Josie Rodriguez is an astute tenant association leader at 85 Strong Street, where she has lived for over 27 years. Her association is amongst those being supported by the Bronx Healthy Buildings Program, an ambitious project focused on health equity as it relates to asthma. Rodriguez knows that there is a connection between her own asthma and where she lives. In a recent meeting, she explained, “I developed it, I didn’t have it…and that’s because the apartment I’m living in right now, it has a lot of mildew and mold issues…the problem is on the outside of the building, the water comes through the structure of the building, or through the roof and I have an apartment on the last floor.” It is the persistence of stories like Rodriguez’s and research that highlights the connection between the conditions in which people live and health outcomes, that public health leaders are pushing for innovative strategies to address health equity.
Early efforts primarily focused on improving the physical environment through initiatives like ensuring safe water and clean air. More recent efforts have identified additional factors that affect health, including income and social status, education, social support networks, housing conditions, and access to health services. In the development of the Bronx Healthy Buildings Program, project partners have investigated a number of precedent setting interventions in order to learn from their successes and challenges. The following case studies highlight partnerships that target the political, social, and/or economic conditions in order to improve health outcomes and limit health disparities.
The Strong Homes Program
In 2011, the non-profit organization, now known as Groundswell, initiated the Strong Homes Program in Maryland to help homeowners leverage their purchasing power in order to drive a more socially responsible economy. The initiative organizes community networks to structure collective purchases of energy services like electricity and home efficiency upgrades at affordable rates. By aggregating their consumption, communities can conquer market barriers and make demands that align with their values – like switching to clean energy sources and supporting local businesses with fair-wage positions. Since 2011, the program has helped 3,500 families switch to wind or solar power and assisted hundreds of families with energy efficiency retrofits. Through a partnership with the D.C. Sustainable Energy Utility, the Strong Homes Program has increased access to qualifying low-income families that otherwise could not afford efficiency upgrades. The initiative helps communities address some of the social and economic barriers to health by creating opportunities to build community power, reduce emissions and pollution, reward local businesses with deep social and environmental benefits, and help households save money on electricity bills.
The San Francisco Tobacco-Free Project (SFTFP)
An initiative of the city’s Department of Public Health, the goal of the San Francisco Tobacco-Free Project (SFTFP) is to reduce exposure to environmental tobacco smoke, reduce youth access to tobacco, and counter pro-tobacco influences. The program devised a participatory approach, the Community Action Model (CAM), to improve the health of San Francisco residents. The CAM starts with skill-based training and the diagnosis of and research into an area of concern by community members that serve as advocates. After identifying and researching a community diagnosis, the advocates analyze their research, prepare an action plan, and then implement it. The final step of the CAM focuses on enforcing and maintaining the action over the long term. Through state funding and skills training from the SFTFP, local community-based organizations employ CAM to address economic and environmental inequalities while building community capacity. In the last twenty years, the SFTFP has provided trainings and resources for nearly a hundred community-based projects and successfully advocated for several tobacco control ordinances. Over that same period of time, San Francisco county has seen the third greatest reduction in its smoking rate, compared to all counties in the US.
The Healthy Homes Project
In order to improve asthma-related health disparities in low-income neighborhoods, Seattle Partners for Healthy Communities developed community-based participatory research projects to reduce exposure to indoor environmental triggers in the homes of children with asthma. The Healthy Homes Project recruited and trained residents from the community with ethnic, linguistic, and cultural backgrounds that reflected the project’s participants to serve as community health workers. They were tasked with delivering the program and serving as liaisons between residents and various partners, including community agencies, community activists, public health professionals, academics, and health care providers. These community health workers helped develop the project protocols with the steering committee and ultimately conducted in-home assessments and outreach. Based on the results of the assessments, the community health workers developed a low-cost action plan with residents to reduce asthma triggers in the home and deliver education on behavioral interventions and asthma self-management practices. Because these workers had a close understanding of the communities they served, they were able to provide culturally competent social support to the program participants. Throughout the various iterations of the project, asthma-symptom days and the use of urgent health services decreased significantly for participants and the quality of life for caregivers improved.
Bringing it Back to the Bronx
Each of the aforementioned cases focused on a limited set of upstream factors and reported improved health outcomes as a result of the intervention. By working with local residents and organizations to create change from within the community, the interventions benefitted from better participant recruitment and retention; greater cultural competence and relevance; and superior social support. The Bronx Healthy Buildings Program also hopes to harness the assets of community advocates, adapting the project guidelines to fit the values, beliefs, and resources of the diverse community.
Some of the persistent challenges to ensuring health equity in the above cases include addressing all of the factors that influence health, prioritizing efforts to address those factors, and developing strategies that last beyond a specific project. So, rather than prioritizing just a few determinants of health, the Bronx Healthy Buildings Program attempts to strategically addresses social, environmental, and economic factors in a comprehensive approach. The program includes opportunities to improve the physical environment, create high-road jobs, provide educational resources, and build community power. By exploring the potential for synergies across multiple interventions, the Bronx Healthy Buildings Program hopes to have a deep and lasting impact on low-income communities living with asthma and serve as a model of how to successfully address health equity.
Post by Jennifer Hiser.