Neighborhood Assessment of

Asthma in South Boston

Amanda Shortell

SB 820: Assessment and Planning for Health Promotion

Final Assignment

April 28th, 2010

Executive Summary

Today, development of South Boston’s waterfront with skyscrapers, commercial

investment, and luxury condominiums is growing. Much of this development, however, is

localized to areas of higher-income and these improvements abut some of South Boston’s six

project housing developments creating a clear geographic demarcation between low- and high-

income communities—evidence of disparities in the physical, economic, social and service

environments. Conversely, “Southie” has a vast network of community resources and many are

located near low-income areas, bringing services to the populations who may need them most.

While asthma affects individuals of all ages, children lack control over many aspects of

their lives and are especially vulnerable. Children, therefore, should receive particular attention

for asthma prevention and intervention efforts in South Boston. According to the 2003-2005

Boston Public Health Commission Report, South Boston has the 8th highest rate of asthma

hospitalizations for children under 5 years old out of the fifteen neighborhoods identified.

Some risk factors of asthma are well documented and consistent: persistent exposure to

airborne allergens, respiratory infections in childhood, genetics, exposure to outdoor air pollution

and environmental tobacco smoke, age and occupational exposure to irritants can all lead to

asthma. These present a good starting point upon which to build asthma prevention and

intervention efforts. Resources in Boston such as the Boston Urban Asthma Coalition, South

Boston Community Health Center programs, Healthy Homes and Asthma Control and

Prevention programs, the Boston Asthma Initiative, and the Healthy Schools Initiative, suggest

local capacity and support to take action to reduce the presence of asthma triggers and the

number of new asthma cases in South Boston.

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Introduction

South Boston is conveniently nuzzled between Midtown to the north, North Dorchester to

the south, Old Harbor to the east, and Boston’s South End to the west. “Southie” is often noted

for its Irish working-class neighborhood, pride in its traditions and strong sense of community.

However, development of South Boston’s waterfront with skyscrapers, commercial investment,

and luxury condominiums is growing. With these improvements abutting some of South

Boston’s six project housing developments, a clear geographic demarcation between Southie’s

low- and high-income neighborhoods is evidence of disparities not only in the physical

environment, but also in the economic, social and services environments as well. South Boston

has many assets to offer residents, yet many of these assets are only available in certain

neighborhoods, namely Citypoint and the waterfront communities. In addition to this lack of

access to many of the resources available only blocks away, the lower-income communities, in

the southern areas of South Boston toward Columbia Road, are also home to many barriers to

healthy living.

One particular aspect of healthy living is the ability to breath freely, but this can often be

affected by triggers of asthma. In South Boston, one out of every ten people reports a lifetime

asthma diagnosis. Asthma is a chronic respiratory condition. Characterized as intrinsic

(allergic) or extrinsic (non-allergic), asthma presents differently depending on many individual

characteristics, but is often exacerbated by triggers in the environment. Children are particularly

vulnerable—asthma is the most common chronic childhood illness. The Healthy People 2010

Report identified reducing not only asthma deaths but also reducing hospitalizations, hospital

emergency visits, missed school and work days, and activity limitations for people living with

asthma as important goals—evidence that asthma is a major public health concern in the United

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States. However, asthma is a serious public health concern, not simply because of these

morbidity measures and its prevalence, but also because of the intricate role one’s environment

plays in disease development and in triggering asthma symptoms. The many triggers of asthma

create various potential pathways for intervention and prevention, as risk and protective factors

exist at several ecological levels.

This paper aims to present the neighborhood of South Boston through a lens of both

assets and barriers to healthy living, identifying community strengths as well as needs pertaining

to asthma prevention and the reduction of environmental asthma triggers. Data to demonstrate

the specific asthma burden in South Boston as well as asthma prevention and intervention needs

of residents will be presented against a backdrop of the Social Ecological Model to showcase the

many levels for potential intervention. Important risk and protective factors of asthma

development and exacerbation will be presented within the context of the effects one’s

environment can have on health. Lastly, this paper aims to present the magnitude and

significance of asthma in South Boston in a way that allows for an incorporation of the unique

individual within a neighborhood as well as in the public health practice of assessment.

Description of South Boston

South Boston is one of Boston’s oldest neighborhoods, annexed in 1804. Once

referred to as ‘Dorchester Neck’, South Boston was at one time a predominantly Irish, Catholic

neighborhood home to many immigrants seeking to be a part of South Boston’s industrial growth

in the mid-1800s (Ibid). Today, South Boston still remains the center of the Irish community in

Boston. South Boston is bordered to the east by Dorchester Bay and Old Harbor providing many

picturesque waterfront views. Midtown to the north, North Dorchester to the south, and

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Boston’s South End to the west occupy the remaining borders of South Boston. See the South

Boston Map in Appendix for more detail.

The South Boston population of 29,938 residents makes up about five percent of the total

city of Boston population of 589,141 people. The largest portion of the South Boston population

is between the ages of 25 and 44 years old (40.1%), following a similar age distribution in the

United States (30.2%), Massachusetts (31.3%), and the city of Boston (35.8%). The majority of

South Boston’s population identifies as White, however according to the 2008 Health of Boston

Report, the percentage of White residents in South Boston decreased from 95.5% in 1990 to

84.4% in 2000. This differs slightly from the race distribution in the city of Boston in which

54.5% of the population identifies as White. In the city of Boston, 25.3% of the population

identifies as Black, compared to only 2.3% in South Boston. About 87.6% of South Boston

residents are U.S. citizens which is similar to proportions in the United States (88.9%) and in

Massachusetts (87.8%), but is slightly higher than the proportion of the city of Boston population

that are U.S. citizens (74.2%). Another notable difference between South Boston and the United

States, Massachusetts, and the city of Boston is the proportion of the population with an income

less than $20,000. In South Boston, 29.0% of the population reports an income less than

$20,000, which is higher than in the United States (22.1%), Massachusetts (19.5%), and the city

of Boston (23.5%). See Demographics Table in Appendix.

