The goal of this study was to create a “cookbook” or guide for programs making a transition from Lead Poisoning Prevention to Healthy Homes. The study is based on qualitative information collected through interviews with program staff from the Baltimore City Healthy Homes Division. These interviews were followed up by focus groups with community members who received services from the Baltimore City Healthy Homes Division.
In 2007, the Centers for Disease Control and Prevention selected Baltimore City's Childhood Lead Poisoning Prevention Program (CLPPP) to coordinate a Healthy Homes pilot team and transition into a comprehensive Healthy Homes Division. The pilot team's goal was to develop, implement, and evaluate a cost-effective, outcome-focused, replicable model to expand an urban CLPPP into a comprehensive Healthy Homes program. Program staff transitioned to conduct comprehensive inspections, develop new referral and educational resources, and assess the efficacy of interventions targeting multiple residential hazards.1 One key assumption of the current qualitative research study is that program staff and program participants' own voices contribute valuable insight into the factors necessary for transition to a comprehensive Healthy Homes program.
Following review and approval from a university institutional review board, we began a period of trust and rapport building by meeting with members of the Healthy Homes pilot team, observing daily activities, and reading documents provided by program staff. Administrative and field staff were informed about the study and given an opportunity to volunteer for an interview. Participants were offered a small gift certificate to a local café in appreciation of their time. All of the staff members who were approached with the consent form agreed to participate in the study. Each interview ranged from approximately 30 minutes to 1 hour.
While 5 to 25 participants is an acceptable sample size for qualitative research,2 the appropriate size of the study sample cannot be estimated by a formula but rather is determined when no new information is received from newly sampled participants.3 We reached saturation at 17 interviews with administrative and field staff.
Data collection procedures
We incorporated purposeful sampling, a strategy in which persons, settings, or events are selected deliberately to provide information that could not be found elsewhere.4 Given the experience of administration and field staff in the Baltimore City Healthy Homes Division, this approach was effective in finding participants who could answer the research questions to the point of redundancy.3
A protocol guided open-ended and loosely organized interviews with Healthy Homes Division staff. Questions were asked to elicit insight into the strengths and challenges of transition from Lead Poisoning Prevention to the establishment of a Healthy Homes program and also to engage the group to think about strategies that were used in the transition period.
The voices that are represented in this report are those of the program staff and the program recipients. Program staff encompass administrative staff and field staff. Administrative staff in the Healthy Homes Division are responsible for overall program management, protocol development, and data analysis. Two types of field staff are environmental sanitarians, more often identified as “Sans” and public health investigators, known as “PHIs.” Sanitarians inspect homes, educate clients, and in the case of lead poisoning, serve as enforcement representatives. Public health investigators educate families, link them to community resources, and provide case management.1 There was consensus among program staff regarding the different roles that each play, noting that Sans focus on the structural aspects of the built environment whereas PHIs concentrate on the child's health status. In the transition from Lead Poisoning Prevention to Healthy Homes Division, field staff members were required to learn new protocols, participate in training, and be ambassadors for the new program. While field staff are categorized as a unit in one sense, PHIs and Sans play independent roles, have separate staff meetings, and conduct home visits separately.
In this study, we established trustworthiness of data (the qualitative equivalent of reliability and validity) with prolonged engagement and triangulation. Prolonged engagement involves spending sufficient time in the field to build rapport and gain understanding of the context for data collected. Triangulation in this study involved using a second methodology and a second group of respondents for corroborating evidence. To triangulate data from individual interviews, 3 small focus groups were held with 3 to 6 community members per group who received services. Invitations were mailed to community members who received services from the Healthy Homes Division living in specific zip codes near the recreational facility where the focus group would take place.
