page 99

Intervention Strategies

Intervention Principles

Prioritizing Interventions

Shared Responsibility for Implementing Interventions

Multiple Benefits of Interventions 

Proper Use of Products

Saving Treatment Costs through Prevention 

Choose Evidence-Based Interventions

Intervention Costs

Principle #1: Keep It Dry

Review of the Evidence

Structural Interventions

Principle #2: Keep It Ventilated

Review of the Evidence

Structural Interventions

Local Exhaust Interventions

General Dilution Ventilation and 

 Heating Systems Interventions

Principle #3: Keep It Pest-Free

Principles of Integrated Pest Management

Review of the Evidence

Structural Interventions

Rental Policies and Use of IPM Professional Services

Principle #4: Keep It Safe

Key Principles of Injury Prevention

Falls

Burns and Scalds

Other Safety Interventions

5
page 100

Principle #5: Keep It Contaminant-Free

Asbestos

Lead-Based Paint Hazards

Combustion Products

Volatile Organic Compounds (VOCs)

Radon Control 

Particulate Matter

Secondhand Smoke

Occupational Take-Home Hazards

Principle #6: Keep It Clean

Review of the Evidence

Structural Interventions

Principle #7: Keep It Maintained

Structural Interventions

Routine Maintenance Schedule

Cleaning for the Control of House Dust 

Containing Lead

Hoarding

Energy Efficiency

Security

Resident Knowledge and Education

Introduction

Keep it Dry

Keep it Ventilated

Keep it Pest-Free

Keep it Safe

Keep it Contaminant-Free

Keep it Clean

Keep it Maintained

Special Focus on Asthma

Intervention Strategies
page 101

I

nterventions include physical modifications to a home to make it 

healthier and safer. They also include educational efforts to change the knowledge 

and behavior of occupants so they can protect themselves from health and safety 

hazards. 

5

A housing assessment (described in Chapter 4) 

helps inform the intervention strategy and prioritize 

selection of interventions. This chapter describes 

intervention strategies according to the Seven 

Principles of Healthy Homes, and reviews evidence 

supporting their effectiveness. Resident education 

is an intrinsic component of all seven principles and 

is discussed at the end of this chapter.

Health benefits from combined structural and 

behavioral interventions are greater than resident 

education alone. The HUD/CDC Healthy Homes 

Reference Manual provides detailed descriptions 

of construction and maintenance practices. 

Appendix 5.1 describes specific healthy housing 

interventions and details their relationship 

to “green” building design systems, such as 

the Enterprise Community Partners’ Green 

Community Standards and the LEED (Leadership 

in Energy and Environmental Design) rating 

system. The Appendix also contains technical 

information on EPA’s Indoor airPLUS Construction 

Specifications for new construction.

Intervention Principles 

Prioritizing Interventions

Depending on the local program and available 

resources, priorities can be established in 

Key Messages

• Healthy housing interventions make a home 

dry, ventilated, safe, contaminant-free, pestfree, clean, and maintained.

• Specific healthy homes interventions 

often have many benefits and should be 

implemented by both owners and occupants.

• Substantial evidence shows that healthy 

housing interventions are effective.

• Interventions require resident education to 

be effective.

• Interventions can prevent harm; they are 

more effective and less expensive than 

acting after harm has occurred.

Intervention Strategies

This chapter is organized 

around the Seven Principles of 

a Healthy Home. Keep it: 

• Dry 

• Ventilated 

• Pest-free

• Safe

• Contaminant-free

• Clean

• Maintained
page 102

several different ways (see Table 4.1 in the 

previous chapter). One general approach 

involves first correcting imminent hazards such 

as carbon monoxide or a sagging roof; second, 

correcting hazards associated with chronic 

health conditions such as asthma triggers; and 

third, taking steps to prevent other housing 

deterioration. While many jurisdictions have 

housing repair programs that address imminent 

hazards, chronic problems and preventative 

strategies also require attention. Further, there 

are likely to be some housing units that simply 

cannot be brought to a healthy status and need 

to be condemned, demolished, or vacated.

Similarly, some localities are slated for widespread 

demolition and development, making healthy 

homes investments in existing housing in the near 

term inappropriate. Healthy homes programs 

should always coordinate their efforts with local 

planning officials in order to maximize the impact 

and durability of the work. The case studies 

in Appendix 1.2 demonstrate how different 

programs have established intervention 

priorities.

Shared Responsibilities for 

Implementing Interventions

Owners, property managers, maintenance staff, 

and tenants share responsibility for a healthy 

and safe home environment in rental housing. 

Because home environments experience normal 

wear and tear and all systems (e.g., electrical, 

plumbing) degrade over time, maintenance 

is also an ongoing responsibility. Owners are 

responsible for providing a living environment 

that complies with housing and building codes, 

responding to tenant reports of needed repairs, 

and conducting periodic inspections (e.g., at unit 

turnover or annually). Tenants are responsible for 

maintaining the cleanliness of the property and 

for immediately reporting maintenance needs to 

the property owner. 

Multiple Benefits of Interventions 

Many healthy homes interventions result 

in multiple health benefits. For example, 

eliminating a moisture problem helps prevent 

mold, dust mites, deteriorated paint, structural 

rot and degradation, and pest infestation. Radon 

mitigation not only reduces exposure to radon 

but is effective in reducing other soil gases 

and can reduce moisture levels.1 Keeping food 

preparation areas clean and maintaining smooth 

and cleanable surfaces helps to eliminate pest 

infestation, prevents dust accumulation, and 

reduces infections and food-borne diseases. 

As part of a program’s education efforts with 

owners and occupants, these varied intervention 

benefits should be presented and emphasized 

so that the outcomes are well understood.

Proper Use of Products 

Some home-related injuries and health problems 

can be traced to improper use and storage 

of certain products. For example, combining 

incompatible cleaning agents such as ammoniabased cleaners and bleach can produce toxic 

gases. Misuse of pesticides can be associated 

with poisonings. Improper installation or 

location of warning devices such as smoke or 

carbon monoxide alarms can promote a false 

sense of security.

Saving Treatment Costs through 

Prevention 

The health and societal costs of housing-related 

disease or injury far outweigh the costs of 

prevention. Savings associated with preventing 

childhood lead poisoning from residential 

lead exposures run well over $67 billion.2 The 

cost of controlling housing-related asthma 

triggers pales in comparison to health care 

costs such as emergency department visits, 

hospitalization, and missed school and work 

days. A Systematic Review of Home-Based 

Multi-Trigger Multi-Component Environmental 

Interventions to Reduce Asthma Morbidity, 

summarizes cost-benefit studies showing 

a return of $5.30 to $14.00 for each dollar 

invested, and a cost effectiveness of $12 to 

$57 per additional symptom-free day.3 See 

http://www.thecommunityguide.org/asthma/

multicomponent.html for more information.

An improvement in health outcomes and 

associated savings should be incorporated in 

your local evaluation plan to document how 

your healthy homes program contributes to 

containing health care costs by preventing 

housing-related disease and injury.

Intervention Strategies
page 103

Table 5.1 Average Costa of 

Interventions per Housing Unitb,c

Intervention Category Cost per Housing 

 Unit (Average)

Allergen reduction (n=17) $1292

Education (n=16) $211

Injury prevention (n=14) $233

IPM (n=14) $290

Lead hazard control (n=8) $5312

Moisture control (n=13) $1272

Weatherization (n=8) $2266

Average total cost per unit $3705

for all interventions (n=10)

a

Benefits not included in cost estimates. Average cost 

includes both cost of materials and labor. Some costs 

are capped by the relevant program and may not be 

related to correction of all hazards or deficiencies. 

bNumbers presented in the table include both 

estimated and actual quantities provided by healthy 

homes programs. Of 44 healthy homes programs, 33 

reported their numbers were estimates.

c

n=number of programs surveyed.

Source: HUD, 2007, p. ES-5.

Choose Evidence-Based 

Interventions

For many interventions, the evidence on 

clinical and environmental health benefits is 

well established. For others, further research 

and field testing is needed. The World Health 

Organization conducted an extensive review 

of the health impacts of inadequate housing.4

The CDC and the National Center for Healthy 

Housing convened a group of experts to 

review scientific findings on the effect of 

housing interventions on improved clinical and 

environmental health outcomes (Figure 5.1).5 The 

resulting report focused on five broad areas: 

• Indoor Biological Agents Interventions.

Studies related to allergens, dust mites, 

asthma, cockroaches, domestic animals, mice, 

and rats.

• Interior Chemical Agents (Toxins) 

Interventions. Studies related to water and air 

pollution, integrated pest management (IPM), 

pesticides, safe chemical storage, particulate 

matter, filtration, ventilation, volatile organic 

compounds (VOCs), formaldehyde, organic 

chemicals, radon, and lead.

• External Exposures (drinking water and sewage 

treatment). Studies related to exposures from 

the water supply, drinking water, in-home 

filtration, wastewater treatment, sewage, waste 

management, water pollutants, purification, 

and water filters. (Not covered in this Manual.)

• Structural Deficiencies (injuries and safety).

Studies related to burns and burn prevention, 

Figure 5.1 Rating of Housing 

Intervention Effectiveness

Housing Interventions and Health panelists 

rated interventions according to:

• Sufficient evidence to consider the 

intervention effective;

• Promising intervention that needs more 

field evaluation;

• Intervention that needs more formative 

research; and

• Intervention with no evidence of 

effectiveness.

Intervention Strategies

accident prevention, home injuries, protective 

devices, accidental falls, and fall prevention.

• Intersection between Housing and 

Community. Studies related to environmental 

justice, universal design, ordinances, law and 

law enforcement, and public policy.

Intervention Costs 

An Evaluation of HUD’s Healthy Homes Initiative: 

Current Findings and Outcomes6 identified the 

most common interventions and their costs. 

Of seven categories, the costliest was lead 

hazard control, with an average per unit cost 

of $5,312 (including labor and materials). The 

least costly was education, with an average 

total cost of $211 per unit (Table 5.1). Because 

costs and activities vary widely, it is important 

for programs to develop local cost databases, 

including relevant units of measurement, such 

as dollars per linear or square foot. It is also 

important for programs to evaluate benefits 

as well as costs. For example, one program 
page 104

installed weather stripping and sealed ductwork 

as part of its weatherization activities while 

another replaced windows.

