Michigan Center for the Environment and Children’s Health: Community Action Against Asthma - A

Community-Based Participatory Research Approach to Understanding and Addressing Environmental Triggers

to Childhood Asthma In Detroit, Michigan * *

Barbara A. Israel*, Dr. P.H., M.P.H.

Professor, University of Michigan

Department of Health Behavior & Health Education

School of Public Health

Lecture presented in Political Science 327: The Politics of the Metropolis

November 14, 2002

*With acknowledgement to all of the partners involved in Community Action Against Asthma

Background: Childhood Asthma Prevalence

Asthma is most common chronic disease of childhood in developed world (~5 million in U.S.)

Prevalence rate of pediatric asthma increased 61% in U.S. (1982-1994)

Mortality rate of pediatric asthma increased by 78% in U.S. (1980-1993)

Childhood asthma particularly prevalent within low income communities, urban areas and communities of color

National trends in increase in childhood asthma are similar in Detroit, Michigan

Risk Factors/Stressors Associated with Childhood Asthma

Causation and aggravation of pediatric asthma complex and multifactorial

Risk factors/stressors associated with childhood asthma include:Genetic disposition;Demographic factors (e.g., socioeconomic status)Indoor environmental exposures (e.g., dust mite and

cockroach allergens, tobacco smoke)Outdoor environmental exposures (e.g., particulate matter,

ozone)Psychosocial stressors (e.g., violence, crime, lack of

community resources)

Implications for Research and Practice

Addressing complex set of factors associated with childhood asthma a major challenge for researchers, practitioners and the affected communities.

Historically research has rarely directly benefited and sometimes actually harmed the communities involved, and has excluded them from influence over the research process.

Implications for Research and Practice (Continued)

Interventions have often not been as effective as could be because:not tailored to concerns and cultures of

participants;not included participants in all aspects of

intervention design, implementation and evaluation.

Increasing calls for more participatory and comprehensive approaches to public health research and practice

DEFINITION OF COMMUNITY-BASED PARTICIPATORY RESEARCH

Community-based participatory research in public health is a partnership approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process; with all partners contributing their expertise and sharing responsibility and ownership to enhance understanding of a given phenomenon, and to integrate the knowledge gained with action to improve the health and well-being of community members.

Key Principles of Community-Based Participatory Research

1. Recognizes community as unit of identity.

2. Builds on strength and resources within the community.

3. Facilitates collaborative, equitable partnership in all phases of the research, involving an empowering process.

Key Principles of Community-Based Participatory Research

4. Promotes co-learning and capacity building among all partners involved.

5. Integrates knowledge and change for mutual benefit of all partners.

6. Emphasis on local relevance of public health problems and the multiple determinants of health and disease (e.g., biomedical, social, economic, physical environmental).

Key Principles of Community-Based Participatory Research (Continued)

7. Involves cyclical, iterative process.

8. Disseminates findings and knowledge gained to all partners and involves all partners in the dissemination process.

9. Involves a long-term process and commitment.

Michigan Center for the Environment and Children’s Health (MCECH)

Detroit Community-Academic Urban Research Center (URC) as original partnership

URC identified diseases related to environmental concerns (including asthma) as priority area

URC applied for and received funding from National Institute of Environmental Health Sciences and U.S. Environmental Protection Agency: Centers of Excellence

MCECH governed by community-based participatory research principles

Michigan Center for the Environment and Children’s Health - Partners

UM School of Public Health UM School of Medicine Detroit Health Department Butzel Family Center Community Health & Social

Services Center Detroit Hispanic Development

Corporation Detroiters Working for

Environmental Justice

Friends of Parkside Kettering Butzel Health

Initiative Latino Family Services United Housing Coalition Warren/Conner Development

Coalition Henry Ford Health System Michigan Department of

Agriculture, Plant and Pest Management Division

Michigan Center for the Environment and Children’s Health (MCECH)

Overall Goal

To investigate the environmental, patho- physiological and clinical mechanisms of childhood asthma, and to implement and evaluate comprehensive community and household-level interventions aimed at reducing asthma-related environmental threats to children, families and neighborhoods.

