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Public Health in Public Housing:Improving Health, Changing Lives

National Heart, Lung, and Blood Institute Education Strategy Development Workshop

SUMMARY REPORT

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESNational Institutes of HealthNational Heart, Lung, and Blood Institute

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESNational Institutes of HealthNational Heart, Lung, and Blood Institute

Administrative Use OnlyAugust 2005

Public Health in Public Housing:Improving Health, Changing Lives

National Heart, Lung, and Blood Institute Education Strategy Development Workshop

SUMMARY REPORT

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Day 1: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Opening Session: NHLBI Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Setting the Stage:

An Overview of Public Housing and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Public Housing and Public Health:

Public Housing Perspectives for Resident-Focused Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Making Public Health and Clinical Connections

To Address Health Disparities: Clinicians Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Public Health Programming in Public Housing:

Presentations From the Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Day 2: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Dream Team Breakout Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Pearls of Wisdom: Things To Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Preparation for the Breakout Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Charge to the Dream Team Breakout Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Dream Team Scenarios and Frameworks Summary Findings . . . . . . . . . . . . . . . . . . . . . . . . . . .32Adjournment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45A. Workshop Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46B. Workshop Objectives (Days 1 and 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50C. Global Workshop Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51D. Participants List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52E. Breakout Group Discussion Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .inside back cover

Contents iii

Contents

The NHLBI would like to thank all workshopparticipants, panel speakers and moderators,and breakout group facilitators and reporters forcontributing their expertise, ideas, and experi-ences in public health and public housing pro-grams to the Education Strategy DevelopmentWorkshop Public Health in Public Housing:Improving Health, Changing Lives, May 5-6,

2004 (see Appendix A: Workshop Agenda,Appendix D: Participants List, and AppendixE: Breakout Group Discussion Instructions fora listing of names). Special thanks is given toCarol Payne, U.S. Department of Housing andUrban Development and Dr. Samuel B. Little,Washington, DC Housing Authority, for theircontribution to the planning process.

Public Health in Publ ic Housing: Improving Health, Changing Livesiv

Acknowledgements

Executive Summary v

The National Heart, Lung, and Blood Institute(NHLBI) hosted the Education StrategyDevelopment Workshop: Public Health inPublic HousingImproving Health, ChangingLives on May 56, 2004, at the NatcherConference Center on the campus of theNational Institutes of Health (NIH) inBethesda, MD. The purpose of the Workshopwas to hear from both public health and publichousing professionals regarding public healthstrategies they have found to be effective in public housing communities. The Workshopfocused on the (1) health conditions: asthmaand cardiovascular disease (CVD) and (2)opportunities to improve the health of residentsin public housing settings. On the first day ofthe Workshop, the guest speakers presented a picture of the public housing setting and shared their perspectives about best practices,lessons learned, and opportunities for reducingthe prevalence of CVD and asthma in publichousing. On the second day, participantsapplied the information shared on Day 1 andtheir collective experiences and knowledge to cre-ate scenarios and frameworks that could be usedto plan future asthma control and cardiovascularhealth programs in public housing settings.

Day 1Dr. Barbara Alving, Acting Director of theNHLBI, welcomed the participants andexplained the purpose of the Workshoptobuild on efforts to reach out to people living inpublic housing and help them take better careof themselves and their families.

Dr. Rob Fulwood, Senior Manager for PublicHealth Program Development of NHLBIsOffice of Prevention, Education, and Control(OPEC) described the offices responsibilities fortranslating and disseminating scientific results toformats for the public, patients, and physicians.He also reviewed the Workshops global objec-tives: to provide participants with a portraitof the public housing setting; to share perspec-

tives and identify opportunities to incorporatepublic health activities in new and/or existingresident services programs; to understand theimportance of integrating clinical and publichealth strategies to address health disparities; to create innovative best practice approaches(scenarios) based on lessons learned from conducting community health programs in public housing and/or related settings; and to engage participants in facilitated exercises tostimulate creative ideas and interactive discussion.

Dr. Samuel Little from the Housing Authorityof Baltimore City and Mr. Ron Ashford fromthe U.S. Department of Housing and UrbanDevelopment HOPE VI Community andSupportive Services in Washington, DC, provided an overview of public housing,describing the socioeconomic characteristics of public housing residents and the problemsfacing themincluding health problems such as CVD, asthma, and obesity. There was discussion of the HOPE VI program, an effort of the U.S. Department of Housing and UrbanDevelopment (HUD) to transform public housing. It was suggested that HOPE VI needsto do more in the area of health. These remarkswere followed by a series of panel presentations.

Panel 1. Public Housing and Health: PublicHousing Perspectives for Resident-FocusedProgramsPanel 1 focused on programs that would helptransform residents attitudes toward health andwellness. Carol Payne of the U.S. Departmentof Housing and Urban Development moderat-ed this session. Panel members spoke fromtheir experience in public housing addressingthe topics of building partnerships, engagingpublic housing residents, and promoting programs in public housing. Irma Gorham (City of Paterson, NJ, Housing Authority); Dr. James Krieger (Seattle-King CountyHealthy Homes Project); Pamela Taylor(National Organization of African Americans

Executive Summary

in Housing); Harry Karas and Martha Benton(Resident Advisory Board of the HousingAuthority of Baltimore City and Hope Villagein Baltimore); and Jack Cooper (MassachusettsUnion of Public Housing Tenants, Dorcester,MA) were panelists. They described their organizations programs, partnerships, targetpopulations, and strategies.

The panel came to several conclusions: Residents are the experts; this expertise

needs to be recognized.

Policies are needed to address health disparities.

Cultural sensitivity is important, especiallywhen addressing diet and language in publichealth activities.

HUD and the U.S. Department of Healthand Human Services should join efforts.One way is to create a health line item in public housing operating budgets.

Relationships are crucial to obtaining program funding; potential partners includehousing authorities and faith- and community-based organizations.

Panel 2. Making Public Health and ClinicalConnections To Address Health Disparities:Clinicians PerspectivesPanel 2 included four clinicians who discussedhow their organizations have implemented pro-grams to address health disparities. Dr. MeganSandel, from the Boston Medical Center,described asthma rates in Bostons public housing. She described how environmentalasthma triggers in some public housing unitswere driving requests for transfer to public hous-ing units free of these triggers. A collaborativeof several organizations and groups established a Public Housing Transfer Policy Workgroup toaddress environmental asthma triggers in public

housing to mitigate the rates of public housingtransfer requests. Dr. Marielena Lara, represent-ing Allies Against Asthma in Puerto Rico,described this community-centered coalitionthat has had early success in promoting asthmacontrol in a housing project. Dr. James Krieger,representing Seattle and King County PublicHealth, described the Healthy Homes project in Seattle, which offers an in-home educationprogram, as well as several other projects in Seattle that aim to improve clinical care.Dr. Henry Dethlefs, representing the HealthDisparities Collaborative in Omaha, described a project in Omahas One World CommunityHealth Center that focuses on improving healthoutcomes in patients with chronic disease bychanging provider practice behavior and systemsand improving community relations.

Panel 3. Models To Promote Healthy Lifestylesin Public HousingPanel 3 speakers described programs that havebeen successful in promoting healthy lifestylesin public housing. Dr. Jeanne Taylor, a healthcare consultant from Global Evaluation andApplied Research, and Anita Crawford, representing the Roxbury ComprehensiveCommunity Health Center (RoxComp) at theOrchard Park Housing Development in Boston,described the RoxComp program. RoxCompwas awarded a HUD grant to upgrade the center and worked with the tenant associationand residents to determine health care servicesneeds. Myron Bennett, representing Healthy-CMHA (Cuyahoga Metropolitan HousingAuthority), described this community partner-ship that promotes health and wellness in 48 housing developments in Cleveland. Thisprogram has implemented a multiculturalhealth promotion/wellness model, which focuseson increasing awareness, implementing healtheducation and, lifestyle enhancement programs,and creating cultural change opportunities within the community to improve health.Staci Young, of the Medical College of

Public Health in Publ ic Housing: Improving Health, Changing Livesvi

Wisconsin) described a community health advocate program in a housing development in Milwaukee. This program trains advocates to provide services and programs for residents in the areas of education, safety, and social activities. Ms. Carol Payne, representing theBaltimore Office of the U.S. Department ofHUD, described the Healthy Hearts in PublicHousing NHLBI-funded CVD EnhancedDissemination and Utilization Center (EDUC)in Baltimore, a program that has helped to raisecommunity awareness about CVD throughtraining and hiring public housing residents as community health workers (CHWs).

