2004 Progress Report: Casa de Salud: A Model For Engaging Community

EPA Grant Number: R828596
Title: Casa de Salud: A Model For Engaging Community
Investigators: Berthold-Frishman, Kay
Institution: Family Service Inc.
EPA Project Officer: Louie, Nica
Project Period: November 1, 2000 through October 31, 2004 (Extended to October 31, 2005)
Project Period Covered by this Report: November 1, 2003 through October 31, 2004
Project Amount: $792,383
RFA: Environmental Justice: Partnerships for Communication (1999) RFA Text |  Recipients Lists
Research Category: Health , Environmental Justice


Casa de Salud is a research and education project designed to engage residents of highly stressed neighborhoods of Lawrence, Massachusetts, in activities to mitigate the health impacts of environmental toxins. Casa de Salud (Health House) is a culturally integrated community education and organizing model developed by a collaboration of service providers to address public health problems, particularly high rates of asthma and lead poisoning affecting the city's Hispanic population.

The goal of Casa de Salud is to engage community residents in identifying, understanding, and mitigating the health impacts of the toxic environment within the City of Lawrence. The primary objective of the research project is to develop and demonstrate the effectiveness of training residents to conduct neighborhood home-based meetings (charlas). The specific objectives of the research project are to:

  1. provide 10 Casas de Salud (Health Houses) in highly stressed neighborhoods as sites for mutual education and planning among health care providers, scientists, and community members;
  2. develop and implement effective, neighborhood-based education tools to help families address the known concerns of lead exposure and asthma through collaboration between community residents, health care providers, and environmental health scientists;
  3. gather data regarding residents’ health concerns and knowledge of environmental health threats to inform the activities of environmental scientists and health care providers;
  4. increase scientific knowledge and community understanding of specific environmental health threats and change strategies;
  5. and develop community-based interventions that build on increased scientific knowledge and community awareness.

In Year 3 of the project, the main focus was to strengthen the Casa de Salud network. The specific objectives of Year 3 of the project were to:

  1. continue to train, educate, and support the 10 leaders who provide the charlas in the highly stressed neighborhoods of Lawrence;
  2. continue to develop and revise activities and materials to deliver health education in the Casa setting;
  3. plan and conduct 60 Casa de Salud charlas delivering health education in 6 Lawrence neighborhoods with the participation of Casa de Salud Leaders, health care providers, environmental scientists, and community outreach specialists;
  4. collect data as determined by the research design to evaluate the effectiveness of the Casa model;
  5. and continue to utilize the resources available through members of the Casa de Salud Advisory Council that meets quarterly.

Progress Summary:

Project Partners

Casa de Salud brings together four key partners in the community, all of whom have been active in ongoing efforts to address environmental health threats to Lawrence families. Each of the partners plays a specific role in the project. The services of each individual and the organizations they represent are coordinated through the Casa Steering Committee, which makes major program and policy decisions for the project. Gretchen Latowsky, John Snow Institute Center for Environmental Health Studies (JSI), is Project Director and is responsible for overall coordination of project activities, the research component of the project, and supervision of Doris Anziani, Community Outreach Coordinator. Doris Anziani, Family Service, Inc., oversees education and outreach to the community, particularly the Latino Community, manages the activities of the Casa Leaders and the charlas, and coordinates logistics of project and community meetings. Kay Berthold Frishman (Principal Investigator) and Elizabeth Sweeney, Family Service, Inc., oversee grant management activities and provide input and guidance through the Steering Committee. Serena Dee, MD, Greater Lawrence Family Health Center (GLFHC), is responsible for conducting education and outreach to the healthcare community, Casa Leaders, and city and state agencies and organizations. Claire Paradiso, Lawrence Teen Coalition, along with Kay Frishman, serves as Co-Chair of the Community Health Network Area Environmental Committee, which serves as a link between Casa de Salud and Lawrence community organizations.

Marta Rentas, Dilsa Toribio, Ceferina Williams, Lizzette Aquino, Maria Alavarse, Zunilda Peguero, Maria Figereo, Janice Vargas, Alba Diaz, and Katherin Pereira serve as Casa Leaders, holding bimonthly meetings in their homes and conducting education and outreach to the Latino community. The Casa Leaders and members of the Steering Committee meet regularly and work closely together, each informing and enhancing the work of the other.

