National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Breysse); and Office of Lead Hazard Control and Healthy Homes, US Department of Housing and Urban Development, Washington, District of Columbia (Dr Gant).
Correspondence: Patrick N. Breysse PhD, CIH, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, 1600 Clifton Rd, Mailstop F61, Atlanta, GA 30333 (email@example.com).
The views expressed in this commentary are solely those of the authors and do not necessarily represent those of their associated agencies.
The authors declare no conflicts of interest.
In this issue, 3 articles summarize the impact of a comprehensive, multisite healthy homes initiative (New York State Healthy Neighborhoods Program [HNP]) on overall housing-related conditions, as well as asthma health outcomes and costs, and remind us of the importance of housing to healthy populations and communities. Housing has long been recognized as a key health determinant.1,2 As early as 1938, the American Public Health Association (APHA) published a book on basic principles of healthy housing.3 More recently, the National Center for Healthy Housing, along with APHA, published an updated National Healthy Homes Standard.4 In 2009, the US Surgeon General issued a Call to Action to Promote Healthy Homes that addressed ways housing can affect health, highlighting the importance of healthy homes.5 This was followed in 2013 by the release of a federal strategy, Advancing Healthy Housing: A Strategy for Action,6 that includes a vision statement of “Substantially reduce the number of American homes with health and safety hazards,” and which identifies multiple actions to accelerate the creation of healthy housing. In a 2011 analysis, the Centers for Disease Control and Prevention (CDC) estimated that 5.2% (5.8 million) of housing units in the United States were classified as inadequate and 23.4 million housing units were considered unhealthy, based on data collected as part of the American Housing Survey.6 That article also identified key racial, educational, and economic disparities in access to adequate housing. While a number of specific housing interventions have been shown to reduce disease and injury in residents, getting wide adoption of these interventions has proven difficult. Efforts to increase access to healthy housing can have significant health and economic impact, as highlighted in the articles presented in this issue.
The health impact pyramid describes a conceptual framework for public health action (see the Figure).7 As you move up the pyramid, you engage in activities that have a greater emphasis on individual efforts and decreased population impacts. Interventions toward the top of the pyramid focus on individuals rather than entire populations. While addressing socioeconomic factors may offer the greatest potential for public health impact, changing the environment to make healthy decisions the simpler choice could be more easily implemented and thus offer more effective public health action. The healthy housing intervention embodied in the New York State HNP demonstrates the importance of changing the context of housing as an achievable goal to address a number of housing-related health issues, particularly with respect to reducing asthma morbidity.
Asthma is a complex disease with a complex set of environmental and genetic risk factors. Since children spend as much as 80% of their time indoors, the home environment has long been identified as an important point for intervention. Important asthma triggers such as mold and excess moisture, tobacco smoke, and cockroach, mouse, and dust mite allergens can be found in the home, and reducing exposure to these triggers is a critical component of asthma management.8,9 Historically, asthma management focused on assessing and monitoring asthma severity and control, along with prescription of appropriate medications for quick relief and long-term control. The National Asthma Education and Prevention Program (NAEPP) guidelines include 4 components: (1) assessing and monitoring asthma severity and asthma control; (2) education for a partnership in asthma care; (3) control of environmental factors and comorbid conditions that affect asthma; and (4) medications. Clinical interventions can suffer from less than optimum adherence, a lack of effectiveness, and economic barriers.10 Despite access to clinically effective medications and knowledge of a wide array of asthma triggers, we have seen little improvement in asthma rates or morbidity in recent years.11 More attention needs to be paid to controlling environmental factors in addressing asthma treatment (NAEPP component 3) in order to help people with asthma live with well-controlled disease.
Reddy, Gomez, and colleagues provide us with compelling additional evidence that a low-cost, low-intensity, home-based environmental assessment can reduce asthma triggers and can improve asthma self-management and morbidity, particularly for people with uncontrolled asthma. As others have shown, these improvements can generate significant cost savings. Given the tremendous cost burden of asthma on society, implementing housing-based interventions, whether the low-intensity approach described in the article or higher-intensity approaches described by others, is an environmental and public health priority.
In the accompanying article, Reddy, Gomez, and Dixon provide additional evidence that the HNP interventions improve housing quality by reducing the total number of hazardous and unhealthy conditions in homes. Based on the scale of the program (ie, 28 491 homes were eligible for the study), this would be expected to result in additional demonstrable benefits to the residents of the homes over time. For example, ensuring that homes have properly installed and working smoke and carbon monoxide detectors would be expected to result in reduced risk for injury or death from fires and exposure to harmful levels of carbon monoxide.