Principle #1: Keep It Dry

Review of the Evidence

Ventilation and moisture control are typically 

related. Both ventilation and dehumidification 

help to reduce humidity levels and exposure 

to dust mites. A national survey found the use 

of a dehumidifier predicted lower levels of 

some asthma triggers and mold.7 Additionally, 

installation of a whole-house mechanical 

ventilation system can reduce humidity, thus 

decreasing dust mites and improving clinical 

outcomes.8, 9 Effective dehumidification in 

temperate climates can be achieved with air 

conditioners and/or dehumidifiers.10 In climates 

with high humidity, whole-house ventilation has 

been less effective.11, 12, 13 Climate zone must 

therefore be considered when making decisions 

about dehumidification. 

Ventilation can improve indoor air quality when 

the outdoor air has lower levels of humidity and 

contaminants than the indoor air. Conversely, 

families in housing near pollution point sources 

such as industrial sites, high-pollen forested 

sites, and high-traffic roadways may need to 

filter or otherwise clean the outdoor air that 

enters the home environment.

Structural Interventions

Structural deficiencies related to moisture 

include water intrusion through the building 

envelope, plumbing leaks, drainage problems, 

and condensation. Key structural control 

methods are shown in Figure 5.2. Chapter 4 

identifies a number of structural factors central 

to moisture control and how to assess when 

these controls have failed. The HUD/CDC 

Healthy Housing Reference Manual describes 

maintenance practices, proper insulation, 

and how to prevent moisture intrusion from 

a home’s foundation, walls, and roof. The 

Reference Manual also provides information on 

the operations and maintenance of plumbing 

systems, venting requirements for plumbing 

systems, and methods to conserve water. 

Finished basements require special 

consideration regarding moisture control. In 

general, such spaces should not use sheetrock 

or paneling to cover exterior walls or wallto-wall carpeting, both of which can lead to 

moisture and mold problems. Capillary breaks 

are discussed below as one way of controlling 

moisture in basements.

Controlling Building Envelope Leaks

Ensuring that roofs, walls, and foundations shed 

water effectively helps to control leaks. Absence 

or deterioration of flashing is a common building 

deficiency associated with water leakage 

through the building envelope. Flashing refers 

to thin continuous pieces of sheet metal or other 

impervious material installed to prevent water 

from passing into a structure through an angle 

or joint (Figure 5.3).

When new building components such as 

windows are installed, they should be 

accompanied by pan flashing to shed water 

away from the wall penetrations and prevent 

water from entering the structure. Flashing at 

the base of structures should allow water that 

has been repelled by the flashing to escape the 

plane of the building surface. The principle of 

flashing should be extended to all penetrations 

in structures. In other words, all of them should 

be sealed to prevent moisture as well as pest 

incursion into the living space.

Maintaining proper grading around a foundation 

and preventing erosion that can lead to pooling 

of water helps prevent moisture intrusion into 

Figure 5.2 Key Structural Controls 

for Moisture

1. Limit water entry (e.g., maintain gutter 

systems).

2. Dehumidify damp spaces such as 

basements.

3. Repair leaks and assure that drains work 

properly.

4. Clean or properly remove wet or moldy 

building components.

5. Manage ventilation systems so that 

moisture is removed at the source.

Intervention Strategies
page 105

basements and reduces the need for expensive 

foundation waterproofing and excavation. This 

practice also promotes the durability of the 

structure by reducing the prospect of settling, 

which can sometimes lead to cracks. Specific 

interventions are discussed below.

• In new construction, install capillary breaks 

around interior foundation walls to prevent water 

from “wicking” up from the ground and into the 

building through capillary action. Capillary breaks 

can also be installed in existing construction. 

Capillary breaks are needed to prevent 

vertical moisture movement, such as from the 

foundation wall up into the wall or floor framing 

(only practical in new construction) and horizontal 

moisture movement, such as soil moisture 

moving through the foundation wall into the 

basement or crawl space. This is accomplished 

by water-proofing or damp-proofing the exterior 

side of the foundation wall during construction. 

While usually very expensive to carry out as a 

retrofit, it is sometimes the most cost-effective 

way to control moisture in existing homes when 

combined with perimeter drainage and proper 

grading away from the structure. Construction 

information on capillary breaks is available in 

EPA’s Indoor airPLUS construction specifications 

(epa.gov/indoorairplus/construction_

specifications.html).

• In existing structures, a retrofit with French 

drains or other means of diverting water away 

from foundations may be needed.

• Gutters and downspouts should drain water 

from the roof to the ground with no breaks in 

the system. Drainpipes or splash blocks should 

redirect water from the downspouts away 

from the foundation, but care should be taken 

not to direct the water near the foundation of 

the neighboring building.

• Planter boxes, decks, or other outdoor 

structures should be placed so that they do 

not obstruct rainwater flow or snowmelt from 

the foundation (Appendix 5.1).

Figure 5.3 Window Flashing 

Source: http://www.energysavers.gov/your_home/windows_doors_skylights/index.cfm/mytopic=13470

Intervention Strategies
page 106

Condensation can occur when warm, moist 

air comes in contact with a cold surface. This 

can lead to mold and other problems, creating 

health hazards and building decay. Sometimes 

condensation occurs within walls, ceilings and 

floors that separate the outside unconditioned 

air from the conditioned air inside the structure 

as warm moist air travels through the cavity. 

Crawl spaces, attics, and exterior walls can be 

affected. In some cases a vapor retarder (often 

called a vapor barrier) is recommended to inhibit 

condensation from the movement of moistureladen air into walls, ceilings, and floors. Placing a 

heavy plastic sheet on the bare ground in a crawl 

space, carefully sealing any seams, and sealing 

the plastic to the foundation can minimize 

moisture movement from the crawl space into 

the structure.

Note that vapor retarders require careful 

thought. If an insulated wall has materials on 

both the interior and exterior surfaces that 

retard vapor movement, moisture can become 

trapped within the wall cavity and cause a 

serious problem. Walls should be designed so 

they dry in at least one direction. 

Similarly, cold water pipes located in areas 

where the air is warm should be insulated to 

prevent condensation. One way of detecting 

this problem is to look for areas of discoloration 

where condensation from pipes has dripped 

onto a lower surface. The same principle 

applies to ductwork that carries warm or cold 

air through air zones with a high temperature 

gradient. Ductwork should be sealed and well 

insulated in unconditioned spaces to prevent 

condensation. Insulation should be applied to 

the exterior of the ductwork, not the interior. 

While insulation of ductwork is a simpler matter 

in new construction, poor insulation of ductwork 

in existing housing can result in condensation 

inside ductwork and become a significant 

breeding ground for mold and other biological 

agents.

Ensure that windows are adequately 

installed, caulked, and insulated to prevent 

condensation—a cause of both mold and leadbased paint failure. Replacing old single-pane 

windows with modern double- and triple-pane 

windows can effectively eliminate window 

condensation problems. This intervention may 

be cost-prohibitive for healthy homes programs 

unless funds can be leveraged through 

partnerships, from lead hazard control and/or 

weatherization programs, or the private sector. 

Reduce moisture sources with high quality 

exhaust fans in bathrooms and kitchen, and 

proper venting of dryers, to substantially reduce 

the likelihood of condensation on windows or 

walls. Finally, eliminate insulation voids in walls 

and ceilings since cold interior wall surfaces in 

the winter can lead to condensation and mold.

Prompt Repair of Plumbing Leaks 

How water and moisture leave a home are as 

important as how they enter. Plumbing is often 

overlooked as a significant source of moisture 

because leaks can be slow or undetected. Drain 

traps can degrade or dry over time if the drain 

trap is not kept full of water. Basement floor 

drain traps should be kept full by adding water 

periodically to prevent harmful soil and/or sewer 

gases from being emitted.

Safe Cleaning or Removal of Wet or Moldy 

Items 

Failure to correct the source of moisture that 

produced mold contamination guarantees the 

eventual failure of mold remediation efforts. 

There are established procedures for safely 

removing wet and moldy building materials and 

furnishings, typically involving minimizing the 

disturbance of such materials to prevent mold 

spores from becoming airborne.14, 15, 16 Projects 

requiring large areas of mold decontamination 

(e.g., more than ten square feet) may warrant the 

use of a mold mitigation professional. Improper 

Intervention Strategies
page 107

solutions, such as blowing air over mold 

contaminated items, can increase exposures 

and may do more harm than good. Individuals 

attempting to mitigate mold problems should 

be trained to prevent exposure to mold during 

the elimination process through the use of 

respiratory, eye and skin protection equipment.

Appropriate Design, Installation, and 

Management of Heating, Ventilation, and 

Air Conditioning (HVAC) Systems

Many kitchen fans in older homes simply recycle 

air coming from stoves and ranges rather than 

vent it to the exterior of the building. Some 

current building codes for new construction 

require that kitchen range hoods be exhausted 

to the outside. Check by looking above the fan 

or range hood to see whether there is ductwork 

and examining the exterior wall for a flap that 

would exhaust the air. Installers often forget 

to remove the manufacturer’s tape on the flap, 

so it is important to ensure that the flap is not 

only present but functioning properly. Bathroom 

exhaust fans and clothes dryers must be vented 

to the outside.

In general, a home’s relative humidity should 

be kept in the 30–50 percent range. Filters 

in clothes dryers, kitchen ranges, furnaces 

and bath exhausts should be cleaned and/or 

replaced to ensure air flow is adequate and 

moisture does not accumulate on the dust in the 

filters. Instructions on when and how to clean 

and replace filters properly should be part of a 

program’s education intervention strategy.

Air conditioning or dehumidifying systems need 

to be checked regularly and cleaned to ensure 

that condensate drains do not become blocked. 

Blockage results in leaks from the drainage 

pans onto surfaces that may not be visible. 

Condensate pans should be properly sloped so 

that water runs to the drain and does not pool 

in other areas. Cooling coils need to be kept 

clear and clean to prevent blockage as well as 

prevent high fuel consumption due to lower heat 

transfer. Homeowners/residents or maintenance 

personnel can take care of this for window air 

conditioners, but for central air conditioning 

systems, a licensed contractor is generally 

needed.

