Community-Based Participatory
Research Reduces Asthma Morbidity
in the Inner-City
The Harlem Children’s Zone Asthma Initiative
NHMA-15th Annual Conference
March 19, 2011
Benjamin Ortiz, MD
Assistant Professor of Clinical Pediatrics
Assistant Attending, Department of Pediatrics
Columbia University Medical CenterThe Affiliation at Harlem Hospital Center
Assistant Professor of Clinical Population & Family Health
Mailman School of Public Health
Co-Principal Investigator and
Medical Director, HCZAI
Disclosure
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I have no relevant financial disclosures or
conflicts of interest to reveal prior to this
presentation
Epidemiology of Childhood Asthma
 7.1 million US children (9.4% prevalence)
 In New York City ~10% prevalence
 Hospitalizations down 8% citywide (2005-2008),
approx 45% decrease since 1997
 Disparities in low SES neighborhoods remain
despite significant reductions (2008)
 CH: nearly double city avg
 HCZAI identified prevalence rate approx 30% (2003)
 EH and SBx: more than double city avg
Overview
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Harlem Children’s Zone is a 100-square
block area in Central Harlem
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HCZAI is a comprehensive childhood
asthma program
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Collaborative partnerships
Home-based educational, environmental and
social/legal interventions
Rigorous evaluation (internal and external)
Headquarters of
HCZAI Collaborators
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Harlem Children’s Zone, Inc. (CBO)
Columbia University Medical Center
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Harlem Hospital Center affiliation
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Mailman School of Public Health (HHPC)
CU Graduate School of Architecture and Urban
Planning
NYC Department of Health and Mental Hygiene
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East & Central Harlem DPHO
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East Harlem Asthma Center of Excellence
NYC Department of Education
Brazelton TouchpointsTM Center
HCZAI Funders
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Robin Hood Foundation
National Institute of Environmental Health
Sciences
American Legacy Foundation
Dyson Foundation (AAP Community Pediatrics)
AstraZeneca
NYC Department of Health & Mental Hygiene
HCZAI Intervention Team
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Pediatric Allergy/Immunology specialist
(Principal Investigator)
General Pediatrician (Medical Director)
Executive Director
2 Nurse Clinicians (Clinical Coordinators)
Health Educator
Community Health Workers (4)
Law firm support (Dewey LeBoeuf)
Initiative Goals
Reduce school absenteeism due to asthma
 Decrease unscheduled and emergency
medical visits due to asthma
 Reduce rates of hospitalizations due to
asthma
 Improve daily quality of life
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Program Design
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Screen every child age 0-12 years in the HCZ
for asthma
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Asthma-specific questionnaire
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demographics
past diagnosis of asthma by MD/RN
source of health care and health insurance coverage
home tobacco exposure
consent for physical examination
Physical examination (hgt, wgt, auscultation)
Peak expiratory flow rate (PEFR) [age > 6yr]
Program Design
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Referrals from:
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Local schools
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7 HHC school-based clinics
20-30 elementary schools in Harlem (via nurses)
Other CBO’s
Local health department office
HHC Emergency Room, inpatient unit & clinics
Local medical providers
Other families…some of our best marketing agents
Survey Results
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6274 surveys collected (through Feb 2010)
29.2% diagnosed with asthma
 31.6% ever had sx’s c/w asthma
 27% ever ER/urgent MD visit for asthma
 19.6% had smoker in home
 In previous 12 months:
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24.2% daytime sx's
24.5% nighttime sx's
19.2% ER/urgent MD visit for asthma
Survey Results
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1832 identified with asthma
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Mean age 7.1 years
51.6% female
76.5% African-American
22.9% Latino
31% exposed to tobacco at home
CW/HE Outreach Mechanisms
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Parent contact directly from surveys
School health provider insistence
Referrals from 3rd parties
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Local health care providers, CBOs, partner
agencies
LOTS OF PATIENCE
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Reticence to participate
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“not really a problem” (i.e. disease chronicity is not seen)
“doesn’t take meds everyday” (who decided this?)