Data analysis procedures
Grounded theory procedures for data analysis incorporate 3 phases: open coding, axial coding, and selective coding.5 Open coding is the process of breaking down, examining, comparing, conceptualizing, and categorizing data.6 In open coding, the researcher examines the text of memos, field notes, and transcripts from interviews for salient categories of information. This process involves taking similar concepts and placing them under a higher-level heading. To theoretically saturate each concept (ie, to reach a level at which no new codes appear), a codebook was developed that reflected concepts emerging as a result of several readings of notes, transcriptions, and codes. The codebook captures the strengths and challenges to developing an ideal program structure with reliable resources and policies. The NVivo software program (QSR International) facilitated the coding process. We read through all interviews and categorized paragraphs. To incorporate a new concept as it emerged, a back-and-forth process was used, revisiting text from interviews coded earlier in the process and immersing researchers in the data in preparation for the axial coding phase.
In axial coding, new connections are made between categories and subcategories defined in open coding. In open coding, the researchers are essentially developing the categories, whereas in axial coding, the relationship between or among categories is explicitly examined.7 This process enabled us to relate codes and subcodes and verify statements with the codebook.
In the final phase, selective coding, data were interpreted to build a narrative that connects the categories defined through open and axial codings.5 The conceptualization of a story line involves giving the central phenomenon a name. In the current study, Transition From Lead Poisoning Prevention to Healthy Homes is the central phenomenon generated during coding that is theoretically saturated (ie, at a level in which no new codes appear) and centrally relevant. In other words, it is the variable that pulls the others together to form an explanatory whole.7
Seventeen interviews were conducted with Baltimore City Health Department staff. Twelve participants were field staff: 5 PHIs or case managers and 7 environmental sanitarians, including the supervisor. Five were administrative staff: program director, epidemiologist, program manager for Healthy Homes Resources, legal compliance officer, and data analyst. Findings for the study are arranged around an organizational framework for which Transition from Lead Poisoning Prevention to Healthy Homes is the central phenomenon. In relation to the central phenomenon, 3 general themes emerged and were explored: (1) programmatic changes; (2) policy changes; and (3) partnerships. Quotations from participating staff and community members provide supporting evidence for the results (Figure).
Staff defined the programmatic changes that occurred in the transition to Healthy Homes as relating to 5 general areas: (1) training, (2) supplies, (3) personnel, (4) home visits, and (5) data collection.
Baltimore City Healthy Homes Division staff identified training strengths and made suggestions for other programs in transition. Participants identified the “Essentials for Healthy Homes Practitioners” course, offered by the National Center for Healthy Housing, as the most effective training opportunity for comprehensive knowledge of Healthy Homes. According to one participant, this course was useful for providing the “big context” whereas a separate training on local community resources was acknowledged as useful for “just knowing what is out there.” Staff mentioned a need for practical, as opposed to academic training in areas such as fire safety, carbon monoxide poisoning prevention, integrated pest management, injury prevention, safe sleep, water testing, blood-borne pathogens, mold remediation, and comprehensive housing inspection.
Staff also identified cultural competency training as a needed focus, noting that language and cultural differences contribute to challenges explaining regulatory codes with immigrant families. Administrative staff and field staff play different roles in the structure and implementation of the Healthy Homes program. One member of the administrative staff believed that training on grants processes would be beneficial for field staff to understand the administrative component of the program, such as documentation requirements for the funders and the need for collecting detailed evaluation data.
One challenge is the amount of time training requires. The material on the built environment presented in training is new to some staff members, particularly the PHIs, whereas sanitarians hold more extensive background knowledge. Although parts of the training fulfill required certification credit hours, the balance between time in training and time in the field is delicate. Participating staff members recommended that programs interested in completing a similar transition ensure adequate planning time for trainings. In Baltimore City, the role of one of the new administrative staff members was to organize the numerous trainings.