Focus now should shift to identifying the barriers to implementation. Since no single governmental agency is responsible for regulating housing, a multiagency approach is needed to translate this evidence into practice, with federal agencies providing coordinated support to state and local agencies. As an example, the President's Task Force on Environmental Health Risks and Safety Risks to Children coordinates a federal action plan to reduce asthma disparities (see companion commentary) and tracks the implementation of the aforementioned strategy for action to advance healthy housing.12 The CDC National Asthma Control Program assists 25 states and territorial health departments by providing direct support for surveillance activities and by implementing evidence-based comprehensive asthma control strategies, including the identification and mitigation of home asthma triggers when appropriate as part of stepwise approach to reducing asthma morbidity. CDC also provides grants to state and local health departments to support blood lead surveillance and lead-poisoning prevention activities.
The Department of Housing and Urban Development (HUD) has also played an important role in preventing lead poisoning and supporting interventions to address other residential healthy and safety hazards. HUD awards grants to state and local agencies to remediate lead-based paint and other priority health hazards in low-income privately owned housing. The department is also taking important steps to improve indoor environmental quality in federally supported housing, including the promotion of smoke-free multifamily housing policies and the sponsoring of training and technical assistance on improved pest control practices (ie, integrated pest management).
Federal programs are a critical and necessary element of the overall efforts to create healthy housing for all Americans. However, increased action and coordination are needed from both the public and private sectors. States and counties may look to other programs for guidance, such as New York State's HNP, along with model building codes, to help them move toward housing stock that is as protective as possible (eg, building codes that require radon-resistant new construction in higher-risk zones). Implementation of policies to require that pre-1978 rental housing meet minimum lead safety standards would reduce exposure among children. Studies have also highlighted the importance and return on investment for health insurance coverage for home assessments and interventions, particularly for low-income and high-risk populations. Specific examples include lead hazard risk assessments and assessment and remediation of asthma triggers in the homes of children with poorly controlled asthma. The steady decline in children's blood lead levels is an example of the progress that can be made through concerted efforts by both the public and private sectors; however, there are still too many communities where children are at risk from lead exposure. Through consistent, coordinated, and strategic efforts, further progress in reducing housing-related illness and injury, particularly among our most vulnerable populations, is well within our grasp.
1. Weitzman M, Baten A, Rosenthal DG, Hoshino R, Tohn E, Jacobs DE. Housing and child health. Curr Probl Pediatr Adolesc Health Care. 2013;5(8):187–224.
2. Breysse PN, Farr N, Galke W, Lanphear B, Morley R, Bergofsky L. The relationship between housing and health: children at risk. Environ Health Perspect. 2004;12(15):1583–1588.
3. American Public Health Association. Basic Principles of Healthful Housing. New York, NY: American Public Health Association; 1938.
4. National Center for Healthy Housing & American Public Health Association. National Healthy Housing Standard. Columbia, MD: National Center for Healthy Housing; 2014. http://www.nchh.org
/standard.aspx. Accessed October 26, 2016.
5. 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.
6. Raymond J, Wheeler W, Brown MJ. Inadequate and unhealthy housing, 2007 and 2009. MMWR Suppl. 2011;60(01):21–27.
7. Frieden TR. A framework for public health action: the health impact pyramid. Am J Public Health. 2010;100(4):590–595.
8. Breysse PN, Diette GB, Matsui EC, Butz AM, Hansel NN, McCormack MC. Indoor air pollution and asthma in children. Proc Am Thorac Soc. 2010;7(2):102–106.
9. Matsui EC, Hansel NN, McCormack MC, Rusher R, Breysse PN, Diette GB. Asthma in the inner city and the indoor environment. Immunol Allergy Clin North Am. 2008;28(3):665–686, x.
10. Zahran HS, Bailey CM, Qin X, Moorman JE. Assessing asthma control and associated risk factors among persons with current asthma—findings from the Child and Adult Asthma Call-Back Survey. J Asthma. 2015;52(3):318–326.
11. Moorman JE, Akinbami LJ, Bailey CM, et al National surveillance of asthma: United States, 2001-2010. National Center for Health Statistics. Vital Health Stat. 2012;3(35).
12. President's Task Force on Environmental Health Risks and Safety Risks to Children, Federal Healthy Homes Work Group. Advancing healthy housing: a strategy for action. http://portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes/advhh. Published 2013. Accessed November 2, 2016.