Running head: CHILDHOOD ASTHMA AND POVERTY 1

Part I: Childhood Asthma and Poverty

Health Disparities in Hispanic Children

Sonila BegajAmy Jaramillo

Carolyn M. MartinHeather Noe

Texas Woman’s UniversityHS 3073.50 – Program Planning

Health Promotion Program Planning & DesignSpring 2012

Dr. M. Massey-StokesFebruary 25, 2012

You’ve done a thorough job on your paper, and I appreciate your hard work and clear writing skills! Please see comments/edits on following pages.

Score = 24+5+9+10 = 48/50

CHILDHOOD ASTHMA AND POVERTY 2

Table of Contents

Part I: Health Program Planning and Design

Childhood Asthma and Poverty – Health Disparities in Hispanic Children

Spring Branch-Houston, Texas

Target Population, Key Health Issue, and Healthy People 2020 Connection…………..Page 3

Community Partners………………………………………………………………............Page 5

Key Leaders/Stakeholders and Supporters……………………………………………..Page 11

Marketing……………………………………………………………………………….…Page 13

References…………………………………………………………………………………Page 17

CHILDHOOD ASTHMA AND POVERTY 3

Appendix…………………………………………………………………………………..Page 20

*Target Population, Key Health Issue, and Healthy People 2020 Connection

The completion of a health needs assessment in the Spring Branch Central neighborhood

in Houston, Texas, has shown a high frequency of asthma within the population of Hispanic

children, particularly Hispanic children who also live in poverty. Childhood asthma is not only

prevalent in this area; it is widespread throughout the United States. In 2003, asthma affected

five million children under the age of fifteen, five percent of children and ten percent of adults in

the United States, of which fifty to eighty percent are diagnosed with asthma before the age of

five (Caple and Schub, 2010).

Target Population

The Centers for Disease Control and Prevention (CDC, 2011)reported that an estimated

25 million people in the US are affected by asthma, and approximately 8 million are children

between the ages of 0-17 (CDC, 2011). One million of these asthmatic children live in the state

of Texas, and it is projected that between 80,000 and 100,000 reside in the southeastern Houston-

Galveston region (Texas Emergency Department Asthma Surveillance [TEDAS], 2007).

Children who live in economically disadvantaged neighborhoods are disproportionately

burdened by asthma, and in Texas specifically, childhood asthma is more prevalent in minority

families, families with lower levels of education, and families who live in low income

communities (Kozyrskyj et al, 2010; Zuniga, et al., 2011). The Spring Branch Central

community is a community which is strongly affected by extreme poverty and health disparities

resulting from the disadvantaged state of its population . [(seeAppendix A).

CHILDHOOD ASTHMA AND POVERTY 4

According to statistics from the CDC (2009), , Hispanic children are 60% more likely to

have asthma than other ethnic groups, and children of Puerto Rican Hispanic descent may be up

to 2.5 times more likely to develop asthma than Caucasian children. Asthma disproportionately

affects minority and Hispanic children who live in poor, disadvantaged urban neighborhoods

(CDC, 2009). In the Spring Branch Central neighborhood, devastating poverty, the urban

environment, socioeconomic barriers, and health disparities all have a negative impact on the

quality of health of its residents which contributes to the high frequency of childhood asthma in

this community (Spring Branch Community Health Center [SBCHC], 2009; HDHHS, 2007).

Health educators must work with schools parents, and social service providers to ensure

that parents know that many options are available for asthma treatment for their children.

Teaching parents how to determine if their child is suffering from asthma or asthma-related

symptoms and teaching them how to obtain proper medical care for their children would benefit

everyone involved. Once the children have obtained a proper diagnosis and medical care, health

educators need to educate parents about controlling asthma triggers related to their home

environment so that their children will not have to suffer needlessly.

Key Health Issue

The 2007 Texas Behavioral Risk Factor Surveillance System reports that 876,000

children, or 13.6 percent, up to age seventeen reported lifetime asthma, and 9.1 percent currently

had asthma at the time of the study (Zuniga et al., 2011). Non-white children who live in urban

areas and children who live in poverty have a much higher risk of asthma (Williams, Sternthal, &

Wright, 2009). In the Spring Branch Central community, over 25% of families live at or below

poverty level, thus, poverty is a significant health and economic issue (HDHHS, 1999-2003). Of

CHILDHOOD ASTHMA AND POVERTY 5

this population in the Spring Branch Central community living at or below the poverty level,

over 40% are children below the age of 18 (HDHHS, 1999-2003; Spring Branch Community

Health Center, 2011). Hispanic children between the ages of 0-17 are disproportionately affected

by extremely high levels of asthma, at more than 60% of the national average (OMHD, 2011).

