Community Coalitions: Long Beach, CA

boy washing his inhalerLong Beach Alliance for Children with Asthma (LBACA)

Reenvisioning the Landscape of Children’s Health

At recess, the students at Long Beach’s Hudson Elementary have a clear view of the 710 freeway and plenty of diesel trucks. According to counts done by Long Beach Alliance for Children with Asthma (LBACA), an average of 600 trucks pass within a hundred feet of the school every hour. It’s no coincidence that many Hudson students—and many others throughout Long Beach—suffer from asthma.

According to recent studies by scientists at the University of Southern California’s Keck School of Medicine, children living close to freeways have a two-fold increase in risk for asthma. Teens growing up in southern California communities with high rates of pollution from traffic have a five-fold risk of reduced lung function.

Elisa Nicholas, M.D., has understood this for a long time. As chief of staff of Miller Children’s Hospital and chief executive officer of The Children’s Clinic, a non-profit, free-standing community medical clinic that serves many Long Beach and South Bay children each year, she understands the social, fiscal and environmental challenges that fuel children’s asthma in the region. In 1999, she formed LBACA with help from Miller Children’s Hospital, Long Beach Department of Health and Human Services, Long Beach Unified School District, legal aid, managed care organizations and a host of others. With initial support from the Robert Wood Johnson Foundation through the Allies program, LBACA focused on raising community awareness about children’s asthma and reducing hospitalizations, emergency room visits and school absenteeism due to asthma.

“The beauty of the coalition is that it is a bridge—the only place a community member can talk with an institutional member,” says Felix Aguilar, M.D., of the Long Beach Department of Health and Human Services. “Coalitions like LBACA provide a space for conversation, for cross-germination. Allowing community members to have an equal voice has been tremendously important in Long Beach. What we thought we knew they needed has been challenged. We don’t have all the answers. Here, community members are not tokens, they are listened to.”

Understanding Long Beach

Long Beach is the fifth-largest city in California, and one of the most ethnically diverse cities in the United States. LBACA’s first task was to identify the areas of greatest need in the community. For Dr. Nicholas, that involved bringing people together and combating widespread misunderstanding of asthma’s causes, symptoms and prevention. “Doctors knew what went on in their office, but did not always know about all the social and environmental aspects of asthma,” she recalls. “Moms knew the home environment; the school district knew the schools. It was all about getting everyone on the same page, and helping each group to realize the multidimensional nature of childhood asthma and its prevention and treatment.”

LBACA decided to focus on four sectors: education and support of health care providers, improved care and care coordination in schools and after-school programs, community education, and policies that influence access to medication or reduce environmental triggers such as diesel emissions and air pollution. In particular, community health worker outreach was directed at the ZIP code where statistics showed the greatest need: 90813, an area where half the residents were born outside of the U.S. and three out of four speak a language other than English at home.

Cultural and legal barriers coupled with lack of awareness of triggers and proper treatment help to keep asthmatic children symptomatic. “Many of our families live on the edge, not really advocating for their children because they’re afraid,” says Long Beach United School District nursing services program specialist Judy Dearing. “Even those who are legal immigrants are hesitant to be advocates for their children in school or at the doctor’s office. LBACA has helped them understand that they really need to advocate, by providing health workers drawn from the community.”

Staff in LBACA’s community health worker “promotora” program have made inroads with more than 300 local families, assessing indoor asthma triggers and educating families about trigger reduction and proper medication use. Promotora Maria Garcia recalls being referred to the home of a 12-year-old boy who, despite taking controller medications, was symptomatic almost every day and inhaling albuterol without a spacer. In the home, she found multiple triggers: roaches, scented oils, a cat and dust from a backyard woodshop. She contacted the child’s doctor and provided the entire family with asthma education and tips for reducing triggers at home. “Today, the child’s symptoms are reduced to almost nothing,” says Garcia. “It’s a great feeling when people thank you for pointing things out to them and say, ‘Thanks to you, my son is better.’ We tell families, ‘You control asthma so asthma does not control you.’”

Promotora health worker and family

 

 

Community health workers break down the cultural and linguistic barriers that can impede asthma control.

 

School outreach programs identify students whose asthma is undiagnosed or poorly controlled, and work with school administrators has changed the landscape of information and communication around asthma. On poor air quality days, orange LBACA flags now fly in front of local elementary schools to alert parents, students and teachers to the need to adjust students’ physical activities. “Trained community health workers are invaluable in terms of working with parents,” says Dearing. “We often don’t need a nurse to do asthma education if we can have a trained community health worker.”

New Voices for Environmental Justice

Long Beach also has some of the highest levels of particulate matter and ozone in the country. This is due, in large part, to the fact that many of the goods that come to the U.S. from Asia come through the port of Long Beach and are loaded onto trucks that then clog local roadways. While LBACA’s asthma outreach is multifaceted, its most dramatic efforts have involved empowering local residents—especially “LBACA Moms”—to speak up for their children’s rights.