Due to major gentrification efforts and development, South Boston continues to see the

presence of economic investment with the building of many new office buildings, restaurants,

condos and hotels. Southie’s easy access to downtown Boston and the South End make it an

ideal location for new development projects. The Institute of Contemporary Art, the Seaport

World Trade Center and the Boston Convention and Exhibition Center are located in South

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Boston’s waterfront area, evidence of economic investment. While this economic investment in

South Boston brings about opportunity for employment, the presence of commercial services,

and an attractive appearance, much of this development, however, is localized to areas of higher-

income. One major barrier to some residents of South Boston is the lack of access to economic

opportunity for all classes which manifests itself in a lack of mixed income housing as well as a

lack of diversity in commercial services in some areas, particularly lower-income

neighborhoods. Driving the streets of South Boston, a noticeable difference between the

commercial services available to low- versus high- income areas exists: from pay-day loan

establishments, convenience stores, fast-food restaurants, and small shops in the former to luxury

condominiums, extravagant hotels, skyscrapers, and picturesque water-front views in the latter.

One of South Boston’s core assets is its strong sense of community. Southie’s large Irish,

Catholic population displays great pride in the neighborhood and has a history of successful

neighborhood events, namely the St. Patrick’s Day parade. Also, South Boston’s multiple

churches, community centers, and locally-owned businesses indicate the presence of social

cohesion and the potential for community leadership. While South Boston certainly has the

capacity for social support and networks, Southie’s strong sense of community is often

underscored by the distinction between its tight-knit communities within the larger South Boston

neighborhood. The clear geographic demarcations between low- and high-income areas within

South Boston contribute to a lack of social cohesion between communities. When the physical

environment is unsupportive of cohesion between social groups, a sort of “us versus them”

atmosphere is often a result, widening the divide initially created by the physical differences in

neighborhoods.

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A key asset to South Boston’s physical environment is its access to public transportation.

The MBTA red and silver lines as well as the number five, seven, nine, ten, and eleven buses

provide access in and out of South Boston. The streets of South Boston are well organized on a

grid system making automobile or bicycle transportation convenient and efficient. Access to

parks and recreation, equipped with playgrounds, benches, picnic tables, and running paths, is

another appealing feature of South Boston. Southie is home to Castle Island, Pleasure Bay, L

and M Street Beaches, Carson Beach, and Moakley Park. Just down the road, however, from

some of these beautiful beaches and parks is Exelon-New Boston L.L.C., Suffolk County’s

fourth leading air polluter.

While investment in neighborhood maintenance is evident in many areas of South Boston

by manicured and litter-free sidewalks, speed bumps, and clearly marked crosswalks, this upkeep

is not consistent throughout South Boston. Potholes on roadways, graffiti, boarded up buildings,

lack of consistent sidewalks, bus stops in industrials area without bus shelters or benches, and

sidewalks not clearly marked on busy streets abound in low-income areas, particularly near

project housing developments. Another barrier in these low-income areas is a lack of access to

nutritious food from chain grocery stores. Many neighborhoods have access to only small corner

stores or convenience stores to purchase food. These neighborhoods also tend to be filled with

fast-food restaurants.

South Boston has a vast network of community resources, home to South Boston

Neighborhood House, Boys & Girls Club, YMCA, ABCD South Boston Action Center, two

public library branches (one within the Old Colony project housing development), and two

community health centers. Many of these community resources are located near low-income

areas and project housing developments, bringing these services to the populations who may

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need them most. South Boston also has two local fire stations and one local police department.

The presence of public safety has contributed to a decrease in total crime by ten percent from

2007 in South Boston. Nonetheless, crime still exists in Southie and accounted for five percent

of Boston’s citywide violent crime and seven percent of citywide property crime in 2008.

South Boston’s many project housing developments contribute to the accessibility of

affordable housing for low-income residents. West Broadway, Old Colony, and Mary Ellen

McCormack developments as well as West Ninth Street, Foley, and Monsignor Powers

developments for elderly and disabled residents are all located in South Boston. South Boston

also has “2-Dollar-A-Bag” sites in two locations in addition to seasonal farmers’ markets that

provide access to low-cost, fresh fruits and vegetables as well as other foods in times of need.

These services improve access, but utilization depends on the motivation of community members

to attend. See the Assets and Barriers Tables and Health Indicator Grading Table in Appendix.

