***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Social epidemiology is the study of relations between social factors and health status in population s. Although recent decades have witnessed a rapid development of this research program in scope and sophistication , causal inference has proven to be a persistent dilemma due to the natural assignment of exposure level based on unmeasured attributes of individuals , which may lead to substantial confounding . Some optimism has been expressed about r and omized social interventions as a solution to this long-st and ing inferential problem . We review the causal inference problem in social epidemiology , and the potential for causal inference in r and omized social interventions . Using the example of a currently on-going intervention that r and omly assigns families to non-poverty housing , we review the limitations to causal inference even under experimental conditions and explain which causal effects become identifiable . We note the benefit of using the r and omized trial as a conceptual model , even for design and interpretation of observational studies in social epidemiology BACKGROUND Community Action Against Asthma ( CAAA ) is a community-based participatory research ( CBPR ) project that assesses the effects of outdoor and indoor air quality on exacerbation of asthma in children , and tests household- and neighborhood-level interventions to reduce exposure to environmental asthma triggers . Representatives of community-based organizations , academia , an integrated health system , and the local health department work in partnership on CAAA 's Steering Committee ( SC ) to design and implement the project . OBJECTIVE To conduct a process evaluation of the CAAA community-academic partnership . DESIGN In-depth interviews containing open-ended questions were conducted with SC members . Analysis included established methods for qualitative data , including focused coding and constant comparison methods . SETTING Community setting in Detroit , Michigan . PARTICIPANTS Twenty-three members of the CAAA SC . MEASUREMENTS Common themes identified by SC members relating to the partnership 's ability to achieve project goals and the successes and challenges facing the partnership itself . MAIN RESULTS Identified partnership accomplishments included : successful implementation of a complex project , identification of children with previously undiagnosed asthma , and diverse participation and community influence in SC decisions . Challenges included ensuring all partners ' influence in decision-making , the need to adjust to " a different way of doing things " in CBPR , constraints and costs of doing CBPR felt by all partners , ongoing need for communication and maintaining trust , and balancing the needs of science and the community through intervention . CONCLUSIONS CBPR can enhance and facilitate basic research , but care must be given to trust issues , governance issues , organizational culture , and costs of participation for all organizations involved Objectives Childhood asthma is a growing public health concern in low-income urban communities . Indoor exposure to asthma triggers has emerged as an important cause of asthma exacerbations . We describe indoor environmental conditions related to asthma triggers among a low-income urban population in Seattle/King County , Washington , as well as caregiver knowledge and re sources related to control of these triggers . Methods Data are obtained from in-person , structured , closed-end interviews with the caretakers of children aged 4–12 years with persistent asthma living in households with incomes less than 200 % of poverty . Additional information is collected during a home inspection . The children and their caregivers are participants in the ongoing Seattle-King County Healthy Homes Project , a r and omized controlled trial of an intervention to empower low-income families to reduce exposure to indoor asthma triggers . We report findings on the conditions of the homes prior to this intervention among the first 112 enrolled households . Results A smoker was present in 37.5 % of homes . Mold was visible in 26.8 % of homes , water damage was present in 18.6 % of homes , and damp conditions occurred in 64.8 % of households , while 39.6 % of caregivers were aware that excessive moisture can increase exposures to allergens . Dust-trapping reservoirs were common ; 76.8 % of children 's bedrooms had carpeting . Cockroach infestation in the past 3 months was reported by 23.4 % of caregivers , while 57.1 % were unaware of the association of roaches and asthma . Only 19.8 % of the children had allergy-control mattress covers . Conclusions Many low-income urban children with asthma in King County live in indoor environments that place them at substantial risk of ongoing exposure to asthma triggers . Subst and ard housing and lack of re sources often underlie these exposures . Initiatives involving health educators , outreach workers , medical providers , health care insurers , housing agencies , and elected officials are needed to reduce these exposures R and omized controlled trials ( RCTs ) are essential for evaluating the efficacy of clinical interventions , where the causal chain between the agent and the outcome is relatively short and simple and where results may be safely extrapolated to other setting s. However , causal chains in public health interventions are complex , making RCT results subject to effect modification in different population s. Both the internal and external validity of RCT findings can be greatly enhanced by observational studies using adequacy or plausibility design s. For evaluating large-scale interventions , studies with plausibility design s are often the only feasible option and may provide valid evidence of impact . There is an urgent need to develop evaluation st and ards and protocol s for use in circumstances where RCTs are not appropriate OBJECTIVES We assessed the effectiveness of a community health worker intervention focused on reducing exposure to indoor asthma triggers . METHODS We conducted a r and omized controlled trial with 1-year follow-up among 274 low-income households containing a child aged 4 - 12 years who had asthma .  