The goal of Breathe Easy at Home (BEAH) is to improve the health of Boston residents with asthma, particularly Black, Latino, and low-income Boston residents, by ensuring that multi-family housing in Boston complies with state housing codes. This will be achieved through the following objectives: Improve communication between 31 Boston health institutions and Boston Inspectional Services Department by January 2009; Boston residents with asthma, particularly low-income, Black, and Latino residents, will be aware of BEAH as a resource for improved health and housing by January 2009; Prevent poor housing conditions, which contribute to asthma, through educating Boston landlords about integrated pest management by July 2008.
Asthma is the most common chronic health condition among children and is also common among adults, particularly elder adults. Studies show that asthma mortality is disproportionately high among African Americans and in urban areas that are characterized by high levels of poverty and minority populations. Massachusetts has among the highest asthma rates in the United States for both children and adults. In 2003-2004, over 10% of Massachusetts children reported having current asthma and asthma rates nearly double for those of the lowest income compared to the highest income.
Boston has the highest rate of asthma hospitalizations in the state (8 per 1000 for children under 10 years old), with the highest rates experienced by Blacks (14) and Latinos (14). Youth under 18 are hospitalized for asthma at a rate of 6.5 per 1,000, compared to 2.8 in the rest of Boston and 3 nationwide. Adults under 65 in the intervention area were 3.5 times more likely to be hospitalized for asthma and 1.5 times more likely to die of asthma than adults in the rest of Boston. Among Boston public housing residents reporting to the 2001 BRFSS, 22% of residents living in public housing or receiving rental assistance reported doctor-diagnosed asthma, as compared to 10% living in market rate housing. Environmental factors, many of which are found in homes, can exacerbate asthma. State sanitary codes for housing address multiple factors that contribute to asthma, including cockroach and rodent infestation, mold and moisture, extremes of heat or cold, and unsafe or moisture damaged carpeting.
Through the BEAH Web-based referral system, physicians, nurses, and others make inspection referrals for their patients with asthma. Clinicians document the housing conditions of concern, including pests, mold, and moisture, initiating an inspection. This technology makes it easier for clinicians to make a referral for public health services, monitor the results and highlights the increased use of electronic health records and other technology in clinical practices. This program addresses racial and ethnic health disparities and improves well-being of low-income residents living with asthma by targeting the program to public housing, which is overwhelmingly located in communities with high numbers of Black and Latino residents.
Agency Community RolesBEAH is a collaboration of Boston Public Health Commission, Boston Medical Center, Boston Inspectional Services Department Housing Division, Boston’s Urban Asthma Coalition (BUAC), and the Medical Legal Partnership for Children. The collaboration now meets monthly and includes Boston health centers, the Boston Housing Authority, and Children’s Hospital Boston. Strengthening Voices, a parent asthma advocacy group (under the auspices of BUAC) is working with the program to ensure program outreach in Boston neighborhoods most impacted by asthma.
Once the BEAH program was launched, it was determined that many BEAH cases were in Boston public housing. The city’s public housing department then joined the BEAH collaborative, and representatives attend monthly meetings. The Housing Authority has signed a memorandum of understanding, ensuring quick response to BEAH cases, and the Housing Authority has worked with the collaborative to resolve particularly challenging cases.
Costs and ExpendituresIn 2007, monies awarded by the Environmental Protection Agency to the Boston Public Health Commission (BPHC) supported a part-time staff coordinator to initiate outreach at health centers and hospitals. Simultaneously, community advocates, including parents of children with asthma, approached the City of Boston requesting funds to create a full-time staff position in the BPHC’s Asthma Prevention and Control Office.
ImplementationIn 2005, a pediatrician from Boston Medical Center approached Boston Inspectional Services to modify the existing BEAH program, making it more responsive to clinician and patient needs, particularly regarding communication. A BEAH collaborative of health center and hospital representatives, legal service attorneys, advocacy organizations, and local government departments convened to enhance the BEAH program. BMC funded the development of a Web-based referral system. The collaborative decided the Boston Public Health Commission would hire and manage a coordinator to oversee the project, including outreach, evaluation and facilitating monthly BEAH meetings.
In May 2006, the program was publicly launched. In 2007, the Environmental Protection Agency supported a part-time staff salary, making it possible to initiate outreach to health centers and hospitals. Also in 2007, advocates approached the City of Boston requesting funds to create a full-time BEAH staff position in the BPHC Asthma Program office. During this period, inspection practices and standards were established that included the growing body of knowledge relating to integrated pest management.
Starting in 2002, the Boston Public Health Commission, in partnership with ISD, began annual inspector trainings that focused on issues contributing to asthma. These trainings grew to over 90 participants, including Section 8 inspectors, public housing operations staff, state and local environmental health officers, and others. Through these annual trainings, the BPHC Asthma Program and ISD strengthened their collaboration. The trainings ensured that the ISD inspectors were well prepared to conduct BEAH inspections.
The program is a collaboration of key stakeholders in housing, health, advocacy, and government agencies that work to address poor conditions in multifamily housing in Boston. During 2007, with a part-time staff person, 28 health centers and hospitals registered as BEAH users and 148 clinicians were trained as users.
Since BEAH's inception, 180 cases have been referred. A user satisfaction survey is underway that will collect information on both the usability of the Web site and the success at improving housing conditions. The Boston Housing Authority has joined the BEAH collaborative and guaranteed a rapid response to cases. Monthly partner meetings are held, resulting in a quarterly newsletter, the development of a bilingual tenant rights brochure and a case review process. A parent asthma leadership group has met with the BEAH collaborative about promoting the program more aggressively in the most affected communities of Boston.
BEAH builds on the core functions of key partners. Resources continue to be necessary to support the collaboration and coordination aspects of BEAH. With the alarming asthma rates, BEAH has been recognized as an important strategy in reducing the burden of asthma in Boston. BEAH’s value has been acknowledged at the highest level of city government and the mayor allocated new monies for salary support. Boston Inspectional Services Department conducts over 5,000 home inspections each year, and inspectors conduct BEAH inspections and enforce the existing codes.
The Boston Public Health Commission coordinates the program, including outreach to residents and health providers, database development and evaluation. The Boston Public Health Commission works closely with Boston’s health and housing institutions and conducts health education, awareness, and promotion campaigns to improve the health of Boston residents with asthma. The BPHC and ISD conduct annual inspector and housing trainings to promote healthier and safer living environments in Boston. The Boston Public Health Commission works with Boston’s health institutions to ensure the health of Boston residents and health institutions report health information to the health commission. BEAH is replicable in any large or medium-sized city or a county with a housing code enforcement infrastructure.