Healthy People 2020 Contribution

Healthy People 2020 provides many objectives which serve to improve the quality of the

Nation’s health (United States Department of Health and Human Services, 2012). This program

will address the topic of Early and Middle Childhood health, whichis a time of great

development and a time in which many predisease pathways begin. During the time of early and

middle childhood, children are more often at risk for developing asthma (U.S. Department of

Health and Human Services, 2012). This program will serve to recognize and educate parents of

the importance of focusing on asthma and how effective treatment will increase their child’s

ability to learn and grow into a healthy adult. The program will educate parents, support parents,

and provide a supportive learning environment which will help enhance the health and well

being of their children.

*Community Partners

In a Houston Department of Health and Human Services (HDHHS) report entitled

“Community Health Profiles 1999-2003,” the Spring Branch-Houston community is reported to

be a predominantly Hispanic neighborhood with a disproportionately high level of poverty. An

overwhelming majority (~65%) of its community residents are uninsured or underinsured, and

residents suffer from high levels of chronic disease including asthma, obesity, diabetes, and

hypertension. (HDHHS, 1999-2003).

CHILDHOOD ASTHMA AND POVERTY 6

But despite the socioeconomic disadvantages of the Spring Branch-Houston

neighborhood, the community has numerous Community Partners which can positively impact

the overall health of its residents.

Significant Community Partners that address childhood asthma and health disparities in

the Hispanic community include the local Spring Branch Community Health Center (SBCHC),

the regional Houston Department of Health and Human Services, and the Houston chapter of a

national non-profit lung health organization, the American Lung Association (ALA). All three

organizations provide abundant educational resources for addressing and managing childhood

asthma, and are well-positioned to assist in the development of a health education/promotion

programs targeted toward parents of asthmatic children. For the purpose of the Program Planning

Project, we will focus primarily the Community Partner, the Spring Branch Community Health

Center (SBCHC).

Community Partner: Spring Branch Community Health Center – Main Clinic

Address: 1615 Hillendahl, Suite 100 – Houston, Texas 77055

Phone: (713) 462-6565

Fax: (713) 462-6581

Director: Marlen J. Trujillo, MBA – Chief Executive Officer

Medical Director: Shruti Varadarajan, MD – Chief Medical Officer

Operations: Michael G. Bsaibes – Chief Operating Officer

Web site: http://www.sbchc.net/aboutSBCHC.html

CHILDHOOD ASTHMA AND POVERTY 7

Mission Statement: “The mission of the Spring Branch Community Health Center is to increase

the number of healthy families in our community by providing high quality, comprehensive

healthcare services” (SBCHC, 2011).

General Information

The Spring Branch Community Health Center (SBCHC) initially opened in 2003 as a

result of collaborative efforts among community advocates, local businesses, churches, and

individual donors to establish an affordable community-based health center for medically

underserved residents. Since opening in 2003, the Spring Branch Community Health Center has

served thousands of families within the community, and due to increased demand for medical

services, the center recently expanded to include a satellite location. What began as a small

community health clinic with limited facilities and resources has now expanded to a Federally

Qualified Health Center (FQHC) which offers comprehensive healthcare services to area

residents regardless of their ability to pay (SBCHC, 2011).

One of the founding members of the Spring Branch Community Health Center was

Marlen J. Trujillo, and she now serves in the role of Chief Executive Officer (CEO). Because

she was raised in the Spring Branch community, she is familiar with the heritage, the culture, and

the medical needs of the residents there (SBCHC, 2011). Dr. Shruti Varadaragjan, Medical

Director, completed her medical training in Houston, and later joined the clinic in 2009. Her

undergraduate studies focused on medical anthropology and cultural differences in health. As an

advocate for the medically underserved, her goals include providing affordable quality healthcare

in a culturally sensitive and appropriate manner (SBCHC, 2011).

