ABSTRACT
Housing quality and affordability are well established as social determinants of health through direct and indirect mechanisms. Respiratory illnesses related to housing are nearly all the result of housing disrepair that allows intrusion into the home of environmental agents that are directly or indirectly associated with disease. Structural deficiencies such as leaks, cracks in the foundation or holes in the home's exterior can facilitate the presence of mould, which is causally linked to the development of asthma and is associated with exacerbation of asthma symptoms in children and adults. Indoor cleanliness can also contribute to the presence of mice and cockroaches. Proper ventilation can improve air quality, reducing exposure to PM, VOCs and infectious respiratory agents. Disparities in exposure to the housing conditions associated with respiratory disease are readily apparent across socioeconomic lines. Low-income families are less likely to be able to afford the costs of maintaining a home, which prevents them from making repairs that could improve respiratory health.Copyright © ERS 2023.
ABSTRACT
Introduction: National Service Evaluations of COVID-19 ARDS care in the US and UK showed significant variability in clinical practice, and adherence to existing guidelines. To better understand the basis for this, we explored factors influencing decision-making around mechanical ventilation in COVID-19. Method(s): We conducted interprofessional focus groups identifying factors that influenced decision-making through thematic analysis. From this, we developed a questionnaire to validate these themes with a larger sample of critical care professionals across the UK. Kruskal- Wallis or Mann-Whitney U tests were used for data analysis. Result(s): There were 179 complete responses from doctors, nurses and physios. In their usual practice, 66% of clinicians reported adherence to national ARDS guidelines. However, 80% thought COVID-19 ARDS presented differently to their previous clinical knowledge/experience of ARDS and 72% thought deviating from usual practice was necessary. Doctors were more likely to think deviation was necessary (p < 0.001) but there was no difference across level of ICU experience (p = 0.845). Clinicians reported their ventilatory decision-making was most influenced by disease factors, followed by team then contextual and least by environmental factors (p < 0.001). Disease factor was seen as most important across profession and experience level. During COVID-19, 68% of clinicians reported not being confident in their ventilatory decision-making;however, clinicians who felt COVID-19 ARDS presentation fitted with their previous clinical knowledge/experience of ARDS reported greater confidence (p < 0.001). Confidence was not affected by experience (p = 0.522) or profession (p = 0.294) (Fig. 1). Conclusion(s): Clinicians were influenced by the uncertain understanding of COVID-19 ARDS, especially when they considered previous experiences to be less relevant. In the event of another novel disease, developing a consistent, understandable clinical models of disease should be prioritised to optimise decision making.
ABSTRACT
RATIONALE: Asthma disproportionately affects low-income and minority adults who are mostly women. The Helping Asthma Patients-3 (HAP-3) Study is designed to engage patients and reveal where health disparity gaps could be reduced. During the intervention, all participants work with a Community Health Navigator, who prepares participants for clinic visits, attends visit while taking notes, and after the session reviews care recommendations with participants. Half of participants are randomized to receive home visits by Navigators, where clinic recommendations are reviewed;health goals are discussed and reported to the patient's clinician. When COVID-19 pandemic forced a widespread shut-down, we were in the 8th month of recruitment and ontarget to reach our enrollment goals for adults with uncontrolled asthma living in low-income neighborhoods. During this unprecedented event, the target community was also traumatized by nationwide episodes of police brutality, hate crimes, and gun violence. With the shutdown and local civil unrest, enrollment slowed. Our goal is to boost enrollment and maintain retention. METHODS: Using a community-based participatory approach, the role of the Community Health Navigator was adapted to boost recruitment, engage participants, and keep clinicians informed of implementation changes, while maintaining the original aims. Using an iterative process with daily huddles of the Navigators and weekly meetings of the Navigators and other team members, including community participants, the protocol was adapted. RESULTS: Over the nine months since the shutdown, we enrolled 73 patients, 60 clinic visits, and 39 number of home visits. We achieved approximately 50% of our original target recruitment goal. We implemented the following innovative adaptations to facilitate enrollment and retention: 1) developed the option of virtual visits for clinic and homes;2) created IRB-approved questionnaires to assess the impact of the pandemic on participants' asthma, general health, and well-being;3) recruited two additional clinics;4) surveyed the impact of social determinants of health on participants;5) standardized our approach to patients;and 6) convened our Community Advisory Board for feedback on adaptations. We improved participant and provider communications through news briefs and fliers, and maintained our presence in clinical offices through in-person and virtual office visits. CONCLUSION: In clinical research, especially of lowincome vulnerable communities, natural events can influence the research and require adaptation of the protocol to preserve its mission. The role of Community Health Navigators is integral in the innovative adaptation of community-based research to capture the needs of patients and inform clinicians.