A Collaboration of Community, University and City

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A Collaboration of Community, University and City Boston Housing

School of Public Health Committee for Boston Public Housing, Inc.

Harvard University School of Public Health Peregrine Energy Group

1 A Collaboration of Community, University and City Boston Housing Authority Boston Public Health Commission Boston University School of Public Health Committee for Boston Public Housing, Inc. Franklin Hill Tenant Task Force, Inc. Harvard University School of Public Health Peregrine Energy Group Tufts University School of Medicine Urban Habitat Initiatives West Broadway Tenant Task Force, Inc.

2 Residents of Boston Housing Authority Socio-economic profile 5% of city population, with equivalent on waiting list 72% female head of household Average household income: < $11,000 for a family of four 17% of Boston s median household income 78% people of color Comparative health data BHA residents report fair or poor health at 3x rate of Boston residents Substantially higher reported rates than city residents of heart disease, stroke, hypertension, and diabetes Report 3-5 times the national rate of child and adult asthma Sources: BHA, PRC, 2003.

3 Asthma: U.S Prevalence (%) Under Total 1992 Source: National Health Interview Survey * 12-month prevalence Year

4 Source: The Burden of Pediatric Asthma, N. Krauss and J.A. Rhoades, Overall Average Pediatric Asthma Rate above 10% Hispanic Black White & other

5 Source: Presentation: The ABC s of Asthma by M. Sandel, MD, MPH, Asthma - Sobering Statistics Leading cause of school absence Leading reason for ER visits among children Prevalence and death rate increasing 5 million children in US with asthma

6 Source: Boston Public Health Commission Asthma Hospitalization, Boston, (per 1,000)

7 Boston Housing Authority Buildings 14,300 units in 68 developments Current capital needs: $300 M Annual capital funding: $25-30 M Under-capitalized and diminishing federal budget. Source: BHA, Photo: Cathedral Housing Development, 2004.

8 Source: BHA, Boston Housing Authority Capital Funding $35,000,000 $30,000,000 $25,000,000 $20,000,000 FY 00 FY 01 FY 02 FY 03 FY 04 Federal capital funds to Boston Housing Authority Total budget reduction FY 2000 FY 2004 = 23%

9 West Broadway Development

10 Franklin Hill Development

11 Source: HPHI Policy Advisory Council Meeting, December HPHI Project Goals Document baseline housing conditions and respiratory health status in Boston public housing. Improve home environments for better respiratory health and increase quality of life for residents of public housing. Build capacity within city agencies, community organizations, & residents to sustain health focus. Impact local, state, and national policy on housing design, integrated pest management, and health care financing for asthma.

12 Source: HPHI Policy Advisory Council Meeting, December HPHI Activities Focus Groups Survey Management Systems Interventions & Health Outcomes Analysis & Policy

13 Role of Community Health Advocates 1. Residents trained as Community Health Advocates (CHAs). 2. CHAs conducted cross-sectional surveys of housing and health conditions: 1998, 1999, CHAs collected environmental samples, temperature and humidity data, asthma health data within integrated pest management intervention study, CHAs participate in reviewing research results and policy group work.

14 Summary of Key Physical Environment Findings Leaks, Moisture and Mold 64% Leaks from ceiling, wall, radiators, toilet, tub or sink 20% Mold growth Ventilation and Heating 46% Not enough fresh air in apartment 66% Apartment is too hot in winter 82% Leave window open in winter 32% Use oven to heat apartment Sanitation and Infestation 48% Visible indications of cockroaches in the building 35% Visible indications of mice/rats around building 48% Dumpsters collected after they overflow 24% Can smell dumpsters from apartment Source: West Broadway Development survey results, H.P. Hynes, et al., 2000.

15 Summary of Key Health and Safety Findings Child Health and Safety 25% Wall/floor steam pipes hot enough to burn 40% Radiator surface can burn 57% Lives above the first floor and has no window guards* 56% Tap water too hot* Smoking 49% Respondent smokes Asthma 26% Respondent reports being diagnosed with asthma Symptoms in Last Month 56% Headaches 50% Sore or dry throat 46% Coughing 40% Excessive tiredness 32% Respiratory problems *Only families with children under 10 years old responded, 22 families. Source: West Broadway Development survey results, H.P. Hynes, et al., 2000.

16 Indoor Exposures and Asthma Development and Exacerbation Dust mites: development of asthma. Environmental tobacco smoke: development of asthma in younger children, less strong evidence for older children and adults. Exacerbation of asthma in all. Cat and cockroach allergens and dust mites: exacerbation of asthma. Fungi or molds and NO2 and NOX: exacerbation of asthma. Formaldehyde and fragrances: limited evidence of exacerbation of asthma. Source: Clearing the Air, Institute of Medicine, 2000.

17 Mold Uninsulated walls. High relative humidity. Inadequate ventilation. Ceiling, wall, and window leaks. Furniture against walls with little air circulation. Photo: BHA apartment, 2001.