CHILDHOOD ASTHMA AND POVERTY 8

Because people of various ethnicities and cultural backgrounds perceive and experience

illness differently (SBCHC, 2011), it is crucial that community healthcare providers are

knowledgeable regarding the socioeconomic and cultural barriers that contribute to health

disparities in this population (SBCHC, 2011). And because Hispanic children have a

significantly higher level of asthma than do non-Hispanic whites [Office of Minority Health and

Health Disparities (OMHD), 2010], healthcare providers should possess a thorough knowledge

of ethnic health disparities when providing asthma management in the Hispanic child.

The Spring Branch Community Health Center offers comprehensive healthcare services

including pediatrics, disease management, adult care, women’s health and OB/GYN services,

behavioral/mental health, vaccinations, laboratory services, and patient education. Vision and

dental referral services are also available (SBCHC, 2011). Family medical services are designed

to be cost-effective, preventive, and culturally-sensitive.

The Spring Branch Community Health Center is an important community asset which

provides asthmatic Hispanic children and their families with the knowledge and resources to

understand and manage childhood asthma. By participating in asthma education programs,

preventive care and optimal disease management, health outcomes can be positively impacted in

the Spring Branch-Houston community (SBCHC, 2011).

Community Partner: Houston Department of Health and Human Services

Address: 8000 North Stadium Drive – Houston, Texas 77054

Phone: (832) 393-5169

Director: Stephen L. Williams, M.Ed., M.P.A.

Email: webadmin@houstontx.gov

CHILDHOOD ASTHMA AND POVERTY 9

Web site: http://www.houstontx.gov/health/

Mission Statement: “Our mission is to work in partnership with the community to promote and

protect the health and social well-being of all Houstonians.”

General Information

The Houston Department of Health and Human Services (HDHHS) provides public

health services for greater than four million residents in the greater Houston metropolitan area

(HDHHS). Stephen L. Williams, M.Ed., M.P.A., is the Director of the Houston Department of

Health and Human Services, and is actively involved in public health issues at the local, state,

and national level (HDHHS, 2011).

The Houston Department of Health and Human Services is an extremely important asset

to the health and well-being of all Houstonians, including asthmatic families and those who live

in poverty. According to the Texas Emergency Department Asthma Surveillance study

(TEDAS), disease rates for asthma in the greater Houston area are among the highest in the

nation (TEDAS, 2007), and the HDHHS addresses this issue by providing preventive care,

immunizations, and patient education regarding asthma management (HDHHS, 2011).

Healthcare services offered by HDHHS work to bridge gaps and health disparities for the

underserved, uninsured, marginalized population because services are intended to improve

access to health care and thereby improve overall health outcomes.

Community Partner: American Lung Association – Plains Gulf Region

Address: 2030 North Loop West, Suite 250 – Houston, Texas 77018

Phone: (713) 629-5864

Fax: (713) 629-5825

CHILDHOOD ASTHMA AND POVERTY 10

Regional Director of Health Promotions & Programs: Linda Cullers

Email: lcullers@breathehealthy.org

Web site: http://www.lung.org/associations/charters/plains-gulf/programs/asthma.html

Mission Statement and Goals:

“To save lives by improving lung health and preventing lung disease.”

The American Lung Association will eliminate tobacco use and tobacco-related lung

disease.

The American Lung Association will improve the air we breathe so it will not cause or

worsen lung disease.

The American Lung Association will reduce the burden of lung disease on patients and their

families.

General Information

For over 100 years, the American Lung Association (ALA) has led the fight for healthy

lungs and healthy air. The ALA works to save lives by improving lung health and preventing

lung disease through health education and promotion, and by working for cleaner air through

environmental advocacy efforts. The American Lung Association is “Fighting for Air” (2012).

Fighting childhood asthma is one of the American Lung Association’s primary goals.

Through partnerships with local schools and communities, the ALA facilitates educational

programs such as the “Open Airways for Schools” program designed for elementary age

children, the “Asthma 101” program which provides community education and asthma

awareness, and the “Counting on You …. Responding to Kids with Asthma” program, which is

CHILDHOOD ASTHMA AND POVERTY 11

designed for childcare providers and others who care for children.