Developing a Successful Collaboration

During the past 3 years, we have made significant progress toward reaching our objectives. Our success can be attributed to the overwhelming enthusiasm and commitment of members of the Steering Committee, the Casa Leaders, and the Advisory Council and support and input from numerous community agencies and organizations. We began our efforts by focusing on the priority issues identified by the community—validating their concerns, respecting their level of knowledge, developing educational programs and materials relevant to their issues, and introducing new information as their level of knowledge increased.

Basing our work on the community's priority issues fostered a close and mutually respectful relationship that has developed between members of the Steering Committee and the Casa Leaders. This relationship has opened a pathway for mutual education. The Casa Leaders learned from the experiences and expertise of project partners and in turn members of the Steering Committee learned from the Casa Leaders about very important issues that affect the project. For example, we taught the Casa Leaders about the health effects of exposure to mercury through consumption of freshwater fish and they told us about the extensive and health threatening ritualistic use of mercury in the community. In response, we worked together to develop educational material that the Casa Leaders are sharing in their charlas. The Casa Leaders also told us that a lot of educational material, even translated into Spanish, is not useful to the community because many residents are effectively illiterate, having been poorly educated in their own country and then poorly educated in the United States. With this new knowledge we are concentrating our efforts on person-to-person communication. They also explained another issue that puzzled us. Some of the Casa Members would not fill out Consent Forms and Report Forms because they could not read them and/or because some of them are not legal residents of the United States and do not want to sign their names.

Organization and Leadership

The Casa de Salud Steering Committee serves as the leadership and decision-making body for the project. It consists of members from each of the four partnership agencies and meets on a monthly basis. The purpose of the Steering Committee is to make programmatic decisions, develop training programs, oversee outreach and education efforts, and conduct research. The Steering Committee continues to review yearly programmatic and Casa Leader goals and evaluate progress toward reaching these goals.

The work of the Steering Committee is supplemented by an Advisory Council that includes 27 individuals, 11 of which are residents of low-income, Latino neighborhoods in the City of Lawrence. The Council meets every quarter to provide guidance and direction to the project, suggest local resources on environmental health issues, provide ideas to help the Casa Leaders take action around identified issues, and help identify health related environmental concerns in the community. The Advisory Council continues to provide strong support and guidance to the Casa de Salud project with representatives, including physicians and school nurses, from GLFHC, Greater Lawrence Community Action Council, Casa Leaders and former Casa Leaders, local neighborhood organizations, JSI, Family Service, Inc., and Lawrence Teen Coalition.

Ten Casa Leaders have been recruited and trained to hold charlas in their homes, to share information and resources about environmental health threats in their neighborhoods, and to take action to address these threats. The Casa Leaders are well-known and well-respected members of our target neighborhoods. Two of the Leaders are teens who graduated from the Lawrence Teen Coalition’s 3-day Leadership Institute, a program that teaches teens how to identify community needs, plan projects, develop a team, and work with diverse groups.

Training Programs

  • Each new Casa Leader is trained in a three-part program that is conducted in Spanish using materials that have been translated into Spanish. The three parts include: (1) meeting facilitation and logistics; (2) environmental health issues in Lawrence; and (3) environmental justice and taking action.

In addition, at the request of the Casa Leaders and in response to their need for more detailed information, bi-monthly training programs are being held to help them develop confidence and leadership skills and gain additional knowledge on environmental health issues. During Year 3 of the project, additional training programs covered the following topics:

  • Indoor asthma triggers and actions to reduce asthma episodes.
  • Integrated pest management and hands-on actions to plug holes and reduce moisture to keep out cockroaches.
  • Exposure to mercury through consumption of local fish.
  • Exposure to mercury from ritualistic uses.
  • New recycling and trash pickup rules in Lawrence.
  • Identifying small sources of exposure in neighborhoods such as auto body shops, hair and nail salons, and small businesses.
  • Hazardous household products.

Results to Date

During Year 3 of the project, each of the 10 Casa Leaders held 5 or 6 charlas for a total of 54 charlas across the city. Below is information from 628 people who attended charlas from the first charla in Year 1 of the project through August 2003.