18 Apartment Mold Associated with many Symptoms Yes No Dizzy * Headaches * Nausea * Cough Tired * Nosebleed Breathing Prob * Blurry Vision * Wheeze * Sneeze Ear Infection ** Skin Rash Burn/Itch Eye * Sore Dry Throat * * p<0.05 ** p<0.001 Source: West Broadway and Franklin Hill Developments survey results, K. Welker-Hood, 2003.

19 Baseline Evaluation Health/risk factor assessment prior to preintervention tracking. Consideration of numerous health endpoints relevant for different phases of analysis: Lung function Respiratory symptoms Health care utilization Self-reported quality of life

20 Health Outcome Measures Quality of life survey Asthma symptom diaries Medication use ER/hospital/doctor s visit/missed school or work Peak flow Spirometry

21 Asthma Severity/Symptoms (in two weeks before enrollment) Never 1-2 per week 3-6 per week At least daily Wheezing, chest tightness, cough 20% 41% 24% 15% Slow/stop play or activities 34% 35% 19% 12% Wake up at night 32% 34% 25% 9% Source: J. Levy et al., 2004.

22 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Allergy Testing Results (n = 44) HPHI NCICAS D. Pteronyssinus Cockroach D. Farinae 11-tree mix Cat Mouse Aspergillus fumigatus 7-grass mix Ragweed Cladosporium Alternaria Dog Penicillin Source: J. Levy et al., Any allergens % with positive allergy test

23 HPHI Project Interventions Asthma Management: In-home asthma management training, access to peak flow meters, maintaining an appropriate medication regimen. Environmental Improvements: New mattresses, pillow covers, air purifier, minor home improvements, deep cleaning, integrated pest management including: - sanitation - removal of cockroach residue - patching and caulking of holes and points of entry - application of gels

24 Integrated Pest Management Pilot Study Cockroach Apartment 1 Apartment Antigen (U/g) Baseline Month Effect of industrial cleaning on cockroach antigen concentrations in settled house dust in two apartments. For both apts 1 and 5, cleaning was done after baseline, prior to measurement of antigen in month 2. For apt 1, cleaning was also done between mos. 4 and 5. Source: D. Brugge, et al., 2002.

25 IPM Outcome Measures Cumulative Frequency Bla g 2 Kit Cumulative Frequencies Bla g 2 Concentration (U/g) Baseline Session 2 Session 3 Source: J. Peters, 2004.

26 HPHI Policy Areas Health Resident Empowerment Capital Planning and Funding Operations & Maintenance Source: HPHI Policy Advisory Council Meeting, December 2003.

27 Photos: Charlestown Environmental Health Project, Spring Principles of Community-Based Research Receptivity toward local knowledge and observation Sharing of skills and knowledge among partners. Just compensation for community participation.

28 Principles of Community-Based Research Data collected for purposes of education, action and social change.

29 Principles of Community-Based Research Sharing data and analysis results with community partners.

30 Principles of Community-Based Research Co-presenting and co-publishing research results with community partners where feasible and relevant. Applied Environmental Science and A Public community-based Health 2003: participatory 1(2) survey of public housing conditions and associations between renovations and possible building- related health symptoms Doug Brugge, 1 Steven Melly, 2 Andrea Finkelman, 1 Mary Russell, 3 Laura Bradeen, 3 Rosaira Perez, 4 Linda Henson, 4 Timothy Heeren, 5 John Snell, 6 Daniel Helms, 7 H Patricia Hynes 5 1 Tufts University School of Medicine, Boston, MA, USA; 2 Harvard University School of Public Health, Boston, MA, USA; 3 West Broadway Task Force, Boston, MA, USA; 4 Franklin Hill Housing Development resident, Boston, MA, USA; 5 Boston University School of Public Health, Boston, MA, USA; 6 Peregrine Energy Group, Boston, MA, USA; 7 Boston Housing Authority, Boston, MA, USA Abstract: This paper reports on analyses of survey data from two public housing developments in Boston, Massachusetts (USA) that house low-income inner-city residents. The two developments differ in that one has had substantial renovations to walls, roofs, piping, heating and water systems while the other has not. In 2002, we collected 238 surveys from the two developments combined, using a questionnaire that recorded self-reports of housing conditions (pest infestation, water leaks, etc), chronic health conditions and symptoms in the preceding month. Because heating and domestic water system replacement at the renovated development occurred between the 2002 survey and a pilot survey we conducted in 1998, we were also able to assess changes in the responses over time. Crude and adjusted odds ratios (ORs) showed that residents reported worse environmental conditions at the unrenovated development. Only the crude OR for skin rashes was statistically significant and only the adjusted ORs for ear infection, skin rashes and sneezing exceeded 2.0. The longitudinal component of the study also showed changes in environmental factors after renovation, but the evidence was more mixed with both negative and positive trends. Only the crude OR for Source:

EPR 3 (2007) Measures of Assessment and Monitoring Education Control of Environmental Factors Medication

EPR 3 (2007) Measures of Assessment and Monitoring Education Control of Environmental Factors Medication EPR 3 (2007) Component 1: Measures of Assessment and Monitoring Component 2: Education Component 3: Control of Environmental Factors Component 4: Medication KEY DIFFERENCES FROM 1997 EXPERT PANEL REPORT