(http://www.lung.org/associations/charters/plains-gulf/programs/asthma.html)

Collaborative health promotion programming between the three Community Partners can

be achieved by conducting existing American Lung Association (ALA) asthma education classes

at the numerous regional health clinics throughout Houston, in local schools, and at the Spring

Branch Community Health Center (SBCHC). And by using the existing framework of

successful, evidence-based health education programs, this knowledge can assist in creating a

unique asthma education program for the Spring Branch-Houston community.

*Key Leaders/Stakeholders and Supporters

Houston Independent School District is the largest public school system in Texas with

more than 202,000 students where 53% of all students are elementary students (Houston

Independent School District, 2010). In the school year of 2009-2010, 125,097 students were of

Hispanic origin which account for 61.7% of all students (HISD, 2010). According to Community

Health Profiles the population of Spring Branch Central is 28,318 where 33% of this population

are children aging in 0-19 years old (Houston Department of Health and Human Services, 1999-

2003).

Approximately 25% of Spring Branch Central population lives in poverty and 40% of

this population are children from families with income below the poverty level (HDHHS, 1999-

2003).

Active community key leader Ms.Wendy Stackel, is aware of asthma issues among

children of Spring Branch Central schools. She has been interviewed about her opinion

regarding socioeconomic factors that contribute to asthma. Ms. Wendy Stackel is a preschool/

CHILDHOOD ASTHMA AND POVERTY 12

kindergarten teacher, who during her 30 years of teaching experience has taught mostly in

underserved communities like Harris and Fort Bend in the Houston area. She is also a licensed

social worker and licensed play therapist. According to Ms. Stackel, the lack of health insurance

is the primary reason for residents of Spring Branch area receiving inadequate health care (W.

Stackel, personal communication, February 3, 2011). She stated that Medicaid is the primary

health insurance for most of the students and their families. However, these families often are not

able to pay the copay of the health insurance because they struggle financially.

Being an immigrant with limited language skills, limited or no transportation and, not knowing

how to access the available community resources are the most common social issues that create

health disparities in the Spring Branch Community (W. Stackel, personal communication,

February 3, 2011). Ms. Stackel stated that asthma, frequent upper respiratory infections,

communicable diseases and childhood obesity are the most prevalent health issues among

children in the community.

When asked how the school district is currently addressing the health needs of Hispanic

population, Ms. Stackel reported that the Spring Branch Independent District is providing

programs on parenting, social skills and literacy to parents in the SBISD. She mentioned the

program Body Works (womenshealth.gov), which is a health/fitness and nutrition program

taught in both languages English and Spanish. The goal of the program is to teach families how

to be healthy and have a healthy lifestyle. Ms. Stackel believes that besides the efforts of many

health programs to create a healthier community, the Spring Branch Community is in need of

other programs that would contribute to improved access health care, improved literacy and

social skills for parents and children. (W. Stackel, personal communication, February 3, 2011).

CHILDHOOD ASTHMA AND POVERTY 13

A great supporter of our health promotion program would be the Houston Independent

School District which is currently offering services and resources related to asthma among

school aged children in Houston. CDC is funding Houston Independent School District to

implement health promoting programs that would prevent and reduce asthma episodes and

absences from school among students affected by asthma (Centers for Disease Control and

Prevention, 2011). The department of Health and Medical Services, HISD, is currently providing

many programs and services about Asthma Management through Student Support Services.

Their Mission Statement is “to increase the student's capacity to benefit from education by

providing professional health and medical expertise that support student achievement” (Student

Support Services, n.d). Rose Haggerty, the director of Health and Physical Education in HISD

and Teresa Blake, Asthma Management Program Coordinator are the two potential partners who

might be willing to support our health program.

*Marketing

Potential Participant Interviews

Kim Elkins, a local preschool teacher, is a 20-year resident of Houston, Texas. She has

two boys, one of whom suffers from asthma. He is 11 now and in the fifth grade. He was

diagnosed around the age of 2 or 3 and has dealt with asthma consistently and seasonally ever

since. Mrs. Elkins was interviewed to help gain further insight into her personal experience with

asthma and her opinion about a community program addressing asthma. Mrs. Elkins felt that it

was very important for childhood asthma to be addressed, particularly because the environment

she resides in is a breeding ground for environmental allergens. She thought a program for

children to learn the signs of asthma, coping skills, and self-management was a great idea to help

CHILDHOOD ASTHMA AND POVERTY 14

offset the burden on caregivers and parents and help build confidence in the child despite their

condition. Mrs. Elkins stated that she would be highly likely, in addition to other community

members, to sign her child up if the program was held locally and wasn’t terribly time

consuming. An early Wednesday evening or Saturday morning were ideal times for her family.