Panel 4. Integrated Chronic Disease ModelsPanel 4 speakers discussed programs that pro-vide integrated chronic disease control. HenryTaylor, representing the University of Illinois atChicago Mile Square Health Center, describedhow this Center provides quality health servicesto a diverse urban community by linking publichousing residents to primary care and socialservices. Patricia Hynes, representing BostonUniversitys School of Public Health, describedBostons Healthy Public Housing Initiative,which works to improve home environments for better respiratory health. The program trainsresidents at home to serve as community healthadvocates. They conduct surveys of housing andhealth conditions and collect environmentalsamples and data as well as educate communityresidents on asthma management strategies andintegrated pest management (IPM). The YESWE CAN program in San Francisco wasdescribed by Dr. Mary Beth Love from SanFrancisco State University and Arthur Hill, a community health worker (CHW) in the YES WE CAN program. This coalition of 17organizations has developed a medical/socialmodel for chronic disease management in children that includes roles for the clinician,clinical care coordinator, and CHW. TheAsthma Ambassador Project was described byJudith Taylor-Fishwick and Lilly Smith of the

Center for Pediatric Research, Eastern VirginiaMedical School/Childrens Hospital of theKings Daughters in Norfolk, VA. This projectidentifies and evaluates the needs of disadvan-taged asthmatic children living in public housingin the Hampton Roads area of southeasternVirginia, using a case finding approach and layhealth workers (Ambassadors) who provide outreach and education at the public housingcommunity.

Day 2 Dr. Janice Bowie, of the Johns Hopkins UniversityBloomberg School of Public Health, facilitatedthe Dream Team Breakout Sessions. To begin,participants shared thoughts and conclusionsabout strategies and best practices for asthmaand CVD programs discussed during Day 1.Then Dr. Bowie held a discussion on what program planners should consider in the areasof community partnership and involvement,implementation, and sustainability, and she provided questions to consider in program plan-ning. Next, she asked the four breakout groupsto identify effective strategies in prevention andtreatment of asthma and CVD in public hous-ing, and to consider global factors associatedwith community partnership and involvement,implementation, and sustainability. In the firsthour, each group would develop two scenariosthat identify and define a problem related toasthma or CVD in terms of issues, needs, and concerns; the population to be reached; the rationale for selecting the problem; andpotential barriers and opportunities for resolu-tion. The next hour would focus on construct-ing a framework/approach for solving at leastone of the scenarios. The groups were asked to define specific objectives and strategies, keystakeholders, the materials/tools/resources thatwould be needed, and how outcomes would be tracked and measured. Other assignmentswere to determine the extent to which the project components form an integrated approach and to construct a pictorial display of the

Executive Summary vii

approach with all the relevant elements to show connectivity.

Dream Team Scenarios and FrameworksSummary Findings Group ICVD focused on multiethnic intergenerational families in public housingand the impact of CVD on them. The groupsscenario addressed residents problems andneeds by developing an inclusive strategy thatinvolves various segments of the target commu-nity to reduce CVD disparities in a high-riskpopulation. The main opportunity to solve the problems discussed was to create links withpower brokers in the community and withorganizations such as social service agencies,churches, schools, and the public housing development residential association. Goals were to enhance awareness of CVD disparities,increase awareness of CVD morbidity and mortality among the target populations, andempower community residents in the targetpopulation. Approaches were to create a resident association and a health committee,hire and train a CHW to educate the commu-nity, hold community forums that involve residents, encourage residents to serve on theboards of community organizations, involve residents in the planning process, and providethem with incentives.

Group IIAsthma developed a scenario thatincorporated the problem of asthma in publichousing in two contexts: by each resident emergency asthma case and by the factors inpublic housing that trigger asthma symptoms in the resident population with asthma. Thescenario involves 30 resident families, with 50 children, who were considering suing theHousing Authority and HUD for very detri-mental conditions in their housing units. Thegoal was to address the environmental condi-tions associated with asthma: mold, insectinfestation, dust, overcrowding, and lack ofcleanliness. This scenario was an opportunity

to build community-based coalitions (amongresidents, the Housing Authority, local proactivegroups, the local community, and governmentofficials) that would focus on each individualasthma emergency case and the conditions inthis public housing development that contributeto asthma. The solution to the problem involvesa triaging process which employs environmentalassessment and clinical evaluation.

Group IIICVD and Asthma viewed theproblems of CVD and asthma in public hous-ing as being interrelated since these chronic diseases have common factors that either contribute to or exacerbate these diseases.Participants created a fictitious scenario todescribe how conditions in public housing may impact asthma. They described an old andovercrowded public housing building situated in a closed-in environment, isolated, and havingpoor-quality services, little transportation, and aculturally diverse population. They assessed thatin this scenario CVD and asthma would be prevented or lessened by addressing disease riskfactors, environmental and psychosocial factors,and barriers. The scenario provides an opportu-nity to build partnerships with the communityand to utilize CHWs. Activities to addressCVD and asthma include holding meetings,classes, and workshops; providing culturallyappropriate health information; and ensuringtransportation to access health services and stores that sell healthy food/products/medications. They recommended tools to support activities, including a Web-based clearinghouse with links to existing resources.

Group IVCVD and Asthma felt that the program should target oppressed, intergenera-tional, multiethnic residents who are at higherrisk for CVD and asthma. The roots of asthmaand CVD start in youth and continue duringones lifetime, and one is never too old tochange health habits. The group concentratedon health education and nutrition and thus

Public Health in Publ ic Housing: Improving Health, Changing Livesviii

CVD initially, because they surmised that nutrition is a link between poverty and poorhealth. They believed that increasing the avail-ability of healthy food would be an importantactivity. They identified that the most effectivestrategy to address poor nutrition is to build a broad, community-based, governing body that would serve as a tool to turn agencies intoallies and empower community residents.Empowerment, advocacy, and the creation of agoverning body were described as key elementsto addressing the health problem. Though thisdiscussion focused on nutrition rather than asthma, the group believed that once communityempowerment is achieved in the area of CVD,its benefits could transfer into activities toimpact asthma as well.

SuggestionsDuring the course of the meeting, the followingsuggestions were made: Raising awareness about CVD and asthma

could help change policies (e.g., for technicalassistance for inspections, to mobilize resi-dent groups to train other residents, and toteach families to adopt healthier lifestyles).

Federal agencies such as the EnvironmentalProtection Agency, the Department ofEnergys National Laboratories, HUD andNIH need to come together around theissues of health and housing through theirprograms and grants.

Building coalitions among stakeholderswould lead to the greatest chance to addressCVD and asthma. A suggestion was madeto establish a Public Housing DisparitiesCollaborative which would be housed nearclinics that have been associated with theHealth Resources and ServicesAdministration Health DisparitiesCollaboratives.

ConclusionAt the conclusion of the workshop, participantswere informed that a Workshop summaryreport will be created, shared with participants,and used as a planning tool by NHLBI.

Executive Summary ix

Day 1:

Introduction

Opening Session: NHLBI Remarks

Setting the Stage: An Overview of Public Housing and Public Health

Public Health Programming in Public Housing:

Presentations From the Field

Day 1 1

The National Heart, Lung, and Blood Institute(NHLBI) hosted the Education StrategyDevelopment Workshop: Public Health inPublic HousingImproving Health, ChangingLives on May 56, 2004, at the NatcherConference Center on the campus of theNational Institutes of Health (NIH) inBethesda, MD. The purpose of the Workshopwas to have both public health and public housing professionals share intervention strategies they have found to be successful in engaging public housing residents in community-based activities for health and community development. The Workshopfocused on ways to control asthma and improvethe cardiovascular health of residents in publichousing settings. On the first day of theWorkshop, the guest speakers presented a picture of the public housing setting and sharedtheir perspectives on best practices, lessons

learned, and opportunities for reducing theprevalence of CVD and asthma in public hous-ing. On the second day, Workshop participantsapplied the information shared on Day 1 andtheir collective experiences and knowledge to cre-ate scenarios and frameworks for future asthmaand CVD program planning in public housing.

Workshop participants were diverse both geographically and professionally. They includedlocal, State, and Federal Government profes-sionals; public housing and public health practitioners; and public housing resident advocates and leaders. Among the participantswere health educators, public health programmanagers, community health workers, housingadministrators/managers, physicians, socialworkers, and consultants. The following sections summarize the Workshop proceedingsand contributions made by participants.

