This document summarizes a study examining the impacts of a community health worker-led asthma home visiting program for older adults in Lowell, Massachusetts. Preliminary results show improvements in asthma symptoms, medication adherence, environmental trigger reduction, asthma control status, and reduced preventable healthcare use among participants. The study aims to help prepare vulnerable older adult asthma patients for the health effects of climate change by improving housing conditions and self-management skills. Future research may explore how community health workers can continue supporting this high-risk population in weather emergencies and periods of poor air quality due to climate change.

1. The ROAAD Ahead –
Preparing Older Adults with
Asthma for Climate Change
Elizabeth Flood, MPH, Massachusetts Department of Public Health, David
Turcotte, ScD, University of Massachusetts Lowell, Terry Greene, M.S., JSI
Research & Training Institute, Wendy Chow, MPH, JSI Research and
Training Institute, Mercy Anampiu, Lowell Community Health Center, Erica
Marshall, MPH, Massachusetts Department of Public Health,

2. Presenter Disclosures
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
Elizabeth Flood, MPH
No relationships to disclose

3. The APCP works to improve the quality of life for all Massachusetts
residents with asthma, and to reduce disparities in asthma outcomes.
APCP also works to reduce exposure to asthma triggers and irritants in
homes, licensed childcare centers, schools, workplaces, and senior
centers. We support the use of community health worker-led asthma
home visits to improve asthma outcomes through the provision of
resources and technical assistance around these interventions.
Funded by CDC XXXXXX
AGO ISA 08103170DPH17A
Logan Airport Health Study ISA
MA Asthma Prevention and Control
Program (APCP)

4.  U.S. ≥65 asthma prevalence is 8.1% (2010)--- up
from 6.0% (2001)
 MA ≥65 asthma prevalence is 9.3%
 Older adults have the 2nd highest hospitalization rate
and highest mortality rate in MA
 Older adults are 5x more likely to die from asthma
than younger patients
Older Adult Asthma is Increasing
BRFSS,CDC (2014).
Moorman et al. 2012

5. Racial/Ethnic Disparities are Prominent
% Distribution of Older Adult Hospitalizations by Race/Ethnicity
Hispanics and Black, non-Hispanics are 3.2 and 2.6x more likely to be
hospitalized than Whites, respectively.
Asthma Among Older Adults in Massachusetts, MDPH (2006-2009)

6.  Average charge for asthma-related
hospitalization for ≥65 in MA was
$15,404.00
 Yearly charges of ~ $30 million
 ~93% of all hospitalizations paid for
by Medicare and/or Medicaid
Older adult asthma is costly
MA CHIA (2012-2014)

7.  Climate change will
increase respiratory
illnesses and
exacerbations
 Older adults are
especially vulnerable
to climate change
Climate Change and Asthma
Adapted from: Making the connection: climate changes allergies and asthma, APHA (2017)

8. Air Pollution
Projected Change in Temperature, Ozone, and Ozone-Related
Premature Deaths in 2030
Adapted from Fann et al. (2015)

9. Pollen
Ziska et al, (2000)
Ziska et al., (2011)
Higher Counts Longer Season

10. Mold and Moisture
Measured increases in the heaviest precipitation events for the
United States (1958–2007)
Karl, Melillo, and Peterson (2009)

11. Asthma exacerbations
2011
Adapted from: Wilson et al., AEHS (2016)

12. 2050
Asthma exacerbations
Adapted from: Wilson et al., AEHS (2016)

13. Resilience
Long TermImmediate
How do we prepare vulnerable populations to deal with
the health effects of climate change?

14.  Intervention to improve health outcomes of older adults with asthma
 Adaptation of pediatric CHW asthma home visiting study completed
in MA
 5-visit protocol
 Environmental trigger remediation supplies
 1 year follow-up call
 Eligibility:
 Patient at Lowell Community Health Center
 Age ≥62 with a diagnosis of not well or very poorly controlled asthma
 Speak English, Spanish, Khmer
The ROAAD Study

15.  Lowell, MA:
 Prevalence: 10.1%
 Hospitalization rate: 303/100,000
 Hispanics are 7x more likely to be hospitalized
than white, Non-Hispanics.
 LCHC:
 98% of asthma patients at LCHC are low income
 45% best served in a language other than
English
Lowell and Lowell Community
Health Center
BRFSS, MDPH (2008-2015)
HRSA (2015)

16. Visit 1
• Consent Form
• Questionnaire
• CHW asthma triggers education
Visit 2
• Questionnaire
• CHW asthma trigger follow up and home walkthrough
• Nurse visit (Medication reconciliation, medication education and peak flow given)
Visit 3
• Questionnaire
• CHW asthma trigger follow up
• Nurse Visit (Education on inhaler use, peak flow and AAP)
Visit 4
• Questionnaire
• CHW asthma trigger follow up
• Asthma Action Plan and vacuum given
Visit 5
• Questionnaire
• CHW asthma trigger follow up and home walkthrough
• JSI post intervention survey
Visit 6
• Phone call to patient to complete questionnaire
ROAAD STUDY PROTOCOL

