page i

U.S. Department of Housing and Urban Development

Office of Healthy Homes and Lead Hazard Control

The Healthy Homes

Program Guidance Manual

July 2012
page ii
page iii

The Healthy Homes

Program Guidance Manual

July 2012

This document was developed for the U.S. Department of Housing and Urban Development (HUD), Office of Healthy 

Homes and Lead Hazard Control (OHHLHC) under Contract No. C-PHI-00931.

Prepared by:

Amy Murphy, MPH, Healthy Housing Solutions, Inc.

David Jacobs, PhD, CIH, National Center for Healthy Housing

Carolyn Kawecki, MA, RN, Healthy Housing Solutions, Inc.

Jackson Anderson, Jr., BA, Healthy Housing Solutions, Inc.

Judith Akoto, MPH, National Center for Healthy Housing

Peter Ashley, DrPH, HUD OHHLHC

Michelle Nusum, BS, Healthy Housing Solutions, Inc.

Eugene Pinzer, MS, CIH, HUD OHHLHC

Acknowledgements

We thank the following individuals for their helpful comments and information used in preparation of this document:

Herbert Bolton, PhD, U.S. Department of Agriculture 

Mary Jean Brown, ScD, RN, Centers for Disease 

 Control and Prevention

Thomas Carroll, BS, New York State Department of Health

Joan Cleary, MM, Joan Cleary Consulting

Nancy Halpern Ibrahim, MPH, Esperanza Community 

 Housing Corporation

Julie Hughes, MS, U.S. Department of Energy

Dennis Jordan, MSPH, CIH, Alameda County Health 

 Department

Arnie Katz, MA, Advanced Energy

James Krieger, MD, MPH, CIH, Seattle/King County 

 Public Health Department

Patrick MacRoy, MA, CNT Energy

Armand Magnelli, BS, Livable Housing, Inc.

David McCormick, BS, Indiana Department of Health

Pamela Meyer, PhD, Centers for Disease Control and 

 Prevention 

M. Deborah Millette, MPH, Centers for Disease Control 

 and Prevention

Rebecca Morley, MSPP, National Center for Healthy 

 Housing

Ruth Ann Norton, BA, Coalition to End Childhood Lead 

 Poisoning

Margaret Reid, BA, RN, Boston Public Health Commission

Megan Sandel, MD, MPH, Boston University School of 

 Medicine

Katherine Seikel, MBA, BS, U.S. Environmental 

 Protection Agency

Madeleine Shea, PhD, Maryland Department of 

 Health and Mental Hygiene

Lisa Smestad, BS, REHS, City of Minneapolis

Alisa Smith, PhD, U.S. Environmental Protection Agency

John Sobolewski, RS, BS, Cuyahoga County Board of 

 Health

G. Wesley Stewart, JD, BA, Coalition to End Childhood 

 Lead Poisoning

Ellen Tohn, MSP, HHS, Tohn Environmental Strategies

Nsedu Obot Witherspoon, MPH, Children’s 

 Environmental Health Network

Joseph Wysocki, PhD, U.S. Department of Agriculture, 

 (Retired)
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page v

Forward

The U.S. Department of Housing and Urban Development (HUD) Office of Healthy Homes and 

Lead Hazard Control (OHHLHC) has issued this Healthy Homes Program Guidance Manual to 

advance our nation’s efforts to create healthier and safer housing.

The Manual is the result of considerable effort and reflects input from many partners and 

stakeholders in the healthy homes community. It is based on proven approaches and 

techniques, and the findings of the most current research. The Manual is written for anyone 

interested in developing or expanding a healthy homes program.

For well over a decade, HUD, the U.S. Centers for Disease Control and Prevention (CDC), and 

the U.S. Environmental Protection Agency (EPA) have implemented a campaign to reduce and 

eliminate childhood lead poisoning. While tackling this challenge, local lead hazard control 

programs recognized the need to address other housing-related health and safety hazards, 

and the “healthy homes” concept was eventually embraced by their federal partners. Evidence 

suggests that problems such as poorly controlled asthma and unintentional injuries are often 

linked to preventable housing deficiencies. Therefore, HUD, CDC, EPA, the U.S. Department of 

Energy (DOE), and the U.S. Department of Agriculture (USDA) have sponsored and supported 

local programs, regulatory and policy initiatives, research and evaluation , and education and 

outreach to establish comprehensive approaches to healthy housing. This Manual draws upon 

these efforts and those of subject matter experts, researchers, program managers, state and 

local officials, representatives of community-based organizations, and advocates for healthy 

homes.