Educational materials and tools to address safety, pest management, and water-related issues are all part of Healthy Homes supply kits taken to home assessments. Specific items mentioned by staff were coloring books for children, roach disks, caulk, night-lights, outlet covers, temperature gauges, cribs, and cleaning supplies. Families appreciate no-cost resources along with educational materials. Staff noted the dual role of supplies-–they help staff to build rapport with families and are instrumental in assisting to remediate identified health and safety issues. Moreover, the Healthy Homes Division developed a partnership with the fire department, a collaboration that resulted in smoke alarm installation for all referred families.
Staff noted that as the program expanded from a pilot to a fully transitioned Healthy Homes program, the amount of supplies to carry to home assessments increased. While field staff found the load burdensome, both administrative and field staff agreed that having consistent access to a broad range of supplies is an important component of an ideal Healthy Homes program. In an ideal program, field staff will deem the supplies they carry to be essential to the well-being of the families they serve.
Participants noted a need for frontline staff or “soldiers in the field.” One administrative staff member advocated, “I think one or two more people would really help spread the burden a bit.” For the ideal Healthy Homes program, participants stated that having enough people in the field to carry out the mission of the program is crucial to its success. A related staffing issue agreed upon by administrative and field staff was the need for a clerical person to take responsibility for some of the scheduling and referral processes currently handled by field staff. It was noted that this would be critical to arranging services with various programs while freeing up field staff members for home visits and other tasks related to their work. Similarly, administrative staff set paperwork reduction as a short-term goal, acknowledging the need for greater efficiency with an expanded Healthy Homes assessment. Time demands undoubtedly place burden on both field and administrative staff; therefore, an ideal program has resources to hire a balanced staff to meet clientele needs.
Another salient staffing need raised by participants was for social workers to address the most pressing issues affecting families. Staff contend that many of the families who are referred to the Healthy Homes Division have unmet basic needs that go beyond the scope of field staff expertise. One staff member, taking on the voice of a community member, raised the concern, “Having somebody come in and talk to you about a smoke detector? I'm worried about food, I'm not worried about a smoke detector.” Another staff member talked about poverty more generally for participating families.
...the degree of poverty that some of our families are living in is just completely morally unacceptable. And what we are doing is putting a band-aid on a gaping wound. You know, people who don't have working toilets. A certain number of our families end up where they are because they are fleeing abuse. There are big issues and healthy housing is incredibly important but there is a hierarchy of needs.
The educational components of a Healthy Homes inspection and home visit were seen as a cornerstone to engendering self-sufficiency in clientele. For Sans, the inspection expanded with the transition to address issues in the home beyond lead poisoning, such as pest management, mold, fire safety, and carbon monoxide poisoning prevention. The related visit from PHIs expanded to address health consequences from pests, molds, and other asthma triggers as well as overall safety hazards, including obstructed stairways, exposed electrical outlets, and infant sleeping arrangements. Time invested is invaluable to the overall success of the Healthy Homes program. One program recipient in the focus group noted that the educational material presented was essential to her family's success at remediating problems in their home. This program participant noted that having experts provide education and following up to check how they used the information “kind of kept us in line.”
Safety issues for field staff, such as exposure to drug and gang activity in the community, existed prior to the transition. One field staff noted that “we put our life on the lines like the police do.” Ongoing efforts to protect staff were presented in the transition to Healthy Homes. However, several new issues emerged in relation to health and safety. One staff member noted apprehension about entering basements to check water temperature, moisture, and other housing issues. Furthermore, staff members mentioned concern about their own liability. For example, one respondent hypothesized,
If there will be an event where a child, let's say, got scalded or burned, they will say “Oh, the Health Department adjusted that, they probably did the wrong adjustment” and again, I am not a specialist so I should not be adjusting that.
An ideal Healthy Homes program will respond to evolving issues to most appropriately serve the needs of families while protecting its staff from harm.
