Barbara A. Israel*, Dr. P.H., M.P.H. Professor, University of Michigan

1. 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

2. 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

3. 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)

4. 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.

5. 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

6. 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.

7. 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.

8. 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).

9. 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.

10. 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

11. 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 - Partners

12. 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.

13. 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

14. 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

15. 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

16. 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 phase • Education (e.g., dustmite, cockroaches, household cleaning) • Materials distributed (e.g., vacuum cleaners, mattress covers) • Integrated pest management • Other (e.g., housing, obtaining city services, furniture, translation)

17. 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)

18. 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

19. 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 checklist • Neighborhood Environmental Checklist • Qualitative evaluation of process of adhering to CBPR principles • In-depth interviews with members of SC

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. Advantages of Using a CBPR Approach • Enhances relevance and use of data • Data collection: content and quality • Increases quality and validity of research and intervention • Recruitment • Retention

27. Advantages of Using a CBPR Approach (continued) • Improves intervention design and implementation • Selection and training of outreach workers • Extends beyond asthma directed needs

28. 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

29. 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

30. Lessons Learned: Recommendations for Conducting CBPR (continued) • Costs and benefits of participation need to be addressed • Need to achieve balance between • research and intervention • completing tasks and maintaining relationships