The data we have are based on those who attended charlas and filled out charla report forms (557 participants). We know that at each charla there were people who do not fill out the forms (71 participants). The Casa Leaders report that some people are undocumented residents and are afraid to fill out anything that may lead to discovery, others are functionally illiterate and cannot follow the forms even when the Casa Leader reads them aloud in Spanish. During Year 4 of the project, we will attempt to document the number of people who attend charlas but do not fill out the forms.

The majority of charla participants are Hispanic. Programs are conducted in Spanish and participants are introduced to the Casa de Salud program and asked to identify their priority environmental health concerns. The introduction is followed by discussion and training on a selected topic. Some of the charlas have been attended by local government figures such as the mayor, members of the city council, and representatives of community organizations. A new initiative was introduced this year to help the Casa Leaders reach broader audiences. It involved conducting charlas with already organized groups of residents, such as in-home day care providers that are required by law to participate in continuing education programs, residents taking citizenship and ESL classes, support groups for diabetic and HIV positive patients, and Head Start program staff.

We have collected participant data for 2 years of charlas plus one charla in Year 1 of the project. To date, we have Casa Member report forms from 628 people who attended charlas. The data show:

  • 407 females and 150 males attended; 71 individuals did not respond.
  • 414 were first-time charla attendees, 180 were repeat attendees, and 34 gave no response.
  • Attendees’ ages ranged from 10 to older than 60.
  • 268 had never attended a public meeting before.
  • 351 had never called a public official about a community issue.
  • 420 thought the Casa Leaders did a good job explaining the environmental health issue that was the topic of the charla.
  • 418 reported feeling comfortable participating in the charlas.
  • 428 reported that they gained knowledge about environmental health issues at the charla.
  • 418 reported that they are more hopeful that they can take action that might make a difference in Lawrence.

Priority Environmental Health Issues Identified by the Charlas

The issues that were identified in Year 1 of the project continue to remain priority concerns. As the Casa Leaders become more knowledgeable about environmental health issues through formal training programs and self-education, their ability to teach in the charlas and their sophistication as community leaders improve. The following issues remain a priority:

  • Air pollution continues to cause concern for residents, including both indoor and outdoor air issues. In discussions about air quality, Casa Members learned about asthma triggers in their homes related to cockroaches, pesticide use, second-hand smoke, mold, household chemicals, and dust. One topic of particular interest to the Steering Committee was an educational program on the health effects of exposure to elemental mercury used for spiritual and ritual purposes. Casa Members also discussed outdoor air issues such as fumes from more than 70 auto body shops located in residential areas, smoke and particulates from cars and diesel trucks, and emissions from several solid waste incinerators in neighboring communities.
  • Health issues have also become a focus of the charlas. Casa Leaders conducted a number of charlas on asthma and lead poisoning and at the request of Casa Members are beginning to address tenants rights as they relate to lead in homes and apartments. This is where the issues of environmental health intersect with issues of power and justice. Seventy percent of Lawrence’s residents live in rental housing and have little or no control over their indoor environment. Attempts to assert their rights often fall on deaf ears, and they do not have the resources to pursue legal action. Living space is hard to find, expensive, and frequently substandard, yet, renters are afraid to lose this space, particularly if they are not legal residents.
  • Ritualistic use of mercury has become a priority educational initiative. Through the Casa Leaders we learned that owners of botanicas (shops that sell religious and spiritual items) sell elemental mercury that is used for religious rituals. It is burned in candles, sprinkled around the home or in the car, ingested, and used for bathing. The practice is widespread in the community and raises serious questions about the health and safety of residents. We received a small grant from the Environmental Justice Office of the Massachusetts Executive Office of Environmental Affairs to conduct a survey to ascertain the extent of ritual mercury use (azogue) in the community and conduct educational programs with residents, botanica owners, and card readers.
  • Auto body shops also have become a focus of the Casa Leaders. There are about 70 auto body shops in Lawrence, mostly owned and operated by Spanish speaking workers. Less than 20 percent are in compliance with laws and regulations and they are clustered next to residential housing in the poorest neighborhoods of Lawrence. One Casa partner, JSI, received an Urban Air Toxics grant from U.S. Environmental Protection Agency (EPA) Region 1 and hired a resident educator to help the auto body shops come into compliance with the law.