Some heating, ventilation, and air conditioning 

systems (HVAC) are equipped with humidifiers, 

especially in northern climates where indoor 

winter air becomes dry. In other cases, 

individual rooms may be equipped with 

portable humidifiers. In both cases, the water 

supply, water tank, and water wheels or other 

distribution systems should be kept clean. If the 

systems are not used for some time, they can 

become breeding grounds for biological agents, 

including mold, bacteria, and viruses. Very dry 

conditions in the house may be due to dry cold 

air entering the home during the winter. Proper 

air sealing may remove the need for a humidifier.

If an area has become wet, drying is typically 

the first step in remediation after eliminating 

the moisture source (Figure 5.4). However, some 

forms of drying can exacerbate the problem. 

Blowing high-velocity air streams over surfaces 

contaminated with extensive mold can cause 

mold spores and fragments to become airborne, 

where they can be inhaled readily or contaminate 

other surfaces. Use of dehumidifiers, personal 

protection and other measures can help to 

avoid these problems. In some cases, it may be 

necessary to discard contaminated items that 

cannot be properly cleaned. If the extent of 

damage is extensive, trained professionals should 

address the problem. It is equally as important 

to identify the moisture source and to make 

needed repairs to prevent reoccurrence. During 

catastrophic water events (e.g., pipe breaks, 

water heater failure, flooding), time is of the 

essence. Typically, water needs to be removed 

within 24–48 hours, after which mold begins to 

develop. Many restoration companies are now 

available to extract water following a flood using 

dehumidifiers, fans, and other tools. 

Figure 5.4 Remediation Guidance

Mold and moisture remediation guidelines are 

available from the following organizations: 

• EPA: http://www.epa.gov/mold/

moldcleanup.html. 

• New York City Health Department: http://

www.nyc.gov/html/doh/html/epi/moldrpt1.

shtml. 

• AIHA: http://www.conferencemedia.net/

store/stores/aihce/american-industrialhygiene-conference-and-expo-2009/

perspectives-on-the-aiha-green-book.html. 

Intervention Strategies
page 108

Figure 5.5 Unhealthy Heating System Using Basement Air

The illustration shows returning air entering the basement air, then supplying the furnace with air distributed 

throughout the house. Figure 5.6 shows a simple fix that avoids contamination of supply air. 

For some moisture problems, changes to the 

HVAC system may be needed. For example, a 

ventilation system that draws air from a moist 

basement instead of a living area may result in 

dispersing moisture and mold throughout the 

house (Figures 5.5 and 5.6). This type of system 

is sometimes called “the Cleveland Drop” 

because it was first identified in a number of 

Cleveland-area houses that were investigated 

for mold and moisture problems. A solution is 

to ensure that the air supplying the furnace is 

supplied from the exterior or from a living area, 

rather than the basement. Leaky ductwork can 

also lead to problems because it may draw 

in air from unconditioned spaces. Ductwork 

should be sealed to prevent such leaks. For new 

construction, information is available in EPA’s 

Indoor airPLUS construction specifications: 

www.epa.gov/indoorairplus/construction_

specifications.html.

Reporting Moisture and Leak Problems 

Owner occupants and renters should be 

encouraged to conduct regular visual 

assessments to identify leaks and condensation. 

Tenants need to have confidence that requests 

for minor repairs and reporting maintenance 

needs are taken seriously or they will fail to report 

problems when they are relatively easy to correct. 

Tenant failure to promptly report problems and 

property owner failure to respond represent 

major problems in economically distressed rental 

housing. Clarifying roles and expectations and 

providing incentives for responsible behavior are 

important tools for healthy homes programs.

Principle #2: 

Keep It Ventilated

A number of housing defects and conditions 

leading to health problems can be corrected by 

Intervention Strategies
page 109

proper ventilation. However, source control—

eliminating certain products or selecting 

materials that have low emissions, thereby 

limiting the chemicals released into the air 

we breathe—should precede any changes to 

ventilation. Using building materials, carpeting, 

and furnishings that have no or low levels of 

formaldehyde or other VOCs is recommended. 

The California Air Resources Board has rules 

limiting the amount of formaldehyde that offgases from building products such as pressed 

wood and particle board.17 Some sources of 

hazards, such as radon, however, can only be 

controlled by specialized systems.

Review of the Evidence

As noted under Keep It Dry, ventilation is 

usually critical to moisture control. Failure to 

provide adequate fresh air supply and proper 

distribution can also lead to a variety of adverse 

health conditions. Two recent studies, one 

Figure 5.6 Healthy Heating System Using Outdoor Air or Air From Living Spaces

Figures 5.5 and 5.6 courtesy of Environmental Health Watch/Cuyahoga County Board of Health, Cleveland, Ohio

Figure 5.7 Ventilation Interventions

• Remove airborne contaminants through 

proper exhaust ventilation.

• Supply fresh air through dilution 

ventilation.

• Test for and conduct radon remediation as 

needed.

Intervention Strategies

related to new construction and the other 

to housing rehabilitation, demonstrate that 

statistically significant health improvements 

can be associated with improved ventilation 

when conducted in association with other 

building improvements.18, 19 Standards for 

applying ventilation to the home can be found in 

American Society of Heating, Refrigeration, and 

Air-Conditioning Engineers (ASHRAE) Standards 

62.1 and 62.2. 
page 110

Structural Interventions

There are two types of structural interventions: 

(1) local exhaust ventilation to remove pollutants 

created at a source, such as moisture vapor 

from a bathroom or cooking fumes from a 

kitchen range; and (2) general ventilation for the 

whole house that helps lower pollutant levels. 

Local exhaust ventilation systems capture a 

contaminant and remove it before it enters the 

entire housing unit. General ventilation provides 

fresh air to reduce the chance that concentrations 

of contaminants raise to hazardous levels. Houses 

should have both types of ventilation.

Local Exhaust Interventions

All kitchens and bathrooms should be equipped 

with exhaust systems to remove moisture and 

odors. Although some building codes permit 

windows to be used for ventilation, windows 

are unlikely to be open during the cold winter 

or hot summer months. Exhaust systems are 

therefore best practice. Local systems should 

be exhausted to the exterior, not into a building 

chase, attic, basement, crawl space or wall 

cavity. All clothes dryers should be exhausted 

to the exterior. Energy conservation devices 

that permit warm moist air from clothes dryer 

exhaust to be re-circulated back into the house 

should not be used.

All combustion burning appliances, such as fuelfired space heaters, water heaters, furnaces, 

boilers, fireplaces, and gas ranges/ovens should 

exhaust to the exterior. If new equipment is 

installed, it should be direct-vent or powervented equipment. A direct vent uses a double 

pipe to carry both exhaust and supply air 

(Figure 5.8). When additional exhaust systems 

are installed, the supply air (makeup air) should 

be installed or planned. If no makeup air is 

provided, serious problems can occur from the 

creation of negative pressure within the home. 

General Dilution Ventilation and 

Heating System Interventions

Ventilation systems should first ensure that the 

supply air is contaminant-free and does not pass 

over standing water or use air from garages 

or high traffic areas. When dilution ventilation 

systems for fresh air are designed or retrofitted, 

they should comply with standards established 

by ASHRAE. Standard 62.1 is the standard for 

multifamily buildings and 62.2 is for low-rise and 

single-family dwellings. ASHRAE recommends 

the amount of fresh air needed based on the 

size of the building and number of occupants. 

Heat recovery systems can decrease the energy 

needed to temper fresh air. A high efficiency 

heat recovery system transfers the heat in 

exhausted air to the incoming untempered fresh 

air supply to reduce added energy costs.

Air filters in ventilation systems need to be 

changed frequently because a dirty filter 

reduces air flow. Furnace filters that remove 

small particles more efficiently are now 

available and rated by ASHRAE according to 

their Minimum Energy Rating Value (MERV) 

(Figure 5.9). MERV ratings of 5–8 mean that 

the filters control the majority of particles of 3 

microns or greater in size. However, particulates 

smaller than 2.5 microns are now subject to EPA 

regulation in ambient air and include asthma 

triggers such as environmental tobacco smoke. 

Intervention Strategies

Figure 5.8 Direct Power Vent 

Increases Energy Efficiency and Helps 

Avoid Back Drafting Problems

Figure 5.9 Air Handler Filter Ratings
page 111

Programs should select the MERV-rated filter 

geared to indoor air contaminants that trigger 

asthmatic reactions and meeting manufacturers’ 

recommendations. Ideally, your program 

should consider recommending a filter with a 

MERV rating above eight, depending on the 

capabilities of the air handling system. Check 

with the equipment manufacturer or HVAC 

contractor to make sure the new filter will 

not put excess strain on the system or create 

negative pressure problems. 

Principle #3: 

Keep It Pest-Free

Pests are an important health issue for many 

residences, but can be particularly troublesome 

in multifamily housing where infestations can 

quickly spread from one unit to the next. 

Pesticides, while sometimes helpful, also pose 

risks. Pests can be managed more effectively 

with fewer pesticides through Integrated Pest 

Management (IPM) (Figure 5.10). IPM is an 

integrated preventive approach that targets 

conditions conducive to pests rather than 

simply treating the symptoms (i.e., pests) with 

pesticides. In short, IPM:

• Is more effective at eliminating pests.

• Prevents pest infestations in the future.

• Is expected to reduce pesticide exposures 

to residents and staff, which is important to 

children, older adults and chemically sensitive 

individuals.

• Can save time, money and energy.

• Can improve quality of life for residents.

Principles of Integrated Pest 

Management (IPM)

IPM is a common-sense approach to managing 

pests while reducing use of harmful pesticides. 

It focuses on getting rid of the food, water 

and shelter that pests need to survive. IPM 

works because integrated approaches for pest 

management are more effective in the end 

than a single one like spraying pesticides. IPM 

is always a team effort among the building 

manager, landlord, maintenance staff, residents, 

and pest management professional. Everyone 

has a role to play and must communicate and 

cooperate.

As a decision-making process to manage the 

control of pests and disease vectors,20 IPM is 

a departure from the traditional practice of 

trapping, spraying, and poisoning. In addition to 

other factors, it uses the least toxic pesticides 

in a way that controls human exposures to 

possible harm. For example, use of gel baits 

to kill cockroaches along with sealing cracks 

and crevices are often key components of 

IPM. It considers the behavior and ecology of 

the specific pest, where it is active, and how 

environmental changes may influence the 

pest. In so doing, IPM has a strong educational 

component because the environment includes 

the behavior of occupants. Education is indeed 

a critical component, and the evidence to date 

documents that IPM is effective in controlling 

pests, reducing exposure to pesticides, 

controlling pest access, reducing moisture, and 

is equivalent to or costs less than traditional 

pest control methods over the long term. Figure 

5.11 lists key elements of IPM.

