW. The CHW first helped the mother fill out an application for low-income housing. However, the mother rejected the housing offered because she feared the neighborhood was not safe for her children. So, the CHW helped the mother complete a housing lottery form that offered a chance of being awarded a new apartment. To everyone’s surprise, the family won the lottery and was awarded a three-bedroom apartment, part of a large new complex. The children’s asthma is under control, and the family is delighted with their new dwelling.
• In another case, a single Latina mother with a 5-year-old girl with asthma lived in a single room with deplorable living conditions. Seven families shared a single shower, a single water closet, and a single kitchen. There was a hole in the kitchen window big enough for a basketball to pass through. Filth and clutter were everywhere. The CHW helped the mother complete an application for a new dwelling to be awarded through the housing lottery program. The woman has won the lottery and is waiting for the dwelling to be completed.
• A CHW delivered self-management education in the clinic for a parent of a child with asthma who lived with her family of four in a small single room. The CHW visited, telephoned, and kept in communication with the mother. She provided the woman a referral for public housing. Another family with a child with asthma was allergic to feathers, yet the family had several birds in the home. The CHW convinced the family to find another home for the birds. Eliminating the feathered animals from the home and adhering to the medication regimen helped improve the child’s asthma symptoms.

Comments from caregivers

Six families enrolled in YES WE CAN were visited in their homes in March 2004 to learn firsthand their experiences with the asthma program and to record some of their observations and comments about the program. The case study investigator was accompanied by the CHW who had worked with the family and was familiar with their circumstances. In each instance, the parent was asked questions from a prepared set of interview questions that addressed (1) enrollment in the program, (2) what the family learned about asthma they did not know before attending clinic, (3) what took place in the home regarding environmental changes and removal of social barriers to asthma care, and (4) changes in the child’s asthma symptoms.

Enrollment in the Program
All of the families reported that they were able to enroll in the YES WE CAN asthma clinic without difficulty. In each instance the family had been referred to the program. Clinicians at pediatric clinics referred four of the families, and the ED referred one family following their child’s visit for asthma. Another family was referred by the hospital after their child was admitted to the hospital because of asthma. In all instances, the families accepted the clinical services, the home visits, and the social assistance offered in their home.

What the family learned about asthma
The families reported that in other healthcare settings they failed to gain sufficient knowledge about their child’s asthma to know what was happening. Confused, upset and uninformed, they just struggled on without the tools to really make a change in the child’s condition. In some instances, the child was given an inhaler and sent home. Over and over again, families reported that the YES WE CAN staff took the time to explain things to them. Caregivers reported that they learned about inflammation in the lungs, they learned about things that trigger asthma episodes in their child, and they learned about the medications and how to administer them. They also learned how to use the Asthma Action Plan. A couple of families just laughed when asked if the asthma knowledge they received at the clinic was ever reviewed and reinforced later. "We get some of it on every visit to the clinic and every time the CHW comes to the home." This increase in knowledge and skill has made caregivers feel more comfortable dealing with their child’s asthma.

What environmental changes and removal of social barriers took place
Whereas most of the families did not discuss a formal environmental assessment carried out with the CHW, each family did talk freely about changes that were made to improve their child’s condition. Several mentioned that they received mattress and pillow covers for the child’s bed, which they installed. Removal of stuffed animals and other items that cause dust from the child’s room, cleaning mildew and mold, and having minor repairs made were mentioned two or more times. Other items that caregivers mentioned that could impact a child’s asthma were learning how to

• wash the bedding to kill dust mites
• obtain needed asthma medications
• fix a bathroom leak to rectify a mold problem
• obtain health insurance.

One of the caregivers, a single father raising a 10-year-old daughter with asthma, said that he needed to be prepared to deal with the child’s condition. He confessed that he was not prepared and that not being prepared was the worst feeling. "The instruction and information received at YES WE CAN was the greatest. We have only good things to say about it, the results really tell us it works. Marisol now plays sports; she runs, and her symptoms are down. The program is wonderful. Yes, it saved my child’s life."