Public Health in Publ ic Housing: Improving Health, Changing Lives2

Introduction

Dr. Barbara Alving, Acting Director,NHLBI Dr. Alving welcomed the participants to theWorkshop and shared that the activity was oneof NHLBIs efforts to focus attention on theneed to address health disparities of high-riskand minority populations living in public housing. Dr. Alvings introduction to publichousing was as a medical student at WashingtonUniversity School of Medicine in St. Louis,MO, where the students provided a nighttimeclinic for the residents of Pruitt-Igo, one of theNations first public housing projects. She men-tioned that medicine at that time was focusedon the very sick patient, but today the hope isto prevent illness, which is one of the goals ofthe NHLBIs Office of Prevention, Education,and Control (OPEC). Dr. Alving stated thepurpose of the Workshop was to build onefforts to reach out to people living in publichousing to help them take better care of themselves and their families.

Dr. Rob Fulwood, Senior Manager forPublic Health Program Development,NHLBI OPEC Dr. Fulwood described OPECs responsibilitiesfor translating and disseminating scientificresults into formats for the public, patients, and physicians. OPEC directs several nationaleducation programs, including the NationalHigh Blood Pressure Education Program,National Cholesterol Education Program,National Heart Attack Alert Program, NationalAsthma Education and Prevention Program,Obesity Education Initiative, Womens HeartHealth Education Initiative, and SleepEducation Initiative. These programs sharecommon tenets. They all have a strong sciencebase, use education and communication strategies, and address the problem of underuti-lization of science-based information. The officeworks in partnerships, using a wide variety of

traditional and nontraditional approaches to get the information utilized.

The Institute has been challenged by HealthyPeople 2010, the Nations health agenda, towork towards eliminating health disparities.To do this, it is supporting activities to reachhigh-risk populations who suffer disproportion-ately from chronic diseases. NHLBIs communityhealth projects that fall under this effort includethe EDUCs and the Minority Health Outreach and Education activities. The outreach processinvolves working in partnership with communi-ties to develop and implement culturally andcontextually appropriate activities that will havepublic health impact and improve both behav-ioral and clinical outcomes.

The Workshops global objectives are to: Provide participants with a picture of the

public housing setting; to share perspectivesand identify opportunities to incorporatepublic health activities in new and/or existingresident services programs;

Understand the importance of integratingclinical and public health strategies to addresshealth disparities;

Create innovative best practice approaches(scenarios) based on lessons learned fromconducting community health programsin public housing and/or related settings; and to engage participants in facilitated exercises to stimulate creative ideas and interactive discussion.

The following sections summarize theWorkshop proceedings and the contributionsmade by participants to better understand issuesassociated with implementation of public healthinterventions in public housing settings.

Opening Session: NHLBI Remarks 3

Opening Session: NHLBI Remarks


Public Housing and Health: Making theConnections at the National, State, and Local Levels(SAMUEL LITTLE, PH.D., AND RON ASHFORD)Public housing agencies must do four thingswell: (1) manage property, (2) redevelop obsolete housing, (3) perform administrativefunctions, and (4) provide core programs forresidents. There are 3,200 public housing agencies nationwide, and 40 percent of thosepublic housing structures are more than 40years old. Most public housing residents havelimited space and are isolated from core socialand health services. One database indicates thatthere are more than 1 million occupied publichousing units with 2.3 million household members who belong to intergenerational families. The majority of tenants are single-parent working families with children (See Box 1for additional socioeconomic and demographicinformation on public housing.).

There is a national crisis in public housing that must be addresseda social cancer

that needs prevention and intervention. Public housing residents must deal with issues of disenfranchisement related to drugs, poverty,chronic disease, disability, racism, blight, hazardous buildings, fragile family structures,crime, overcrowded units, and unemployment.Residents problems include health (e.g., obesity,hypertension, diabetes, cancer, CVD, HIV) and safety and security issues (e.g., crime, drugs)(See Figure 1 on page 5.). One group of hous-ing residents identified their three most impor-tant concerns as economic conditions, healthbarriers, and safety and security.

The HOPE VI program is an effort of the U.S. Department of Housing and UrbanDevelopment (HUD) to transform public housing. HOPE VI was established in 1993with a budget of $5.6 billion to improveapproximately 100,000 public housing unitsthat were in poor condition. The programbegan with 196 grants, which were originally$50 million each and are now reduced to $20million per grant. Housing authorities typically

Setting the Stage: An Overview of Public Housing and Public Health

41 percent are younger than age 18.

35 percent are 1850; 8 percent are 5161; 13 percent are 6282;

and 2 percent are older than age 83.

31 percent of the families have elderly members.

14 percent of families have members who are disabled.

52 percent of families have stayed in public housing 5 years or more.

50 percent of residents are white and 47 percent are African American.

90 percent of residents have annual incomes less than $15,000,

average annual income is $10,473, and average monthly rent is $237.

31 percent report wages as a source of income, and 71 percent receive public assistance.

Box 1: Who Are Public Housing Residents?

Sett ing the Stage: An Overview of Publ ic Housing and Publ ic Health 5

use these grants to clear outdated, obsoletehousing and build new housing. Depending on the community, the new housing may be amixed-income community that includes publichousing units, affordable housing (Section 8),and housing at the market rate. The goal ofmixed-income housing is to improve the lives of public housing residents. For example, in Baltimore, many of the traditional hi-risehousing project buildings were demolished andreplaced with new buildings and townhouses,but the lives of the people who live in themmust also be rebuilt by addressing the humanproblems and concerns they face.

HOPE VI could do more in the area of health.As a construction program, only 10 percent of HOPE VIs funding is designated for community and supportive services. With theadvent of the Temporary Assistance for NeedyFamilies (TANF) program, the focus is economicself-sufficiency. Case management staff workwith families to help them become economicallysolvent. The case management program has alsobegun to stress the need to identify health prob-lems such as depression and to refer residents toparticipating clinics. An article on the Movingto Work programa demonstration programdeveloped by HUD to promote self-sufficiency

Fragile

Families

Poverty

Drugs

IsolationDisability

BlightRacism

Disability Reform

Crime

Hazardous Buildings

Unemployment

Chronic Diseases

Over Crowded Units

Welfare Reauthorization

Figure 1: Web of Issues Impacting Public Housing Residents

among assisted families, achieve programmaticefficiency and reduce costs in public housing,and increase housing choice for low-incomehouseholdsshows that when housing residentswere relocated to new neighborhoods, theybegan to experience better health.

A new programmatic direction for resident programs in public housing should be based on an assessment of the problems resident families are faced with today. These programs

could include health resources and health intervention programs as a core set of services,efforts to transform the way residents thinkabout health and wellness, expansion of partner-ships to address health disparities, and new initiatives with more resources to address the root causes of disenfranchisement.Redevelopment without healthy people andfamilies means an unhealthy community, anunhealthy city, and an unhealthy Nation.


Public Housing and Public Health:Public Housing Perspectives for Resident-Focused Programs

Public Housing and Health: Public Housing Perspectives for Resident-Focused Programs 7

(MODERATED BY CAROL PAYNE, R.N., M.S.N.)This panel was convened to discuss resident-focused programs that would help transformresidents attitudes toward health and wellness.Carol Payne asked the panelists to discuss howto build partnerships to start a health programin public housing and how to offer programs to meet the needs of residents. The panelistsresponses provided insight into these topics.

Building Partnerships Irma Gorham noted that the City of Paterson,NJ, Housing Authority started a number ofhealth programs by contacting the Public Boardof Health and then expanded to include localhospitals, universities, advocacy and faith-basedgroups, resident councils, community members,local businesses, and lenders. This consortiumbrought everyone to the table to address healthconcerns in the community.

Dr. James Kreiger said that key players are the groups represented at this meetingpublichousing, public health, community leaders, etc.The Public Health Department in Seattle, WA,worked with the Seattle Housing Authority, the resident community council, communityhealth centers, and the Seattle-King CountyHealthy Homes Project to identify childrenwith asthma through the schools and thenestablished neighborhood asthma committees.

Pamela Taylor said that all groups must partnerfor the same goal: to provide affordable, decent,and safe housing for public housing residents.One organization working toward this goal isthe National Organization of African Americansin Housing (NOAAH), which was establishedin 1999 to provide affordable housing and toadvocate for people of color. African Americansmake up 12 percent of the U.S. population and47 percent of public housing residents. As such,one-third of NOAAHs membership and direc-tors is required to be public housing residents orrepresent resident organizations. At its national

conference each year, NOAAH honors a resi-dent, a resident organization, a public housingorganization or staff person, and an industrygroup. Other industry groupsthe Council of Large Public Housing Agencies, NationalAssociation of Housing RedevelopmentOrganizations, and the Public Housing AgencyDirectors Associationhave been excellentadvocates for residents of public housing.