Review of the Evidence

Several rigorous studies have demonstrated 

the effectiveness of IPM in reducing exposure 

to cockroaches.21, 22, 23 Arbes found that roach 

allergen levels were significantly reduced in 

beds and kitchens with IPM, and the levels in 

the beds dropped below thresholds for both 

asthma sensitization and exacerbation. Wang 

and Bennett showed a significantly greater 

decrease in roach counts with IPM compared to 

gel bait alone. Miller and Meek found that while 

IPM was initially more costly, it was much more 

effective in reducing cockroaches compared to 

Intervention Strategies

Figure 5.10 Principles for Keeping 

It Pest-Free

• Educate residents/tenants

• Reduce moisture

• Remove harborages

• Eliminate food sources

• Use low toxicity pesticides as needed

• Monitor 
page 112

traditional pesticide treatment.24 Useful case 

studies describing successful IPM programs in 

affordable housing can be found at: http://www.

healthyhomestraining.org/ipm/Studies.htm. 

Different types of pests depend to some 

extent on climate, locale, and type of 

building. However, the methods of detecting 

pests are fairly similar and are described in 

Chapter 4. Most states require that pesticide 

applicators be trained, certified, and 

licensed. Contract specifications, standard 

operating procedures, landlord and tenant 

training videos and educational materials are 

available at: http://www.bphc.org/programs/

cib/healthyhomescommunitysupports/

healthyhomes/healthypestfreehousing/Pages/

Home.aspx or from http://www.stoppests.org.

Structural Interventions

Typical structural modifications used in 

implementing IPM include the following:

• Copper mesh screens to seal holes. Steel wool 

may rust and should not be used.

• Use of low VOC caulks or sealant to seal 

penetration openings, which also prevents 

moisture infiltration.

• Correction of all water leaks.

• Use of trash cans with tight-fitting lids.

• Regular cleaning of trash chutes.

• Elimination of exterior harborage, including 

sealing rat burrows and placing trash 

Intervention Strategies

HUD’s Office of Public and Indian Housing Notice 

PIH-2007-12 (HA) defines the key components of 

an IPM program as:

• Communicating the Housing Authority’s 

IPM policies and procedures to all building 

occupants, administrative staff, maintenance 

personnel, and contractors.

• Identifying (1) pests and (2) environmental 

conditions that limit the spread of pests, 

including the presence of pests’ natural 

enemies.

• Establishing an ongoing monitoring and record 

keeping system for regular sampling and 

assessment of pests, surveillance techniques, 

and remedial actions taken, including 

establishing the assessment criteria for 

program effectiveness.

• Determining, with involvement of residents, the 

pest population levels—by species—that will 

be tolerated, and setting action thresholds at 

which pest populations warrant action.

• Improving sanitation, waste management, 

mechanical pest management methods, and/or 

natural control agents that have been carefully 

selected as appropriate in light of allergies or 

cultural preferences of staff or residents.

• Monitoring and maintaining structures and 

grounds (e.g., sealing cracks, eliminating 

moisture intrusion/accumulation) and adding 

physical barriers to pest entry and movement.

• Developing an outreach/educational program 

and ensuring that leases reflect residents’ 

responsibilities for (1) proper housekeeping; 

(2) reporting presence of pests, leaks, and 

mold; and (3) cooperating with specific IPM 

requirements such as obtaining permission 

of Housing Authority management before 

purchasing or applying any pesticides.

• Enforcing lease provisions regarding resident 

responsibilities such as housekeeping, 

sanitation, and trash removal and storage.

• Using pesticides only when necessary, with 

preference for products that, while producing 

the desired level of effectiveness, pose 

the least harm to human health and the 

environment, and, as appropriate, notifying 

management before application.

• Providing and posting “Pesticide Use 

Notification” signs or other warnings.

Figure 5.11 Key Elements of Integrated Pest Management

Also see: GSA Guidelines for Structural Pest Control Operations: http://schoolipm.ifas.ufl.edu/doc/bus_prac.html
page 113

dumpsters on concrete pads at least 50 feet 

away from the building.

• Information on controlling bedbugs can be 

found in the National Center for Healthy 

Housing report: What’s Working for Bed Bug 

Control in Multifamily Housing: Reconciling 

best practices with research and the realities 

of implementation, which can be found at 

http://www.nchh.org/Portals/0/Contents/

Bed_Bud_Report_2=12-10.pdf.

Rental Policies and Use of IPM 

Professional Services

In addition to structural modifications, programs 

need to establish guidelines for rental property 

owners and property managers about which 

services will be provided for pest management, 

responsibilities of maintenance staff in the shortterm, and conditions under which trained IPM 

professionals should be engaged. Practices, 

roles and responsibilities vary by locality. 

However, all healthy homes programs should 

have guidelines addressing the following issues.

• Define who is responsible for applying lowtoxicity pesticides (such as boric acid) along 

insect runways. 

• Determine whether the program or property 

owner/property management firm will supply 

trash cans for tenants’ use. Some programs 

have provided trashcans with tight-fitting lids 

for interior use by tenants.

• Establish a monitoring system to ensure the 

effectiveness of IPM. A monitoring system 

Intervention Strategies

typically includes observation of sticky traps to 

determine if pests are re-emerging.

Pest management professionals should be used 

and can be certified by Green Pro, Green Shield 

Certified, or Eco-wise (see http://www.healthyhomestraining.org/ipm/PMP_comparisons.htm).

Principle #4: Keep It Safe

Key Principles of Injury Prevention

Fatal and nonfatal injuries are often caused 

by structural and other housing deficiencies 

ranging from construction, design, and 

installation issues as well as lack of monitoring or 

maintenance. Structural deficiencies in a home 

can account for falls, smoke inhalation from fires, 

burns and scalds, carbon monoxide and other 

forms of poisoning, drowning, and other injuries. 

See Figure 5.12 for ways to prevent certain 

injuries.

Healthy homes programs should focus on 

populations at greatest risk, including children 

and older adults. While safety hazards can exist 

in any home, other threats may be seasonal 

or regional in nature. For example, swimming 

pool risks may be higher in summer. Disaster 

preparedness in the home may take on added 

importance during tornado or hurricane season. 

While infrequent, healthy homes programs 

should help prepare the families for these 

emergencies throughout the year. Programs in 

earthquake-prone areas may need to consider 

other actions. 

Environmental Health Watch, a nonprofit 

organization in Cleveland, Ohio that is 

involved in community environmental 

health programs, reports that when tenants 

observe the immediate effect of flushing and 

vacuuming cockroaches, they are motivated 

to improve their daily cleaning practices. In 

many cases, residents whose homes have 

a history of pest problems feel it is useless 

to try to do anything. However, once they 

see results, they are willing to establish 

partnerships and accept division of labor to 

deal with pest management.

Figure 5.12 Principles for Keeping 

It Safe

• Educate residents/tenants. 

• Prevent falls by installing railings on 

stairways and grab bars in bathrooms.

• Keep hot water temperature maximum at 

120 degrees.

• Ensure that smoke and carbon monoxide 

alarms are working and in the right 

locations.

• Store chemicals and medicines properly.
page 114

Falls 

Review of the Evidence

Falls account for 45 percent of all injuries in 

the home that require medical attention.26

Residential injury-related deaths for 

persons aged 65 years and over account for 

approximately 60 percent of all household 

deaths due to falls.27 Structural residential 

hazards associated with falls among older adults 

include lack of handrails on stairs, lack of grab 

bars and non-slip surfaces in the bathroom, 

tripping or slipping hazards (e.g., throw rugs 

without nonskid backings), waxed flooring, 

inadequate lighting, and the presence of 

electrical or telephone cords in the walkway.28

Individual behaviors and physical ability levels 

also are important factors contributing to falls 

among older adults.29

Falls also are a major cause of nonfatal injury in 

children and result in an estimated 2.7 million 

emergency room visits each year.30 Residential 

structural hazards associated with falls among 

children include a lack of safety devices such as 

safety gates and window guards, uncarpeted 

or concrete floors, missing or damaged window 

locks or catches, structural defects (e.g., 

inadequate spacing and height of railings, lack 

of handrails), and insufficient lighting over stairs 

and in other areas.31

There is evidence that certain structural 

modifications, such as installation of handrails, 

grab bars, and improved lighting, can 

reduce falls among older adults.32, 33 Home 

modifications, including installation of stair rails, 

non-slip mats, and night lights, resulted in 30 

percent decrease in falls compared to homes 

receiving no modifications. Additionally, handrail 

installation and improved floor coverings 

resulted in a 10 percent decrease in falls.34 Yet 

another study showed that installation of grab 

bars and improved lighting also resulted in 

significantly fewer falls.35

A community-wide program to provide window 

guards in high-risk apartments demonstrated 

that window guards reduce childhood morbidity 

and mortality from falls. Falls declined 50 percent 

in the two years after the program’s inception.36

There is also a reduced risk of injury in homes 

with fitted stair gates and other safety devices.37

A review of 37 studies showed that home 

education produced a statistically significant 

increase in the odds that a home would have a 

fitted stair gate and a modest, non-significant 

increase in the prevalence of installed window 

locks and other window guards.38 Building codes 

that require window guards, safe stair and 

balcony design, and other modifications are likely 

to be effective for fall prevention. 

Proper lighting has also been associated with 

reductions in falls and also in depression.39

Installation of nonskid surfaces, such as abrasive 

strips on porch steps and use of throw rugs with 

nonskid backings, can help to prevents skids and 

falls. 

Intervention Strategies

Figure 5.13 Grab Bars, Window Guards, Stair Railings, and Stair Gates.

Grab bars can help to prevent 

falls in showers and baths.

Window guards help to 

prevent falls.

Stairs should have properly 

designed hand rails.

