# Indoor Air Quality in Schools: Improving the Air Our Children Breathe 

# 2006 - 2007 

# 

#  Environmental Public Health Leadership Institute Fellow:

**Toni Herring Bounds, PhD, MPH**

*Director, Communicable & Environmental Disease Services*

*East Tennessee Region*

*Tennessee Department of Health*

*1522 Cherokee Trail*

*Knoxville, TN 37920*

*(865) 549-5378*

[*toni.bounds@state.tn.us*](mailto:toni.bounds@state.tn.us)

# Mentor:

**Dwayne Roadcap, REHS, CPSS, AOSE**

*Program Manager, Division of Onsite Sewage and Water Services, Virginia
Department of Health*

# Acknowledgements:

**Paul Campbell Erwin, MD, MPH**

*Director, East Tennessee Region, Tennessee Department of Health*

**Sericea S. Smith, MPH**

*Student Intern, Public Health Program, The University of Tennessee,
Knoxville*

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Indoor air pollution is a prevalent health concern in schools within the
East Tennessee Health Region (ETHR). Most indoor air quality (IAQ)
complaints received by the ETHR are related to suspected mold problems
resulting in school systems not focusing on other indoor air pollutants.
Indoor Air Quality Management Programs (IAQMPs) decrease indoor air
pollution by addressing all indoor air pollutants thereby decreasing the
resulting adverse health effects in children. Effective IAQMPs monitor
environmental and health status in the schools, inform, educate and
empower people within the schools, mobilize community partnerships,
develop policies and plans, and evaluate effectiveness and quality.
Using Systems Thinking, Mental Models and Logic Models, this project
describes a methodology and strategy to implement effective IAQMPs
within the ETHR school systems that address all indoor air pollutants
rather than focusing only on mold. A needs assessment survey identified
seven ETHR county school systems interested in participating in the
initial development of IAQMPs. The next steps for this project include
expanding partnerships, developing resources that can assist with the
implementation of IAQMPs, educating children, teachers, and parents
about IAQ, identifying and allocating resources not presently used for
IAQMPs and verifying that schools within the ETHR have effective IAQMPs.

# INTRODUCTION/BACKGROUND:

The Environmental Protection Agency (EPA) ranks indoor air pollution as
one of the top five environmental health risks to the public and is the
most prevalent environmental problem encountered in schools.^1^ The
components of indoor air pollution include chemicals (formaldehyde,
volatile organic compounds), biologicals (mold, dust mites), moisture,
radon, particulates, lead and asbestos (older buildings). Poor indoor
air quality (IAQ) in schools aids in decreasing a favorable learning
environment for children, contributes to loss of productivity by
teachers and staff, is costly to resolve, generates negative publicity,
strains relationships between the school and parents, and can facilitate
adverse health conditions.^1^

Adverse health conditions associated with poor IAQ can range from cough,
eye irritation, headache, and nausea to allergic reactions, carbon
monoxide poisoning, and severe asthma attacks. The leading cause of
school absenteeism due to chronic disease is asthma.^1^ In addition,
poor IAQ promotes the spread of airborne infectious diseases. Also,
exposure to some chemical pollutants may lead to chronic diseases such
as cancer. Children are especially vulnerable to the components of poor
IAQ in that they take in more air than adults relative to their body
size.^1^ Therefore it is important that school systems successfully
decrease the possibility of exposure to indoor air pollutants by
children.

The Tennessee Department of Health has 13 health regions that provide
public health services to the citizens of Tennessee. The East Region is
located in central, East Tennessee and contains 15 non-metropolitan or
rural counties (Anderson, Blount, Campbell, Claiborne, Cocke, Grainger,
Hamblen, Jefferson, Loudon, Monroe, Morgan, Roane, Scott, Sevier and
Union). The three northern-most counties border Kentucky and four
counties in the southeastern part of the region border North Carolina.
In the East Tennessee Health Region (ETHR) there are 21 school systems
consisting of approximately 230 public schools with approximately 16,000
students.^2^

Each school year, the ETHR office routinely receives complaints from
parents that their children are sick because of the environment at the
child's school. The parent relates the sickness to the school because
the child is sick during the week while in school but gets better during
the weekend only to become sick again when the child goes back to school
the next week. Likewise the child is ill during the school year but is
better during summer break but becomes ill again when school starts in
the fall. Most of those who complain cite mold as the source of the
illnesses. Usually the parent initially complains to the local school
administrator who contacts the school maintenance director who inspects
the child's classroom area for mold. If mold is found, it is cleaned up.
If mold is not found, the determination is made that the illness is not
caused by the school environment. However, the pattern of illness
remains the same so the parent continues to associate the illness with
the school. This is the point at which the parent contacts the ETHR. On
occasion, the issue becomes adversarial, media reports the dilemma and
there is pubic demand for action to clean up the school. In extreme
cases, schools have been closed and classes relocated in an effort to
clean up a mold problem that may or may not exist. Much money is spent
and the problem may not be resolved. Because the focus is on mold, the
school usually does not address other possible IAQ pollutants.