Magnitude of Asthma

Death rates from asthma for the U.S., Massachusetts, and Boston presented in this report

may be difficult to compare and limit the reliability of conclusions drawn due to the varying

years from which the rates are calculated. Taking this into consideration, however, reflecting on

these rates at the national, state, and city level presents an important view, although limited, of

the public health burden of asthma. For example, the asthma mortality rate in Massachusetts (0.8

deaths per 100,000 people) is substantially lower than in the United States (1.72 asthma deaths

per 100,000 people), and Boston (1.3 asthma deaths per 100,000 people). In Massachusetts and

Boston, the asthma mortality rate for males is substantially less than the asthma mortality rate for

females. For example, the asthma mortality rate for males in Massachusetts is 0.5 asthma deaths

per 100,000 people while the asthma mortality rate for females is 1.1 asthma deaths per 100,000

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people. Likewise, the asthma mortality rate for females in Boston is 1.9 asthma deaths per

100,000, which is more than triple that of the asthma mortality rate for males (0.6 asthma deaths

per 100,000 people).

Among the races considered (Non-Hispanic White, Non-Hispanic Black, Hispanic and

other races), the asthma mortality rate is highest for Non-Hispanic Blacks in the U.S.,

Massachusetts, and Boston. Also, the asthma mortality rate is substantially higher for people 65

years of age or older than any other age category in the U.S. (6.99 asthma deaths per 100,000

people), Massachusetts (4.2 asthma deaths per 100,000 people), and Boston (5.0 asthma deaths

per 100,000 people). See Mortality Table in Appendix.

Asthma is a chronic respiratory condition with which those diagnosed may live for their

entire lives. For this reason, other morbidity measures of asthma such as lifetime diagnosis or

hospitalization may be more appropriate ways of considering asthma’s impact on the public’s

health. For this report, lifetime asthma prevalence is used to compare the burden of asthma on

national, state, city, and neighborhood levels. Lifetime prevalence counts and rates include data

from people who self-report ever having received a diagnosis of asthma from a health care

professional. When considering asthma morbidity, lifetime prevalence proves to be an important

marker for asthma’s public health impact because this measure not only includes those with a

current diagnosis, but also those who may have been diagnosed earlier in their lives, such as

during childhood.

In many ways, asthma morbidity data mirrors asthma mortality data. For example,

lifetime asthma prevalence rates are highest among females in the U.S. (14.9 per 100 people

compared to 11.6 per 100 people for males), Massachusetts (17.7 per 100 people compared to

11.8 per 100 people for males) and Boston (16.0 per 100 people compared to 11.6 per 100 people

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for males). Also, among the races considered, Non-Hispanic Blacks have the highest lifetime

asthma prevalence across the U.S., Massachusetts, and Boston levels. While the asthma

mortality rate in Massachusetts is substantially lower than in the United States and Boston, the

lifetime asthma prevalence in Massachusetts (14.9 per 100 people) is higher than both the United

States (13.3 per 100 people) and Boston (13.9 per 100 people). Also, lifetime asthma prevalence

is highest among the 18 to 24 year old age group in the U.S., Massachusetts, and Boston.

Another important measure of asthma morbidity is hospitalization rate. The asthma

hospitalization rate for children under 5 years old in South Boston is 7.9 per 1,000 people and the

asthma hospitalization rate for children 5 to 17 years old is 2.7 per 1,000 people. The 2003-2005

Boston Public Health Commission Report revealed that of the 15 neighborhoods identified in the

report, South Boston has the 8th highest rate of asthma hospitalizations for children under age 5

years.  This data supports the need for children to receive particular attention and special focus

for asthma interventions due to their particular vulnerability and lack of control over their

environmental conditions. See Morbidity Table in Appendix.

Risk and Protective Factors for Asthma by Social-Ecological Level

Multiple personal characteristics, behaviors, and environmental conditions exist as

asthma causes, as well as triggers exacerbating asthma for individuals already diagnosed. Yet,

asthma protective and risk factors do not always represent causal relationships; some are

associated with or mediate the relationship between factor and asthma development. Certain risk

factors of asthma are well documented and consistent: persistent exposure to airborne allergens,

respiratory infections in childhood, genetics (parents who have asthma), exposure to outdoor air

pollution and environmental tobacco smoke, age and occupational exposure to irritants can all

lead to asthma. However, some asthma risk factors present more intricate associations.

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Consider, for example, hygiene and asthma. While untidy home environments can foster many

airborne allergens such as dust mites, cockroaches, and pet dander, conditions that are too

sanitary may also be a cause of asthma. The hygiene hypothesis proposes that the especially

sanitary conditions of Western life lead to a lack of environmental exposures and infections in

childhood, which in turn affect immune system development and may increase the risk of

asthma. Gender also has an unique relationship with asthma. In children, more boys than girls

have asthma, yet in adults, more women than men have asthma. This trend is consistent in

Massachusetts as well as Boston (BRFSS Data, 2004).

An interpersonal asthma risk factor is exposure to environmental tobacco smoke, or

secondhand smoke. While the choice to smoke cigarettes is left up to the smoker, many

exposures to environmental tobacco smoke are experienced innocently without control over the

situation. Consider, for example, children whose parents smoke cigarettes. Children lack power

as well as influence and cannot dictate the behavior of their parents. When parents choose to

smoke in the vicinity of their children such as in the car or home, for instance, children are

exposed unwillingly. This is also the case for many individuals working in restaurants, bars, and

other establishments that do not regulate the smoking behavior of their patrons. Workers’ right

to a smoke-free working environment is violated with the exposure to environmental tobacco

smoke and therefore, their risk of developing asthma is increased.

Building quality, a neighborhood factor, also influences asthma risk. The poor quality

and unsafe housing or community structures, such as schools, community centers, or office

buildings in which community members spend extended periods of time, may harbor airborne

allergens. Similarly, the trend to build energy-efficient homes may potentially trap and keep

allergens inside the house. This intricate relationship of building quality and asthma

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development is complicated by trends to spend more time indoors. In modern societies, ninety

percent of time is spent indoors. While indoor environments have the potential to foster good

health for their occupants, many shelter airborne allergens that trigger asthma.