Stair gates can help to prevent 

falls by young children.
Intervention Strategies page 115

Structural Interventions

Before implementing structural changes, 

programs should consult local codes to ensure 

that the modification does not conflict with local 

laws and regulations. Programs can reduce fall 

hazards by adopting the following protocols:

• Ensure that interior and exterior stairs and 

railings are in good repair. Ideally railings 

should be continuous (i.e., no breaks in the 

railings from one stairwell to the next) and 

they should be located on both sides of the 

stairwell. 

• Install window guards and safety gates for 

households with young children.

• Install grab bars in baths, showers, and near 

toilets for households with older adults. 

• Ensure that toilets, showers, and bath entries 

are at an appropriate height.

• Use nonskid surfaces in bathrooms.

• Increase lighting in stairwells, entryways, and 

hallways/passageways.

A home safety checklist for preventing falls 

can be useful for resident education, and is 

discussed at the end of this chapter.

Burns and Scalds 

Review of the Evidence

In 2006, U.S. fire departments responded to 

412,500 residential fires that resulted in 2,580 

deaths, 12,925 injuries, and nearly seven billion 

dollars in property damage (Figure 5.14).40

Groups at increased risk of fire-related injury 

and death include infants and young children 

(0–4 years) and the elderly (75 years and older), 

African Americans, Native Americans, lowincome Americans, rural residents, and those 

living in manufactured (e.g., mobile) homes and 

substandard housing.41, 42 The lack of functioning 

smoke alarms near or inside bedrooms and on 

every floor of a house, and lack of adequate 

escape routes in the event of a fire43, 44 are the 

primary residential hazards associated with 

fire-related injuries. Other important causes of 

fire-related injury include faulty wiring, defective 

appliances, misuse and poor maintenance of 

electrical appliances, lack of arc fault circuit 

interrupters (AFCIs), and overloaded circuits and 

extension cords.45

Structural Interventions

Smoke alarms. Installing working smoke alarms 

is one of the most important intervention 

strategies to prevent fatalities and burns 

from fire (Figure 5.15). Be sure to consult local 

building codes.

Numerous studies demonstrate that working 

smoke alarms in the home reduce death and 

injuries from residential fires.46, 47, 48, 49 Homes 

with working smoke alarms have a 40–50 

percent lower fire death rate compared to 

homes without working smoke alarms.50 A total 

of 70 percent of all home fire deaths occur in 

homes without working smoke alarms.51 To have 

“working” smoke alarms, they must be properly 

located (outside sleeping rooms on each level) 

and properly and regularly maintained by 

replacing batteries at established intervals. 

Installing hard-wired smoke alarms (with a 

battery back-up) or alarms with sealed, ten-year 

lithium batteries is preferable as they reduce the 

need for annual maintenance. Fire extinguishers 

should be present and checked at least yearly.

Figure 5.14 Fire Facts

Residential fires resulted in over 2,500 

deaths, nearly 13,000 injuries, and $7 billion 

in property damage in 2006. Many fatalities 

and burn injuries can be prevented by use of 

properly placed smoke alarms, implementing 

evacuation plans and installing anti-scald and 

anti-burn devices.

Figure 5.15 

Smoke and Carbon Monoxide Alarms
page 116

high-risk groups include the elderly and those 

with physical or mental disabilities.56 Scald burns 

commonly occur from contact with hot foods 

or liquids and hot tap water, and are typically 

more severe from hot tap water. Most occur in 

the bathtub or shower, but may also occur in the 

kitchen or bathroom sink. Primary residential 

deficiencies associated with scalds include 

lack of anti-scald devices for showerheads 

and faucets (see Figure 5.17) and water heater 

thermostats set above 120o F.57 New hot water 

heaters may be pre-set at higher temperatures 

and service companies may reset temperatures 

at higher levels than appropriate.

In addition to keeping water heater temperatures 

below 120o F, healthy homes programs should 

recommend installation of safety knobs for stoves 

and ovens to prevent burns (Figure 5.17).

Other Safety Interventions

Poisoning. Injuries and fatalities can stem from 

improper storage of household chemicals and 

medicines. When young children are present, 

cabinets should be equipped with childproof 

locks (Figure 5.17). 

Residents should not use portable fuel-fired 

electrical power generators indoors because of 

carbon monoxide exposure. Stoves and ovens 

should not be used to heat the home. Attached 

garages should be sealed and/or placed under 

slight negative pressure with respect to the living 

space. Some observers advocate housing codes 

changes that require exhaust fans in garages. 

Healthy homes programs support all these 

Evidence points to findings that education 

combined with community-based installation 

of smoke alarms reduces fire-related injuries 

in high-risk homes.52 Further, communitybased programs that install smoke alarms are 

significantly more effective than communitybased programs that give away smoke alarms 

but do not install them.

Healthy homes programs should recommend 

that families adopt and practice a formalized 

fire escape plan, including alternative means of 

egress, particularly from upper floors (see Figure 

5.16). The plan should include a nearby but 

offsite regrouping meeting place. 

Temperature controls for water heaters. In 1997, 

an estimated 12,400 children were scalded, 

nearly a quarter of the burns caused by hot 

tap water.53 Most scald-related deaths occur in 

children younger than four years old.54, 55 Other 

Intervention Strategies

Figure 5.17 Anti-Scald Hot Water Faucets, Oven Knob Covers and Cabinet Locks

Figure 5.16 

Fire Escape Plan

Example of a fire escape plan.
page 117

measures, plus installation of carbon monoxide 

alarms which can be located next to smoke 

alarms and are often available as a single device.

Carbon monoxide alarm. Similar to smoke 

alarms, carbon monoxide alarms should be 

placed on each floor of the house and adjacent 

to bedrooms.

Choke hazards. Securing ends of window 

curtain pull strings so that they are out of 

reach of children is an inexpensive yet effective 

measure to prevent choking hazards. Cord windups are a simple intervention as well as cutting 

loops in pull strings a no-cost strategy for 

preventing strangulation. 

Drowning and Pool Fencing. An average of 823 

drowning deaths (across all ages) occurs in or on 

home premises yearly.58 In 2004, for every child 

under 15 years who died from drowning, five 

additional children received emergency room 

care for nonfatal submersion injuries, which can 

result in brain damage and long term disability.59

The risk of drowning is also high for adults 70 

years and older. Forty-five percent of drowning 

cases occur in swimming pools and 33 percent in 

bathroom tubs and showers. Primary structural 

deficiencies associated with residential drowning 

include lack of barriers (e.g., having an unfenced 

or uncovered swimming pool) and lack of pool or 

door alarms.60 Drain vents for pools should always 

be kept clear. Four-sided (fully-enclosed) pool 

fencing significantly reduces childhood drowning 

(see Figure 5.18) 61, 62, 63, 64 and performs significantly 

better than three-sided perimeter fencing. Note 

the pool fence with wire mesh that completely 

surrounds the pool in Figure 5.18. The height of 

the fence should comply with local codes.

Firearms control and security systems. Healthy 

homes programs should include information on 

keeping firearms and ammunition in a secure 

location away from children and teens. Owners 

should use trigger locks and store ammunition 

separately. This general rule also applies to 

knives, bows and arrows, and tools. 

Home safety and disaster planning. Healthy 

homes programs should provide information 

on key components of a home emergency kit 

that can be easily transported in the event of 

evacuation. There are also materials available on 

what occupants can do to protect themselves 

during cleanup following floods, hurricanes, and 

other natural disasters. Arrange a place for rapid 

dissemination of such materials if such a disaster 

strikes. The Federal Emergency Management 

Agency provides information on disaster 

planning at www.fema.gov/plan/index.shtm.

Intervention Strategies

Figure 5.18 Fully Enclosed Pool Fencing
page 118

Principle #5: 

Keep It Contaminant-Free 

Asbestos

Inhalation of asbestos fibers causes cancer. If 

asbestos is maintained in an intact, non-friable 

condition within materials and is not disturbed, 

there is no opportunity for exposure. Typically, 

asbestos remediation takes place when there is a 

danger of fibers being released into the air. The 

remediation involves, either controlling airflows 

by putting the area under negative pressure and/

or using glove bags or other containment systems 

that prevent fibers from getting into the air. 

Common sources of asbestos include pipe and 

boiler insulation, floor tiles, siding, vermiculite 

insulation, and roofing materials. Respiratory 

protection, proper waste disposal and special 

cleanup procedures, and air sampling are all 

part of asbestos abatement jobs. Individuals 

performing such tasks must be trained and 

certified. More information is available at http://

www.epa.gov/asbestos/pubs/pubs.html.

Lead-based Paint Hazards

Reducing exposure to lead-paint hazards can be 

accomplished by numerous methods, including 

abatement and interim controls, such as keeping 

lead-based paint intact, covering bare soil with 

mulch, plantings, or other coverings, or hiring 

certified firms and workers to handle renovation, 

repair, and painting work in older housing. Lead-safe 

work practices and other methods of controlling 

lead-based paint hazards are detailed elsewhere65, 66

(see the “Keep It Maintained” section below).

Combustion Products

Combustion by-products include carbon 

monoxide, oxides of nitrogen, particulates and 

other substances. Proper exhaust ventilation for 

combustion sources, including adequate makeup 

air, helps minimize entry of these gases into the 

living space (see ventilation section). Attached 

garages should be air sealed between the living 

space and garage. Carbon monoxide alarms 

will also help prevent harm from combustion 

products (see safety section). Regular servicing 

and maintenance of furnaces is essential 

because cracked heat exchangers are a source 

of combustion by-products.

Stoves should not be used for heating and all 

fuel burning appliances should be vented to the 

outside.

Volatile Organic Compounds (VOCs) 

VOCs are a class of carbon-containing chemicals 

that become gases at room temperature 

and, when inhaled, can produce a variety of 

adverse health effects. Examples of VOCs 

include toluene, benzene, methyl ethyl ketone 

and paradicholorbenzene. They are present 

in cleaners, adhesives, carpets, air fresheners, 

mothballs and many other home products. To 

the extent possible, exposure to VOCs should 

be minimized by controlling or eliminating the 

sources. For example, air fresheners merely add 

these substances to indoor air without providing 

a benefit, and can conceal odors that indicate 

problems that should be addressed. Healthy 

homes programs should advise residents not to 

use air fresheners indoors. 

Exposures to some substances like 

formaldehyde can produce sensitization, making 

even low levels of future exposures risky to 

health. (See ventilation section above for more 

detailed information.)