LBACA hosted a legislative tour in 2001 and has been invited to testify before state legislature on numerous occasions. Recently LBACA took a leadership role in bringing health issues to focus in the proposed 710 freeway expansion. With advocacy fueled by information from LBACA, local parents were able to keep the planned expansion away from homes and schools.

According to Andrea Hricko, an associate professor in the Department of Preventive Medicine at the University of Southern California’s Keck School of Medicine, LBACA has been instrumental in bringing information about asthma and air pollution into public discourse. Hricko and her colleagues have formally partnered with LBACA on a scientific study of traffic and particularate emissions. Volunteer “A-Teams” identify and test outdoor air pollution hot spots, monitor traffic patterns and test ultra-fine particulate matter in the air. LBACA then uses the information to petition for clean air legislation for the Long Beach area. The A-Teams are run by parents who receive technical training from Keck. Their work has already identified serious air quality problems near several elementary schools and they are currently expanding their monitoring efforts to three other elementary schools in the area.

“LBACA is one of the only community organizations in Southern California that understands air pollution science,” says Hricko, “and is able to take science and use it to train the community. They are informed voices. LBACA Moms, in particular, have gained the attention of lawmakers.”

According to Dr. Nicholas, “tying together the sectors that touch a child’s life is an important role for coalitions. With LBACA, we try to focus not just on single factors that have impact, but on the whole picture—from homes and schools to policies and protocols that include the built environment.”

LBACA’s volunteer “A Team” monitors traffic outside Hudson Elementary.

Why a Coalition Approach?

“Asthma is a complex disease with multiple triggers and etiologies,” says Dr. Nicholas. “Its control and treatment require a multifaceted, holistic approach. Coalitions bring a depth and coordination of services and approaches that can truly make a difference, whether it’s moving a freeway or making sure a doctor prescribes the right medicine.”

Coalitions can also effect change in ways that institutions cannot. The health department’s Dr. Aguilar concedes that the real power of coalitions may reside in their grassroots origins: “The coalition gave the health department cover to work on large polluters. The coalition could take a position. The health department could not have done that—it was too much of a ‘hot potato.’ The moms could do it, and for that reason coalitions are very important.”

Dr. Nicholas acknowledges that the coalition approach can be challenging. “The coalition approach requires knowing that the perspective of parents, doctors and school nurses all have equal weight and equal value,” she concedes. “Sometimes it takes longer to accomplish the goal but the results are much richer and longer lasting.”


Summary

Founded in 1999, LBACA’s goals are twofold: to raise awareness about asthma in ways that can lead to system change, and to improve measurable clinical outcomes including reduced hospitalizations and emergency visits and fewer school days missed due to asthma. LBACA educates Long Beach residents about childhood asthma, its triggers, treatment and prevention, and strives to improve the lives of children with asthma.

LBACA is a partnership program of Miller Children’s Hospital of Long Beach Memorial Medical Center and The Children’s Clinic. LBACA’s members include representatives from the Long Beach Department of Health and Human Services, Long Beach Unified School District, legal aid, managed care organizations, the state legislature, Long Beach Department of Parks and Recreation, YMCA and many more organizations.

Strategies and Programs

  • Educating the community regarding childhood asthma, its causes, triggers and treatment
  • Community health worker home visiting program
  • Asthma resource center
  • Physician Asthma Care Education (PACE)
  • Teaming up with schools, after-school programs and park and recreation centers to develop asthma-friendly environments and policies
  • Mobilizing the community to respond to air quality issues, both indoors and outdoors

Children and Families Served

Almost 150,000 children under the age of 18 live in Long Beach.

Results

  • Trained 179 health care providers in PACE.
  • Community health workers have made over 1,265 visits to over 300 families, educating them about asthma medications, triggers and remediation.
  • Interventions by community health workers resulted in fewer daytime symptoms, nighttime symptoms and emergency department visits.
  • Made children’s asthma a community priority, particularly in schools, day care centers and after-school programs.
  • Became a well-known entity now called upon to help form coalitions in other parts of California.
  • Nurtured and encouraged community members to become informed advocates for their children and improved health policies.

Lessons Learned

  • Draw community health workers from the communities they serve.
  • Form work groups to tackle individual issues: e.g., schools and recreation, professional practices, policy and environment.
  • Continually assess community needs and make it easy for community members to be part of the process by providing child care, transportation and translation services.
  • Create strong partnerships with other organizations working on similar issues.
  • Use data and research to educate the community and policymakers.

Adoption

LBACA continues to build upon the Allies work supported by the Robert Wood Johnson Foundation. With current support from The California Endowment, The University of Southern California (USC) and the Miller Foundation, LBACA continues to expand coalition membership and activities into the greater Long Beach area and surrounding communities, improve school and after-school program management and prevention of childhood asthma, and conduct outdoor air monitoring through a USC study of eight local schools. Plans are to expand the community health worker program into new areas, continue PACE training and Tools for Schools, and continue local policy efforts to improve indoor and outdoor air quality. In 2006, LBACA received significant funding from a penalty settlement against BP West Coast Products LLC for alleged air pollution violations at the firm’s nearby Carson refinery, thus enabling the coalition to expand its work.