From a societal prospective, policies and regulations can be protective against asthma.

For example, regulating where pollution producing enterprises can be located as well as how

much and what kinds of pollution can be emitted, has the power to reduce the threat of negative

health effects from exposure. In addition, strict policies regulating building quality and

maintenance can have a powerful impact on protecting community members from unhealthy

indoor environments. However, negligent or non-existent polices create environments in which

whole neighborhoods of people may be exposed to outdoor pollution and indoor allergens.

Location plays a key role in risk of asthma. Low-income, urban children are most likely

to suffer from indoor environment-induced asthma. Social environments differ from place to

place, making some less protective against asthma than others. For example, Gottlieb, Beiser,

and O'Connor found in their analysis of asthma hospitalization rates in Boston that where and

under what circumstances one lives contribute greatly to one’s experience with asthma. Their

study revealed that asthma hospitalization rates in Boston were not only positively correlated

with the poverty rate, but also that asthma hospitalization rates in Boston were inversely

correlated to income (Ibid). See Web of Causation and Community Health Plan Worksheet in

Appendix.

Health Risk Behavior and Possible Points of Intervention

Smoking, namely while in the home and during pregnancy, can be a powerful contributor

to exposure to environmental tobacco smoke, especially for a particularly vulnerable group:

children. Smoking in the home exposes children to environmental tobacco smoke unwillingly

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and contributes to chronic exposure to indoor allergens that can cause as well as trigger asthma

symptoms in those already diagnosed. Likewise, smoking during pregnancy makes that child ten

times more likely to develop asthma. Therefore, smoking in the home and during pregnancy are

important health related behaviors that can be modified by intervention to reduce exposure to

asthma triggers and the development of new asthma cases in young children.

The estimated prevalence of current cigarette smoking among adults (greater than or

equal to eighteen years of age) is about eighteen percent in Massachusetts, and about twenty

percent in the greater Boston area (BRFSS Data 2006 and 2000, respectively). See BRFSS

Table in Appendix for more detail. While South Boston specific prevalence data is not available,

some inferences can be made. South Boston residents contribute to the twenty percent of adults

who consider themselves current cigarette smokers in the greater Boston area. Therefore, while

specific prevalence may differ slightly in South Boston from the greater Boston area, about one

in five adults are current cigarette smokers, many of who may smoke indoors and during

pregnancy.

One theory of health behavior change that could guide these adult smokers to change

their behavior is the Transtheoretical Model, or Stages of Change. The Stages of Change theory

emphasizes behavior change as a process in which intrinsic rewards or incentives are built to

sustain behavior change. In the Stages of Change theory, progress through a series of stages

guides behavior change in time, although progress does not always happen linearly. The

Stages of Changes theory provides an appropriate lens through which to consider the process of

changing smoking behavior because it takes into account the emotional and physical steps an

individual takes in order to change, suggesting many potential pathways for supportive

intervention. Further, the Stages of Change theory is also important because it has the ability to

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incorporate relapse prevention, which is essential when working to change an addictive behavior

like cigarette smoking.

The stages proposed by this theory include pre-contemplation, contemplation,

preparation, action, maintenance, and termination. In pre-contemplation, an individual does not

have any intention of changing behavior in the near future, in this case does not intend to quit

smoking in the home or while pregnant. Individuals in the pre-contemplation stage may have

tried to change smoking behavior but without any success have become discouraged, they may

be uniformed about the consequences of their smoking behavior, and they may avoid activities in

which they would be forced to consider the risky nature of their behavior (Ibid). In

contemplation, individuals intend to change their behavior in the near future and engage in cost-

benefit considerations of that behavior. Preparation is the stage in which individuals create an

action plan for behavior change and begin taking steps to change their behavior. In the action

stage, individuals take specific, overt action to change behavior (Ibid). Maintenance of behavior

change involves working to prevent relapse and sustain behavior change. Lastly, termination is

the stage in which individuals no longer succumb to behavioral temptations and are confident in

themselves to maintain behavior change. Effective intervention strategies to encourage an

individual to change behaviors, such as smoking in the home or during pregnancy, will consider

the many stages through which one progresses to change and maintain that change, as the Stages

of Change theory suggests.

Other intervention strategies effective in reducing new asthma cases and triggers of

asthma symptoms include the Healthy Homes Program in Seattle, Washington which was

effective in reducing children’s asthma symptom days as well as use of urgent care services by

providing education and resources for improving housing quality and safety. The Boston

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Public Health Commission also hosts a Healthy Homes program. Another effective intervention

strategy for those already suffering from asthma symptoms, a Disease Management Program,

provides asthma control that is supported by a care plan and the practitioner-patient relationship.

Housing codes and guidelines, complemented by ways for implementation and enforcement,

can also be effective ways to regulate building quality to be supportive of healthy indoor

environments. Lastly, minimizing contact with asthma triggers and reducing exposure to

potentially harmful components of the home environment can be helpful both in controlling

asthma symptoms if already diagnosed and in protecting against future development of asthma.

See Community Health Plan Worksheet in Appendix.