Community health workers provided in-home environmental assessment s , education , support for behavior change , and re sources . Participants were assigned to either a high-intensity group receiving 7 visits and a full set of re sources or a low-intensity group receiving a single visit and limited re sources . RESULTS The high-intensity group improved significantly more than the low-intensity group in its pediatric asthma caregiver quality -of-life score ( P=.005 ) and asthma-related urgent health services use ( P=.026 ) . Asthma symptom days declined more in the high-intensity group , although the across-group difference did not reach statistical significance ( P=.138 ) . Participant actions to reduce triggers generally increased in the high-intensity group . The projected 4-year net savings per participant among the high-intensity group relative to the low-intensity group were 189 - 721 dollars . CONCLUSIONS Community health workers reduced asthma symptom days and urgent health services use while improving caregiver quality -of-life score . Improvement was greater with a higher-intensity intervention Pediatric asthma is a growing public health issue , disproportionately affecting low-income people and people of color . Exposure to indoor asthma triggers plays an important role in the development and exacerbation of asthma . We describe the implementation of the Seattle-King County Healthy Homes Project , a r and omized , controlled trial of an outreach/education intervention to improve asthma-related health status by reducing exposure to allergens and irritants in the home . We r and omly assigned 274 low-income children with asthma ages 4 - 12 to either a high- or a low-intensity group . In the high-intensity group , community health workers called Community Home Environmental Specialists ( CHES ) conducted initial home environmental assessment s , provided individualized action plans , and made additional visits over a 12-month period to provide education and social support , encouragement of participant actions , provision of material s to reduce exposures ( including bedding encasements ) , assistance with roach and rodent eradication , and advocacy for improved housing conditions . Members of the low-intensity group received the initial assessment , home action plan , limited education during the assessment visit , and bedding encasements . We describe the recruitment and training of CHES and challenges they faced and explain the assessment and exposure reduction protocol s addressing dust mites , mold , tobacco smoke , pets , cockroaches , rodents , dust , moisture , and toxic or hazardous chemicals . We also discuss the gap between the practice s recommended in the literature and what is feasible in the home . We accomplished home interventions and participants found the project very useful . The project was limited in resolving structural housing quality issues that contributed to exposure to indoor triggers The goal of this investigation was to use a community-based participatory research approach to develop , pilot test , and administer an asthma screening question naire to identify children with asthma and asthma symptoms in a community setting . This study was conducted as the recruitment effort for Community Action Against Asthma , a r and omized trial of a household intervention to reduce exposure to environmental triggers of asthma and was not design ed as a classic prevalence study . An asthma screening question naire was mailed and /or h and delivered to parents of 9,627 children , aged 5 to 11 years , in two geographic areas of Detroit , Michigan , with predominantly African American and Hispanic population s. Additional question naires were distributed via community networking . Measurements included parent report of their child 's frequency of respiratory symptoms , presence of physician diagnosis of asthma , and frequency of doctor-prescribed asthma medication usage . Among the 3,067 completed question naires , 1,570 ( 51.2 % of returned surveys , 16.3 % of eligible population ) were consistent with asthma of any severity and 398 ( 12.9 % of returned surveys , 4.1 % of eligible population ) met criteria , for moderate-to-severe asthma . Among those meeting criteria for moderate-to-severe asthma , over 30 % had not been diagnosed by a physician , over one half were not taking daily asthma medication , and one quarter had not taken any physician-prescribed asthma medication in the past year . Screening surveys conducted within the context of a community-based participatory research partnership can identify large numbers of children with undiagnosed and /or undertreated moderate-to-severe asthma . These children are likely to benefit from interventions to reduce morbidity and improve quality of life The environment is suspected to play an important role in the prevalence and severity of asthma in inner-city children . This paper describes the implementation and baseline data of an inner-city community-based participatory research clinical trial design ed to test the effectiveness of a pollutant and allergen control strategy on children 's asthma morbidity . Participants were 100 elementary-school-aged children with asthma , graduates of a school-based asthma education program in East Baltimore . The intervention for half of the r and omly assigned families consisted of environmental control education , allergen-proof encasements , pest extermination , and a HEPA air cleaner at the beginning of the study . Controls received the same at the end of the study . Participants visited a clinic for question naires , allergy skin testing , spirometry , and blood sample at baseline and 12 months . Home environments , NO(2 ) , O(3 ) , airborne particulates , and allergens were evaluated at baseline and at 6 and 12 months . Asthma morbidity and adherence was assessed quarterly . Collaboration with the community proved very beneficial in creating a study design and procedures acceptable to an inner-city community 
    Output:
    
The collaboration among government scientists , university research ers and community partners emerged as a new model of CBPR partnerships that effectively integrates research and action .