The Stove project: an Interdisciplinary and Community Collaboration for Clean Air Javier F. Sevilla-Mártir MD Associate Professor of Clinical Family Medicine, Director Hispanic/Latino Health and International Medicine and Global Health, Department of Family Medicine, Indiana University School of Medicine AAFP Global Health Workshop, Minneapolis, September 6-8,2012

Co-authors Scott Renshaw, MD, Assistant Professor of Clinical Family Medicine, Family Medicine Clerkship Director, IU School of Medicine Scott Renshaw, MD, Assistant Professor of Clinical Family Medicine, Family Medicine Clerkship Director, IU School of Medicine Jennifer Custer, MA, Manager, ENLACE Global Health Project & Underserved Medicine Program Recruitment and Retention Specialist, AHEC. Ambassador, National Health Service Corps Jennifer Custer, MA, Manager, ENLACE Global Health Project & Underserved Medicine Program Recruitment and Retention Specialist, AHEC. Ambassador, National Health Service Corps

Objectives Describe process for project development and implementation Describe process for project development and implementation Describe project relevance and outcomes Describe project relevance and outcomes Discuss practical ways to implement relevant/similar projects and partnerships Discuss practical ways to implement relevant/similar projects and partnerships Discuss audience experiences in development and implementation of international global health collaborations and interventions Discuss audience experiences in development and implementation of international global health collaborations and interventions

Introduction The Stove Project is a collaboration of the Honduras Enlace Project sponsored by the IU Department of Family Medicine, in partnership with the community of Sabanas, Taulabe, Honduras and the IU Department of Public Health. The Stove Project is a collaboration of the Honduras Enlace Project sponsored by the IU Department of Family Medicine, in partnership with the community of Sabanas, Taulabe, Honduras and the IU Department of Public Health.

Background/Epidemiology 3 billion people worldwide use biomass for cooking and heating. WHO billion people worldwide use biomass for cooking and heating. WHO 2002 Indoor air pollution from biomass burning estimated to kill two million women and children/year. World Bank 1999 Indoor air pollution from biomass burning estimated to kill two million women and children/year. World Bank 1999

Justification We reviewed approximately 2,000 patient records from the Honduras project medical services showing high incidence of respiratory illnesses, (Emery, 2007). We reviewed approximately 2,000 patient records from the Honduras project medical services showing high incidence of respiratory illnesses, (Emery, 2007). These findings supported the need for a proactive preventive health care initiative through health education and community participation. These findings supported the need for a proactive preventive health care initiative through health education and community participation.

Description Cross-sectional, prospective, epidemiological study designed to be completed in three phases in the Village of Sabanas, Taulabe, Honduras to assess the impact of the wood burning stoves in the indoor air and respiratory health of the community Cross-sectional, prospective, epidemiological study designed to be completed in three phases in the Village of Sabanas, Taulabe, Honduras to assess the impact of the wood burning stoves in the indoor air and respiratory health of the community Sabanas:35 houses,164 residents, all households use wood burning stoves Sabanas:35 houses,164 residents, all households use wood burning stoves

Equipment Mine Safety Appliance (MSA) ELF portable pump - Measures TSP in air Mine Safety Appliance (MSA) ELF portable pump - Measures TSP in air Validated by Ministry of Health and WHO Validated by Ministry of Health and WHO EL-USB-CO carbon monoxide data logger EL-USB-CO carbon monoxide data logger Collect readings every 10, 20, 30 seconds, 1 minute intervals Collect readings every 10, 20, 30 seconds, 1 minute intervals

Equipment/supplies Health Respiratory Survey Health Respiratory Survey Simplified version of American Thoracic Society ATS-DLD-78-A Simplified version of American Thoracic Society ATS-DLD-78-A Peak Flow Meter- Measures Peak Expiratory Flow Rate (PEFR) Peak Flow Meter- Measures Peak Expiratory Flow Rate (PEFR)

Phase I A partnership with the community of Sabanas was established and a health education campaign was implemented. A partnership with the community of Sabanas was established and a health education campaign was implemented. A questionnaire was developed and administered to assess respiratory symptoms in children and adults A questionnaire was developed and administered to assess respiratory symptoms in children and adults

Phase I Peak flow meters were used to measure peak expiratory flow rates (PEFR). Peak flow meters were used to measure peak expiratory flow rates (PEFR). A built-environment questionnaire was completed for each household A built-environment questionnaire was completed for each household Escort ELF portable pumps and EL-USB- CO were used to test air quality. Escort ELF portable pumps and EL-USB- CO were used to test air quality.

Elf Pump and old Stove

Phase II Selection of wood burning stove with chimney to be built with materials available locally. Selection of wood burning stove with chimney to be built with materials available locally. Control homes with stoves to asses effectiveness of intervention Control homes with stoves to asses effectiveness of intervention intervention was implemented through installation of stoves in all homes of the village. intervention was implemented through installation of stoves in all homes of the village.

New Stove

Phase III Post intervention assessment of air quality and respiratory health with Elf pumps and EL-USB-CO (carbon monoxide data logger) and respiratory questionnaires Post intervention assessment of air quality and respiratory health with Elf pumps and EL-USB-CO (carbon monoxide data logger) and respiratory questionnaires Added questions to assess anecdotal higher efficiency of new stoves Added questions to assess anecdotal higher efficiency of new stoves

Methods/Results Post intervention questionnaire showed improved respiratory health of participants Post intervention questionnaire showed improved respiratory health of participants Statistically significant change in the TSP from µg/m 3 in phase I to µg/m 3 in phase III (p-value =0.018) Statistically significant change in the TSP from µg/m 3 in phase I to µg/m 3 in phase III (p-value =0.018) Only two households had CO readings of more than cero Only two households had CO readings of more than cero

Methods and Results Phase III (N=29 people) Phase I (N=79 people) (N=79 people) Respiratory Questionnaire No (%) Yes (%) No (%) Yes (%) Do you usually have a cough? Do you usually cough up phlegm? Have you ever had an attack of wheezing resulting shortness of breath? Are you troubled by activity induced shortness of breath? During the past 3 years have you had any chest illnesses that have kept you from working/at home? Have you ever smoked cigarettes? Have you ever smoked a pipe?

Methods and Results Phase I TSP Phase III TSP P-value (microgram/cubic meter of air) microgram/(cubic meter of air) Paired t-test Findings show a statistically significant change in levels of TSP between Phase I and Phase III, with a dramatic reduction in Phase III February 2009

Methods and Results February 2009 Carbon Monoxide House Number Number of readings (ppm) Maximum CO (ppm) C C C070A C070B C C C C C C C C C C C C C C C C C

Future Directions Construction of stoves in all the villages of the area Construction of stoves in all the villages of the area Promote reproduction in other regions of the country in collaboration with ministry of health Promote reproduction in other regions of the country in collaboration with ministry of health Assess/compare efficiency of stoves prototypes and promote more efficient one Assess/compare efficiency of stoves prototypes and promote more efficient one

Summary/Recommendations Asses community needs/assets Asses community needs/assets Establish collaborations Establish collaborations Be proactive Be proactive

Gracias Gracias