Fear of revealing true home environment (“I don’t want intruders in my
home”
Enrollment and Intervention
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All enrollees have history of asthma (n=1415)
Baseline Interview (1st step)
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Written consent prior to enrollment (HIPAA/IRB)
Community Workers & Health Educators
1st opportunity for Asthma Education
Home assessments
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Evaluation of every room in home
Home environmental interventions
Every 3-4 months
Psychosocial assessment
Enrollment and Intervention
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Follow-up home visits (every 3-4 months x 1yr)
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Environmental inspection of each room
Primary care/ER use, hospitalizations (3 mo period)
School absences (2 week period)
Daily asthma symptoms (2 week period)
Replacement/supplementation of asthma tools
Psychosocial assessment
Alternate phone calls with home visits every 3
months for another 1 year
Baseline and Follow-Up Results
Asthma symptoms reported
in the last 14 days
Baseline
(n=950)
6 mos
12 mos
18 mos
24 mos
p-value
Child wheezing or chest
tightness
64.0%
47.4%
40.0%
35.0%
29.1%
<.0001
Child with night asthma
symptoms
53.6%
41.5%
36.8%
29.7%
29.1%
<.0001
Child missed school due to
asthma
29.7%
21.2%
8.7%
7.2%
9.3%
<.0001
Child made ER or unscheduled
clinic visit
45.6%
19.9%
16.8%
12.2%
10.1%
<.0001
Child hospitalized
10.0%
3.8%
1.2%
1.2%
1.7%
<.0001
46.9%
57.2%
59.4%
62.9%
62.9%
<.0001
Asthma symptoms in the last
3 months:
Reported use of asthma
management strategies:
Child took any preventive
asthma meds
Environmental Findings:
Pre & Post Intervention
Baseline
(n=950)
6 months
12 months
18 months 24 months
p-value
64.0%
48.5%
47.3%
50.6%
58.2%
<.0001
15.0%
6.9%
6.8%
3.0%
3.3%
<.0001
Mice
23.4%
18.0%
20.3%
15.6%
15.7%
0.01
Roaches
57.2%
62.3%
58.0%
63.3%
56.9%
0.14
Spray Bombs
6.7%
1.0%
2.5%
2.1%
2.0%
<.0001
Smoking
13.3%
7.2%
8.9%
5.1%
2.6%
<.0001
Perfume
14.2%
1.6%
3.6%
1.7%
2.0%
<.0001
Living Room Triggers
Dust (Living Room)
Bathroom Triggers
Mold (Bathroom)
Pest Triggers
Other Triggers
Academic Activities
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Publications
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MMWR January 2005
AJPH February 2005
American Planning Association January 2006
Journal of Urban Health May 2006
Academic Activities
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National presentations
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National Hispanic Medical Association
Harvard University School of Public Health
National Medical Association
NIH National Conference on Asthma
Pediatric Academic Society (platform session)
American College of Chest Physicians
American Academy of Pediatrics
UCSF-Fresno State Childhood Asthma Leadership Summit
Council on Social Work Education
Spanish American Medical & Dental Society of NY
Orlando Children’s Hospital
Wisconsin Asthma Coalition
Florida International University School of Medicine
US Department of Health and Human Services, Office of Minority Health
National Institute of Environmental Health Sciences
Conclusions
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Childhood asthma prevalence in HCZ much higher
(30.4%) than predicted
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Intensive home-based interventions have reduced:
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daytime asthma symptoms by 55% (over 24 mo period)
nighttime asthma symptoms by 46%
school absences by 69%
ER visits by 78%
hospitalizations by 83%
Increased controller use by 34%
Conclusions
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Environmental interventions have reduced:
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Indoor dust exposure by 9%
Indoor mold exposure by 78%
Home tobacco smoke exposure by 81%
Recommendations
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Home visiting model effective when culturally &
linguistically appropriate education is provided
Measurable reductions in ER visits, hospitalizations and
school absences are achievable by mitigating
behavioral and environmental triggers
Schools & public health experts must be strong
partners in any community-based effort to identify
children with poorly controlled asthma
Adapt case identification strategies as situations arise
Recommendations
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Educating primary care providers on best
practices in asthma management is a key
component of community-based asthma case
management
Medical-legal partnerships add tremendous
value in addressing the social and environment
determinants of poorly controlled asthma in
poor, urban settings
Recommendations
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Navigation of relationship with community
partners
Missions may not be the same (CBO vs. academia)
 Need to suppress our academic egotism
 It’s OK to share information and data
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Memorandum of Understanding is important
Share responsibilities (marketing, evaluation, etc.)
 Think equally...everyone needs to be equal, valued
partner
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Recommendations
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Keep staff happy
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Competitive salary & benefits
Provide opportunities for professional growth
Recruit from the community
Maintain close working relationship with funders
Start small and expand as resources (human, financial)
allow
Develop relationships with community stakeholders
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Schools
Churches
Community centers
Recommendations
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Evaluation!!!
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Internal and external capacity (big and small views)
Frequent assessments of major program outcomes
Qualitative measures are important as well
Perspectives of participants (focus groups)
 Perspectives of referring sources
 Perspectives of healthcare providers
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Make systematic changes as necessary (for us, building
internal database that integrates with external one)
Disseminate results quickly
Recommendations
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Get out there
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Go to homes, schools and community centers
Educate everywhere you can
Provide the best service
Say “Please” and “Thank You”