Jack Cooper described the Massachusetts Union of Public Housing Tenants (MUPHT),founded in 1969, as the first statewide agency of its kind and is responsible for resident advo-cacy and rights in 237 housing authorities inMassachusetts. MUPHTs executive board of public housing residents operates as a com-munity partnership with Housing Authoritymanagement and 12 residents from housingprojects in different parts of the State. Many of the housing authorities part of MUPHT do not have a formal relationship with healthcenters and hospitals, but some do, particularlyin Boston. Some of the organizations partneringwith Bostons public housing are the BostonAsthma Group and other agencies serving children in Boston.

Engaging Public Housing Residents Dr. James Krieger said that public housing residents are partners in change, and the firststep is to involve them because they know the issues. Working with residents, the healthcommunity brings its knowledge of what worksfrom the clinical and public health realms.Multiple strategies are needed because each public housing community is unique. Health isdetermined not only by the actions of individualsbut also by access to services and the social andphysical environment in which they live. TheSeattle public housing population representsgreat ethnic and linguistic diversity, includingWhites, African Americans, Vietnamese andother Southeast Asians, and, more recently, persons from East Africa and the Soviet Union.


These multiple minicommunities often requiresimultaneous translation at community meet-ings, an important consideration in developingeducational activities for these diverse publichousing communities.

Mr. Harry Karas agreed that resident groupsknow best; they must be involved and encour-aged to take responsibility. He stated that thereis enough data to know what needs to be done,and that it is time to look at the results fromsurveys that have been done and to build onexisting resources.

Programs in Public HousingThe participants mentioned several successfulprograms that were not labeled as health activities but raise awareness about health anddiseases. For example, the Paterson HousingAuthority offered a program to young people as an opportunity to audition for a talent show;another was offered as a get-together chat for women.

Mr. Karas described programs offered by HopeVillage in Baltimore, MD. This nonprofitorganization started with a $40,000 budget and now has almost $300,000 a year to providecultural, education, and social programs foryouths, including art, music, martial arts, and a summer camp. Seniors in the communitybenefit from diet and exercise programs. Livingin healthy homes conclusively leads to bettermental health and allows residents to takeresponsibility for their lives.

Mr. Cooper noted that 5 years ago, MUPHTran a program (with funding from BostonHealthy Start) to address problems such asinfant mortality and to bring services to thepublic housing community. The program pro-vided training and held health celebrations and

other activities. Several resident board membershave raised the need for programs to addressdomestic abuse and keeping families together.

Conclusions Carol Payne summarized the following keypoints made by the panel discussants: All social issues converge at the point

of health.

Residents are the experts; their expertiseneeds to be recognized and utilized.

The focus on behavior is important, but poli-cies are needed to address health disparities.

Issues such as diet choices and language need to be addressed in a culturally sensitive manner.

HUD and the U.S. Department of Healthand Human Services (DHHS) should joinefforts, perhaps by combining budgets forhealth and housing, to lead to a health lineitem in public housing. These agencies havea common goal: healthy families who are self sufficient.

Healthy families make healthy communitiesand cities. People cannot be healthy withouthousing that is safe, clean, and decent, andthey cannot work if they are not healthy.

Relationships are crucial to obtaining pro-gram funding. Potential partners include, butnot limited to, housing authorities and faith-and community-based organizations (CBOs).

This session was a useful way to start theWorkshop, since it touched on several topicsthat would be explored further during the following sessions.

Making Public Health and Clinical Connections To Address Health Disparities: Clinicians Perspectives 9

(MODERATED BY SYLVIA FLACK, ED.D., M.S.N.)Dr. Flack introduced the panel members andasked them to provide their perspectives as clinicians to help inform planning for programsin public housing. The panelists described severalprograms that address the needs of public housing residents in different settings: asthmapatients in Boston public housing; a community-centered coalition to fight asthma in PuertoRico; the Healthy Homes project in Seattle; andthe Health Disparities Collaborative in Omaha.

Asthma and the Need for Transfer inPublic Housing: Is There a Better Way? (MEGAN SANDEL, M.D., M.P.H.)Asthma rates are higher in public housing residents. The baseline asthma rates are gener-ally


Many residents with asthma want to move.Clinicians working with public housing resi-dents often write letters requesting moves forresidents with family members with asthma.The Boston Housing Authority receives almost2,500 transfer requests a year (from a total ofmore than 11,000 households). The most common requests relate to asthma and requestsfor first-floor accommodations. The PublicHousing Transfer Policy Workgroup was estab-lished to address this problem. This Workgroupis made up of a tenant advocacy organization(the Committee for Boston Public Housing),the Boston Housing Authority (BHA), BostonMedical Center, the Boston Public HealthCommission, and tenant task forces at eachdevelopment. The hypothesis is that most residents do not want to move; they want a better home. The Workgroup advocates for better maintenance practices by public housingdevelopment managers, better resident educa-tion about what they can do to keep their homehealthy, and better medical documentation for severe cases of asthma that cannot wait fortransfer, or where maintenance practices andresident education were not enough to remedypoor housing situations.

Within 64 housing developments in Boston, theproject chose 8 that were part of the State-fundedportfolio. This project trains development managers, maintenance supervisors, and mainte-

nance staff to do health-related maintenance.It also trains residents through the tenant taskforces in evening sessions. Training consists of a slide show connecting asthma and housingconditions, a review of Boston HousingAuthority protocols around mold and pests, and a review of resident work orders protocolsand things residents can do themselves. Box 2provides an example of how the partnershipsestablished for this project help to address housing conditions triggers of asthma, as well as educate residents on how to better manageasthma. After 1 year, the project will look at work orders and transfer requests in eightdevelopments.

Mutual suspicion between public housing man-agement and residents is a problem. Potentialneutral third parties could include visiting nurses,public health departments, community outreachworkers, or special public health inspectors.

Allies Against Asthma in Puerto Rico(MARIELENA LARA, M.D., M.P.H.)Community-centered coalitions are a possiblesolution to the asthma problem. One suchcoalition is the Allies Against Asthma (AlianzaContra el Asma) program in Puerto Rico, a coalition of the RAND Corporation, theUniversity of Puerto Rico, and the Luis LlorensTorres Community Center. During the plan-ning phase (200103), a trusting relationship

A resident whose childs asthma became worse reported mold in her apartment.

A public health worker found a roof leak with resulting water damage in the kitchen,

and observed that the resident boiled water often to cook meals and never opened

a window. The manager replaced the water-damaged ceiling, and the resident got

a window fan to flow steam out of the kitchen.

Box 2: An Example of How a Partnership Can Help


with the community was established. The intervention began in 2003, linking a qualityimprovement program with increased healthinsurance coverage and community healthworkers (CHWs) who provide outreach andeducation. The program includes local housingproject leaders and organizations; Puerto Rico-wide organizations with commitment andexpertise in asthma-related issues; a local health clinic, managed care company, and an insurance company; and university and researchinstitutions. The fact that Puerto Rico has uni-versal health insurance has helped the program.

The programs vision is to establish a modelhealth service program in Puerto Rico toimprove the quality of life for children withasthma and their families through communityintervention strategies and interagency collabo-ration agreements. The programs goal is to do this in three steps: (1) develop a pilot modelin the Luis Llorens Torres Housing Project within 4 years, (2) prepare this community to sustain services by itself after 3 years, and (3) develop strategies to disseminate the modelin Puerto Rico and, potentially, to otherHispanic communities.

The Luis Llorens Torres Housing Project is the largest low-cost housing project in theCaribbean, with about 2,600 apartments in 140 buildings. It includes a local health clinic,sports complex, police station, three Head Startprograms, and four schools. One-third of thehouseholds are headed by single mothers, andhalf of the residents have monthly incomes lessthan $500. Initially, it is difficult for outsidersto access the housing community for healthprogramming. Once accepted, however, thecommunity members and public health planners form a partnership.

