Breath of Fresh Air

State: CT Type: Model Practice Year: 2003

In Stamford, 8.5 percent children have asthma. This prevalence exceeds the county by 35 percent. Stamford children are hospitalized for asthma 2.4 times more often than children in neighboring communities. Pediatric asthma in Stamford is concentrated in certain geographic "hotspots" and disproportionately affects African-American children. In response, Stamford Health Department established an in-home pediatric asthma environmental education initiative. Asthmatic children are identified from a school health database and voluntary home visits are scheduled for families in targeted geographic hotspots that are characterized by high poverty, poor housing stock, large ethnic and racial minority populations, non-English speaking immigrants, and a high prevalence of lead poisoning and housing code violations. Home visits are conducted by a nurse educator and a housing code inspector. At each visit, they complete a standardized quantitative assessment and perform an educational and environmental intervention is performed. Follow-up visits occur at 3, 6, and 12 months.
Stamford’s asthma program is called Breath of Fresh Air (BOFA). It is responsive to a nationally and locally articulated need to better document asthma prevalence and better control asthma environmental triggers, particularly in vulnerable populations that may be subject to environmental racism. The most innovative aspect of the Breath of Fresh Air Program is the unparalleled degree of accuracy with which the target population is identified and enrolled. According to the 2000 Census, there are 26,914 children under the age of 19 in Stamford. Of these children, 19,502 are in the public, private, and parochial school system and an additional 2,421 of these children are in institutional day care programs. Therefore, 81 percent of all children in Stamford are enrolled in school programs overseen by Stamford Health Department’s school health program. These children are tracked in a comprehensive school health database. Approximately 21 percent of these children have no health insurance. An additional 22 percent are on Medicaid. As a result of detailed geographic data analysis, the Breath of Fresh Air Program is able to focus its outreach on precisely those children that live in inner city, predominantly minority communities; have limited access to health care’ have high levels of poverty; and live in deteriorating multi-family housing. Implementing the Breath of Fresh Air Program in these neighborhoods has decreased asthma symptom days, thereby decreasing unscheduled medical care visits, hospitalizations, and school absenteeism. By employing these innovative methods, the Breath of Fresh Air Program is responsive to a pressing community need and accurate in its ability to target precisely those children that many other programs find most difficult to reach.
The City of Stamford has the ability and resources to tackle a complex environmental health challenge such as that posed by pediatric asthma. In Stamford, every critical component for a comprehensive citywide collaboration is in place in the Breath of Fresh Air Program. As a result, this program offers a unique opportunity to address this health problem in a multifaceted and comprehensive manner. The Stamford Health & Social Services Department has made pediatric asthma a priority. Because the health department is fully integrated into the city’s school system, it has been able to develop a detailed pediatric health database that contains every school-aged child in Stamford. Every child with asthma in the Stamford schools has been identified and is known to the health department’s school nurses. The genesis of the program dates from 1996 when the department formed the Stamford Asthma Planning Council, a collaborative made up of the health department, the board of education, Stamford Hospital, the American Lung Association, two private corporations, and local physicians. Since 1996, the Stamford Asthma Planning Council has introduced the Open Airways curriculum in all of the Stamford schools and arranged to send inner-city children to an asthma summer camp (Camp Treasure Chest). The Council meets regularly to advise the health department on the progress of the program. After a series of presentations to the hospital medical staff and board of directors, the program was awarded a substantial financial grant from the hospital to hire a medical epidemiologist to further refine and track the asthmatic children in the department database. The program benefits greatly from the collaboration with its many community partners and, as a result, has access to Stamford Hospital pediatric asthma emergency room and inpatient utilization data and to school absenteeism data. These data allow the program to perform evaluations. The program core staff consists of two full-time community health nurses, two full-time housing code inspectors, and a part-time epidemiologist. This staff works within a health department with 35 community and school nurses, 15 health inspectors, and 2 epidemiologists. The program is supported by a three-year $850,000 grant from HUD and a $60,000 grant from Stamford Hospital. The HUD grant is devoted to personnel costs (~80%) and housing abatement/rehabilitation costs (~20%).
In its first year, the program has enrolled over 120 children and has produced favorable interim results that show that by using a targeted school-based enrollment process, the health department is accurately identifying children with demographic characteristics that other programs find hard to reach. Once identified, these children have enrolled in the program at high rates that have exceeded projections.The objective data gathering system has provided rich insight into the severity, housing conditions, level of asthma trigger awareness, and treatment adequacy of this large group of enrolled children. In 1997, the National Asthma Education and Prevention Program (NAEPP) published the Guidelines for the Diagnosis and Management of Asthma, an expert panel report. The Guidelines approach asthma through four core components: Assessment, Control, Therapy, and Education. The Stamford Health Department Breath of Fresh Air Program utilizes these four NAEPP components to establish the program’s core assessments and in the design of the program’s standardized educational intervention. From among the variables important in the management of asthma established by NAEPP, the Breath of Fresh Air Program’s distilled the following six core measures to track: Presence of asthma triggers in the home environment Parental knowledge of asthma  Child’s knowledge of asthma  Degree of asthma severity Adequacy of treatment Degree of asthma control  The Breath of Fresh Air program further stratifies the enrolled children into high, moderate and low risk based on variables related to the child’s medical history. Interim data reveals overall improvement in each of the six core measures between the initial and the three-month visit. The greatest area of improvement has been in the child’s knowledge of asthma and the presence of asthma triggers in the household. Additional evaluation data will include emergency room visit rates and school absenteeism pre- and post-enrollment into the program.
The program has had an effect because it simultaneously addresses two important aspects of pediatric asthma control - access to care and self-management skills. Many families of asthmatics lack adequate access to care even if they have insurance. Frequently, the care is not state-of-the-art and is delivered sporadically in fragmented health care systems. Additionally, patients lack the confidence to engage in appropriate disease self-management. The program has refined its focus to enhance these important elements.While it appears that the standardized intervention is having a positive effect on several of the core assessment measures, what is not clear is which component of the intervention, the nurse performed educational intervention or the housing code inspector performed abatement intervention, is more efficacious. Many local health departments do not have jurisdiction over the local housing code. Thus, it is important to demonstrate the degree to which the housing code enforcement component of the BOFA model adds value to the program’s efficacy. The department is currently seeking additional grant funds to permit the Breath of Fresh Air Program to operate a parallel community health nurse environmental education intervention and compare its efficacy to the nurse/inspector model in order to determine the added value of the health inspector component. This is extremely important to determine because many local health agencies do not have enforcement authority over the local housing code and are thus limited to a community nurse driven educational intervention. If it can be demonstrated that a nurse driven model is as efficacious as a nurse/inspector model, then virtually any local health agency would have the potential to develop an in-home environmental education program to reduce the burden of asthma. There are three key elements to the Breath of Fresh Air Program: a comprehensive school asthma database, GIS mapping capability, and housing code enforcement authority. The most important element is the school health database, which allows asthmatic children to be readily identified and targeted. Barriers such as confidentiality of school health data can be overcome by developing a good relationship with the school superintendent, principles, and nurse. All of these school officials recognize the adverse impact that asthma can have on a child’s ability to learn and to participate in physical activity. It is by working together to improve the quality of life for these children that barriers between school systems and health departments can be broken down. These three key elements are not mandatory but they are important components of the comprehensive asthma environmental intervention. Other important elements include a close data relationship with the local hospital and a good relationship with the local pediatrician community.