In order to address this problem, the EPA recommends that schools
implement IAQ management programs (IAQMPs) such as the EPA's Tools for
Schools program.^1^ These programs take a proactive approach in
establishing and maintaining good IAQ in schools. EPA defines a good
IAQMP as one that includes control of airborne pollutants and adequate
outdoor air exchange for acceptable temperature and relative humidity
throughout the building.^1^ This project describes a developing program
initiated to help school systems within the ETHR establish IAQMPs to
provide good IAQ in schools thereby providing a healthy indoor air
environment for the children in East Tennessee.

####### ***Problem Statement:*** 

####### *East Tennessee Health Region school systems need Indoor Air Quality Management Systems to insure that schools have good indoor air quality providing a healthy environment for East Tennessee school children.*

####### 

####### ***Behavior Over Time Graph:***

Figure 1 depicts the variables that contribute to the continuing problem
of poor indoor air quality in ETHR school systems. Periodically parents
complain that their children are sick from mold. Areas within the
schools are tested for mold and if found is cleaned up and the source of
the children's sickness is assumed to be eliminated. If mold is not
found, it is assumed that the school environment is not contributing to
the child's illness. Over time, both the complaints related to mold and
mold clean up continue to occur periodically. IAQ management programs
may be considered but are not implemented because of lack of knowledge
and resources.

####### 

####### 

> **Figure 1: Behavior Over Time Graph**

#######   {#section-5 .unnumbered}

####### ***Causal Loop Diagrams and applicable archetypes:***

####### 

**Figure 2: Causal Loop Diagram -- Shifting the Burden**

####### ***Causal Loop Diagrams and applicable archetypes:***

Figure 2 is an archetype that applies to this project - Shifting the
Burden. The problem is sick children at school and mold is considered
the only source of the illnesses. The short-term fix is to clean up the
mold. This shifts the burden away from the ideal which is to maintain
good IAQ through an IAQMP that address all IAQ issues using a proactive
approach. Several scenarios can occur. First the resources allocated for
IAQ are used in cleaning up mold thus reducing the budget resulting in
no additional resources available for IAQMPs. Second, the mold clean up
is perceived as solving the problem when in fact eventually parents will
complain again that their children are sick at school. A third scenario
may occur when the issues become adversarial and there is pubic demand
for action. All these actions take resources away from establishing an
IAQMP that would address all issues providing a more comprehensive
approach to providing good IAQ in the school.

####### 

####### ***10 Essential Environmental Health Services:^3^***

This project addresses five Environmental Public Health Essential
Services as identified by the CDC's Environmental Health Services
Branch.

> 1\. Monitor environmental and health status to identify community
> environmental health problems.

An indoor air quality management program would provide a mechanism for
monitoring schools environment as well as the health status of the
children, faculty and staff.

2\. Inform, educate and empower people about environmental health
issues.

Because it is an issue before the public, mold has become the most
prevalent IAQ issue. This project proposes a goal to inform, educate and
empower school officials, parents, and the public that mold is only one
of many issues related to IAQ. These IAQ issues may be addressed by
developing an IAQ management program.

> 3\. Mobilize community partnerships to identify and solve
> environmental health problems.

Most East Tennessee rural, county school systems have limited or no
resources to initiate IAQMPs. Identifying local resources would mobilize
community partnerships to enable the school systems to develop and
implement IAQMPs.

> 4\. Develop policies and plans that support individual and community
> environmental health efforts.

Because the IAQMPs are an ongoing process to proactively maintain good
IAQ, policies and plans must be developed to sustain these programs over
time.

> 5\. Evaluate the effectiveness, accessibility, and quality of personal
> and population based environmental health services.

After implementation, each of the school IAQMPs should be routinely
evaluated to assure continued effectiveness.

