Place-Based Approach to Improve Asthma and Health in Public Housing Presented by–the Boston Housing Authority-Ketsy Carballo and John Kane and Boston Medical Center- Johnna Murphy National Healthy Homes Conference May 28, 2014 HUD Grant # MAAIH

Health in Public Housing Approximately 3 million people live in public housing across the nation; about 850,000 children or 41% (and many more live in leased housing) Source: CLPHA – HUD Resident Characteristics Report as of April 2006

Boston Housing Authority Largest housing authority in New England Largest property owner in Boston 9% of Boston residents in BHA housing (over 50,000 residents)

HUD and BHA 2010 – 2014 Strategic Plan Utilize HUD assistance to improve health outcomes Strengthen and expand the BHA’s health and wellness initiatives such as those established through the Partners in Health and Housing Prevention Research Center

Partners in Health and Housing Behavioral Risk Factor Surveillance System (BRFSS) Are you a public housing resident or live in subsidized housing such as Section 8?

Health in Public Housing City of Boston – comparing Boston residents with Boston public housing residents More diverse, more non-US born, lower education, lower income, fewer married Source: Boston Behavioral Risk Factor Surveillance System 2006 and 2008, Boston Public Health Commission

Fair or Poor Self-Rated Health by Housing Status, Boston Adults, 2006 and 2008 Combined DATA SOURCE: Boston Behavioral Risk Factor Survey 2006 and 2008, Boston Behavioral Risk Factor Surveillance System (BBRFSS), Boston Public Health Commission DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

Poor Mental Health by Housing Status, Boston Adults, 2006 and 2008 Combined DATA SOURCE: Boston Behavioral Risk Factor Survey 2006 and 2008, Boston Behavioral Risk Factor Surveillance System (BBRFSS), Boston Public Health Commission DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

Current Smoking by Housing Status, Boston Adults, 2006 and 2008 Combined DATA SOURCE: Boston Behavioral Risk Factor Survey 2006 and 2008, Boston Behavioral Risk Factor Surveillance System (BBRFSS), Boston Public Health Commission DATA ANALYSIS: Boston Public Health Commission Research Office

Asthma in United States Number of people diagnosed with asthma has been growing Approximately 1 in 12 Americans have asthma (about 25 million people) Source: CDC, May 2011

Asthma in New England Rates of asthma in New England are higher than other parts of the country (9.7% compared to 8.1%) Lifetime Asthma Rates for MA was 14.5% as of 2006 Source: Asthma Regional Council: Living with Asthma in New England, Feb 2010 report

Asthma Triggers Indoor Triggers: –Mold and Mildew –Dustmites –Pet Dander –Outdoor Air coming in your windows –Smoking –Nitrogen Dioxide –PESTS

Health in Public Housing

Lenox Camden Built 1939/1949 ~ 58% Hispanic and 30% Black ~375 units ~650 people ~$13,000 avg. ~40% age 0-18

Alice Taylor Built 1951 ~ 48% Hispanic and 45% Black ~366 units ~850 people ~$15,000 avg. ~36% age 0-18

Project LEAP Public Housing Community Health Workers: A Place-Based Approach to Improve Asthma, General Health Living Environmental Assessment Project = Project LEAP

Project LEAP Partners with Boston Medical Center and the Boston Public Health Commission HUD Grant # MAAIH Years Enroll 160 families

Project LEAP Goals and Objectives: Effect of CHW in Place-Based Model Reduce Exposure to Triggers Home-based Asthma Environmental Education

Project LEAP Timeline: 2012 – Training 2013 – Outreach 2014 – Ongoing Completion

Project LEAP Community Health Worker Training: Community Health Education Center (CHEC) 7 Core Sessions: Assessment, Leadership, Outreach CHEC 7 Health Modules: Mental Health, Family Planning, Emergency Preparedness

Project LEAP Training continued: IPM in MultiFamily Housing Essentials of Healthy Housing Institutional Review Board Asthma Training in Worcester BPHC shadow staff Asthma Home Environment Training in RI Learn and Teach About Asthma

Project LEAP Reina Sanchez “Project LEAP is a very good program. They helped me out and still are. I am satisfied.”

Project LEAP: 1 st Visit Informed Consent & Surveys Environmental Assessment Tupper Ware Healthy Homes Book (Eng/Span) Work Order assistance if needed

Project LEAP: 2 nd Visit Education & Surveys Environmental Assessment Cleaning Supplies / Recipes Trash Can with Lid Glue Trap / Roach Monitors if needed

Project LEAP: 3 rd Visit Education and Surveys Environmental Assessment HEPA vacuum / Swiffer Mop $20 gift card Work Order follow- up if needed

Project LEAP Home Visits / Incentives: 4 th contact Phone call or Visit Repeat of survey questions Measures sustainable change after program

Project LEAP: Data Study data collected on Ipads using REDCap Stands for Research Electronic Data Capture Secure, firewalled web- based application Allows for validated data entry

Project LEAP Key Measures: Environmental triggers (pests, mold, pets, chemicals, smoking and pesticides) Stress (Perceived Stress Scale) General Health and Wellbeing (Wellbeing Scale) Asthma Control (Asthma Control Test) Hospitalizations and urgent care and ER visits

Project LEAP: Preliminary Demographics 95 residents have completed at least one visit Gender: 79% female 21% male Race/Ethnicity: 46% Hispanic 39% Black (Not Hispanic) 6% White (not Hispanic) 1% Asian 14% Don’t know or Refused Education: 39% did not graduate high school 35% high school graduate or GED 26% at least some college Age: Average age=50 ranges from 22-74

Project LEAP Preliminary Asthma Results, Visit 1 39 Asthmatics Total 37% (30) homes with at least 1 asthmatic 31% well controlled asthma, 28% not well controlled, 41% poorly controlled 23% reported an asthma related hospital visit 28% reported an emergency or urgent care visit

Project LEAP Preliminary Perceived Stress Results Perceived Stress Scale: Designed to tap how uncontrollable and unpredictable subjects find their lives 13=average N=91 N=63N=47 Perceived Stress Scores, Visit 1,2, and 3

Project LEAP Preliminary Asthma Trigger Results An overall asthma trigger score is determined by any presence or reporting of mold, pests, dust, strong smelling chemicals, pets, or smoking. Percentage of Families with Asthma Triggers on Visit 1

Project LEAP Preliminary Asthma Trigger Results Average trigger score by visit Percent chemical use by visit LEAP teaches healthier cleaning alternatives!

Clutter Leaks, holes, etc Heating Concerns Asthma Medication Use Smoking Habits Allergies Work Orders Project LEAP Other Measures Collected Cats are like Potato Chips… You Can’t have Just One!

Project LEAP Work Orders: pest; 11 mold and mildew; 5 plumbing leak; 22 other “I have nothing negative to say about Project LEAP. It is a very good program.”

Project LEAP CHW Assistance: 95 enrolled Education: Environmental Triggers Work Orders Advocacy – Social Services Referral free local resources Continued Support-Phone call away Follow up

Project LEAP Lessons Learned: Work Order System Place-Based recruitment-benefits and challenges Employee / Resident CHWs

Place-Based Approach to Improve Asthma and Health in Public Housing