1. Healthy Homes for All: Improving Children’s Health in Diverse Communities University of Massachusetts Lowell UMass Medical School David Turcotte, ScD Heather Alker, MD, MPH Emily Chaves, MA Susan Woskie, PhD Worcester State University Rebecca Gore, PhD Stephanie Chalupka, EdD Fred Youngs, PhD Joann Vaillette, MA Lowell Community Health Center Carla Caraballo Bophamony Vong

2. Presenter Disclosures David Turcotte, ScD Joann Vaillette, MA Emily Chaves, MA Susan Woskie, PhD Rebecca Gore, PhD Fred Youngs, PhD Heather Alker, MD, MPH Carla Caraballo Bophamony Vong “No relationships to disclose”

3. Funded by the U.S. Department of Housing and Urban Development Why asthma? Why Lowell? –High asthma rate –Diverse community –Poor housing stock –Community health partners

4. U.S. Asthma Rates –General Population 8.2% –Puerto Rican 16.6% (National Health Statistics report on asthma prevalence in the United States, 2011) Hospitalization rates for asthmatic children age 0-4 –Massachusetts 430 per 100,000 –Lowell 805 per 100,000 (Asthma report for Lowell mortality and hospital data. Massachusetts DPH, 2007-2009)

5. Project Goals: Families First time home buyers Home assessmentsEducation Home interventions Education Partners Education

6. Partners & Roles University of Massachusetts Lowell Lowell Community Health Center Coalition for a Better Acre Community Teamwork, Inc. Lowell Housing Authority Merrimack Valley Housing Partnership

7. Families – who are they? Live in Lowell, MA Have at least one child with asthma (<=14) Low-moderate income 165 families enrolled (245 children)

8. What is Asthma? A serious & sometimes life-threatening respiratory disease Affects the quality of life for millions of Americans No cure for Asthma yet Can be controlled through medical treatment & management of environmental triggers

9. Americans spend up to 90% of their time indoors Indoor concentrations of most pollutants are higher than outdoor Indoor Environment and Asthma

10. Indoor allergens and irritants can play significant roles in triggering asthma attacks –Ex: pet dander, mice, cockroaches, dust mites, harsh chemicals, fragrances, smoke, moisture/mold, pollen Important to recognize potential asthma triggers & reduce exposure

11. Home Intervention - Assessment Health/environmental assessments –Health questionnaire with parent –Environmental walk-through assessment –Environmental questionnaire with parent –Dust sampling Assessment Education, Supplies, Remediation Mid-term Assessment 6 th month Final Assessment 12 th month

12. Education, Supplies, Remediation Education –Dust mites and healthy cleaning practices –Pets –Avoiding pests –Moisture/mold control –Smoking –Air pollution (indoor & outdoor) –Safety Supplies –HEPA vacuum –Allergen-proof mattress and pillow covers –Trash can with lid –Food containers –Non-toxic cleaner –Baits and traps for pests –Safety items Assessment Education, Supplies, Remediation Mid-term Assessment 6 th month Final Assessment 12 th month Based on findings from assessment:

13. Education, Supplies, Remediation Cont. Remediation –Carpet removal –Install ventilation –Integrated Pest Management (IPM) –Industrial cleaning Assessment Education, Supplies, Remediation Mid-term Assessment 6 th month Final Assessment 12 th month

14. Mid-term Assessment Health questionnaire (abbreviated) Environmental questionnaire (abbreviated) More supplies if needed Reinforce education Assessment Education, Supplies, Remediation Mid-term Assessment 6 th month Final Assessment 12 th month

15. Final Assessment Health questionnaire Environmental questionnaire Environmental walk-through Gift certificate Assessment Education, Supplies, Remediation Mid-term Assessment 6 th month Final Assessment 12 th month

16. Accomplishments Conducted 178 home assessments Completed 160 interventions Evaluation of intervention effectiveness (midterms & final assessments) Trained 75 partner staff in HH practices Provided HH education to 1,537 community members

17. Results Table 1. Demographics of participants Children not completing study (n=75) Children completing study (n=170) Respondent: Parent90.794.7 Respondent gender: Female94.795.9 Child race/ethnicity Black/African American6.74.7 White/Caucasian*412.4 Asian/Oriental10.715.3 Spanish/Hispanic57.352.9 Other21.314.7 Child gender: Male54.759.4