Possibilities for Intervention in South Boston

South Boston is home to many assets and resources to aid in reducing the presence of

asthma triggers and the number of new asthma cases in South Boston. For example, South

Boston Community Health Center offers health education and smoking cessation programs, both

key efforts in keeping the residents of South Boston healthy because of their potential to inform

South Boston residents of the consequences and risks of smoking indoors or during pregnancy,

as well as can provide support in achieving and sustaining behavior change. Also, the Boston

Urban Asthma Coalition is dedicated to improving the problems asthma poses for Boston

residents through community collaborations, advocacy, and educational programs. Likewise, the

Boston Asthma Initiative provides education services to children and families living with

asthma. Efforts like those of the Boston Urban Asthma Coalition and the Boston Asthma

Initiative provide capacity and support at the local level to foster positive changes in Boston in

order to create environments conducive to asthma symptom- and trigger-free living. Asthma

Control and Prevention programs such as Healthy Homes and the Breath Easy At Home program

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of the Boston Public Health Commission contribute to efforts to curb asthma triggers in Boston.

Lastly, the Massachusetts Coalition for Occupational Safety and Health hosts a program, Healthy

Schools Initiative, to promote healthy indoor air environments. This initiative is especially

important in protecting children, who spend much of their time in school environments and are

particularly vulnerable to asthma triggers. All of these programs, initiatives, and coalitions are

suggestive of local capacity to take action in reducing the presence of asthma triggers and the

number of new asthma cases in South Boston.

Unfortunately, the presence of Exelon New Boston, LLC, Suffolk County’s fourth

leading contributor of air pollution, undermines many of these efforts for a healthy community in

South Boston. With a lifetime asthma prevalence of ten cases per one hundred people in South

Boston, exposure to outdoor pollution from Exelon poses a threat to the respiratory health of

those living, working, and playing in surrounding areas (Health of Boston Report 2008). Also,

South Boston has a poverty rate of 17.3 percent (2000 Census of Population and Housing).

Many of the asthma triggers plaguing the low-income, urban children most likely to suffer from

indoor environment-induced asthma may be housed in the almost one out of five people living in

poverty in South Boston.

Conclusion

While asthma affects individuals of all ages, children lack control over many aspects of

their lives and are especially vulnerable to asthma risk factors and triggers. Children, therefore,

should receive particular attention for asthma prevention and intervention efforts in South

Boston. Furthermore, low-income, urban children are most likely to suffer from indoor

environment-induced asthma. Therefore, key to protecting children from developing asthma

or from triggering asthma symptoms for those children already diagnosed will be ensuring safe

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physical environments supportive of health, such as home, school, daycare, playground, and

community centers.

Efforts to protect children should be creative and take place on many social, ecological

levels. For example, focus can be placed on changing individual behaviors such as encouraging

parents to refrain from smoking indoors or while pregnant. Changes could be made to the indoor

environment, reducing exposure to indoor allergens such as dust mites, cockroaches, and pet

dander, or on the neighborhood level, improving building quality to create safe and healthy

community environments for children. Efforts could be aimed at improving the outdoor

environments of children and reducing outdoor asthma triggers such as pollution. This could be

fostered by strict policies and systems for regulation. Lastly, efforts could be aimed at more

systemic, mediating factors such as reducing disparities and inequalities among races, socio-

economic statuses, and neighborhoods within South Boston. For example, a clear geographic

demarcation exists in South Boston between low-income and high-income areas, with fewer

assets for and more barriers to healthy living existing in low-income areas. To reduce the

presence of asthma triggers and the number of new asthma cases in South Boston, it will be

important to engage many aspects of the lives of residents from personal behaviors to

neighborhood factors to upstream organizational and societal factors. Intervention and

prevention efforts must exits on all social, ecological levels in order to attain systemic change.

See Asthma Analysis Worksheet in Appendix.

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References

1. Asthma Overview. Asthma and Allergy Foundation of America website. www.aafa.org.

Accessed April 1st, 2010.

2. Diseases and Conditions Index: Asthma. National Heart, Lung and Blood Institute: National

Institutes of Health website. www.nhlbi.nih.gov. Accessed March 25th, 2010.

3. Disease and Conditions: Asthma. MayoClinic website. www.mayoclinic.org/asthma.

Accessed March 25th, 2010.

4. Franco Suglia S, Duarte CS, Sandel MT, Wright RJ. Social and environmental stressors in the

home and childhood asthma. J Epidemiol Community Health. 2009 Oct 20 (Epub ahead

of print).

5. Gottlieb DJ, Beiser AS, O’Connor GT. Poverty, race, and medication use are correlates of

asthma hospitalization rates. A small area analysis in Boston. Chest. 1995;108(1):28-35.

6. Hill R, Williams J, Britton J, Tattersfield A. Can morbidity associated with untreated asthma

in primary school children be reduced?: A controlled intervention study. BMJ.

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7. Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public

Health. 2002;92(5):758-768.

8. Lemmens KM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-

management interventions in asthma and COPD. Respir Med. 2009; 103(5):670-91.

9. Maciejewski ML, Chen SY, Au DH. Adult Asthma Disease Management: An Analysis of

Studies, Approaches, Outcomes, and Methods. Respir Care. 2009;54(7):844-6.

10. Simon, H. Asthma. HealthCentral website. www.healthcentral.com/asthma/causes.html.

Accessed March 25th, 2010.

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11. Wu F, Takaro TK. Childhood asthma and environmental interventions. Environ Health

Perspect. 2007;115(6):971-5.