![](media/image2.png){width="3.84375in" height="3.652083333333333in"}

Figure 3: Relation of Essential Services to Core Functions^3^

####### 

####### 

####### ***National Goals Supported:*** 

This project supports the following national goals:

**1. CDC Health Protection Goals^4^**

**Healthy People in Healthy Places -** The places where people live,
work, learn, and play will protect and promote their health and safety,
especially those at greater risk of health disparities.

**Healthy Schools**

-   Increase the number of schools that protect and promote the health,
    safety and development of all students, and protect and promote the
    health and safety of all staff.

-   Increase the number of schools that promote the health and safety of
    students, their families, and school staff by implementing a
    comprehensive program of instruction, programs, policies, and
    services.

-   Increase the number of schools that have a safe, healthy, and
    accessible social, psychological, emotional, and physical
    environment.

**Healthy Workplaces**

-   Promote and protect the health and safety of people who work by
    preventing workplace-related fatalities, illnesses, injuries, and
    personal health risks.

-   Increase the number of workplaces that coordinate worker safety and
    health efforts with efforts to promote the health and well-being of
    workers, their families, and their communities.

**Healthy People in Every Stage of Life**

-   All people, and especially those at greater risk of health
    disparities, will achieve their optimal lifespan with the best
    possible quality of health in every stage of life.

-   Prevent chronic diseases and their consequences among children.

-   Increase the numbers of children who live, learn, and play in social
    and physical environments that are accessible, that support health,
    safety, and development, and that promote healthy behaviors.

**2. National Strategy to Revitalize Environmental Public Health
Services^5^**

**Build Capacity**

-   Strengthen and support environmental public health services at the
    state, tribal, territorial and local levels.

**Communicate and Market**

-   Improve communication and information sharing among environmental
    public health agencies, communities, strategic partners, and other
    stakeholders and better market environmental public health services
    to policy makers and the public.

**Foster Leadership**

-   Foster leadership to enhance environmental public health services.

**Create Strategic Partnerships**

-   Foster interactions among agencies, organizations, and interests
    that influence environmental public health services.

####### ***Figure 4: Project Logic Model***

# Goal: Increase the number of Indoor Air Quality Management Programs among school systems in the East Tennessee Health Region thereby providing good indoor air quality in the schools and a healthy environment for school children. 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

***Program Goal*:** Increase the number of Indoor Air Quality Management
Programs in the East Tennessee Health Region school systems thereby
providing good indoor air quality in the schools and a healthy
environment for school children.

***Health Problem:*** Children are getting sick at school.

***Outcome Objective:*** By May 31, 2008, increase the number of IAQMPs
in ETHR county schools.

***Determinant:*** The number of new ETHR IAQMPs.

***Impact Objective:*** By May 31, 2008, the number of ETHR county
schools utilizing an indoor air quality management program will be
increased by 50%.

***Contributing Factors:***

1\. Lack of knowledge about indoor air quality (IAQ) hazards.

2\. Lack of resources allocated to all IAQ hazards

3\. Lack of knowledge about available indoor air quality management
programs.

***Process Objectives:***

1\. By May 31, 2007, there will be an increased awareness of the health
effects of hazardous indoor air in schools.

2\. By August 30, 2007, partnerships will be developed to address IAQ in
schools.

3\. By January 31, 2008, at least two county schools systems will be
offered resources to develop indoor air quality management programs.

####### 

# METHODOLOGY:

####### ***Events and Activities***

**Event**: Implement an indoor air hazards health educational program.

**Activities:**

-   Determine existing resources related to indoor air hazards.

-   Compile a comprehensive module containing information related to
    indoor air hazards in schools.

-   Develop methods for disseminating the information to the county
    school officials, parents, teachers, school staff, industry and
    media.

**Event:** Establish associations of local organizations that will
enable school systems to develop IAQMPs.

Activities:

-   Identify local organizations that are willing to support the
    development and implementation of IAQMPs in schools.

-   Invite these organizations to participate in local school-supported
    associations.

**Event:** Implement indoor air quality management programs in at least
two ETHR school systems.

**Activities:**

-   Develop an indoor air quality survey for ETHR county school systems
    to determine if each system's willingness to participate in an air
    quality management program if none exists.

-   Conduct an indoor air quality survey of county school maintenance
    directors.

-   Provide survey results to each county school system.

-   Utilizing the EPA Tools for Schools program, and other regional
    resources, develop air quality management plans specific for at
    least two ETHR school systems.

