Translating an Evidence-based Urban Asthma Program for Rural Adolescents: Testing Effectiveness & Cost-effectiveness and Understanding Factors Associated with Implementation

项目摘要/摘要 背景与理论：哮喘是儿科最常见的慢性病，具有较高的患病率和 青少年中的发病率。很少有干预措施在高中进行测试；当由 社区卫生工作者(CHWS)，尽管这种模式在诊所和家庭干预中取得了成功。 此外，农村青少年代表着非常大的人口，在哮喘干预中被忽视。 研究。鉴于哮喘在这一群体中的高患病率，这种疏忽是一个重大的公共卫生问题 担忧。哮喘干预方面也缺乏成本效益分析和实施研究 研究。这项研究解决了这些治疗和方法上的差距。我们开发并建立了 青少年哮喘自我管理(ASMA)的有效性，这是一项为期8周的高中干预措施 城市西班牙裔和非裔美国青少年。目标：使用有效性-实施混合方法 设计，我们：(1)系统地评估在真实世界条件下实施ASMA的有效性 (2)评估Asma的成本效益；及(3) 进行基于理论、混合方法、多方利益相关者的流程评估，评估 ASMA的广泛实施。假设：与对照组相比，一年以上的ASMA学生将有 显著减少(1)因哮喘症状而夜间醒来，以及(2)有哮喘相关活动的天数 局限性(主要结果)。次要结果包括其他发病率指标(例如，急诊室就诊， 住院、生活质量)和护理过程结果。我们还假设阿斯玛会有 与医疗保健资源的替代用途相比，优势价值(ICER&lt；100,000/QALY)超过1和5 好几年了。方法：我们将在3年内招收400名9至11年级哮喘未得到控制的学生。 南卡罗来纳州农村社区的9所高中；我们将在一所学校内随机选择学生到阿斯玛和 进入注意力控制状态。社区卫生组织将提供这两种干预措施。学生和照顾者将被跟踪 用于12个月的治疗后。意向治疗(ITT)原则将应用于线性和一般性 线性混合效应模型。成本效益分析将依赖于决策分析马尔科夫模型。这个 过程评估建立在RE-AIM模型的基础上；我们收集学生的定性和定量数据， 照顾者、社区卫生工作者和学校管理人员。与来自不同环境的关键利益攸关方一起，我们将 制定模式，广泛传播和实施ASMA。意义：这项研究具有很高的公共卫生水平 重大意义，因为(1)它针对的是未得到充分研究的人群，(2)它依赖于现有的社区资源 干预实施；(3)通过成本效益分析评估ASMA的价值；(4) 通过确定与实施相关的因素，弥合研究和实践之间的差距。

PROJECT SUMMARY / ABSTRACT Background and Rationale: Asthma, the most common pediatric chronic illness, has high prevalence and morbidity among adolescents. Few interventions are tested in high schools; none when delivered by Community Health Workers (CHWs), despite this model's success in clinic- and home-based interventions. Further, rural adolescents, who represent a very large population, are overlooked in asthma intervention research. Given the high prevalence of asthma in this group, this oversight is a significant public health concern. Cost effectiveness analyses and implementation research are also lacking in asthma intervention research. This study addresses these treatment and methodological gaps. We developed and established the efficacy of Asthma Self-Management for Adolescents (ASMA), an 8-week, high school-based intervention, in urban Hispanic and African American adolescents. Objective: Using an effectiveness-implementation hybrid design, we: (1) evaluate systematically the effectiveness of ASMA when delivered under real world conditions by CHWs to rural adolescents with uncontrolled asthma; (2) assess the cost-effectiveness of ASMA; and (3) conduct a theory-based, mixed-methods, multi-stakeholder process evaluation of the barriers and facilitators of ASMA's widespread implementation. Hypotheses: Over 1 year, relative to controls, ASMA students will have significantly fewer (1) night awakenings due to asthma symptoms, and (2) days with asthma-related activity limitations (primary outcomes). Secondary outcomes include other measures of morbidity (e.g., ED visits, hospitalizations, quality of life) and care-process outcomes. We also hypothesize that ASMA will have favorable value (ICER < 100,000/QALY) compared to alternative uses of health care resources over 1 and 5 years. Methods: We will enroll over 3 years, 400 9th through 11th grade students with uncontrolled asthma from 9 high schools in rural communities in South Carolina; we will randomize students within a school to ASMA and to an attention control condition. CHWs will deliver both interventions. Students and caregivers will be followed for 12-months post-treatment. The intention-to-treat (ITT) principle will be applied using linear and general linear mixed effects models. The cost-effective analysis will rely on a decision-analytic Markov model. The process evaluation is built on the RE-AIM model; we collect qualitative and quantitative data from students, caregivers, CHWs and school administrators. Together with key stakeholders from a variety of settings, we will develop models to widely disseminate and implement ASMA. Significance: The study has high public health significance because (1) it targets an understudied population, (2) it relies on existing community resources for intervention implementation, (3) it assesses ASMA's value through cost-effectiveness analyses, and (4) it bridges the gap between research and practice by identifying factors associated with implementation.