12. Your Online Source for Credible Health Information: Asthma. Centers for Disease Control

and Prevention website. www.cdc.gov/asthma. Accessed March 25th, 2010.

13. Glanz, K., Schwartz, M. Stress, Coping, and Health Behavior. In: Glanz, K., Rimer, B.,

Viswanath, K., ed. Health Behavior and Health Education: Theory, Research, and

Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008: 98-101.

14. Pollution Report Card. Scorecard: The Pollution Information Site website.

www.scorecard.org. Accessed February 11th, 2010.

15. The Health of Boston 2008. Boston Public Health Commission: Research Office.

Boston, Massachusetts: 2008.

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Appendices

Appendix A: Map of South Boston Page 19

Appendix B: Demographics Table Page 20

Appendix C: Assets and Barriers Tables Page 21-23

Appendix D: Health Indicator Grading Table Page 24

Appendix E: Mortality Table Page 25

Appendix F: Morbidity Table Page 26

Appendix G: Asthma Web of Causation Page 27

Appendix H: Community Health Plan Worksheet Page 28-29

Appendix I: BRFSS Table Page 30

Appendix J: Asthma Analysis Worksheet Page 31

Appendix A: Map of South Boston

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Appendix B: Demographics Table

  United States % Massachusetts % Boston % South Boston %

Total population 281,421,879   6,349,097   589,141   29,938  

Sex                

Females 143,368,343 50.9% 3,290,281 51.8% 305,593 51.9% 16,084 53.7%

Males 138,053,536 49.1% 3,058,816 48.2% 283,548 48.1% 13,854 46.3%

Age                

0-17 years 72,293,812 25.7% 1,500,064 23.6% 116,559 19.8% 5,385 18.0%

18-24 years 27,143,454 9.6% 579,328 9.1% 95,476 16.2% 2,751 9.2%

25-44 years 85,040,251 30.2% 1,989,783 31.3% 211,182 35.8% 12,007 40.1%

45-64 years 61,952,636 22.0% 1,419,760 22.4% 104,588 17.8% 5,798 19.4%

65+ years 34,991,753 12.4% 860,162 13.5% 61,336 10.4% 3,997 13.4%

Ethnicity                

Hispanic 35,930,975 12.8% 428,729 6.8% 85,199 14.5% 2,244 7.5%

Non-Hispanic 246,116,088 87.5% 5,920,368 93.2% 503,942 85.5% 27,721 92.6%

Race                

White 216,930,975 77.1% 5,472,809 86.2% 320,944 54.5% 25,397 84.8%

Black 36,419,434 12.9% 398,479 6.3% 149,202 25.3% 683 2.3%

Asian 11,898,828 4.2% 264,814 4.2% 44,284 7.5% 1,192 4.0%

Other 16,172,642 5.7% 212,995 3.4% 74,711 12.7% 2,666 8.9%

Citizenship                

US Citizen 250,314,017 88.9% 5,576,114 87.8% 437,305 74.2% 26,221 87.6%

Naturalized 12,542,626 4.5% 337,617 5.3% 56,681 9.6% 1,169 3.9%

Not a citizen 18,565,263 6.6% 435,366 6.9% 95,155 16.2% 2,548 8.5%Household Income                

Less than $20,000 23,325,275 22.1% 1,234,899 19.5% 54,832 23.5% 3,932 29.0%

$20,000-$59,999 47,438,634 45.0% 2,463,449 38.8% 82,746 35.6% 4,855 37.0%

$60,000-$99,999 21,802,674 20.6% 1,526,322 24.0% 47,370 20.4% 2,984 22.0%

$100,000 or more 12,972,539 12.3% 1,123,790 17.7% 47,814 20.5% 1,596 12.0%

*U.S. Census Bureau, Current Population Survey: Demographics in the United States, Massachusetts, Boston, and South Boston Census Tracks: 2000.

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Appendix C: Assets and Barriers Tables

SOUTH BOSTON ASSESTSAsset Evidenced by… Source

Economic Environment Presence of economic

investment -The Institute of

Contemporary Art-Boston Convention and

Exhibition Center-New office buildings, restaurants & condos-World Trade Center

-Citypoint-Location of many films

-First-hand observation

Investment in youth/education

-Public: 3 high schools, 3 elementary schools, 1 K-8,

& 1 middle school-Private: 2 K-8 schools

-First-hand observation

Access to higher education opportunities

-University of Massachusetts- Boston

-First-hand observation

Social EnvironmentAccess to community news

and networks-South Boston Tribune -www.southbostoninfo.com

Efforts to prevent substance abuse and support for

recovery

-South Boston Collaborative Center

-www.southbostoncollaborativecenter.org

Strong sense of community -Large Irish culture-Pride in neighborhood-History of successful neighborhood events

(St. Patrick’s Day parade)

-www.cityofboston.com-First-hand observation

Presence of social cohesion and potential community

leadership

-Multiple churches, mostly Catholic

-Multiple community centers

-Many locally-owned businesses

-First-hand experience

Physical EnvironmentEconomic investment in

physical environment and infrastructure

-The South Boston CSO Storage Tunnel to clean up S. Boston’s storm drainage and sewer system problems

- www.southbostononline.com /articles/news/2007/10-

25-07 PaulMcDevittSheehanaward.cfm

Transportation and access in/out of Southie

-MBTA Red & Silver Line and Buses (5, 7, 9, 10, 11)