18. Table 1. Demographics of participants (Cont.) Children not completing study (n=75) Children completing study (n=170) Parent marital status: Married1222.4 Mother’s education: Any college2733.3 Father’s education: Any college25.620.2 Household income: 0-50% AMI90.784.7 Smoker in primary home13.316.5 High risk asthma group4438.2 Child age (mean)5.976.08

19. Within ½ mile of home% (n=114) Gas Station89 City Bus Stop88 Restaurant86 Dry Cleaner65 Auto Body Shop58 Truck Loading Area46 Bakery43 Other25 Furniture Refinisher5 Housing conditions at baseline – Outdoor sources of pollution Trucks drive on street Often – 42% Occ. – 25%

20. Reported pest activity in past month Baseline %Final % Rodents2916.5 Cockroaches*3018 Change in housing conditions

21. Flooring type in child’s bedroom Baseline % (n=170) Final % (n=170) Wall-to-wall carpet5856 Area rug*6.51.8 Throw rugs*20 Hard floors3542

22. Baseline % (n=115) Final % (n=114) Any surfaces with mold/mildew 4032 Changes in housing conditions - Mold

23. Change in Asthma Trigger Activities Baseline %Final % Air freshener used most days*6231.5 Candle/incense used most days*2915 Cleaning chemical use8576 Only “Green” cleaners used*127 Some “Green” cleaners used*846 Own HEPA vacuum cleaner*998 Mattress and pillow covers*096 Wash linens in hot water*6689 Dry linens with hot air*98100

24. Health Results – Asthma Severity Baseline Average Final Average Percent Change Wheezing # of times child experienced wheezing in the past 4 weeks 6.42.3-65% Asthma Attacks # of times child had asthma attack or trouble breathing in the past 4 weeks 0.80.2-76% Doctor Visits # of times child went to doctor office or clinic for asthma problems in the past 4 weeks 0.70.2-64% Emergency Room/ Hospital Visits # of emergency room or hospital visits due to asthma in the past 4 weeks 0.20.04-79% n=170

25. Health Results – Change in CHSA Scores Baseline Mean Final Mean Change (paired values) Physical Health66.889.323.3 Activity Child84.993.08.4 Activity Family88.797.48.7 Emotional Health Child67.988.020.5 Emotional Health Family 71.281.19.9 n=170 (scores range from 0-100)

26. Health Results – Med use Reduced use of asthma medication (Reported use in prior 4 weeks) Baseline: 145 of 164 using meds (88%) Final: 101 of 164 using meds (62%)

27. *The hospitalization and ER data was provided by the MA Department of Public Health assessment of average charges in Lowell in 2010 due to usage because of asthma. **The $100 per doctor visits is an estimated average cost based on discussions with local doctors’ offices. Cost Savings from Health Outcome Improvements

28. Which components of our interventions had the biggest impact on health outcomes? No component was associated with health improvements on its own Asthma Trigger indices: –Allergen Risk Index –Chemical Risk Index –Cleaning Risk Index –No statistically significant associations Conclusion: Single-component interventions or interventions of smaller scope may not result in positive health outcomes for asthmatics.

29. Allergen Risk Index Any pet Pet in bedroom Rug (wall to wall or area) Mold Rodents Cockroach Feather bedding No allergen pillow cover No allergen mattress cover Chemical Risk Index Use air freshener Use candles Use cleaning chem. most days Used pesticides in past month Smoking Professional rug cleaning* Gas stove* Cleaning Risk Index Infrequent dusting in child’s room Infrequent mopping in child’s room Wash linens Does not wash linens in hot water Does not dry linens with hot air Food debris in kitchen*

30. Conclusions Prevalence of Environmental Asthma Triggers Multi-trigger, multi-component interventions improve health and emotional well-being Decrease in healthcare utilization & medication use Incentive for medical providers/insurers to fund interventions Importance of lay community health outreach workers Involve key stakeholders to increase impact Research needed on optimal intervention design to maximize ROI

31. Contact Information David Turcotte, Sc.D. University of Massachusetts Lowell Email: David_Turcotte@uml.eduDavid_Turcotte@uml.edu Telephone: (978) 934-4682 Emily Chaves, M.A. University of Massachusetts Lowell Email: Emily_Vidrine@uml.eduEmily_Vidrine@uml.edu Telephone: (978) 934-4778