Substantial savings in health care costs and improved quality of life for occupants 

can be realized by remediating health and safety hazards in the home. We hope 

that this Manual will advance the field of healthy housing by providing practical 

recommendations and guidance to build local program and community capacity.
page vi
page vii

Contents

Forward.............................................................................................................................................................................page v

Chapter 1

Introduction..................................................................................................................................................................page 1

Focus of the Manual............................................................................................................................................................page 3

Manual Development.........................................................................................................................................................page 4

Impact of Housing on Health...........................................................................................................................................page 4

Health Issues Commonly Addressed by Healthy Homes Programs...................................................................page 5

Housing Conditions that Post a Risk to Health Status.............................................................................................page 6

Vulnerable Populations......................................................................................................................................................page 7

What is Healthy Housing?..................................................................................................................................................page 8

Seven Principles of Healthy Homes...............................................................................................................................page 9

Pathways to Healthy Housing..........................................................................................................................................page 9

A Variety of Program Approaches..................................................................................................................................page 12

Characteristics of Successful Healthy Homes Programs........................................................................................page 17 

Chapter 2

Community Involvement in Program Planning.....................................................................page 23

Identify and Engage Stakeholders.................................................................................................................................page 26

Community Asset Mapping.........................................................................................................................................page 26

Coalition Building and Maintenance.............................................................................................................................page 28

Analyze and Share Relevant Data ..................................................................................................................................page 29

Protocols for Assessing Community Excellence in Environmental Health (PACE-EH) ............................page 31

Building Consensus on Program Priorities..................................................................................................................page 31

Environmental Justice ........................................................................................................................................................page 31

The Community’s Long Term Role.................................................................................................................................page 32

Chapter 3

Program Design........................................................................................................................................................page 37

Program Design Questions...............................................................................................................................................page 40

Mainstreaming Healthy Homes Activities...................................................................................................................page 40

Healthy Homes Program Components........................................................................................................................page 41

Program Parameters...........................................................................................................................................................page 43
page viii

Eligibility Requirements................................................................................................................................................page 43

Recruitment.......................................................................................................................................................................page 47

Setting Benchmarks..........................................................................................................................................................................page 47

Recruitment Strategies....................................................................................................................................................................page 47

Key Recruitment Partners...............................................................................................................................................................page 48

Recruitment and Educational Messages...................................................................................................................................page 50

Confidentiality and Ethical Concerns.........................................................................................................................................page 51

Priorities for Assessment and Intervention ............................................................................................................page 52

Assessment Considerations ...................................................................................................................................................................page 52

Intervention Considerations ..................................................................................................................................................................page 53

Organizational Structure...............................................................................................................................................page 57

Staffing ................................................................................................................................................................................page 57

Clarifying of Roles and Responsibilities...................................................................................................................page 58

Budget Priorities...............................................................................................................................................................page 59

Evaluation and Program Performance Measures.................................................................................................page 59

Chapter 4

Housing-Related Health and Safety Hazard Assessment............................................page 65

Resident Interviews.............................................................................................................................................................page 68

Purpose................................................................................................................................................................................page 68

Past Experience ................................................................................................................................................................page 69

Interviewer Staffing ........................................................................................................................................................page 69

Interviewer Training........................................................................................................................................................page 70

Interview Documentation ............................................................................................................................................page 70

Quality Control/Quality Assurance............................................................................................................................page 71

Managing Confidential Data and Resident Concerns for Privacy ..................................................................page 71

Interview Tools..................................................................................................................................................................page 71

Interview Data Security .................................................................................................................................................page 72

Visual Assessment................................................................................................................................................................page 72