-Streets well organized on a grid system

-First-hand observation-www.mbta.com

Access to parks and recreation

- Parks: Castle Island, Pleasure Bay, L & M Street

-First-hand experience-21-

Beaches, Carson Beach, Moakley Park

Good water quality - Every standard was met in S. Boston water supply for the 128 contaminants tested

-www.mwra.state.ma.us/annual/waterreport/2008results/metro/boston.pdf

Investment in neighborhood maintenance

-Manicured and litter-free sidewalks in some areas

-Speed bumps

-First-hand observation

Service Environment Presence of public safety -2 local fire stations

-1 local police department-Total crime in police

district C-6 is down 10% from 2007

-www.cityofboston.gov/police/pdfs/2008Crime%20

Summary.pdf

Investment in community resources

-South Boston Neighborhood House-Boys & Girls Club

-YMCA-South Boston-ABCD South Boston

Action Center-2 public library branches

-2 community health centers

-First-hand observation

Access to affordable housing for low-income

groups

- West Ninth Street (elderly/disabled), West Broadway, Old Colony, Mary Ellen McCormack

development, Foley (disabled/elderly), Monsignor Powers (disabled/elderly)

-First-hand observation

Access to low-cost, fresh fruits, veggies, and other

foods in times of need

-2-Dollar-A-Bag sites in two locations

-Seasonal Farmers’ Market

-www.fairfood.org- www.farmfresh.org/food/

farmersmarkets_details.php?market=144

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SOUTH BOSTON BARRIERSBarrier Evidenced by… Source

Economic Environment Lack of economic

opportunity for all income classes

-Lack of mixed income housing

-Lack of diversity of commercial services in

certain areas

-First-hand observation

Social EnvironmentLack of social cohesion -Clear geographic

demarcations between wealthy and low-income

areas

-First-hand observation

Physical EnvironmentSources of pollution -Exelon New Boston LLC -First-hand observation

-www.scorecard.orgLack of investment in neighborhood upkeep

-Pot holes on roadways, missing sidewalks in places,

graffiti, boarded up buildings, etc.

-First-hand observation

Lack of access to nutritious food from chain grocery

stores

-Access to only small corner stores or

convenience stores in places-Multiple fast-food restaurants in areas

-First-hand observation

Lack of commercial zoning regulations to protect youth

-Liquor store across the street from a youth community center

-First-hand observation

Lack of economic investment in physical

environment and infrastructure

-Potholes on roadways, lack of consistent sidewalks, bus

stops in industrial areas without bus shelters or benches, sidewalks not clearly marked on busy

streets in areas

-First-hand observation

Service Environment Elements of crime -District C-6 accounted for

5% of citywide violent crime and 7% of citywide

property crime in 2008

-www.cityofboston.gov/police/pdfs/2008Crime%20

Summary.pdf

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Appendix D: Health Indicator Grading Table

Physical & Built Environment GradeWell-equipped and safe parks B

Plentiful green spaces BEasily navigable for pedestrians and cyclists A-

Distance from freeways and heavy traffic B-Distance from toxic sites and polluting industries D

Thriving retail areas B-

Social Environment GradeFear of crime C

High crime rate in relation to region DNumber of noise complaints to police or perception of noise disturbance that

affects sleep or concentrationB-

Range of community centers with active community participation AIntegration (Are 50% or more of the residents of one race?) D

Neighbors know and trust each other A

Economic Environment GradeAvailability of farmer’s markets B-

Local supermarkets C-Number of fast food restaurants C

Affordable housing (Is rent less than 30% of income?) B+Abandoned shops and foreclosed homes B

Service Environment GradeMajor bus or train routes B

Public libraries BAffordable healthcare clinics B+

Museums and other cultural institutions CBanking options C

Health Outcomes GradeAsthma rates CObesity rates C

Pedestrian safety B-Levels of violent crime in the region C

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Appendix E: Mortality Table

Deaths From Asthma for the U.S., Massachusetts, Boston, and South Boston

United States Massachusetts Boston South BostonData Source Morbidity and Mortality

Weekly Report Surveillance Summary,

1999

Three year aggregates: 2005-2007 Mortality

(Vital Records) ICD-10 based

Three year aggregates: 2005-2007 Mortality

(Vital Records) ICD-10 based

*Unable to find mortality data on the neighborhood level.

Number of cases

Rate per 100,000 people

Number of cases

Rate per 100,000 people

Number of cases

Rate per 100,000 people

Number of cases

Rate per 100,000 people

Total 4,657 1.72 184 0.8 19 1.3

Male 1,620 1.31 48 0.5 4 0.6Female 3,037 2.04 136 1.1 15 1.9

White (Non-Hispanic) 3,328 1.42 141 0.7 6 0.8Black (Non-Hispanic) 1,145 3.87 25 2.6 12 3.5

Hispanic 15 2.0 1 0.8Other 184 2.04 30 0.6 0 0.0

0-4 years 32 0.17 0 0.0 0 0.05-14 years 144 0.36 0 0.0 0 0.015-34 years 444 0.59 17 0.3 1 0.235-64 years 1,637 1.58 60 0.8 9 1.565+ years 2,400 6.99 107 4.2 9 5.0

-25-

Appendix F: Morbidity Table

Lifetime Asthma Prevalence in Adults for the U.S., Massachusetts, Boston, and South Boston

United States Massachusetts Boston South BostonData Source BRFSS Data-2004 (CDC) BRFSS Data-2004 (CDC) Mass. BRFSS Annual

