Healthy Homes and Lead Poisoning Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Brown); and Office of Healthy Homes and Lead Hazard Control, Department of Housing and Urban Development (Mr Ammon), and Office of Children's Health Protection, Environmental Protection Agency (Dr Grevatt), Washington, District of Columbia.
Correspondence: Mary Jean Brown, ScD, RN, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS F60, Atlanta, GA 30341 (firstname.lastname@example.org).
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, the US Department of Housing and Urban Development, or the US Environmental Protection Agency.
The authors thank Dr Warren Friedman's and Ms Katherine J. Siekel's for careful review of a previous version of the manuscript.
Numerous studies have demonstrated that housing interventions such as addressing structural deficiencies or lack of safety devices improve health. These successes, coupled with reports by health care and housing professionals of other health and safety issues in homes that they were unable to address, have renewed interest in promoting health by addressing unhealthy housing conditions—but with a holistic approach. The Centers for Disease Control and Prevention, US Department of Housing and Urban Development, and US Environmental Protection Agency fund programs to improve indoor air and drinking water quality and prevent childhood lead poisoning. All of these programs offer valuable lessons for designing more integrated programs. The federal agencies and their grantees have demonstrated that interagency collaboration is essential for successful outcomes. However, the Department of Housing and Urban Development, the Environmental Protection Agency, and the Centers for Disease Control recognize that no individual agency has all of the necessary resources or expertise to formulate national programs and policies and implement a national healthy homes agenda. Thus, they have come together with the US Department of Health and Human Services, the Department of Energy, the US Department of Agriculture, the National Institute of Standards and Technology, the National Institute of Environmental Health Sciences, and the Office of the Surgeon General to form an interagency working group to ensure that vigorous, healthy homes policies are implemented at federal, national, and community levels.
In 2009, the US Surgeon General issued a Call to Action to promote healthy homes. The call focused on the impact of housing on public health and urges a dynamic and coordinated effort to improve housing factors that affect health. It called upon people in all walks of life to make informed, shared, and compassionate decisions and develop imaginative and realistic solutions to ensure the availability of safe, healthy, affordable, accessible homes to everyone in the United States.1 In concert with the call, the Department of Housing and Urban Development (HUD) issued Leading Our Nation to Healthier Homes: The Healthy Homes Strategic Plan. This plan serves as a road map for the HUD to protect the health of children and other sensitive populations in a comprehensive, cost-effective manner.2
“Healthy homes” is a century-old concept that promotes safe, decent, and sanitary housing to prevent disease and injury. The connection between housing risk factors and communicable diseases was recognized first. Later, housing characteristics were linked to injuries caused by fires and falls, poisonings due to toxic exposures such as lead and carbon monoxide, and chronic diseases such as asthma. In response to the compelling evidence of associations between health and housing, federal, state, and local governments have launched policies and preventive programs to respond to specific housing characteristics. Over time, other programs, unrelated to housing conditions but clearly related to health, were initiated. Some of these program activities include home visits to families that are at risk for a negative health outcome, such as child maltreatment or infant mortality. Home visits are also conducted by some programs that are not health focused, such as weatherization and housing assistance programs, for which the inspections help to ensure basic occupant safety and the effectiveness of the assistance provided.
Numerous studies have demonstrated that housing interventions such as addressing structural deficiencies or lack of safety devices improve health.3–5 These successes, coupled with reports by health care and housing professionals of other health and safety issues in homes that they were unable to address, have renewed interest in promoting health by addressing unhealthy housing conditions—but with a holistic approach.6 Today, the goal of healthy homes programs is to increase public health impact by thinking broadly about the many health and safety elements in homes and on surrounding property and collaborating across organizations to address these elements more comprehensively and efficiently.
Building Healthy Homes Programs
The many single-issue health and housing programs provide a necessary foundation for a broader integrated healthy homes program. The Centers for Disease Control and Prevention (CDC) has funded state and local lead poisoning prevention, asthma and injury programs; the HUD has funded lead hazard remediation programs, healthy homes technical studies, and demonstration programs. The US Environmental Protection Agency (EPA) has funded programs to improve indoor air and drinking water quality and prevent childhood lead poisoning. All of these programs offer valuable lessons for designing more integrated programs. The federal agencies and their grantees have demonstrated that interagency collaboration is essential for successful outcomes.
Health programs partner with colleagues such as real estate agents, housing court officials, and architects, whereas housing programs partner with community health workers, doctors, nurses, and social workers. These partnerships result in powerful networks that can serve as advocates for protective legislation and policies.
In 1999, HUD expanded the scope of its Office of Lead Hazard Control to include other housing-related health hazards, becoming the first federal agency in the United States to establish a healthy homes program. Since then, HUD has funded more than 140 projects to demonstrate the feasibility of integrated approaches that address several housing-related health and safety hazards; these projects have included not only applied research but also field demonstrations of hazard evaluation and control and outreach approaches. CDC has funded 10 programs to expand their focus to include asthma interventions, injury prevention, radon mitigation, and integrated pest management; these programs are a natural outgrowth of childhood lead poisoning programs. Program staff members have learned to identify other health and safety issues in the homes of children with lead poisoning and now can use their experience to address these health and safety issues.