Products and substances containing VOCs, 

particularly fuels, gasoline, paint thinners, and 

paints, should be stored in well-ventilated 

exterior locations, not inside the building. If 

this is not feasible, then such products and 

substances should be stored in a place that 

is sealed to the living area. In all cases, they 

should be stored in airtight containers. Old 

paint, banned pesticides, and other products 

that will not be used should be disposed of 

properly. Most local jurisdictions have household 

hazardous waste disposal locations.

Intervention Strategies

Figure 5.19 Principles to Keeping It 

Contaminant-Free

• Safely address lead-based paint hazards.

• Be aware of volatile organic compounds 

when making purchases.

• Control occupational take-home hazards.
page 119

Radon Control 

An EPA review of radon mitigation studies 

concluded that 97 percent of houses with high 

baseline radon level (76 percent had baseline 

radon level ≥ 10 picoCuries per liter (pCi/L) could 

be remediated with active soil depressurization 

systems to less than 4 pCi/L.67 A national survey 

showed that 95 percent of remediated homes 

had < 4 pCi/L, and 69 percent actually had < 

2 pCi/L (n=238 houses) levels.68 The durability 

of these active systems has been assessed in 

relatively small studies, with the exception of 

one that showed 95 percent of houses had < 

4 pCi/L levels 18 months after installation.69

Another found that 11 of 13 houses evaluated 

had levels below 4 pCi/L two years after 

installation.70

A qualified or licensed contractor is necessary 

to guarantee proper installation of the various 

radon mitigation systems. Many national and 

local green building standards now include 

radon-resistant elements.

Passive radon mitigation. Passive radon 

mitigation techniques are used most often in new 

construction. A passive system is comprised of 

a pipe that runs from beneath the foundation 

slab up thorough the house (usually in a wall void) 

to above the roof where the radon gas vents. 

This system may not be effective in consistently 

reducing indoor radon level to less than 4 pCi/L. 

These systems are described in greater detail 

by EPA in Radon Reduction Techniques for 

Existing Detached Houses: Technical Guidance 

(Third Edition) for Active Soil Depressurization 

Systems.

71 While sealing cracks and other 

openings in the foundation reduces the loss of 

conditioned air and makes other radon reduction 

techniques more effective and cost-efficient, 

sealing has not been shown to lower radon levels 

significantly or consistently by itself.

Radon-resistant new construction measures 

should always be implemented in EPA Zones 

1 and 2 as indicated on its radon map. The 

techniques involve the use of gas impermeable 

membranes at the foundation and sealing of 

all penetrations. Chapter 5 of the HUD/CDC 

Healthy Homes Reference Manual describes 

the installation process in detail. For new 

construction, details are available at: www.epa.

gov/radon/rrnc/index.html.

In some instances, sealing crawl spaces, which 

has other benefits, increases radon levels in the 

home; thus, radon testing should always be done 

in concert with crawl space sealing. Further 

details are at: www.epa.gov/radon/index.html.

Active radon soil depressurization. Active soil 

depressurization is in most applications the most 

effective radon mitigation technique. It can be 

used in mitigating radon exposure in existing 

homes and installed as a system in new homes 

at the time of construction. It is comprised of a 

vent pipe with a fan in it that runs from beneath 

the foundation slab up (either outside or inside 

the home) to above the roof where the radon 

gas is vented. EPA’s current recommended 

standard of practice for these systems is ASTM 

E 2121. Merely sealing the basement is usually 

inadequate due to the stack effect and also 

because most buildings are under negative 

pressure with respect to the exterior. The stack 

effect means that air rises from lower to higher 

levels in most buildings.

Particulate Matter

Inhalable particles, which can trigger asthma, 

can be controlled by use of efficient filters in air 

handlers, use of High-Efficiency Particulate Air 

Filter (HEPA) vacuum cleaners, elimination of 

“dust sinks” like older soiled carpets, adoption 

of smoke-free housing policies, and regular 

cleaning. Central vacuum cleaners, if available, 

are another way of reducing exposures. Although 

studies to date provide insufficient evidence of 

effectiveness, portable air cleaning devices are 

available for use. They have been used as part 

of multi-component interventions to improve 

asthma control for children and are appropriate 

to control small particles that stay suspended in 

the air (e.g., environmental tobacco smoke, mold 

spores, pet allergens). However they are not 

appropriate for control of larger particles such as 

the allergens associated with cockroaches and 

dust mites. Devices that produce ozone, however, 

should be avoided. (See ventilation section for 

more details on filtration of indoor air.) 

Secondhand Smoke

Also known as environmental tobacco smoke 

(ETS), secondhand smoke is a major issue in 

both single- and multi-family housing. A number 

Intervention Strategies
page 120

of studies in non-residential settings have 

demonstrated the effectiveness of smoking bans 

in improving health and reducing exposure to 

ETS.72, 73, 74, 75 Because ETS can migrate between 

apartments, smoking bans are particularly 

relevant for multifamily buildings. Research has 

shown that children living in multifamily housing 

have greater exposure to ETS, regardless 

of whether or not there is a smoker in the 

immediate household.76 Many green building 

programs now include bans on smoking (e.g., 

Enterprise, LEED).77 The cost of cleaning and 

maintaining units in which smoking has occurred 

is substantially greater than for non-smoking 

units. Adopting smoke-free policies is an 

effective intervention and described in detail in 

the “Keep It Clean” section below.

More and more landlords, property 

management companies and condominium 

associations are making properties completely 

smoke-free. Many take this step because they 

value the health of their residents; many want 

to reduce fire risk; and many are responding 

to the demand for smoke-free living. Just like 

prohibiting pets, landlords and associations 

can prohibit smoking. It is entirely legal. Simply 

write into your lease, “No Smoking anywhere on 

the property, including inside any apartment.” 

Refer to Boston Smoke Free Homes for model 

lease language (bostonsmokefreehomes.org). 

Having smoking cessation assistance available to 

residents will increase the chances of success.

Occupational Take-Home Health 

Hazards

Healthy homes programs should include 

information on how exposures to toxic 

substances on the job can be inadvertently 

transferred to the home environment on clothing 

(especially shoes) and in family automobiles. 

Some OSHA standards, such as the one on 

lead, provide requirements for decontamination 

before leaving worksites. Decontamination 

measures include:

• Removing work shoes and or clothes 

if necessary before entering the family 

automobile or home.

• Shower immediately after arriving home

• Laundering work clothes separately from the 

family laundry.

Contact one of the following for more 

information on occupational health and takehome hazards: Occupational Safety and Health 

Administration: http://osha.gov/workers.html or 

the Center to Protect Workers’ Rights: http://

www.cpwr.com/about-overview.html. 

Principle #6: Keep It Clean

Proper cleaning and maintenance, including 

preventive maintenance, represent two 

important and related healthy housing 

principles. Cleaning is typically the occupant’s 

responsibility (except for common areas in multifamily housing) although there are exceptions 

to this general rule such as cleaning at unit 

turnover. Maintenance is typically the owner’s 

responsibility. Information on cleaning education 

and controlling asthma triggers are discussed 

in the resident education section at the end of 

this chapter. Cleaning to control asthma triggers 

should be consistent with recommendations of 

the National Guidelines for the Diagnosis and 

Management of Asthma Expert Panel Report 

3 (2007): http://www.nhlbi.nih.gov/guidelines/

asthma/asthgdln.htm. 

Review of the Evidence

Cleaning and maintenance alone are usually not 

sufficient to create healthy housing because 

sources of hazards must also be addressed. 

For example, Tohn et al., (2003)78 showed that 

even repeated professional cleanings alone 

do not prevent childhood exposure to leadcontaminated dust. It is important to note, 

however, that cleaning is often appropriate as 

an immediate, short-term fix for many housingrelated health hazards and as a component of 

multi-faceted interventions.

Figure 5.20 Principles for Keeping 

It Clean

• Assure smooth and cleanable surfaces.

• Reduce exposure to environmental tobacco 

smoke.

• Use low toxicity cleaning supplies only as 

directed.

Intervention Strategies
page 121

Structural Interventions 

Cleanable surfaces

Difficult-to-clean surfaces, although not hazards 

in and of themselves, may facilitate a host of 

problems. For example, if food preparation 

surfaces are not smooth, they cannot be 

adequately cleaned to prevent food-borne 

communicable diseases. Food particles can also 

become available to pests. Difficult-to-clean 

surfaces on floors and window sills may also 

make the re-accumulation of lead-contaminated 

dust and subsequent exposure more likely. 

Carpets

Carpets are not appropriate for wet areas, such 

as kitchens, baths and laundry rooms because 

they are more difficult to dry and keep clean. 

Carpets in other rooms can also act as dust 

reservoirs if not routinely cleaned. Carpet 

removal and substitute materials have been 

the subject of numerous studies, with mixed 

evidence as a means to reduce airborne dust 

levels or biological and chemical contaminants 

in settled dust (NCHH July 2008 Fact Sheet).79

If your program chooses to replace carpet, 

consider the following practices:

• If you choose to install new carpet, check 

whether the product has the Green Label Plus 

designation from the Carpet and Rug Institute, 

an organization that sets product standards 

for indoor air quality and identifies those 

with very low VOC emissions. Also, low pile 

carpeting is easier to clean than higher pile 

carpeting.

• Use low-VOC adhesives when installing wood 

underlayment and padding. 

Heating, ventilation, and air conditioning 

systems 

Inadequate cleaning of these systems can lead 

to mold from blocked coils and higher fuel 

bills due to energy inefficiency. Condensate 

drains should be kept clear. Furnace filters 

should be changed when they become overly 

loaded in order to permit proper air movement 

throughout the dwelling and adequate removal 

of particles. Cooling coils should also be kept 

clean (Figure 5.22).

There is little evidence to support the need 

for routine cleaning of ductwork because 

particulate matter settles inside the ducts and 

is likely to stay, barring physical disturbance 

of the ducts. Therefore, duct cleaning is often 

unnecessary and, if performed, may produce 

more hazards.80 Extensive wetting of ducts and 

mold infestation are exceptions. In this situation, 

ductwork should be cleaned and the source of 

moisture removed and in some cases the duct 

work may need to be replaced. Depending on 

the size of the mold infestation, duct cleaning 

may require mold professionals and ventilation 

specialists. Bare metal ductwork can be cleaned, 

but for fiberglass duct board, flexible ducts, 

and metal ducts with interior liners, the efficacy 

of cleaning is questionable and are typically 

replaced when contaminated.