Alianza Contra Asma has had early success inpromoting asthma control in a housing project.The community center coalition approach is a

promising one, with strengths and challenges.One strength is that the coalition approach promotes integration and synergism. For example, a local physician did not know aboutall the social services available but the communitydirector did. Challenges include lack of aware-ness and apathy of some families; gaps in somecommunity capacities; communication gapsabout expectations and priorities; the length oftime it takes to establish a program; a tendencyto hold the coalition accountable; and powerand role conflicts. Successful strategies include anadolescent troupe that has put on a play aboutasthma, which was very well received, the par-ticipation of an influential community leader asa key clinical staff coordinator in the program,and an agreement with a managed care companyto provide increased insurance coverage.

The project has developed several communitycapacity outputs to address asthma and otherhealth issues. A formal pre- and post-evaluationof the program will look at asthma prevalence,symptom control, environmental risk factors,and hospitalization and emergency department(ED) visits. There will also be qualitative andquantitative evaluation of the coalition structure.

Public Housing and Asthma: From Clinic to Community (JAMES KRIEGER, M.D., M.P.H., AND CARMEN OLVERA)A spectrum of interventions around asthma,housing, and public health exist in Seattle.These efforts include the Seattle-King CountyHealthy Homes Project funded by the NationalInstitute for Environmental Health Science(NIEHS); the Better Homes for Asthma proj-ect, funded by HUDs Healthy Homes Office;Allies Against Asthma, funded by the RobertWood Johnson Foundation; as well as otherprojects funded by the Centers for DiseaseControl and Prevention (CDC), the local healthdepartment, the Nesholm Family Foundation,and the Seattle Foundation. Asthma cannot be


managed only in the clinicthere must be aholistic approach that takes place in the home,community, and housing.

The Healthy Homes project offers an in-homeeducation program. In a randomized controlledtrial (RCT), CHWs make five to nine visitseach year to persons in the high-intensity groupand one visit to those in the low-intensitygroup. The CHWs make a home environmentassessment and develop an action plan toimprove the indoor environment. They alsooffer education, social support, and referral to resources; work on landlord-tenant commu-nication; and provide liaison with the HousingAuthority for transfer issues. Residents in theprogram are given trigger control resources, such as bedding covers and vacuum cleaners.Box 3 describes a case study of how the applica-tion of changes to the physical and social environment, together with behavior change,can make a difference is asthma management.The study found significant declines in thenumber of symptom days in children with asthma and improved quality of life in both thehigh- and low-intensity groups. However, onlyin the high-intensity group were there decreasesin hospitalizations, ED visits, and unscheduled

clinic visits, as well as greater improvements inquality of life. The study also showed decreasesin exposure measures as well as changes in resident behaviors and actions. Cost analysis indicated that savings in health care utilization were significant enough to justify the cost of the program.

Healthy Homes II is an RCT that will compareasthma education delivered by CHWs in homeversus clinic-based education. Enrollment willbe completed this month, and the families willbe followed for 1 year.

Improving Clinical Care. Clinical care projectsare being carried out with the King CountyAsthma Forum (a local asthma coalition) andAllies Against Asthma. These projects include a learning collaborative that brings cliniciansand other staff together with experts to examineapproaches to changing the system to providemore effective care. Other projects provideinformation support (data systems and registries) to track care, resources (such as training and machines to measure lung function), and technical assistance in how to set up system change in clinics.

A 15-year-old girl with asthma had been hospitalized twice and had had three ED visits.

The girl was not using Flovent but was using Albuterol three times a day. A walk-through

in her apartment showed mold in the kitchen and bathroom, a hole in a wall, and no fan.

Better Homes for Asthma partnered with the landlord to remove the mold, repair the hole,

and add a fan. The CHW worked with the teenager to explain the role of the controller

medication. After these interventions, the girl increased her use of Flovent, had no further

hospital or ED visits, and fewer missed school days. This is an example of how changes

in the physical and social environment, together with behavior change, can make a difference.

Box 3: Case Study


Linking the Home With Clinics. Anothereffort uses CHWs to link home visit activitieswith clinics. Health care providers refer patientsto CHWs who then send back home visitreports. A nurse works with the CHWs andrelays information to the providers. TheCHWs are trained in medical aspects of self-management as well as environmental aspectsof asthma control.

Linking the Clinic and Environment.In a public housing project at Hyde Point,health care providers at the health clinic includeenvironmental and exposure assessments in their patient intake histories, thus linking asthma with the home environment. Providersare trained to recommend simple steps toreduce exposure.

Making Existing Housing Healthier. BetterHomes for Asthma is working to remediate 70 substandard homes and then compare theresults with asthma education provided by theCHW. Because many of the homes are in public housing sites, this involves working withthe local Housing Authority. The cost of reme-diation is $3,000 per unit to repair and preventwater damage, remove mold, replace flooring,and improve ventilation. Injury prevention anddealing with lead contamination are otherissues. Families have been enrolled in this study,and data will be available in about 18 months.

Building Healthy New Housing. As part of theHealthy Communities/Healthy Homes Projectat the Hyde Point development, 1,600 units are being redeveloped with HOPE VI funding.This project uses the principles of sustainablebuilding to create a green community that will make the homes energy-efficient and water-tight and use finishes without volatile toxic substances. A subset of this project will provide35 Breath Easy units that will include specialheating and ventilating systems to minimize

allergen exposure for people with asthma.The project will also provide CHW support to work on behavior issues. An evaluation with pre- and post-measures will look at theprograms effects on exposures and health outcomes. Lease agreements will require nosmoking and no pets and recommended behaviors such as avoiding clutter.

Building Healthy New Communities. Also atHyde Point, community resources provided bythe King County Asthma Forum will set upneighborhood asthma committees to work onresidents asthma-related concerns and provideonsite asthma education classes. A goal is tobuild community capacity and cohesion byestablishing action teams made up of youthand adult residents to work on environmentalprojects. The physical environment at HydePoint will include open space trails, easy accessto public transit, spaces to promote social interaction, low-allergen landscaping, local markets, and community gardens. Pre- andpost-evaluations will examine the effect of theproject on global health measures as well as on social factors and community empowermentand cohesion. The study will include a subset of families with asthma.

Health Disparities Collaborative, Omaha, NE(HENRY [HANS] DETHLEFS, M.D.)The Health Disparities Collaborative is a project of the Health Resources and ServicesAdministration (HRSA) Bureau of PrimaryHealth Care. It focuses on improving healthcare in patients with chronic disease (diabetes,asthma, CVD, depression). One WorldCommunity Health Centers of Omaha, NE,participated in this program. The HealthDisparities Collaborative is an effort directed at improving systems and community relation-ships, not just changing provider behavior.The chronic care model includes interactions


between informed, active patients and a prepared,proactive practice team to improve outcomes.The larger framework involves communityresources and policies; a health care system thatprovides self-management support in additionto clinical care; delivery system design (e.g., get-ting clinic staff to check the feet of diabetics);decision support (e.g., practice guidelines); andclinical information systems that provide data to see if changes have an effect (See Figure 3 on page 15.).

One such system is the Patient Electronic CareSystem (PECS), a dynamic patient registry thatincludes key information from clinic visits. Thisinformation is used to drive improved care forchronic diseasesboth for individual patientsand for populations of patients. PECS providesaggregate data for selected health measures,which is then reported and tracked nationally tosee whether the Health Disparities Collaborativesare improving care for their patients.

Improved outcomes require system change,including negotiating with the pharmacy to get low-cost drugs; training people to enter datain the electronic registry; training patients onmedication self-management; opening aSaturday lab once a month to improve access;

generating a list of patients from the registrywho need chart reviews and contacts; creatingreminders that appear at the time of visit; andeducating providers to change behavior. Thisinfrastructure can be used for improvements indiabetes, depression, and other chronic diseases.Box 4 shows how the practical application ofthe Health Disparities Collaborative Model forcontrolling low-density lipoprotein (LDL) haslowered LDL in a diabetic patient population.

The project started with clinicians entering theirown data. Later, the clinic received fundingfrom grants to permit hiring a database managerand data entry person. Purchasers of health careand managed care organizations are a potentialsource of funding. Many clinicians who chooseto work in public housing depend on grants.

The Health Disparities Collaborative has severalimplications for public housing. Changes inhealth care need to fit within the context of system change (the chronic care model). Processand outcome measures need to be tracked fromthe outset. Improvements should have a dualfocuson both individual patients and patientpopulations.

Population: Diabetic patients ages 40 and older

The application steps are to check patients LDL cholesterol levels, teach the patients

self-management and/or prescribe statins, and monitor data to assess improvement.

The Collaborative now has about 350 diabetic patients, with 74 percent now on statins.