Several EPA offices have funded programs to advance healthy housing. The Office of Children's Health Protection has funded education and outreach programs; the Office of Pesticide Programs funded the Integrated Pest Management in Housing Initiative; and the Indoor Environments Division has funded radon, asthma, and indoor air quality science and information programs. The newest healthy homes program, Indoor airPLUS, was developed jointly by EPA's Indoor Environments and ENERGY STAR programs. Indoor airPLUS labels new homes that are designed, and have been verified, to meet strict indoor air quality requirements. Some of these new home requirements reduce potential exposure to radon, mold, asthma triggers, pests, volatile organic compounds, and combustion pollutants.
In 2007, CDC convened an expert panel to review the existing scientific literature and assess the effectiveness of interventions designed to reduce 4 key housing exposures that cause or exacerbate adverse health outcomes. The panel reviewed interventions designed to reduce interior biological agents, chemical agents, and structural deficiencies and community-level housing interventions. Using a structured review process, the panelists categorized the interventions as (1) with sufficient evidence for implementation; (2) needing more field evaluation; (3) needing basic research and (4) with sufficient evidence demonstrating that they are ineffective or harmful.7 The panel's recommendations have been incorporated into HUD and CDC healthy homes programs.
HUD, CDC, and EPA also have collaborated to support infrastructure development for healthy homes. Through CDC and HUD support, a wide variety of health care and housing workers in state and local agencies have been trained and certified. These workers may also be cross-trained in related fields such as home weatherization, housing assistance, and voluntary programs. The first Federal Healthy Homes Conference, sponsored by HUD, CDC, EPA, and US Department of Agriculture, helped to focus national attention on the need to provide safe, healthy, and efficient homes for America's families.
Coordination of Federal Programs
The federal Healthy Homes Work Group (HHWG) was formed in 2009 with the goal of ensuring universal access to safe, affordable, and healthy homes. It recognizes that no individual agency has all of the necessary resources or expertise to formulate national programs and policies and implement a national healthy homes agenda, so the agencies must work together. The HHWG comprises HUD, US Department of Health and Human Services, CDC, EPA, Department of Energy, US Department of Agriculture, the National Institute of Standards and Technology, the National Institute of Environmental Health Sciences, and the Office of the Surgeon General.
HHWG agencies are collaborating to implement a vigorous, healthy homes agenda at federal, national, and community levels. The HHWG works to influence existing programs and identify new opportunities and ensure that programs are operating effectively and efficiently. It also links program activities to the broader mission of each individual agency and encourages incorporating healthy homes goals, principles, and criteria into federal programs. HHWG efforts are targeted toward achieving the following strategic goals:
Enhance America's ability to reduce health hazards in housing through strong and strategic partnerships: The HHWG has established a framework to support collaboration with both government and external stakeholders to develop principles and standards for a healthy home and ensure that healthy homes messages are widely available.
Support initiatives that build local capacity to address unhealthy housing: The HHWG has developed and implemented training and certification programs for a wide variety of health care and housing workers. The training includes practical advice on incorporating healthy homes principles into other health or housing activities such as checking smoke alarm batteries during home health aide visits or reducing water heater temperature when conducting an energy audit. The HHWG is also working to incorporate healthy homes principles into local housing codes.
Incorporate healthy homes principles into federal programs and funding opportunities: The HHWG is exploring streamlining the application process and making income thresholds comparable across federal needs-based programs. It is also supporting market transformation by raising public demand for healthier homes and integrating healthy homes principles into existing programs.
Support research that informs the creation of healthier homes: The HHWG is developing a strategic interagency research agenda and working to combine existing health and housing surveys and surveillance systems. The results of these studies can help to establish an agenda for widespread implementation, whereas improved surveillance of the impact of housing on health will provide valuable insight into determining the most effective interventions.
We must improve the nation's housing to improve the nation's health. Strengthening and widening our efforts is an urgent goal that will have a direct, immediate, and measurable effect on the health of the nation. The time is right to ensure healthy homes, healthy families, and healthy communities by improving the quality of housing conditions. These efforts will yield substantial returns to help prevent injuries and illnesses, reduce associated health care and social services costs, reduce absence rates for children in school and adults at work, and reduce stress—all improving the quality of life for Americans and our communities.
1. US Department of Health and Human Services. The Surgeon General's Call to Action to Promote Healthy Homes. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2009. http//www.surgeongeneral.gov
. Accessed February 22, 2010.
2. US Department of Housing and Urban Development. Leading Our Nation to Healthier Homes: The Healthy Homes Strategic Plan. Washington, DC: US Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control; 2009. http//www.hud.gov/offices/lead/library/hhi/hh_strategic_plan.pdf
. Accessed February 22, 2010.
3. US Department of Health and Human Services. Report of the Surgeon General's Workshop on Healthy Indoor Environment. Washington, DC: US Department of Health and Human Services; 2005.
4. Breysse P, Farr N, Galke W, Lanphear B, Morley R, Bergofsky L. The relationship between housing and health: children at risk. Environ Health Perspect. 2004; 112(15):1583–1588.
5. Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002; 92(5):758–768.
6. Krieger J, Takaro TK, Song L, Beaudet N, Edwards K. A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Healthy Homes II Project. Arch Pediatr Adolesc Med. 2009; 163(2):141–149.
7. Jacobs DE, Brown MJ, Baeder A, et al. A systematic review of housing interventions and health: introduction and methods. J Public Health Manag Pract. 2010; 16(5S):S5–S10.
federal agencies; healthy homes; interagency collaboration; quality of life
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