Figure 5.21 Carpets

The following green building guidelines recommend against wall-to-wall carpet in certain areas: 

• Enterprise Community Partners’ Green Communities Criteria: Requires the use of materials that 

have smooth, durable, cleanable surfaces in wet areas. 

• U.S. Environmental Protection Agency Energy Star with Indoor Air Package: Prohibits wall-to-wall 

carpet adjacent to toilets and bathing fixtures (i.e., tubs and showers). 

• National Association of Home Builders Green Builder Guidelines: Prohibits carpets in bathrooms. 

• U.S. Green Building Council’s LEED for Homes: Requires water-resistant flooring in kitchens, baths, 

and spa areas and within 3 feet of exterior doors 

Source: NCHH, 2008 Fact Sheet: Carpets and Healthy Homes

Intervention Strategies
page 122

Asbestos may be present in pipe and boiler 

insulation and other building insulation systems. 

Cleaning operations should not disturb such 

insulation. If it deteriorates or is disturbed, 

cleaning should be performed by a licensed 

asbestos contractor.

Adopting a Smoke-Free Rental Policy

Public housing authorities and others have begun 

to adopt smoke-free rental policies, not only 

because of health benefits but also because it 

reduces costs of cleaning, repairs, and component 

replacement at unit turnover (Figure 5.23). 

Low-Toxicity Cleaners and Safe Use and Storage 

of Supplies and Equipment

Some cleaning agents carry their own health and 

safety hazards. Bleach and ammonia compounds 

are common cleaning products that can cause 

severe eye and skin injuries if not handled 

properly. If mixed, they release dangerous gases 

(such as phosgene and other gases) that can 

cause severe respiratory injury and even death. 

If the instructions call for dilution, then use of 

the undiluted product may cause high exposures 

as well as damage to building structures. 

Products (such as bleach and ammonia) should 

never be mixed and instructions on the product 

label must be followed. Proper eyewear and skin 

protection should also be worn if exposures are 

likely. If eye contact with cleaning agents does 

occur, then a full 15-minute immediate rinsing of 

the eyes is critical. Avoidable eye injuries have 

occurred because injured persons attempted to 

seek medical attention instead of performing 

the rinsing, resulting in permanent damage to 

the eyes on the way to the hospital.

New “non-toxic” cleaning products are 

appearing on the market, some carrying 

“green” or “natural” labeling. While intuitively 

appealing, such products may not, in fact, be 

any safer than others. Therefore, healthy homes 

programs should instruct occupants to read 

product labels closely to ensure proper use of 

all cleaning products. While voluntary labeling 

programs exist, there are no national standards 

that enable consumers to make truly informed 

choices. 

All carpets should be vacuumed periodically. 

Normal household vacuum cleaners can emit 

fine particulates through the exhaust, which can 

lead to increased levels of airborne particulate 

matter. Use of High-Efficiency Particulate Air 

(HEPA) vacuum cleaners is one solution. HEPA 

vacuums are equipped with special filters to 

remove nearly all of the small particles from 

Figure 5.23 Smoking and NonSmoking Housing Costs

Boston One Touch: Action Steps for Healthier 

and Greener Homes for Boston Families

reported sizeable cost differences in smoking 

and non-smoking units.81

Cleaning Guidelines

• Use low toxicity products.

• Use cleaning products only according to 

the label instructions.

• Use appropriate eye and skin protection 

when using cleaning products.

Intervention Strategies

Figure 5.22 Dirty Cooling Coils 

Should Be Cleaned
page 123

the vacuum exhaust that would otherwise reenter the room air, and are now widely available 

and affordable. Some healthy homes programs 

offer a HEPA vacuum rental or loan services. 

All vacuums used on carpeted floors should 

be equipped with a beater bar to dislodge 

bound particulate matter. Conventional 

vacuums with micro-filtration bags may also be 

effective.82 Vacuum cleaner reviews and rating 

are available from Consumer Reports at www.

consumerreports.org/.

Another option is to install a central vacuum 

system, which filters the indoor air and deposits 

the exhaust air outside the house. Central 

vacuum systems are increasingly used in new 

construction; retrofits into existing housing may 

be quite expensive.

All cleaning agents, as well as other products 

containing poisons, irritants, or VOCs should 

be stored in locked areas that children cannot 

access. 

Portable Air Cleaners 

The ability of portable room air cleaners to remove 

particulate matter of certain size ranges from air is 

well established (Figure 5.24). Specifically, air cleaners 

are known to be able to achieve a 30–70 percent 

reduction in the half-life of airborne particulate 

matter between 0.3 to 1 microns.83 However, portable 

air cleaners do not reduce larger airborne particles 

between 1 to 5 microns because they deposit at rates 

that are much higher than the equivalent loss rate 

due to typical residential ventilation. Air cleaners 

are less effective as the particle size increases and 

they have not been demonstrated to reduce volatile 

organic compounds or other gases such as carbon 

monoxide, oxides of nitrogen and others.84 It is also 

unlikely that these systems can adequately control 

exposures to environmental tobacco smoke; source 

control through smoking cessation will be far 

more effective. This has led the National Academy 

of Sciences to conclude that there is only limited 

evidence that air cleaners are effective in reducing 

asthma.85 This is most likely because allergens may be 

concentrated in the larger particle size ranges. EPA 

provides information on air cleaner technology for 

the home environment at: http://www.epa.gov/iaq/

pubs/airclean.html.

Some air cleaners emit high levels of ozone 

under the theory that this reactive gas will clean 

the air. Exposures to ozone should always be 

avoided because it is a strong lung irritant and 

has many adverse health effects. These devices 

should not be used in the home environment. 

Occupants should be encouraged to avoid using 

ozone generating air cleaners. EPA provides 

additional information on ozone generators sold 

as “air cleaners” at http://www.epa.gov/iaq/

pubs/ozonegen.html. 

Principle #7: Keep It 

Maintained

Structural Interventions

The previous sections of this chapter have 

described conditions that require correction 

to create a healthy home. However, simply 

correcting the deficiencies will not have a longterm impact unless a regular maintenance 

program is implemented so that new deficiencies 

are promptly addressed (Figure 5.26). Regular 

Figure 5.24 Portable Air Cleaner

Intervention Strategies

Figure 5.25 Principles for Keeping 

It Maintained

• Conduct preventive maintenance and 

regular inspections.

• Respond to maintenance concerns in a 

timely manner.

• Keep dust levels low through regular 

cleaning.

• Address hoarding behavior.
page 124

inspections are part of maintenance.

For example, if existing leaks only in the roof 

are repaired without implementing a system 

that identifies roof conditions before leaks 

occur, mold damage can take place before it is 

discovered. Similarly, if enclosures that prevent 

exposure to lead-based paint fall into disrepair, 

lead paint that previously did not present a 

hazard because there was no exposure could 

become a hazard. Condensate drainage systems 

that are not kept clean can fail to drain properly, 

leading to mold and moisture problems. Radon 

mitigation systems can fail if not monitored. 

Some building systems become so aged and 

deteriorated that proper maintenance is no 

longer feasible or financially viable. Healthy 

homes programs refer these homes to 

Community Development Block Grant (CDBG) 

housing rehabilitation programs for capital 

improvements or building code enforcement for 

condemnation and/or demolition.

Maintenance and cleaning operations apply 

to both the interior of the home and the site. 

Vegetation should be trimmed and maintained 

to avoid moisture and mildew problems or water 

ponding on the grounds. Furnace filters should 

be changed regularly.

Routine Maintenance Schedule 

A simple checklist for owner-occupied singlefamily housing has been developed by the 

National Center for Healthy Housing (Appendix 

5.2). For multifamily large apartment complexes, 

schedules with more frequent inspections may 

be necessary, depending on the complexity 

and operation of the building systems. The 

sample checklist is not exhaustive but is a good 

indication of key items that should be examined 

on a regular, ongoing basis.

Cleaning for the Control of House 

Dust Containing Lead

There are numerous resources on how to clean 

effectively to control lead dust after disturbing 

lead-based paint. Contractors and maintenance 

staff should take a formal lead-safe work 

practices course and the EPA-certified renovator 

training. EPA now regulates many renovation, 

repair and painting activities. Occupants can 

use many of these same practices to continue to 

keep dust levels low after renovation. Key leadsafe work practices include:

• Clean from ceiling to floor.

• Vacuum all surfaces first with a HEPA vacuum, 

then wet wash using separate containers for 

soapy water and clean rinse water, and repeat 

vacuuming.

• Use cleanable floor mats in the entryway and 

remove shoes before entering the living space 

to avoid track-in of lead-contaminated soil.

• Wash hands and face before eating, drinking, 

smoking, or applying skin lotions if in contact 

with lead-contaminated dust or soil.

• Wash clothes that may have been in contact 

with lead-contaminated dust or soil separately 

from the rest of the household’s laundry.

The New England Lead Coordinating 

Committee’s Don’t Spread Lead video provides 

a simple review of these practices, as well as 

lead-safe work practices for “do-it-yourselfers.” 

Detailed information on lead hazard control is 

discussed in the cleaning section above.

This lead-contaminated dust cleaning protocol 

can also reduce exposure to other contaminants 

in dust.

Hoarding

Healthy homes practitioners should be aware 

that some occupants may suffer from the 

compulsion to hoard, resulting in clutter. 

Hoarding increases risk of pest infestations, 

Intervention Strategies

Figure 5.26 Maintenance

Maintenance is a key component of a healthy 

home. Key educational messages include the 

following:

• Maintenance needs should be addressed 

promptly.

• A regular schedule for maintenance can 

be adopted to help ensure deferred 

maintenance does not lead to major repairs 

later.
page 125

injuries, and other problems. In some cases, this 

may require a referral to professionals for mental 

health services.

Hoarding situations must be handled in a 

multidisciplinary manner. Healthy homes 

programs should address hoarding as part of 

a team that may include the sufferer, family 

members, the housing provider, local health 

departments, representatives of the judicial 

system, and providers of therapeutic, social and 

clean-up services. Long-term case management 

and monitoring is needed. 

