Healthy Homes for All: Improving Children’s
Health in Diverse Communities
University of Massachusetts Lowell
David Turcotte, ScD
Emily Chaves, MA
Susan Woskie, PhD
Rebecca Gore, PhD
Fred Youngs, PhD
Joann Vaillette, MA
UMass Medical School
Heather Alker, MD, MPH
Worcester State University
Stephanie Chalupka, EdD
Lowell Community Health Center
Carla Caraballo
Bophamony Vong
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”
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
• 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)
Project Goals:
Families
Home assessments
Home interventions
Education
First time home buyers
Education
Partners
Education
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
Families – who are they?
• Live in Lowell, MA
• Have at least one child with asthma
(<=14)
• Low-moderate income
• 165 families enrolled (245 children)
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
Indoor Environment and Asthma
•Americans spend up to 90% of their time indoors
•Indoor concentrations of most pollutants are higher than
outdoor
Indoor Environment and Asthma
• 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
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
Final
Assessment
6th month
12th month
Education, Supplies, Remediation
Based on findings from assessment:
• Education
• Supplies
– Dust mites and healthy
cleaning practices
– Pets
– Avoiding pests
– Moisture/mold control
– Smoking
– Air pollution (indoor & outdoor)
– Safety
Assessment
Education,
Supplies,
Remediation
– HEPA vacuum
– Allergen-proof mattress and
pillow covers
– Trash can with lid
– Food containers
– Non-toxic cleaner
– Baits and traps for pests
– Safety items
Mid-term
Final
Assessment
Assessment
6th month
12th month
Education, Supplies, Remediation Cont.
• Remediation
–
–
–
–
Carpet removal
Install ventilation
Integrated Pest Management (IPM)
Industrial cleaning
Assessment
Education,
Supplies,
Remediation
Mid-term
Assessment
Final
Assessment
6th month
12th month
Mid-term Assessment
•
•
•
•
Health questionnaire (abbreviated)
Environmental questionnaire (abbreviated)
More supplies if needed
Reinforce education
Assessment
Education,
Supplies,
Remediation
Mid-term
Assessment
Final
Assessment
6th month
12th month
Final Assessment
•
•
•
•
Health questionnaire
Environmental questionnaire
Environmental walk-through
Gift certificate
Assessment
Education,
Supplies,
Remediation
Mid-term
Assessment
Final
Assessment
6th month
12th month
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
Results
Table 1. Demographics of participants
Children not
completing study
(n=75)
Respondent: Parent
Respondent gender: Female
Child race/ethnicity
Black/African American
White/Caucasian*
Asian/Oriental
Spanish/Hispanic
Other
Child gender: Male
Children
completing study
(n=170)
90.7
94.7
94.7
95.9
6.7
4
10.7
57.3
21.3
54.7
4.7
12.4
15.3
52.9
14.7
59.4
Table 1. Demographics of participants (Cont.)
Children not
completing study
(n=75)
Parent marital status: Married
Mother’s education: Any college
Father’s education: Any college
Household income: 0-50% AMI
Smoker in primary home
High risk asthma group
Child age (mean)
12
27
25.6
90.7
13.3
44
5.97
Children
completing study
(n=170)
22.4
33.3
20.2
84.7
16.5
38.2
6.08
Housing conditions at baseline – Outdoor sources of pollution
Within ½ mile of home
Gas Station
City Bus Stop
% (n=114)
89
88
Restaurant
Dry Cleaner
Auto Body Shop
86
65
58
Truck Loading Area
Bakery
Other
46
43
25
Furniture Refinisher
5
Trucks drive
on street
Often – 42%
Occ. – 25%
Change in housing conditions
Reported pest activity
in past month
Baseline %
Final %
Rodents
29
16.5
Cockroaches*
30
18
Change in housing conditions
Flooring type in child’s Baseline %
bedroom
(n=170)
Final %
(n=170)
Wall-to-wall carpet
Area rug*
Throw rugs*
58
6.5
2
56
1.8
0
Hard floors
35
42
Changes in housing conditions - Mold
Baseline % Final %
(n=115)
(n=114)
Any surfaces with
mold/mildew
40
32
Change in Asthma Trigger Activities
Baseline %
Air freshener used most days*
62
Candle/incense used most days* 29
Final %
31.5
15
Cleaning chemical use
Only “Green” cleaners used*
Some “Green” cleaners used*
85
1
8
76
27
46
Own HEPA vacuum cleaner*
Mattress and pillow covers*
Wash linens in hot water*
9
0
66
98
96
89
Dry linens with hot air*
98
100
Health Results – Asthma Severity
Baseline
Final
Average Average
Wheezing
# of times child
experienced wheezing in the past 4 weeks
Asthma Attacks
# of times child had asthma attack or trouble
breathing in the past 4 weeks
Doctor Visits
# of times child went to doctor office or clinic for
asthma problems in the past 4 weeks
Emergency Room/
Hospital Visits
# of emergency room or hospital visits due to
asthma in the past 4 weeks
n=170
Percent
Change
6.4
2.3
-65%
0.8
0.2
-76%
0.7
0.2
-64%
0.2
0.04
-79%
Health Results – Change in CHSA Scores
Baseline
Mean
66.8
84.9
88.7
67.9
Final
Mean
89.3
93.0
97.4
88.0
Physical Health
Activity Child
Activity Family
Emotional Health Child
Emotional Health
71.2
81.1
Family
n=170
(scores range from 0-100)
Change
(paired values)
23.3
8.4
8.7
20.5
9.9
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%)
Cost Savings from Health Outcome Improvements
Urgent Care
Per Decrease 4-week recall 6 month 12 month
Usage in Occurr- period (~1
savings* savings*
Cost
ence
**
**
month
savings)
8
39,376 236,256 472,512
Hospitalization 4,922
*
834
29
24,186 145,116 290,232
Emergency
Room*
Doctor Visits**
100
76
7,600
45,600
91,200
Decrease in Costs
71,162 426,972 853,944
Intervention Cost
32,640
32,640
32,640
Net Savings
$38,522 $394,332 $821,304
*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.
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.
Allergen Risk Index
• Any pet
• Pet in bedroom
• Rug
Chemical Risk Index
(wall to wall or area)
• Use air freshener
• Mold
• Use candles
• Rodents
• Use cleaning chem.
most days
• Cockroach
• Used pesticides in past
• Feather bedding
month
• No allergen pillow cover
• Smoking
• No allergen mattress
• Professional rug
cover
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*
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
Contact Information
David Turcotte, Sc.D.
University of Massachusetts Lowell
Email: David_Turcotte@uml.edu
Telephone: (978) 934-4682
Emily Chaves, M.A.
University of Massachusetts Lowell
Email: Emily_Vidrine@uml.edu
Telephone: (978) 934-4778