After several years in this program, the patients LDL cholesterol levels were lowered,

which translates to fewer heart attacks.

Box 4: Practical Application of the Health Disparities Collaborative Model for Control of LDL Cholesterol


Discussion and ConclusionThis panel ended with a discussion about fund-ing. Dr. Dethlefs said his project started withclinicians entering their own data. Later, grantfunding permitted hiring a database managerand data entry person. Grants may also provideincentives for clinicians to work with publichousing residents. It was noted that purchasersof health care and managed care organizationsare a potential source of funding. Other topics

raised were the need for research to define cul-turally competent care, and a suggestion thatpatient advocates accompany residents on theirdoctor visits.

By describing several diverse public health programs in public housing, this panel helpedto identify some important issues for furtherdiscussion.

Health System Health Care Organization

CommunityResources and Policies

Self-ManagementSupport

Delivery System Design

Decision Support

Clinical InformationSystems

Informed,ActivatedPatient

Prepared,Proactive

Practice Team

ProductiveInteractions

Functional and Clinical Outcomes

Figure 3: Chronic Care Model


Dr. Bowie introduced the panelists, whoincluded people working in public housing programming nationwide. Objectives of thissession were to appreciate the multifaceted community outreach interventions that havebeen implemented in public housing settings;understand the role of CHWs in connectingmedical and public health interventions in public housing settings; discuss best practicestrategies for CVD and related risk factor interventions and for asthma management and control; appreciate the level of involvementof various stakeholders and partners; and under-stand aspects of community participatory intervention efforts.

Models To Promote Healthy Lifestyles in Public Housing(MODERATED BY MARY LUNA HOLLEN, PH.D.,R.D., L.D.)Dr. Mary Luna Hollen introduced the paneland noted that she represents a lay health education project for Hispanics at theUniversity of North Texas.

Health Care and Public Housing, Boston, MA(Jeanne Taylor, Ph.D., and Anita Crawford)The Roxbury Comprehensive CommunityHealth Center (RoxComp) in Boston was established in 1969 and offers a number ofancillary support services for the community.In 1991, RoxComp responded to a request for proposal (RFP) from HUD to providehealth care services at public housing.RoxComp enlisted the Orchard Park HousingDevelopment (OPHD) to participate in thisproject. The tenant association was attracted by the fact that HUD was involved because thedevelopment needed upgrading. The planningprocess included design of a survey to determinewhat services residents felt were needed and tohelp develop the project plan. Group meetingsrun by the tenant association were held.

RoxComp won the HUD grant and was rankednumber 1 of 50 applicants. An article in TheBoston Globe helped gather the support of otherstakeholders to fund renovation of the site for asatellite center within the grounds of OrchardPark. HUD donated the building, and the tenantassociation helped design it and determine whatservices would be provided. Monthly OrchardPark meetings included both the tenant associa-tion and other residents who were not part of thisassociation, all having a voice to determine healthcare service needs. The health center at OrchardPark provided a comprehensive list of medicaland special services, including: primary care

vision care

health screenings

case management

mental health services

substance abuse services

Saturday office hours

home visits for high-risk patients

trainings for resident community healthaides, and

monthly health fairs

Operational challenges facing RoxComp atOPHD were similar to those at RoxCompsmain site (e.g., inappropriate walk-in visits, frequent requests for lost medications, residentconflicts in the waiting room). Orchard Parkclosed in 1997 for several reasons: the area had become a prime real estate area, tertiaryhospitals began to seek ethnic patients as clients,

Public Health Programming in Public Housing:Presentations From the Field

Public Health Programming in Publ ic Housing: Presentat ions From the Field 17

residents had choices of access to primary careservices, and residents voted not to replace thehealth center. One reason residents voted not to replace the health center was the new welfare-to-work program, which created a need for daycare (the health center was replaced with adaycare facility). The entire family practicehealth care unit was moved to Roxburys mainfacility, allowing residents to keep their healthcare providers. Major clinical health outcomesin October 1997 indicate that the modelworked well. An example of one successful outcome from the clinic is that 95 percent ofchildren 6 years of age or younger were up-to-date with immunizations based on a chart audit.

HealthyCMHA, Cleveland, OH(Myron Bennett, M.B.A., M.B.H.)HealthyCMHA is a community partnershippromoting health and wellness at the CuyahogaMetropolitan Housing Authority (CMHA) in Cleveland that includes 48 housing develop-ments and more than 20,000 residents. Healthy-CMHA was established because of the level of health disparities found in the low-incomeresidents in nine of the housing developmentslocated in Clevelands central neighborhood.This area had the highest poverty rate in thecity, with almost 95 percent of its children livingbelow the poverty line. In addition, CVD is the leading cause of death in this area, andCleveland has a high rate of risk factors, such assmoking, overweight, and sedentary lifestyles,which have proven resistant to intervention overthe last 10 years. A survey found a higher num-ber of businesses selling tobacco and alcoholnear public housing areas, and many billboardsmarket these products.

A survey of individuals living in the housingdevelopments targeted by onsite primary careclinics found that while 88 percent of respon-dents were aware of the clinics, only 57 percentof adults and 37 percent of children used them.In addition, 22 percent of adults and 11 percent

of children had no usual source of health care.Many residents were not aware that health facilities had to accept them as patients regard-less of their ability to pay. Also, there was nocoordinated system for referring residents tohealth services or social services.

In 1997, CMHA leadership created the ResidentOpportunities and Community Initiatives(ROCI) program to unite and coordinate resi-dent services and join with new collaborators toset health goals. This led to HealthyCMHA, amulticultural health promotion delivery modelwith three partners: HealthSpace Cleveland (ahealth museum that provides health education),CMHA, and Case Western Reserve UniversityMedical School. Initial funding was from theRWJF; cofunders were the ClevelandFoundation, Mount Sinai Health CareFoundation, Abington Foundation, MurphyFoundation, and Bruening Foundation.

The goals of the program are to motivate residents to fully utilize the many health servicesalready available to them, coordinate wellnessefforts within the community, and provide newprograms and services as needed. HealthyCMHAtargets 9 of the 48 housing projects in the central area. Of its 16,000 residents, 99 percentare African American; the average annual percapita income is $2,371; 26 percent of residentsreceive TANF funds; 15 percent are employed;and 10 percent report no income. On average,there are 2.26 children per household; 94 percenthave female head of households; and three out of four are single-parent homes.

HealthyCMHA implemented a corporate wellness strategy within the public housingcommunity based on the U.S. Public HealthServices National Coordinating Committee on Worksite Health Promotion model, whichwas refined in British Petroleum Americasmultinational workforce.


The programs address four categories: AwarenessIncrease health awareness, hold

an intensive social marketing campaign, andfoster collaborative relationships among exist-ing health and social service providers.

Health EducationHelp people withhealthy decisionmaking, provide screeningsand health education classes (exercise/fitness,nutrition, stress management), hold an annualhealth fair, and sponsor field trips to theHealthSpace museum(no fee).

Lifestyle EnhancementSupport behaviormodification and long-term healthy lifestyledecisions; hold a Heart Healthy HappyHour every Friday; sponsor a walking clubknown as CMHA Walks; and offer Fit forLife fitness classes, smoking cessation pro-grams, and nutrition and cooking programs.

Culture ShiftPromote a healthy culture(e.g., offer healthier foods at events), do plan-ning and development for identified gaps inservice, foster policy changes within CMHAand the health care infrastructure, and offerthe HealthQuest Club that gives points andincentives for participation.

Funding for HealthyCMHA will end in July2004. There is a need to transition from soft-to-hard money. It takes 45 years to build trust;without long-term funding, the program will end.

Community Advocates in Milwaukee PublicHousing, Milwaukee, WI(Staci Young, M.S.)A community health advocate (CHA) programwas established in the Highland Park housingdevelopment in Milwaukee, the most stigmatizedof 13 housing developments in Milwaukee.CHA programs recruit and train communityresidents to advocate for and assist other community members regarding health andother community issues. CHAs improve the

accessibility, quality, and sustainability of healthcare services; empower communities to effectchange; translate information for residents; and increase collaboration among families, community members, and health care providersin identifying and resolving problems.Partners in the Milwaukee CHA programinclude the Center for Healthy Communities;Department of Family and CommunityMedicine; Medical College of Wisconsin(MCW); Service, Empowerment andTransformation (SET) Ministry, Inc. (whichhad an existing contract with the HousingAuthority to provide nursing case management);the Highland Park Resident Organization andresidents; the MCW Cancer Center; FroedtertHospital; and Boys and Girls Clubs of GreaterMilwaukee.