One challenge of contributing to a national database with other CLPPPs is federal- and state-level reporting requirements, which account only for lead poisoning data. In Baltimore City, a second database was created specifically for Healthy Homes assessments. Field staff report that this makes reporting “much more complicated” in an environment where getting pretest information and collecting 30-day follow-up data is a challenge in itself. Administrative staff also noted that it was a priority to continue refining Healthy Homes assessments until questions are only asked that are “going to result in some kind of action.” Staff recommended that programs in transition avoid evaluation questions that may make a family member uncomfortable and jeopardize rapport. The data collection process in an ideal program advances the program goals while continually being refined. Staff members also indicated need for a postassessment satisfaction survey to help gauge “what was helpful, what wasn't helpful.”
In May 2006, the Baltimore City Health Department appointed an assistant commissioner for Healthy Homes. This position was the first in the nation1 and considered by staff an enhancement that corresponded to “the trend nationwide to expand to more of a holistic approach rather than a specialized lead focus.” Subsequently, the Lead Poisoning Prevention program expanded to address other problems in the home. Staff defined policy changes in the transition to Healthy Homes occurring in 3 general areas: (1) lead poisoning versus Healthy Homes policy; (2) internal policy development; and (3) policy and sustainable programs.
Lead poisoning versus Healthy Homes policy
Staff members indicated that lead is a “political football” in Baltimore City, affecting program management and design. On a federal level, health problems associated with elevated levels of lead in blood in children were targeted by Healthy People to be eliminated by 2010.8 While this goal will not be fully realized in Baltimore City, it is an important factor in swinging the political pendulum away from lead as an isolated issue in housing and environmental health. With fewer lead poisoning cases anticipated in future years, staff suggested that concerns about program sustainability were a factor leading the program to expand to focus on an array of housing issues.
Healthy Homes may take some time to enter fully into the lexicon, considering that Lead Poisoning Prevention programs have existed on the state and federal levels for decades. While programmatically the transition to the Healthy Homes Division proceeded relatively quickly in Baltimore, policies continue to lag behind. One staff member suggested that support and encouragement from parent agencies and ancillary boards will assist programs in their transition process.
Internal policy development
Administrative staff hired as part of the transition present “new rules and regulations and protocols.” One such administrative staff member describes the role of administration to include policy development and management of strategies that will serve families best.
I'm trying to think about things more broadly on a policy and strategic level with what are we doing with other agencies... . Is there a way the housing authority can change this behavior? Or can we reach more people through this direct service? Or can we change the policy of another agency? Or can we encourage some community based organization to get involved in Healthy Homes issues?
Administrative staff stressed that an ideal Healthy Homes program “keeps communication open” between the various program components. Staff identified the lines of communication within the Healthy Homes Division as multidirectional. Case conferences were added after transition as an important forum to learn from each other about client issues and strategize for a shared vision of successful program policies.
It was also expressed by staff that an ideal Healthy Homes program will ensure that service recipients are included in the policy-making process, communicating their needs at all phases of program development, implementation, and evaluation.
Bring them in to sit around the table and give them an idea of what is going on, why we are here. Don't just knock on the door... . Invite them into the nucleus and let them see it. Just maybe pick one or two or three or four families and get them actually involved in the whole process. Get their viewpoint of being this affected family.
Policy and sustainable programs
Among the policy issues raised by the Healthy Homes Division staff was the quintessential public health issue of whether to cast a wide net or to narrowly target high-risk families. According to one participant, this dilemma is often resolved as a sustainability issue. That is, a program may have a competent staff member who can provide “comprehensive education, enforcement, and abatement” but must have the resources to do so. One staff member noted the importance of both assessing the need and lobbying the local, state, and federal governments for sustainable funding.
In addition to funding concerns, staff members explained that they are accustomed to having responsibility for coding violation enforcement as part of the lead program. Yet, they do not have the same enforcement power for new parts of the program, leaving the onus on property owners to make recommended repairs to reduce the risk for themselves or their tenants.
