Reducing asthma-related hospitalizations in South Texas
When Genny Carrillo, M.D., ScD, MPH, MSPH moved to South Texas in 2007, she realized that asthma was, in her words, “a big problem.” Determined to use her background in environmental health to help, she formed the McAllen Asthma Coalition (MAC) in 2008. Over the years, this program has brought together various collaborators to develop a curriculum to teach children with asthma and their parents how to identify asthma triggers and manage symptoms.
Recent research indicates these interventions are working, with drops in asthma-related hospitalizations, number of doctor visits needed and total asthma attacks.
An estimated 617,000 children in Texas, or 9.1 percent, had asthma in 2013. Those in South Texas may be especially vulnerable, due to high levels of pollen in the air, high use of agricultural pesticides and a high poverty rate, said Carrillo, an associate professor at the Texas A&M Health Science Center School of Public Health in McAllen. The asthma hospitalization rate in the Rio Grande Valley is 13.4 percent.
There were 10,075 asthma hospital discharges reported among children in 2012, according to the 2014 Texas Asthma Burden Report. The number visiting emergency departments for asthma was undoubtedly much higher. “These visits represent over $650 million in health care costs, 90 percent of which is totally preventable,” Carrillo said. “The amount of money the state is expending on asthma by not preventing asthma attacks in kids is huge.” These numbers might be underreported, due to a lack of a standardized health electronic system that allows for tracking of patients from one hospital to another.
During her time in South Texas, Carrillo began to notice patterns of issues—cultural, financial, and situational—that perhaps contributed to uncontrolled asthma that led to these emergency room visits.
Many of the parents were unaware of how to control and manage asthma in their children. “Medication adherence is extremely important, and many don’t understand that asthma is a chronic condition and that to keep it controlled, children need to keep using medications even when they’re feeling good,” Carrillo said.
Cultural issues also play a role. For example, according to Mexican folklore, if a Chihuahua dog sleeps by an asthmatic child, the asthma will transfer from the child to the dog. Therefore, one of the first steps of the intervention is to educate parents about this myth and guide them away from these folk remedies and toward scientifically proven treatments.
Financial issues are also a concern. Many of the parents work long hours, so finding time for them to attend these interventions can be difficult. Also, the public health professionals lose track of families because of their “hard-to-reach” status (in other words, they cannot pay their cell phone bill, lose coverage, get new phone numbers when they do resume service, and they are highly mobile.)
There are other barriers unique to the border area. Carrillo described an asthma educational event she had planned where she expected a large group of parents and other community members to attend. However, that same day the border patrol agents were doing sweeps for undocumented immigrants, and many were afraid to leave their homes.
“It’s a cycle, because of poverty, lack of health insurance and lack of information about resources in the community,” Carrillo said, “that keeps asthma in these children uncontrolled.”
A Solution: Providing education and resources
With the above knowledge, Carrillo got to work creating self-management training programs for children with asthma and their families. She began in schools and hospitals, but when schools became concerned about the amount of time taken away from classroom instruction, the program relocated to community centers. “There’s a lot of pieces in the puzzle,” Carrillo said, “but we needed to take care of these children.”
Children in the program and their parents learn about asthma, including how to make it manageable, how to predict when symptoms will occur and what to do during an attack. “All of this is done in a very culturally sensitive way,” Carrillo said, “with lessons taught in Spanish—the native language spoken by families in the program.”
Carrillo’s background in environmental health led her to focus on the indoor environment and how improving it can also improve asthma symptoms. Therefore, the program also teaches some basic information about how to eliminate common asthma triggers—mold, dust mites, cleaning products, pesticides, cigarette smoke, pet dander and rodent and insect droppings—from the home. For example, Carrillo described families emptying an entire can of insecticide to kill a single cockroach, and while she applauds the instinct to get rid of pests in the house, the chemicals in the insecticide can make asthma worse. “This is the kind of behavior we have to change,” she said.
“We can’t change their homes,” Carrillo said, “we can just provide them with the tools and education to begin making changes little by little.” They then follow up with home visits to each family, which provides individual training for their specific environment.
The program also provides spacers for children in the program to help more medication in the inhaler reach the lungs, as well as peak flow meters so the children can measure their lung functioning. A medication assistance program helps participants with reduced-cost asthma medications for families who are uninsured or underinsured, because, Carrillo said, “we can give them a lot of education, but if they don’t have the medication that they need, it doesn’t help.”
Still, Carrillo said the program is very sustainable, because she coordinates the on-site visits herself and the education is done largely by respiratory therapy students from South Texas College and area nursing students as part of their clinical rotations. “This year I trained 70 respiratory therapy students,” Carrillo said, “and they enjoy the program because they learn how to develop rapport with the kids.”
Carrillo reaches out to local hospitals, namely Rio Grande Regional Hospital’s Respiratory Therapy Department, a collaborator for many years. If patients return to the hospital within the month, the hospital is penalized, so “hospitals are really interested in working with us to make sure their patients’ asthma is controlled,” Carrillo said.
Due to a grant award from the Knapp Community Care Foundation, Carrillo has a new collaboration with the Boys & Girls Club of America in Weslaco, Texas, which will provide another setting for teaching children about managing their asthma. This grant will expand the education and outreach on asthma to residents in Weslaco and surrounding communities of the Rio Grande Valley in South Texas.
Promising results and plans to expand
“In order to measure the success of the program,” Carrillo said, “we had to collect data to measure behavioral changes after the intervention.” To this end, she and her collaborators measured improvements in families’ emotional and physical health and activity levels, as measured by the Children’s Health Survey for Asthma. They also looked at overnight asthma-related hospitalizations as a proxy for poor control of asthma. The data showed “a very big drop” in hospitalizations, from six percent before the intervention to one percent after, Carrillo said. “The education was very well received by program participants.”
Carrillo was recently awarded a grant to use her Asthma and Healthy Homes curriculum to continue and expand the work that has proven so effective. She and her collaborators hope to include more hospitals and more areas in South Texas and to standardize the methodology. “There will always be some tailoring based upon the community,” she said, “but we hope to be able to standardize so we can compare county by county.”
“When we help people with asthma and their families, we can do so much. Increased quality of life, fewer missed school days—there are so many things that you can achieve,” Carrillo said. “It’s a matter of control and prevention—that’s what public health is.”