1. 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 jsevilla@iupui.edu AAFP Global Health Workshop, Minneapolis, September 6-8,2012

2. 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

3. 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

4. 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.

5. Background/Epidemiology 3 billion people worldwide use biomass for cooking and heating. WHO 2002 3 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

6. 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.

7. 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

8. 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

9. 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)

10. 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

11. 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.

12. Elf Pump and old Stove

13. 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.

14. New Stove

15. 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

16. 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 604.8 µg/m 3 in phase I to 136.3 µg/m 3 in phase III (p-value =0.018) Statistically significant change in the TSP from 604.8 µg/m 3 in phase I to 136.3 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

17. 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? 78.520.6 79.720.3 Do you usually cough up phlegm? 82.117.9 7525 Have you ever had an attack of wheezing resulting shortness of breath? 86.213.7 72.727.3 Are you troubled by activity induced shortness of breath? 75.824.1 63.236.8 During the past 3 years have you had any chest illnesses that have kept you from working/at home? 89.610.3 67.132.9 Have you ever smoked cigarettes? 85.114.8 8713 Have you ever smoked a pipe? 1000 1000

18. Methods and Results Phase I TSP Phase III TSP P-value (microgram/cubic meter of air) microgram/(cubic meter of air) Paired t-test 91.66666667204.16666670.01808732 862.583.33333333 Findings show a statistically significant change in levels of TSP between Phase I and Phase III, with a dramatic reduction in Phase III 142.307692341.66666667 49.180327871525 20.66115702387.5 28.68852459412.5 20.49180328537.5 92.920353981483.333333 39.285714291500 62.5683.3333333 360.1694915625 9683.33333333 28.45528455887.5 136.2733583604.797619 February 2009

19. Methods and Results February 2009 Carbon Monoxide House Number Number of readings (ppm) Maximum CO (ppm) C040320.00000 C050300.00000 C070A300.633312 C070B330.00000 C080300.00000 C100340.26479 C110300.00000 C120160.00000 C130300.00000 C150300.00000 C160830.00000 C170300.00000 C180260.00000 C200290.00000 C220450.00000 C240300.00000 C270360.00000 C290310.00000 C300550.00000 C330320.00000 C360320.00000

20. 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

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

22. Gracias Gracias