# RESULTS:

A partnership has been formed between the ETHR, the Department of
Environment and Conservation, the University of Tennessee Extension and
the Department of Education and is dedicated to helping school systems
within the ETHR provide safe and healthy school environments for
students, faculty and staff. The partnership is working to increase
membership and is compiling a resource list for each county in the ETHR.

In an effort to identify the present status related to IAQMPs among the
ETHR school systems, a survey was conducted to determine which counties
within the ETHR have existing IAQ problems and management programs to
address the problems. Fourteen of the 15 counties participated in the
survey for a 93% response rate. The survey identified three county
systems that had existing IAQMPs and one of these systems (Blount
County) utilizes the EPA's Tools for Schools program in all schools
within that county. Seven school maintenance directors responded that
they are interested in additional information about IAQMP and/or they
are interested in initiating an IAQMP within their school system. The
results of this survey serve as a guideline in the allocation of
resources in regards to the promotion and implementation of IAQMPs in
this region.

A special note is made here about the Blount County IAQMP: Dr. Brian
Bell, Director of Maintenance and Facilities for the Blount County
School System, initiated the Tools for Schools program after a high
school in that county was closed because of IAQ issues. The clean up was
extensive and costly. This ongoing IAQMP has received national awards
for their efforts to improve the IAQ in their schools and will serve as
an example for the other school systems within the ETHR.

# NEXT STEPS:

The next step for this project is to implement the plan as presented by:

-   expanding partnerships such as local industry who may be willing to
    adopt a school; the Tennessee Tools for Schools coordinator, school
    systems with IAQMPs serving as mentors to other school systems, etc.

-   continuing to identify resources such as community services,
    available funding sources^6^, volunteers, etc.

-   increasing IAQ awareness by educating media, community groups,
    parents, schools and county officials, etc.

-   following up with the maintenance directors who indicated an
    interest in implementing an IAQMP.

The ultimate goal of this project is to facilitate the establishment of
indoor air quality maintenance programs within all school systems in the
East Tennessee Health Region in an effort to provide a safe and healthy
environment for school children.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

My year as an EPHLI fellow has been a great professional and personal
growth experience. I had no idea in the beginning that it would have
such a profound effect on me. I have learned new ways to think about my
work through organizational learning and systems thinking. I have
incorporated new language such as logic models, feedback loops and
mental models into project development. The Individual Development Plan
that I worked on all year has helped me learn to stay focused and keep
on task. Most importantly I am grateful for the opportunity to have met
and worked with such a dynamic group of environmental public health
professionals. I am honored to be a member of the EPHLI Class of 2007.

# ABOUT THE EPHLI FELLOW

Toni Herring Bounds received a Master of Public Health degree in
Environmental and Occupational Health and Safety from the University of
Tennessee, Knoxville, and a PhD degree in Epidemiology from the School
of Public Health at the University of South Carolina, Columbia. She has
participated in occupational and environmental epidemiologic research
studies, taught graduate public health courses and served as Research
Epidemiologist for the Department of Obstetrics and Gynecology at a
teaching hospital. She has worked for the State of Tennessee Department
of Health as the Director of Cancer Surveillance, Program Director for
the Tennessee Cancer Registry and Program Coordinator for the Tennessee
Comprehensive Cancer Control Program. Currently, she is Director of
Communicable and Environmental Disease Services and Environmental
Epidemiologist for the East Tennessee Region of the Tennessee Department
of Health.

**REFERENCES**

1.  U.S. Environmental Protection Agency. *Indoor Air Quality Tools For
    Schools Action Kit*, 402-K-95-001, 2^nd^ ed. Washington, DC. August
    2000.

2.  The Tennessee Department of Education. *The Tennessee School Report
    Card 2004*, Nashville, TN, May 2005.

3.  Osake, C. *Essential Services of Environmental Health*, Northwest
    Center for Public Health Practice, University of Washington School
    of Public Health and Community Medicine, Seattle, WA. July 2004.

4.  U.S. Department of Health & Human Services, Centers for Disease
    Control and Prevention. *Health Protection Goals Fact Sheet*,
    Atlanta, GA.

5.  U.S. Department of Health & Human Services, Centers for Disease
    Control and Prevention. *A National Strategy to Revitalize
    Environmental Public Health Services*, Atlanta, GA September 2003.

6.  National Association of Counties. *The County Official's Indoor Air
    Quality Handbook*, The Indoor air Quality Program, Washington, DC.
    January 2005.