We very much agree with the observation that coalitions mobilizing stakeholders across a community to introduce improvements in asthma care and education is relevant to developing countries not just developed ones.1 The types of components developed in Goias, Brazil, by their city-wide Asthma Program (a holistic approach, strengthening links across levels of care, patient education, clinical provider training) are central to achieving the structures and behaviors necessary for asthma control.2 Our evaluation of the Allies Against Asthma coalitions provided evidence that new and invigorated policies are necessary to sustain such structural and behavioral change. The perspectives of stakeholders across communities are needed to identify areas of policy and practice that require enhancement, and to activate the available levers of change.
Getting asthma sufferers onto the right medicine is a necessary objective.3 However, it is neither easy to do nor is it sufficient. Studies have shown that many clinicians do not follow asthma clinical guidelines.4 Even when taught how to use metered dose inhalers and spacers, both patients’ and providers’ skills decay over time,5,6 and access to medicines does not ensure adherence to recommendations.7
Asthma control requires a range of concerted and integrated elements. These include assistance to individuals and families with initial and follow-up education and support to enable them to become high-level self-managers.8 They also include health professionals who provide gold standard care, clinical systems where coordination of care is routine, data sharing to target those most in need and to monitor outcomes, insurance that is comprehensive and based on evidence of effectiveness, physical environments that are clean and healthful, and community resources and strategies that function optimally. Policies that can create such a system and that address and complement each other are dependent on getting the right people together at the right time, including some who have never before been at the same table. Their joint expertise and influence can effect improvements not only at the organizational and community level but, as shown in our article, at regional and state levels as well. High-functioning coalitions can mobilize the needed expertise and experience and can realize asthma outcomes that reach people population-wide. Equally as important, they can produce fundamental change in the way medicine and public health approach chronic diseases in general.
Public health can play a critical role, especially, in decentralized systems like Goias where across regions approaches to health and health care can differ significantly. By seeking consistency and standardization in practice, data sharing, and sharing of resources, public health-led coalitions can help to close the clinic–community gap. The goal is seamless provision of support to individuals and families managing asthma that stretches from their physicians’ offices to schools and workplaces to their homes and community centers. Coalitions can tackle the policy development needed to make the links of this chain stronger and more likely to control not only asthma but the staggering costs associated with it.
Acknowledgments
The original article was supported by multiple grants from the Robert Wood Johnson Foundation, and additional support was provided by the W.K. Kellogg Foundation.
We gratefully acknowledge the guidance and contributions of Michele Carrick, MSW, Elaine Cassidy, PhD, Mary desVignes-Kendrick, MD, MPH, Susan Downey, MEd, Rachel A. Gonzales-Hanson, Rob Fulwood, PhD, JA Grisso, MD, MPH, Barbara Israel, PhD, Talmadge King, MD, Floyd Malveaux, MD, PhD, Robert Mellins, MD, Steve Page, MPA, Guy Parcel, PhD, Stephen Redd, MD, Jeanne Taylor, PhD, Abe Wandersman, PhD, Sandra Wilson, PhD, Albert Yee, MD, Sarah Hearn, Yagiang Li, and Charles Brinker. Additionally, we thank Christine Joseph, MD, for matches of Allies zip codes. We also wish to thank the dedicated members of all the Allies coalitions.
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