The social and economic factors of a community can affect health of residents.9 , 10 Staff noted that myriad stressors impact the families that participate in their program. Program policies, therefore, must be sensitive to the predominant concerns that families bring and strike a balance between a comprehensive approach and a targeted, client-focused approach. For example, participants noted that all the resources and supplies are immaterial without access to safe housing, employment, food, and other basic needs. That is, to “get rid of lead exposure and reduce asthma,” the program policies need to be sustainable and address larger systemic issues.
Staff members revealed that they feel more responsive to the needs of clientele when they are capable of connecting families to resources. The recommendations that relate to partnerships are delineated in 2 general areas: (1) range of referrals to offer and (2) universal partners. Staff affirmed that the referral process improved with the transformation to Healthy Homes.
Range of referrals to offer
Transitioning to a Healthy Homes program offered the program staff members an opportunity to enhance their skills, while providing access to a wider range of referral sources. As a Healthy Homes program, the field staff can and do provide a “myriad of resources for assistance” and that change was viewed positively by staff. Staff members of the former Lead Poisoning Prevention program were not trained to handle issues outside of those related to lead, nor did the program have the resources to extend toward other housing problems.
Lead was a means to get into some of these houses so that we could see some of the things that were going on but it might be a need for social services, child protective services, or we may need to get them a list of contractors—particularly homeowners. If it's rental, they may not be aware of their rights as a tenant so we are able to provide a lot of information regarding their rights as well as medical information, social information that they need to help get them a better life.
While their partnership list continues to evolve, staff can share information on potential resources with families. Staff recommended that transitioning programs set up an accessible database to maintain this list, include up-to-date partners, and certify referrals for specific housing issues.
While staff members noted that partnerships were critical to a program transitioning to a Healthy Homes model, there is not one ideal program strategy for forming partnerships. That is, one city will differ from another when identifying the essential partnerships for an ideal Healthy Homes program. Participants mentioned several partnerships that are universally needed when transitioning to Healthy Homes. The partnership with the fire department was indicated as a model by many staff members. When a field staff member identifies a home without working smoke detectors, the fire department will go out to that home. Partnerships with the local housing department, child protective services, and asthma programs were also mentioned as critical resources to handling crisis situations by using a partnering approach (Table 1).
Our findings have implications for programs in transition, providing insight as to the strengths of a Healthy Homes program in contrast to a Lead Poisoning Prevention program. This study also provides us with a glimpse at the challenges that were encountered by Baltimore City when making the transition to Healthy Homes. In summary, we planned this study with the goal of creating a “cookbook” with the recipes for transition from Lead Poisoning Prevention to Healthy Homes. The “cookbook” originates in Baltimore City, Maryland, the site of the first Healthy Homes program cited by the Centers for Disease Control and Prevention's CLPPP. We conclude with the key “ingredients” for each of the 3 themes: programmatic changes, policy changes, and partnerships.
- Streamlined training opportunities for staff
- Judiciously selected supplies that are essential to the well-being of families served
- Personnel who include an adequate frontline staff to limit caseloads, social workers who can address significant social issues, and clerical staff to assist with referrals
- Restructuring of home visits to include a broad array of educational materials
- Staff expertise to address Healthy Homes while limiting time/paperwork and focused on the health and safety of staff
- Data collection procedures that capture the strengths and weaknesses in a Healthy Homes program
- Expanded Healthy Homes Policy that adopts a holistic approach rather than specialized lead focus
- Internal policy development as impacted by a new assistant commissioner for Healthy Homes, new administrative staff, and related communication issues
- Programmatic structure that strategically addresses key policy issues to increase the likelihood of program sustainability
- Enhanced referral ability with system in place that is easily manipulated and accessible to all staff members
- Establishment of key partnerships such as the fire department, the housing department, child protective services, and asthma prevention
One staff member described the change from “following blood tests” as a Lead Poisoning Prevention program to “making a difference in the families' homes” as a Healthy Homes program. The implications for improving the health and well-being of Baltimore City residents are far reaching. Moreover, changes on a national level will continue to progress as programs around the country transition to provide families with comprehensive Healthy Homes services.