The Housing Authority and SET Ministryalready had a HUD grant to increase social services around mental health and to providecore leaders in the housing development.Highland Park already had regular health discussion groups and presentations. Fliers wereplaced in the buildings to announce a possibleadvocate program; 11 residents (of 120) came to a meeting and 8 were recruited. To be anadvocate, a resident had to have lived in thedevelopment for a minimum of 6 months.

The recruited advocates and the planning teamdefined eight advocate characteristics, includingrespect for confidentiality, personal and sociallevel of maturity, and ability to be a team player.The planning process took about 4 months.Two community advocate training sessions wereconducted (in 1999 and 2001). The trainings,offered in 1-hour sessions over 6 weeks in thesummer, included presentations and small groupdiscussions. The topics included effective communication, conflict resolution, health andwellness, community organizing, and leadershipdevelopment. The topic of how to run effectivemeetings was added in the second training


session. All building residents were invited tothe graduation ceremony and dinner, and half(60) of the residents attended. This was thebeginning of something exciting, for this build-ing had long been stigmatized.

To begin, the advocates developed a tenant safety patrol because safety was a major issue.A coffee club, weekly discussion group, andspirituality group helped to develop social networks in the building. The HousingAuthority donated an exercise room and equipment. Other activities are an annual community health fair and health presentationsby medical students every other month.

Program outcomes include increased numbersof residents participating in advocate activities.Advocates report an improvement in their interpersonal skills and increased awareness of important health issues in the community.Two community resource guides were devel-opedone specific for Highland Park and onefor community resources for CVD, cancer, and diabetes.

The following are some of the lessons learnedfrom the project: Reimbursement for advocates (vouchers for

a local store) was found to interfere with the public assistance benefits of some of the advocates, so they decided to donate the vouchers to the program.

Living and working together led to someproblems. The roles of elected building officers and advocates had to be defined.

Community stressors (e.g., the closing of a building) affected the program.

HOPE VI construction activities to teardown old buildings and build new onesimpacted activities.

The CHA program has no more grant fundingand has continued to operate without it for ayear. It has applied for new funding.

Healthy Hearts in Public Housing, Baltimore, MD (Carol Payne, R.N., M.S.N.)Healthy Hearts in Public Housing was established in 2002 to address the needs of the50,000 public housing residents in Baltimore,where 47 percent of deaths are caused by heartdisease, stroke, and diabetes, and where morethan 90 percent of the public housing commu-nity is African American. The program got itsstart in 2001 when a Strategy DevelopmentWorkshop brought together housing leaders and residents as well as leaders from the broadercommunity. This workshop helped identify the state of CVD and what a public housingprogram might look like. CHWs and residentsasked that the project be a lasting one that provides comprehensive training and compensa-tion. In a separate effort, there was a residentneeds assessment for community-based outreachand education.

Healthy Hearts has four partners: the HousingAuthority of Baltimore City (HABC), theBaltimore Office of HUD, Morgan StateUniversitys Public Health Program, and theBaltimore City Department of Parks andRecreation (which was already working with the NHLBIs Hearts N Parks program). Thispartnership will raise the communitys awarenessabout the prevalence of CVD among AfricanAmericans, promote cardiovascular healthawareness through community-based educationand prevention, build on existing programs and leadership, and test the CHW model byrecruiting, training, and hiring a cadre ofCHWs. The program expects to demonstratethat high-risk populations will engage in hearthealthy lifestyles, that strategic partnerships canstimulate change, and that decisionmakers can


be persuaded to embrace policies that promote cardiovascular health.

The CHW model is central to the program.The Institute of Medicine report, UnequalTreatment: Confronting Racial and EthnicDisparities in Healthcare (2003), identifiedtrained CHWs as a strategy to address healthdisparities. A flier was posted in public housingcommunities of Baltimore to recruit CHWs,and 20 of the 70 people who responded wereselected. Training consisted of a competency-based, 9-week curriculum delivered byBaltimore City Community College (leading to three college credits). One part of the cur-riculum focused on personal skills building and team building. Another part focused oncardiovascular health promotion, including core CHW roles and functions, (from NHLBIsYour Heart, Your Life manual), which wasadapted for use in the African American community, and training in blood pressuremeasurement and CPR. In June 2003, thegraduation of 18 CHWs was celebrated.

The programs activities are all led by theCHWs, with support of the partnership (SeeFigure 4 on page 21.). These activities includean annual health fair, presentations on cardio-vascular health throughout the year, specialevents, and radio broadcasts. Six Heart HealthyClubs have been established, two each foryouths, seniors, and families. The program paidfor residents to participate in a 10-week weightmanagement program brought onsite, and public housing residents in the program participated in a 5-mile Health Freedom Walkthat took place recently along the trail of theUnderground Railroad in Baltimore City.

To engage policymakers, the program held a Health Disparities Leadership Forum that was cosponsored by the Greater BaltimoreCommittee, which comprises the CEOs ofmajor corporations in Baltimore City. One goal

was to create a call to action around CVD anddiabetes and to gain support for the HealthyHearts in Housing program.

Important lessons have been gleaned from the project and include: Challenges that include time, money,

and infrastructure.

Enablers that include community support, relationships and partnerships, and the abilityto continue to revise the project plan.

The tight bond that developed amongCHWs and the sense of community that was established around project activities was an unexpected outcome. These two out-comes have resulted in the project serving as a facilitator of other programming in thispublic housing community.

Community building through health promo-tion that offers significant potential forimproving years and quality of life, as wellproviding jobs for community residents.

ConclusionBy describing several successful public housingprograms, this panel provided practical anddetailed information on developing and sustain-ing programs for the Workshop participants to consider.

Integrated Chronic Disease Models(MODERATED BY KRISTEN WELKER-HOOD,SC.D., M.S.N.) Dr. Kristen Welker-Hood introduced this panel,which would focus on integrated chronic diseasemodels in Chicago, IL; Hampton Roads, VA;Boston, MA; and San Francisco, CA. She notedthat the process of program development andimplementation is important, but there must beevaluation to show effectiveness and to promotesustainability.


University of Illinois at Chicago (UIC) Mile Square Health Center, Chicago, IL(Henry Taylor, M.P.H.)The mission of the Mile Square Health Centeris to provide holistic quality health care servicesto a diverse urban community with a continu-ing commitment to address the needs of theunderserved. Goals are to link public housingresidents to primary care and social services,serve as advocates for the residents, providehealth education and outreach, collaborate

with other agencies in order to leverageresources, serve as a liaison between the academic environment at the University of Illinois at Chicago (UIC) and the community,and be viewed as the provider of choice for pub-lic housing residents. The hope is to developstronger families and communities.

According to the City of Chicagos Departmentof Public Health Epidemiology Report (2000),the communities served by Mile Square had

Inputs

Residents

Resident leaders

CHWs

Policymakers

HHH staff

Outcomes Awareness/knowledge/attitude Intentions Skills/confidence Satisfaction Blood pressure, weight, wast circumference

Taking action Sharing with others Advocacy CHW skills Body Mass Index

CHAMP Health Freedom Walk CHAMP 10-Week Weight Management Program Shopping tours Heart healthy cooking demonstrations Physical activity offerings Existing community and organization resources integration

Gain policymaker support for Healthy Hearts project

Create a call to action among policymakers around cardiovascular disease in the Baltimore community

Policy Forums

Community Health Workers

Overall Evaluation

Heart HealthyLifestyle and

Behavior SkillsInterventions

CHW Delivered Screenings, Awareness Raising, and Education Interventions

Resident-Driven

Healthy Heart Clubs

Training, Screening, cardiovscular health PowerPoint presentations ( Your Heart, Your Life), educational sessions, specialty events, health fairs, radio programs, literature dissemination Process Counts Attendance Screened Referred

Figure 4: CWH Model: Healthy Hearts in Public Housing EDUC


some of the worst socioeconomic and medicaloutcomes when compared with the other 77communities throughout Chicago. Annual family income in public housing in 2000 was $6,400, compared to $34,800 for allChicagoans. In the late 1990s, low-income residents were displaced by the ChicagoHousing Authoritys redevelopment programand were replaced by higher income residents.The redevelopment plan includes new housing,principally mixed-income buildings, and marketrate and affordable (Section 8) housing.