Actions to Address These Concerns

A number of actions were taken to address the concerns identified by the Casa Leaders and Casa Members.More frequent neighborhood meetings were held. In addition to the bi-monthly charlas, Casa Leaders attended neighborhood association meetings, many of which were facilitated by a city council member. This gave the leaders an opportunity to talk about the concerns of their charla members and find ways in which these two groups could join to address neighborhood problems.

Casa leaders collaborated with other community organizations by attending meetings, planning neighborhood health fairs, and distributing educational material. These organizations include Hispano Month Celebration–EPA Region 1, the Merrimack Valley Environmental Coalition, Groundworks Lawrence, Latino Chamber of Commerce, Greater Lawrence Family Health Center, the Prevention Center Lead Program, Casa Dominicana, Puerto Rican Alliance, Northeast Center for Healthier Communities, neighborhood associations, Lawrence schools and churches, the Mayor’s Health Task Force, Lawrence Housing Authority, and Child Care Circuit.

The media has been an active bridge between Casa de Salud and the community to continue the education campaign for a cleaner environment through bilingual newspapers, television shows, and radio spots. This vehicle has been extremely effective, as evidenced by the volume of feedback from residents and organizations that have contacted the Casa program to request our services.

Health fairs have been an effective tool for reaching a broader part of the community. Casa Leaders and members of the Steering Committee organized or attended the Weed and Seed Safe Neighborhood Health Fair, National Night Out, Kids Fest, Farmer’s Market, and the Hancock Housing Project Health Fair.

Several new publications have been developed for Casa Leader training programs that the Casa Leaders use for their charlas. These include PowerPoint presentations in both Spanish and English on lead poisoning, exposure to mercury, pesticides and integrated pest management, health effects of exposure to auto body shop chemicals, environmental justice, and Casa de Salud.

We were invited to present our work at the EPA New England Region’s Hispano Month celebration, which was attended by more than 50 EPA staff. We also met with the health departments in Methuen, Massachusetts, and Hartford, Connecticut, and we have been invited to meet with the Massachusetts Department of Public Health.

Future Activities:

During Year 4 of the project, the Steering Committee and Advisory Council will continue to oversee the planning and facilitation of program activities. Activities for Year 4 of the project include:

  1. maintaining a full staff of 10 Casa Leaders and recruit additional leaders as funding allows;
  2. conducting a minimum of 60 Casa de Salud charlas supplemented by additional meetings with community organizations in Lawrence;
  3. meeting with agencies and organizations across Massachusetts and abroad;
  4. formally training primary health care providers in a format that encourages dialogue and practice of patient care and interview techniques as well as didactic presentation of information regarding indoor and outdoor environmental impacts on respiratory disease;
  5. developing education and outreach materials based on needs identified through the charlas;
  6. increasing outreach to community organizations such as childcare providers, schools, and places of worship to inform them of environmental health issues in the community;
  7. and intensifying research activities, exploring levels of participation and awareness and outcomes of the charlas. Survey and interview samples will include neighborhood residents, charla participants, and Casa Leaders.

Journal Articles on this Report : 1 Displayed | Download in RIS Format

Other project views: All 3 publications 2 publications in selected types All 1 journal articles
Type Citation Project Document Sources
Journal Article Latowsky G. Report: Community-based, participatory research in Lawrence, Massachusetts, flags environmental health hazards and fuels education and action. Science Communication 2003;25(2):204-208. R828596 (2004)
R831709 (2006)
R831709 (2007)
  • Abstract: Sage Journals Online-Abstract
  • Supplemental Keywords:

    minority communities, environmental justice, urban environment, public health interventions, toxics, health risk assessment, Hispanic, Casa de Salud, community based intervention, community outreach, cultural differences, education, hazardous environmental exposures, intervention strategies, lead, neighborhood home-based meetings, charlas,, RFA, Economic, Social, & Behavioral Science Research Program, Scientific Discipline, Health Risk Assessment, environmental justice, Social Science, hazardous environmental exposures, partnerships, public health intervention, education, lead, cultural differences, latino community, community outreach, environmental toxicants, intervention strategies, casa de salud, community based intervention, neighborhood home-based meetings (charlas)

    Progress and Final Reports:

    Original Abstract
  • 2001
  • 2002
  • 2003
  • Final