Energy Efficiency

Healthy homes programs should build ties with 

local programs that weatherize or otherwise 

improve energy efficiency. Installed and used 

correctly, there is evidence that energy-efficient 

measures indirectly improve respiratory health86, 

87, 88 by reducing drafts, increasing thermal 

Intervention Strategies

comfort and controlling excess moisture and 

mold. There is also evidence that sealing 

building envelopes below prescribed building 

tightness limits can necessitate adding 

additional fresh air supply to prevent the 

creation of other health hazards, such as mold.

A Seattle-based Healthy Homes project89

incorporated a variety of green, healthy homes 

and energy efficiency measures that produced 

significant health improvements for asthmatic 

children. The diagram below shows some of 

the interventions, including fresh filtered air 

ventilation, high-efficiency windows, and a heat 

recovery system (Figure 5.27). 

Improving energy efficiency can also significantly 

increase household disposable income for low 

income families, which can improve health 

through better nutrition and diet.

Security

Figure 5.27 Healthy Housing Interventions Used In New Construction at 

Seattle’s High Point “Breathe Easy” Homes
page 126

Inadequate security can increase stress, which 

in turn has been associated with encouraging 

or worsening asthma. Broken windows, nonoperational locks, and inadequate lighting 

have all been associated with adverse health 

outcomes. Crime and fear have also been 

associated with adverse health outcomes. 

Healthy homes programs should determine if 

program clients are concerned about security 

issues and, if so, tailor interventions to improve 

their sense of security.

Resident Knowledge and 

Education

Introduction

Residents in housing units served by healthy 

homes programs can be either tenants or owner 

occupants. In rental property, it is crucial that 

tenants and property owners and maintenance 

staff work together to assure a healthy living 

environment. Program considerations for 

healthy homes interventions aimed at resident 

education and behavior change are delineated in 

Figure 5.28.

Video instructional tools can also be very 

useful for tenant education. Examples of short, 

Intervention Strategies

practical videos for tenant education in English 

and Spanish can be found at: http://www.

healthyhomestraining.org/ipm/videos.htm. 

Keep it Dry 

Resident behavior has a significant impact on 

moisture levels in a home. For example, failure 

to turn on kitchen and bathroom fans during 

cooking and bathing, respectively, can raise 

moisture levels significantly. Elimination of 

cardboard boxes and other cellulose building 

materials in areas prone to high moisture levels 

helps to control mold and moisture problems.

Tenants should promptly report leaks, 

condensation and other moisture problems 

to the property owner. Education programs 

should address how to use exhaust ventilation 

to remove moisture while showering and 

cooking. Tenants should also be taught how to 

use and maintain equipment properly such as 

humidifiers, dehumidifiers, and drains.

Keep it Ventilated

Use of supplemental unvented heating 

equipment, such as kerosene heaters, should 

be discouraged because they can produce 

high levels of carbon monoxide and other 

combustion gasses. Also, residents should be 

taught how to assess that kitchen and bathroom 

exhaust fans are vented to the outside and are 

working properly. A simple test is to hold toilet 

or tissue paper over a bathroom fan intake 

vent. If the paper is not kept aloft by the fan, 

there is insufficient exhaust. Also, since many 

low-income families worry that running fans will 

increase electricity bills, they should be provided 

with information on the average monthly cost 

to run this equipment compared to home repair 

and health costs that can result from non-use. 

Families can also be prompted to watch for signs 

of excess humidity, such as water condensing 

on windows and bathroom mirrors taking a long 

time to clear after showering.

Keep it Pest-Free 

It is important that tenants understand the 

life cycle of pests common to their region and 

begin pest control as soon as the problem is 

first observed. Although a new problem may 

Figure 5.28 Behavioral Change

Programs that demonstrate the most significant and permanent behavioral change also:

• Engage Community Health Workers 

from the same cultural or socioeconomic 

background to deliver the training.

• Conduct multiple home visits to build trust, 

deliver education at “teachable moments,” 

and engage family members in demonstration 

and return demonstration of specific practices.

• Provide resources residents may need to 

accomplish the behavioral change. Many 

programs provide cleaning supplies referred 

to as “cleaning buckets,” or “home cleaning 

kits,” as an incentive for participation and to 

support behavior change.

• Provide education on the seven healthy 

homes principles.
page 127

appear trivial, it may be far more serious than 

it seems. Pests such as cockroaches colonize in 

large groups behind walls; others, such as rats, 

prefer to live outside but enter buildings to find 

food and water. Pests can be a health hazard. 

For example, cockroach and mouse allergens are 

important asthma triggers. Critical educational 

messages include: 

• Promptly clean up food and drink spills.

• Remove clutter (such as cardboard boxes or 

paper) so pests have fewer places to hide.

• Put food in tightly sealed containers. Do not 

leave open containers of food on counters 

or in cabinets. Put pet food dishes away 

overnight.

• Keep trash in a closed container and take it 

out frequently, every day if possible. Do not 

let trash pile up inside or outside.

• Use roach baits properly and only when 

necessary. Place baits out of the reach of 

children and pets.

• Put baits close to the pests’ hiding places. 

Baits must be closer than other sources of 

food.

• Good spots for baits are next to walls, 

baseboards, under sinks, in cabinets and near 

plumbing fixtures. Place baits in areas of roach 

activity.

• Do not spray pesticides, as it will keep the 

pests away from the baits.

Keep it Safe 

The Home Safety Council’s checklist can be 

used as part of your education strategy to help 

occupants find and fix hazards in their homes. 

While not all-inclusive, it is helpful (http://

www.homesafetycouncil.org/SafetyGuide/sg_

safetyguide_w001.asp).

Keep it Contaminant-Free

There are numerous ways residents can reduce 

or prevent exposure to contaminants such as 

lead dust and environmental tobacco smoke. 

They should be instructed to report chipping 

or peeling paint promptly to their property 

Intervention Strategies

owner so that is can be safely repaired. Products 

containing VOCs should be limited to minimize 

exposures. Vacuuming should be conducted 

regularly to keep dust levels low. Exposure 

to secondhand smoke can be minimized by 

smoking outside of the housing unit.

Keep it Clean 

“Cleanliness” is a concept with powerful cultural 

and emotional connotations. Few individuals 

want to hear they do not live in a “clean” house, 

even when evidence of clutter, mold, or pests 

is obvious. Moreover, many low-income families 

lack the resources for cleaning supplies readily 

available to higher income families. Others 

may feel that the source of their problem is out 

of their control, such as failure of owners and 

property maintenance staff to address holes, 

leaks, and pests. As a result, tenants can give 

up. They lose the motivation to undertake action 

that would protect their health without clear 

support and engagement of rental property 

owners and managers in the process.

Low toxicity cleaning supplies should be used 

whenever possible. Reducing clutter and 

storing food and trash in pest-proof containers 

are important aspects of integrated pest 

management. Regular cleaning and mopping 

of horizontal surfaces—counters, tables and 

floors—and vacuuming should be conducted to 

reduce dust levels, pet dander and food sources 

for pests.

Regular washing of bedding in hot water is 

effective in reducing dust mites. If pets are 

present, controlling dander is also helpful, 

especially for those with asthma. Pets can also 

be kept out of the bedrooms to help minimize 

exposures. Extensive clutter can promote pest 

infestation and result in injuries, such as trips 

and falls and should be eliminated.

Keep it Maintained

Resident knowledge of maintenance practices 

should be a key focus of healthy homes programs 

in support of physical interventions. Tenants 

need to report maintenance needs to rental 

property owners promptly and with confidence 

their requests will be respected and addressed. 

Furnace filters should be checked each time the 
page 128

Figure 5.29 Asthma Education 

Issues

• Identification and control of asthma 

triggers such as pet dander control, dust 

mite control, actions to reduce colonization 

by mold or pests.

• Use of non-toxic cleaning products and 

product storage.

• Use of allergen-proof covers to encase 

mattress and pillows in. Weekly washing of 

sheets and blankets in hot water.

• Reducing indoor humidity to less than 60 

percent, ideally between 30–50 percent.

• Minimizing the number and weekly 

washing of stuffed toys.

• Reducing cockroach and rodent 

allergen exposure with an integrated 

pest management approach including 

a combination of blocking access, low 

toxicity pesticides, traps, and vacuuming 

and cleaning.

• Controlling pet allergen by (ideally) 

removing the pet from the home or 

barring it from the bedroom and keeping it 

off upholstered furniture and carpets.

• Taking such mold and moisture control 

measures as:

 Fixing leaks and other sources of 

moisture that support mold growth.

 Cleaning moldy surfaces with soap and 

water and drying thoroughly.

 Discarding and replacing items that can 

not be cleaned and dried effectively.

 Do not use the oven to heat the home 

and, if available, use the stove vent when 

cooking.

• Instituting a smoke-free home policy.

season changes and replaced as needed.

Special Focus on Asthma

Residents need to recognize and address 

conditions that trigger allergic or asthmatic 

reactions (Figure 5.29). Responses call for a multifaceted, comprehensive approach focused on 

those allergens/irritants to which the person with 

asthma is sensitive. Common measures include:

• Regularly washing bedding and toys kept in the 

bed in hot water (120° F) to control dust mites, 

as well as using breathable mite-proof mattress 

and pillow covers. Other furniture used as beds, 

such as sofas, should be kept clean.

• Damp-dusting or mopping floors and 

horizontal surfaces.

• Slow and careful vacuuming, preferably with 

vacuums equipped with dirt sensors and 

bags to trap collected dust and debris. HEPA 

vacuums should be used if feasible to control 

emission of particles from vacuum exhaust.

• Controlling exposure to pet dander by 

restricting pets’ access to sleeping areas.

• Avoiding secondhand tobacco smoke.

• Controlling mold and moisture.

• Minimizing carpet and dust-collecting items in 

the bedrooms of asthmatics.

• Storing food in pest-proof containers and trash 

in containers with secure lids.

• Reducing clutter in order to prevent conditions 

where pests can live and breed.

• Dry steam cleaning of upholstered furniture to 

kill and remove dust mites. 

Intervention Strategies
page 129

Chapter 5 References*

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Intervention Strategies

*Websites were verified during the drafting of this document but may have changed.
page 130

17 California Air Resources Board. 2008. Final 

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Notes

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