Reports 2000-2005 *MassCHIP

The Health of Boston Report 2008 (2004-2006)

Number of cases

Rate per 100

people

Number of cases

Rate per 100

people

Number of cases

Rate per 100

people

Number of cases

Rate per 100

peopleTotal 29,064,305 13.3 743,248 14.9 81,890 13.9 2,994 10.0

Male 12,248,661 11.6 279,148 11.8 32,891 11.6Female 16,779,644 14.9 464,100 17.7 48,894 16.0

White (Non-Hispanic) 20,418,529 13.4 614,985 14.9 14.2Black (Non-Hispanic) 3,121,759 14.6 29,880 17.5 13.0

Hispanic 3,298,292 11.2 61,435 15.3 14.2Other 1,339,670 13.6 25,027 12.2 11.1

18-24 years 4,961,160 17.4 114,915 19.015.2

* *25-34 years 5,457,718 13.7 147,458 16.535-44 years 5,495,790 12.4 143,930 13.8 11.945-54 years 5,273,390 13.1 124,244 13.9 14.155-64 years 3,832,287 13.7 94,324 15.0 12.565+ years 3,949,841 10.9 110,480 12.6 12.7

*Asthma hospitalizations for children under 5 years old—Count: 36 & Rate: 7.9 per 1,000 people*Asthma hospitalizations for children 5-17 years old—Count: 32 & Rate: 2.7 per 1,000 people

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Hygiene

Race

Socio-Economic

Status

Age Gender

Atopy

Genetics

Low Birth Weight

Exposure to Environmental Tobacco Smoke

Respiratory Infections in Childhood

Exercise

Amount of Time Spent Indoors

Dietary Habits

Exposure to Pollution

Occupational Exposure to Irritants

Exposure to Airborne Allergens

Building Quality

Policy/Regulations

ASTHMA

Cultural Practices

Not breastfed in Infancy

Appendix G: Asthma Web of Causation

Location

-27-

Appendix H: Community Health Plan WorksheetAsthma in South Boston

Health Problem:One out of every ten people living in South Boston reports a lifetime asthma diagnosis

(Health of Boston Report 2008).

Goal Statement:-To reduce the presence of asthma triggers in

South Boston-To reduce the number of new asthma cases in

South Boston Risk FactorsIndividual:-Age -Gender

-Genetics -Low Birth Weight

-Socio-economic status -Race

-Respiratory infections in childhood -Dietary habits

-Exercise-More time spent indoors -Not breastfed as infant

Interpersonal:-Exposure to environmental tobacco smoke

Institutional/Organizational:-Occupational exposure to irritants

Neighborhood/Community:-Building quality

-Exposure to airborne allergens-Location-Exercise

-Exposure to pollutionSocietal:

-Policy/Regulations

Protective FactorsIndividual:

-Age: Asthma is the most common chronic childhood illness.

-Breastfed as an infant-Gender: In children, more boys than girls have

asthma and in adults, more women than men have asthma. Interpersonal:

-Not smoking in the homeInstitutional/Organizational:

-Occupational safetyNeighborhood/Community:

-Reduced opportunity for airborne allergen exposure

Societal:-Policy/Regulations

Resources & Assets Available:-Boston Urban Asthma Coalition

-South Boston Community Health Center -Boston Public Health Commission Programs:

Healthy Homes & Asthma Control and Prevention

-Boston Asthma Initiative provides education services to children and families living with

asthma-Massachusetts Coalition for Occupational

Safety and Health-Healthy Schools Initiative

Effective Intervention Strategies:-Healthy Homes Programs provide education

and resources for improving quality and safety of the home

-Housing codes and guidelines as well as ways for implementation and enforcement

-Disease Management Programs provide asthma control which is supported by a care

plan and the practitioner-patient relationship

-28-

-Reduce exposure to potentially harmful components of the home environment-Minimize contact with asthma triggers

Barriers to Consider:-Presence of Exelon New Boston, LLC: Suffolk County’s fourth leading contributor of air

pollution (www.scorecard.org)-Lack of access to nutritious foods from chain grocery stores; Access limited to only small

corner stores, convenience stores, and fast food chains in some areas of South Boston-10.0 lifetime asthma cases per 100 people in South Boston (Health of Boston Report 2008)

-South Boston’s poverty rate is 17.3% (2000 Census of Population and Housing)

-29-

Appendix I: BRFSS Data

Estimated Prevalence of Current Cigarette Smoking Among Adults (Greater Than or Equal to 18 Years of Age)

United States2006

Massachusetts2006

Boston/Worcester/Lawrence/Lowell/

Brockton2000

South Boston*Data

unavailable.

Male (%) 23.9 19.6 21.0Female (%) 18.0 16.4 19.8Total (%) 20.8 17.8 20.4

-30-

Asthma

Environmental Triggers

Personal Behaviors

Exposure to Environmental Tobacco

Smoke

Exposure to Pollution

Exposure to Airborne Allergens

Amount of Time Spent Indoors

Diet & Exercise

Hygiene

-Race-Socio-Economic Status -Policy/Regulations-Building Quality-Location

-Race-Socio Economic Status-Policy/Regulation-Location

-Race-Socio Economic Status-Building Quality-Location

-Race-Socio-Economic Status-Cultural Practices

-Race-Socio-Economic Status-Cultural Practices-Smoking Behavior-Location

-Race-Socio-Economic Status-Cultural Practices-Location

Appendix J: Asthma Analysis Worksheet

-31-