Pediatric Asthma, Mold, and a Community Health Worker Program
A community health center serves a neighborhood where 38% of children live below the federal poverty level. The nearest full-service grocery store is 2.5 miles away; two dollar stores are closer. Buses run every 45 minutes. Pediatric asthma emergency visits are twice the county rate. A community health worker visits the home of a 9-year-old with asthma. The child has wheezing three nights a week, an inhaler but no spacer, and a school action plan that was never completed. The family's apartment has visible mold in the bathroom, and the landlord has not responded to repair requests. The mother works two jobs and speaks limited English. The clinic has one bilingual CHW and a small flexible fund. The team wants to reduce ED visits without blaming the family.
1. Apply the social ecological model to this child's asthma and identify at least one factor at each level.
Read the worked answer
Individual-the child's asthma control, inhaler technique, and knowledge; the mother's work schedule and English proficiency are also individual-level barriers. Interpersonal-family routines, caregiver confidence, and support from relatives. Organizational-the clinic's ability to provide spacers, teach-back, and follow-up; the school's readiness to use the asthma action plan and to address triggers. Community-housing conditions, mold, food access, transportation, and the availability of a full-service grocery store. Policy-housing code enforcement, landlord accountability, Medicaid coverage, and school health policies.
The mold is not a lifestyle choice; it is a community- and policy-level exposure. The child's nighttime symptoms suggest poor control and trigger exposure rather than simply nonadherence. A plan that only lectures the mother would be incomplete and unfair. The clinic should address the physical environment and access barriers while building on family strengths.
2. Design a multi-level intervention the clinic and community partners could implement within existing resources, and explain how cultural humility and health literacy would shape delivery.
Read the worked answer
A realistic multi-level plan: (1) Clinic-same-day asthma check, spacer with teach-back, written action plan in the family's language, and a follow-up call in one week. (2) Home-bilingual CHW visit to assess triggers, provide mattress covers and cleaning supplies, and document mold with photos and a letter. (3) Legal/community-refer to legal aid or a housing advocate for repair enforcement; use flexible funds for a HEPA vacuum or temporary relocation if needed. (4) Food access-enroll in a produce prescription or food pantry, and arrange transportation vouchers or delivery. (5) School-complete the action plan, identify a school nurse contact, and ensure rescue inhaler access. (6) Policy-support a housing code complaint and track response.
Cultural humility means asking what the family wants, using an interpreter rather than the child, avoiding blame, and recognizing the mother's two jobs. Health literacy means plain language, pictures, teach-back, and a written plan using the family's own words. Measure whether the mold is remediated, not just whether the family attended a visit.
3. What outcomes would you measure at 6 and 12 months, and what confounders could make the program look ineffective?
Read the worked answer
At 6 months, measure process and proximal outcomes: CHW visits completed, action plans in place, spacer use, controller medication fills, asthma control score, school absences, and housing repair status. At 12 months, measure ED visits and hospitalizations, oral steroid courses, and caregiver quality of life. Compare with the clinic's other pediatric asthma patients or with the county rate.
Confounders include season and influenza, housing moves, changes in insurance or Medicaid, clinic staffing, and regression to the mean because children often enroll after a bad spell. A before-after drop in ED visits may not prove the program worked. Use a comparison group if possible, adjust for baseline severity, and track whether mold was actually remediated. Also watch for unintended effects, such as families being reported to child protective services for housing conditions; establish a clear, non-punitive referral policy. Report both successes and null findings.