17. Preliminary Results

18.  77% rent, 47% live in
public housing.
 43% had Medicare, 69%
Medicaid.
 68% < high school
education.
Demographics
 78% female
 49% Hispanic/Latino
 29% Asian (Cambodian)
 73% Non-English speakers
 Average age: 70 years
 19% have COPD
 14% reported smoking some or every
day(s)
N=100

19. Reduced Asthma Symptoms
The number of days in the past 14 that patients reported asthma symptoms
decreased from an average of 8 days to 5 days.
*statistically significant differences denoted by *p<0.05, **p<0.01, ***p<0.0001
A total of 59 patients have completed visits 1 and 5 and were included in pre-post analyses

20. Improved Medication Adherence
The number of days in the past 14 that patients reported using their controller
medications increased from an average of 7 to 11 days.
*statistically significant differences denoted by *p<0.05, **p<0.01, ***p<0.0001

21. Reduced Environmental Triggers
*statistically significant differences denoted by *p<0.05, **p<0.01, ***p<0.0001

22. Improved Asthma Control Status
* p=0.06
58%32%
10%
PRE
Very Poorly
Controlled
Not Well
Controlled
Well
Controlled
37%
43%
20%
POST
Very Poorly
Controlled
Not Well
Controlled
Well
Controlled

23. Reduced Preventable Healthcare Use
Compared to baseline, a smaller percentage of patients at visit 5 reported any
asthma-related hospitalizations, ER visits and office visits in the last six months. Oral
steroid medication use was slightly higher at visit 5, potentially due to seasonal
effects.
*statistically significant differences denoted by *p<0.05, **p<0.01, ***p<0.0001

24. Improved Access to Care

25. Improved Access to Medication and
use of Asthma Action Plan
1.6 1.6
56
86
76 78
0
10
20
30
40
50
60
70
80
90
100
Have AAP Use AAP Have both rescue &
control meds
%ofparticipants
PRE POST
N=59

26.  CHW’s bridge the gap between clinical and community settings
and may be a valuable resource in:
 Keeping in close contact with older adults who are especially
vulnerable to climate change activities
 Ensuring older adults have needed asthma medications in weather
emergencies
 Serving as a housing resource for older adults suffering from poor
IAQ, mold, excessive heat etc.
 Supporting vulnerable older adults in moving to safe shelter prior to
heavy precipitation event
Future Research

27. Planning for Climate Adaptation in
Massachusetts
Couple climate projections with health data to
more effectively anticipate, prepare, and
respond to climate sensitive health impacts.

28. References
American Public Health Association. (2017). Climate Change . Retrieved October 20, 2017, from American Public Health Association:
https://www.apha.org/~/media/files/pdf/topics/climate/asthma_allergies.ashx
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population
Health. BRFSS Prevalence & Trends Data [online]. 2015. [accessed Oct 25, 2017]. URL: https://www.cdc.gov/brfss/brfssprevalence/.
Global Climate Change Impacts in the United States, Thomas R. Karl, Jerry M. Melillo, and Thomas C. Peterson, (eds.). Cambridge University
Press, 2009.
Massachusetts Department of Public Health. (2011). Asthma among Older Adults in Massachusetts. Boston, MA.
Massachusetts Center for Health Information and Analysis. (2012-2014). Massachusetts Hospitalization/Emergency Department Discharge
Database.
Moorman JE, A. L. (2012). National surveillance of asthma: United States, 2001-2010. Vital Health Statistics Series 3, 1-58.
Neal Fann, Christopher G. Nolte, Patrick Dolwick, Tanya L. Spero, Amanda Curry Brown, Sharon Phillips & Susan Anenberg (2015) The
geographic distribution and economic value of climate change-related ozone health impacts in the United States in 2030, Journal of the Air &
Waste Management Association, 65:5, 570-580
Wilson, L., Adams, K., Sardone, C., Round, M.M., Nascarella, M.A. (2016, October). Evaluating and Communicating the Health Impacts of
Climate-Related Changes to Heat and Air Quality. Poster session presented at the Annual Convention of the Association for Environmental
Health & Sciences Foundation, Amherst, MA
Ziska et al.,(2011). Recent warming by latitude associated with increased length of ragweed pollen season in central North America.
Proceedings of the National Academy of Sciences of the United States of America, 4248-51.
Ziska LH, Caulfield FA. Rising carbon dioxide and pollen production of common ragweed, a known allergy-inducing species: implications for
public health. Aust J Plant Physiol. 2000;27:893–898.

29.  MA Attorney General’s Office
 Lowell Community Health Center Staff
 Carla Caraballo, Lead CHW
 Keyla Cineus, RN
 Chana Sath, CHW
 Lorna Kigplat, CHW
 Dharma Cortes, PhD
 Margaret Round, MA DPH, BEH
Acknowledgements