With regard to cost, she felt that people would attend if the cost was low or better yet free. “For

my family, the cost isn’t the issue because we have dealt with this for 9 years and paid co pays

and prescription bills numerous times. “A program involving my son and educating my husband

and I further is worth a reasonable cost” (K. Elkins, personal communication, February 18,

2012). In terms of marketing the program, Elkins felt that posting reading material in health

clubs (YMCA), pediatrician offices, allergist offices, and libraries were great, common areas to

spread the word about an asthma program for children (K. Elkins, personal communication,

February 18, 2012).

Luz Palacios, a social worker is a 3 year resident of Houston, Texas. Her daughter is 7

years old and her son is 4 years old and they both suffer from seasonal asthma. She feels an

asthma program would be very beneficial particularly in a city where air pollution ranks high.

Currently, Mrs. Palacios and her family participate in many activities at the YMCA and in the

past those have included health fairs. She agrees that she would be more than likely to participate

in a youth asthma program where adults could benefit too. Potential barriers for her family

include transportation and time where incentives include freebies such as water bottles, pens,

recyclable bags and bilingual education. She emphasized the bilingual importance. Saturday

mornings is an ideal time for her family, and she would like to see a program at the local

community center, park, or YMCA. For her children, a combination of individual learning and

CHILDHOOD ASTHMA AND POVERTY 15

small groups would be best. She commented that children would enjoy the social interaction of a

small group, while often times kids learn well and thrive on individual attention. She felt that

children would respond well to someone warm and friendly like a teacher. With regard to cost, it

depends on the population. For communities such as Kingwood, where she lives, she felt that

residents would pay to attend a program as long as it was reasonable, whereas impoverished

communities would be unable to afford an extracurricular program. Mrs. Palacios thinks the way

to market an asthma program is through flyers posted in the community and door-to-door

delivery. Again, she stresses the importance of bilingual advertising (personal communication,

February 22, 2012).

Marketing Strategies

Asthma can cause distress in children’s lives as they learn to live and cope with their

asthma. Asthma often leads to numerous school absences and decreased involvement in family

and recreational activities (Braman, 2006). As both interviewees agreed, education is key. A

diagnosis of asthma doesn’t have to mean it’s the end of a fun life for a child. It just means that

lifestyle changes are necessary. Children need to be educated about triggers and what signs of an

asthma attack look and feel like. Children need to discover that there are alternatives for the

activities that they can’t participate in and as long as they know how to use their inhaler they can

enjoy most things. A health program designed to educate at a child’s level is a positive idea to

help alleviate stress in the family and empower children to live with asthma rather than feel

hindered by it. Physicians are seeing a rise in asthma among the Hispanic population (Braman,

2006); therefore, Mrs. Palacios’ emphasis on a bilingual program is appropriate.

CHILDHOOD ASTHMA AND POVERTY 16

Several different approaches can be taken to market this type of program. One agreed

upon strategy to market this program per the interviewees is to post flyers around the

community. This strategy is the fastest, easiest, and most cost-efficient way to market. A second

way to market the program is to visit physician’s offices and highlight the program so that they

may educate their patients that there is another resource to help children in addition to

medication management. Flyers or brochures would also be available in the waiting rooms.

Asthma is often triggered by allergens in the environment; therefore,informational flyers and

brochures about the program would be appropriate to place in allergist’s and dermatologist’s

offices. Finally, advertising in the newspaper about a local health program for children with

asthma would reach even more people. Work has already begun on asthma management; and as

a reference and guide, program planners can use the Six-Point Asthma Management Program

outlined by GINA (Global Initiative for Asthma) (Braman, 2006). “The plan focuses on patient

education, written medication plans, and ongoing communication and review with patients and

their providers” (Braman, 2006, para 21). The support of GINA in program planning will

strengthen the program and remain aligned with the effort on asthma reduction and management

nationally and even globally.

CHILDHOOD ASTHMA AND POVERTY 17

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CHILDHOOD ASTHMA AND POVERTY 20

Appendix A: Spring Branch Community Health Center – Demographic Profile