MCECH Core Research Projects

Household and neighborhood level interventions focusing on reduction of environmental triggers for childhood asthma

An exposure assessment to assess the separate and possible interaction effects of outdoor and indoor air quality on exacerbation of asthma in children

A murine model project to determine if the mechanism of chronic pulmonary inflammation due to repeated exposure to allergens is mediated by the excessive local production of chemokines

Community Action Against Asthma (CAAA)Intervention and Exposure Assessment Project

Participants from two geographic areas within city of Detroit, east side (90% African-American) and southwest (50% African-American, 40% Latino and 10% non-Latino white)

300 families with at least one child age 7 to 11 with probable or known asthma enrolled

Recruited through screening questionnaire distributed through mail and at schools

Community Action Against Asthma - Household-Level Intervention Activities

Staggered research design - families randomly assigned to Wave 1 or Wave 2

Two year intervention in intensive and less intensive phases

Community Action Against Asthma - Household-Level Intervention Activities

(continued)

Minimum of nine visits by “Community Environmental Specialists” in intensive phase, and 3 visits in Year 2 less intensive phaseEducation (e.g., dustmite, cockroaches, household

cleaning)Materials distributed (e.g., vacuum cleaners, mattress

covers)Integrated pest managementOther (e.g., housing, obtaining city services, furniture,

translation)

Community Action Against Asthma - Household Level Intervention Objectives

Increase knowledge and perceived self-efficacy of participants about asthma and behaviors to reduce environmental triggers

Increase behaviors to reduce indoor environmental triggers (e.g., vacuuming, damp mopping)

Reduce indoor exposures to environmental triggers (e.g., dust levels, cockroach antigens)

Community Action Against Asthma - Household Level Intervention Objectives

(continued)

Strengthen psychosocial factors associated with asthma-related health status (e.g., social support)

Improve asthma-related health status (e.g.., quality of life, functional status, symptom severity)

Reduce use of medications and asthma-related health services utilization

Community Action Against Asthma - Evaluation Research Methods

Skin test assessment Annual measurements

Questionnaires for parents and children (e.g., psychosocial factors and health)

Household dust sampling and environmental checklistNeighborhood Environmental Checklist

Qualitative evaluation of process of adhering to CBPR principlesIn-depth interviews with members of SC

Community Action Against Asthma - Exposure Assessment

Two weeks in duration (total of 11 assessments over 2 1/2 years)

Assessment of health outcomes (e.g., symptom diary, lung functioning)

Daily ambient measures of particulate matter 2.5, PM10, ozone, meterological variables in each community

Community Action Against Asthma - Exposure Assessment (continued)

Daily indoor measures of PM2.5, PM10, and Vapor Phase Nicotine in homes of 20 children

Daily personal exposure monitoring of PM10 for same 20 children

Community Action Against Asthma - Community-Level Intervention Activities

Neighborhood and policy level organizers in east side and southwest communities

Identifying priority environmental concerns through data already collected and interviews with key groups and organizations

Community Action Against Asthma - Community-Level Intervention Activities

(continued)

Establishing inter-organizational network to address priority concerns

Will work with existing organizations and coalitions on environmental organizing campaigns and facilitate other activities based on priorities selected

CAAACommunity Level Intervention

Objectives Increase knowledge and awareness about

asthma and indoor and outdoor environmental triggers

Increase neighborhood and community social support and cohesion

Increase capacity of neighborhoods to work collectively to reduce environmental triggers associated with asthma

CAAACommunity Level Intervention

Objectives (continued)

Increase knowledge about available resources in the community (e.g., tenants’ rights organizations, environmental groups)

Reduce physical environmental hazards in the neighborhoods involved (e.g., illegal dumping, air pollution)

Advantages of Using a CBPR Approach

Enhances relevance and use of dataData collection: content and quality

Increases quality and validity of research and interventionRecruitmentRetention

Advantages of Using a CBPR Approach (continued)

Improves intervention design and implementationSelection and training of outreach workersExtends beyond asthma directed needs

Advantages of Using a CBPR Approach (continued)

Knowledge gained and actions taken benefit the community

Joins partners with diverse expertise to address complex public health problems

Has potential to translate research findings to guide development of further interventions and policy change

Lessons Learned: Recommendations for Conducting CBPR

Time and support needed up front to establish trust and jointly define priorities

Partnerships need to constantly re-assess to maintain trust and ensure involvement and influence of all members

Different cultures of partner organizations need to be recognized and respected

Lessons Learned: Recommendations for Conducting CBPR (continued)

Costs and benefits of participation need to be addressed

Need to achieve balance betweenresearch and interventioncompleting tasks and maintaining relationships