LaGrappe, Desiree

School of Nursing - School of Nursing/ JHSPH HBS/IH

MSN / MPH

Peru

Household Air Pollution and Health: A multi-country LPG stove intervention trial (HAPIN Trial)

Household air pollution (HAP) resulting from the use of solid fuels (e.g., wood, coal, crop waste, and dung) for cooking and heating contributes to a significant proportion of the global burden of disease. Multiple diseases have been associated with HAP, including low birthweight in infants, pneumonia in children, and chronic obstructive pulmonary disease (COPD), lung cancer, and cardiovascular disease (CVD) in adults. We are rolling out a large, multicenter randomized control trial. One of the four sites for this study is Puno, Peru (3825m above sea level). We will be enrolling 800 pregnant woman into the study and the woman will be randomized to receive a gas stove vs continue to use their traditional solid fuel stoves that are known to cause high levels of HAP. We will be evaluating various components of household air pollution including particulate matter and carbon monoxide levels. We will perform both kitchen and personal monitoring. We will be monitoring various clinical outcomes as well including infant birthweight, incidence of childhood pneumonia and blood pressure to determine the effects of reduced indoor air pollution. We seek to identify if elimination of HAP helps to decrease the burden disease in this region. This is a large multicenter randomized controlled trial. Participation in this study provides a very unique opportunity to be part of a large, potentially influential, field intervention trial.

PI Mentor: William Checkley

The main focus of my placement was to conduct a quality assurance audit of the pneumonia surveillance protocol to identify areas for improvement.  This project was also used for my school of nursing community assessment practicum.  The recommendations and evaluation plan were carried forward by another GHEFP student who remained at the site for a longer period of time.  The strong student involvement and training commitment of the Center means that projects can be sustainable. 

I also assisted with other research projects such as those related to gas conservation and the measurement of time use for participants in the intervention arm of the trial who received a gas cookstove.  The placement was well supported by the PI Dr. Will Checkley as well as other investigators and research staff. I was able to apply previous community health and research experience to identify a main challenge for the project: a lack of ongoing community engagement with the Ministry of Health frontline staff and the participating communities.  As a nurse, I was able to build rapport quickly with the pneumonia surveillance team which was comprised of nurses and physicians.  We were able to have a kick-off party with one of the facilities before I left in order to initiate the recommended intervention.  Overall, the practicum was a strong introduction to partnering with a Ministry of Health in a low-, middle- income country.   This experience also helped me to gain new skills in survey development using software such as Qualtrix and RedCap.  

During the placement, I often reflected on how committed and thorough the entire in-country staff were in support of the research and the leadership among the senior staff ; that level of dedication is not easily replicated and speaks to a belief in the mission of the center and desire to help the local community among the staff.  Through the process, I also learned that the standard workweek in Peru is 48hrs by law, not 40 hrs per week as is the norm in the United States.  The NGO team work extremely hard.  For example during the Andean New Year, an important cultural celebration, many of the team were at the office until 8pm to complete their tasks so that it does not ‘build up.’ A found this an interesting juxtaposition to the assumption that the inability to meet timeframes or maintain data quality could be related to work -ethic, which was a reminder of how important systems are to improve processes beyond a focus on individual behavior. 

In completing the observations in the hospital, I noticed the practicum, as an experienced Registered Nurse, was different from practicums when I was a nursing student.  It difficult to witness substandard care and resist the urge to intervene, knowing what else could or should be done.  I witnessed patients turned away, or screamed at, and overheard patient and family conversations about their dissatisfaction with the care they received.  The research staff described that in the region of Perú where we were located, the health care system is extremely hierarchal and patient-and-family centered care is not prioritized in comparison to other parts of the country or the US health care system which has refocused on the patient experience as a consequence of the Affordable Care Act.  While sometimes, I think the US health care system could benefit from a better balance between patient/family expectations and the medical staff professional expertise – I can appreciate now why ensuring patient satisfaction is so critically important and the impact on care-seeking.  Through this experience, I gained many new insights professionally, academically and professionally.  I am very thankful for the experience and new skills which I will carry forward in my career. 

People

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases
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