Miles Square Health Center is a full componentof the UIC Medical Center. It collaborates with 27 community and city organizations and has developed a Community AdvisoryCouncil. The Center hired community residents to serve as health educators and healthadvocates and developed an intensive 6-weektraining curriculum in the areas of asthma education, good work habits, and identifyingcommunity resources. The CHWs utilized skills they learned and deployed them in thecommunity, making home visits and holdingworkshops. The program had a specific empha-sis on linking males to health care, leading tothe development of an African American MaleHealthcare Initiative.

Some of the lessons from this project include: Staff can successfully link residents to needed

medical and social services.

The level of pride and accomplishmentsamong staff, the level of trust among publichousing residents, and the level of under-standing of issues affecting residents can beincreased.

Staff can benefit from understanding the impact of violence in the community, the value of the relationship with the localadvisory council, and the new ways to reach residents.

The Asthma Ambassador Project, Hampton Roads, VA(Judith Taylor-Fishwick M.Sc., F.A.E.C., A.E.-C., and Lilly Smith)The Asthma Ambassador Project is a commu-nity-based intervention to evaluate the needs of disadvantaged, hard-to-reach children livingin public housing in the Hampton Roads areaof southeastern Virginia. The project uses acase finding approach to identify asthmaticchildren living in public housing and to assesshealth care utilization, quality of life, and self-management strategies. Lay health workersprovide an outreach education program at the public housing community.

The Report of the Health of Children inHampton Roads identified asthma as a problem in the pediatric population. A grantfrom the Robert Wood Johnson Foundation established the Ambassador Project. To targetthe intervention, an analysis of hospital and EDrates by ZIP Code found a high rate of asthma-related morbidity in housing projects.

A controlled trial included intervention andcontrol groups, with 100 children in each groupand case finding in targeted housing projects.The study looked at hospitalizations, ED visits,symptoms, medications, self-managementbehavior/self-efficacy, and quality of life.

The project development process began byholding community orientations. Ten localwomen living in targeted housing projects were interviewed and trained, and four wereselected to work as asthma ambassadors.The Ambassador Project offers education andappropriate referrals, and also provides andassists families with applications for FamilyAccess to Medical Insurance Security (FAMIS),a State-funded Medicaid insurance program.In a series of four home visits, educational top-ics are: (1) a basic understanding of asthma and asthma action plans, (2) a review of early


warning signs and triggers, (3) medications andspacer use (the child must be in attendance),and (4) asthma managementasthma actionplans and asthma diary.

Three ambassadors (one full-time, two part-time) cover five housing projects and a total of 100 clients. A nurse supervisor is responsiblefor clinical oversight of clients, and shadows at least two ambassador visits per month per ambassador. The Ambassador ProjectCoordinator is responsible for program oversight and management of ambassadors,making weekly visits to review cases and determine needs.

Program and educational resources include asheet of family concerns and priorities, a check-list of family outcomes, a medical informationrelease form, A Parents Guide to Asthma, low-literacy materials, a checklist of asthma triggers,and a list of questions and concerns for the doc-tor. Other resources include a spacer, a spacer

video (produced by Childrens Hospital of theKings Daughters), an Allies Against Asthma bag,a T-shirt for the child, a Frisbee, magnet, book-mark, Galaxy of Gifts incentives (provided by anonprofit organization), special events for fami-lies enrolled in the Ambassador project, and giftvouchers for completion of the survey.

The Ambassador Project is linked with otherprograms in the community (See Figure 5.).For example, the Physician Asthma Care andEducation (PACE) program provides a two-partcourse to educate physicians on NHLBI guide-lines, communication strategies with patientsand reimbursement for patient education.The Healthy Kids Kit for Asthma targets faith-based groups by providing slides and trainingwith ministers. A housing summit that was heldin conjunction with the Housing Authority and housing residents led to changes in extermi-nation contracts. School nurses attend ParentTeacher Association (PTA) meetings and provide asthma resources. The program works

Ambassadors

Healthy Kids Kit

Pace Provider Asthma Days

Housing Summit

Referral to other

programs

Asthma Action Plan

School Nurses

EZ Breathers

Figure 5: Linked Programs: Asthma Ambassador Project


with managed care organizations to allow visitsby home nurses and avoid duplication of services.A standard asthma action plan gives schoolnurses the authority to call physicians. The pro-gram also collaborates with the EZ Breathersprogram in selected Head Start Centers.

Preliminary baseline data on 144 children aged212 shows that 85 percent are on Medicaid, 53percent are male, and 99 percent are AfricanAmerican. Fifty-six percent had at least one visitto the ED in the last 12 months, and 8 percenthad more than five visits; 7 percent had one hospitalization; 83 percent did not have an asthma action plan; 33 percent were takinginhaled corticosteroids; 13 percent had takenoral steroids; and 18 percent were takingSingulair. Caregiver concerns were worries abouttheir childrens performance in normal dailyactivities (29 percent), about their children notbeing able to lead a normal life (30 percent), andabout side effects of medications (36 percent).

The following are lessons learned from this project: Include plenty of advertisement before

implementing the program (e.g., newsletterarticles).

Include community resource agencies (e.g., rental office managers).

Use schools, churches, physicians offices, and community health centers to promotethe program.

Provide community activities that are botheducational and entertaining. Health fairs are not always the best venue to promotehealth-related programs.

Ensure that programs are feasible, practical,and viewed as a priority by the target population.

Bostons Healthy Public Housing Initiative,Boston, MA(Patricia Hynes, M.A., M.S.)The Healthy Public Housing Initiative (HPHI)is funded by HUD, the Kellogg Foundation,and several local foundations. Partners includethe Boston Housing Authority (BHA), BostonPublic Health Commission, Boston UniversitySchool of Public Health, Committee for BostonPublic Housing, Inc., Franklin Hill Tenant TaskForce, Inc., Harvard University School of PublicHealth, Peregrine Energy Group, Tufts UniversitySchool of Medicine, Urban Habitat Initiatives,and West Broadway Tenant Task Force, Inc.

Five percent of the Boston population lives inpublic housing with an equivalent percent onthe waiting list. People of color make up 78percent of this population; 72 percent of thefamilies have a female head of household; andthe average annual income for a family of four isless than $11,000. There are 68 housing devel-opments with 15,000 units in Boston, manybuilt in the 1940s. Current capital improve-ment needs exceed annual capital funding.

When the Behavioral Risk Factor SurveillanceSystem (BRFSS) was administered in Boston,an additional question asked whether respon-dents live in public housing. The survey results indicated that BHA residents reported fair orpoor health at three times the rate of otherBoston residents. They also reported substan-tially higher rates of heart disease, hypertension,and diabetes, and three to five times the nationalrate of child and adult asthma.

The goals of the HPHI are to: (1) documentbaseline housing conditions and respiratoryhealth status in Boston public housing; (2)improve home environments for better respira-tory health and increase quality of life for residents of public housing; and (3) impactlocal, State, and national policy on housing


design, integrated pest management (IPM), and health care financing for asthma. HPHIactivities include focus groups with residents, a survey of health in housing conditions, andinterventions such as IPM. HPHI also examinesthe effect of interventions on health outcomesand focuses on analysis and policy. Residents aretrained to serve as community health advocates(CHAs) who conduct cross-sectional surveys ofhousing and health conditions and collect envi-ronmental samples, temperature and humiditydata, and asthma health data within the IPM.The CHAs include 10 women and 1 man. TheHPHI project interventions include in-homeasthma management training, access to peakflow meters, and maintaining an appropriatemedication regimen. Environmental improve-ments include IPM, which involves sanitation,removal of cockroach residue, patching andcaulking of holes, application of gels, and pro-viding resident education. Followup will createjob training for CHAs so that they can becomeIPM assistants. Project indoor monitoring resultsshowed high NO2 (nitrogen dioxide) concentra-tions in kitchens with gas stoves and a need for ventilation.

Data are collected for purposes of education,action, and social change, and the results areshared with community partners. The followingare HPHI survey results in one development: 64 percent of housing units were affected

by leaks, moisture, and mold (compared with 1746 percent of regular housing).The mean apartment mold index score was related to symptoms of respiratory conditions.

48 percent of the units showed visible indications of cockroaches.

49 percent of respondents smoke.

26 percent of adults reported being diagnosed with asthma.

37 percent of asthmatics had a written asthmaaction plan; 27 percent had a peak flowmeter; and 36 percent used long-term con-trol medications (The most frequent reasonfor not using these medications was that thelocal pharmacy did not carry them.).

About 80 percent of children were allergicto something, such as dust mites an

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