Purpose—Identify Housing Defects and Causes.................................................................................................page 72

Limitations of Visual Assessment and Training Needed....................................................................................page 72

Scope....................................................................................................................................................................................page 73

Sequencing Areas............................................................................................................................................................page 73

Healthy Home Rating System......................................................................................................................................page 74

Specific Housing Conditions to Assess Visually....................................................................................................page 76

Moisture ...........................................................................................................................................................................page 76

Exterior Grading and Pooling ....................................................................................................................................................page 79

Ground Treatment..........................................................................................................................................................................page 79

Water Pipes.......................................................................................................................................................................................page 79

Ductwork ...........................................................................................................................................................................................page 79

Flashing ..............................................................................................................................................................................................page 79

Condensation...................................................................................................................................................................................page 80

Drains..................................................................................................................................................................................................page 80

Other Moisture Sources................................................................................................................................................................page 80

Ventilation System and Combustion Safety........................................................................................................page 81

Safety/Injury Hazards..................................................................................................................................................page 81
page ix

Falls..................................................................................................................................................................................................... page 81

Poisoning......................................................................................................................................................................................... page 83

Fire and Burns................................................................................................................................................................................ page 83

Choking............................................................................................................................................................................................ page 83

Drowning......................................................................................................................................................................................... page 83

Suffocation and Strangling....................................................................................................................................................... page 83

Firearms............................................................................................................................................................................................ page 83

Structural Defects......................................................................................................................................................................... page 83

Insulation and Temperature Regulation .............................................................................................................................. page 84

Cleanliness and Clutter............................................................................................................................................................... page 84

Hoarding.......................................................................................................................................................................................... page 84

Prioritizing Visual Assessment Results....................................................................................................................page 84

Environmental Sampling...........................................................................................................................................page 86

Specific Testing Methods..........................................................................................................................................page 88

Testing Ventilation Systems...................................................................................................................................................... page 88

Moisture Measurement.............................................................................................................................................................. page 89

Mold Sampling .............................................................................................................................................................................. page 90

Testing for Gases........................................................................................................................................................................... page 90

Testing for Allergens in Settled Dust..................................................................................................................................... page 91

Monitoring for Pests.................................................................................................................................................................... page 91

Sampling for Lead ........................................................................................................................................................................ page 93

Energy Audits...................................................................................................................................................................page 93

Chapter 5

Intervention Strategies.....................................................................................................................................page 99

Intervention Principles......................................................................................................................................................page 101

Prioritizing Interventions.............................................................................................................................................page 101

Shared Responsibility for Implementing Interventions....................................................................................page 102

Multiple Benefits of Interventions............................................................................................................................page 102

Proper Use of Products.................................................................................................................................................page 102

Saving Treatment Costs through Prevention........................................................................................................page 102

Choose Evidence-Based Interventions...................................................................................................................page 103

Intervention Costs...............................................................................................................................................................page 103

Principle #1: Keep It Dry ....................................................................................................................................................page 104

Review of the Evidence.................................................................................................................................................page 104

Structural Interventions................................................................................................................................................page 104

Controlling Building Envelope Leaks....................................................................................................................page 104

Prompt Repair of Plumbing Leaks.........................................................................................................................page 106

Safe Cleaning or Removal of Wet or Moldy Items............................................................................................page 106

Appropriate Design, Installation, and Management of Heating, Ventilation, 

and Air Conditioning (HVAC) Systems..................................................................................................................page 107

Reporting Moisture and Leak Problems..............................................................................................................page 108

Principle #2: Keep It Ventilated.......................................................................................................................................page 108

Review of the Evidence.................................................................................................................................................page 108

Structural Interventions................................................................................................................................................page 110

Local Exhaust Interventions........................................................................................................................................page 110

General Dilution Ventilation and Heating System Interventions..................................................................page 110
page x

Principle #3: Keep It Pest Free..........................................................................................................................................page 111

Principles of Integrated Pest Management............................................................................................................page 111

Review of the Evidence..................................................................................................................................................page 111

Structural Interventions.................................................................................................................................................page 112

Rental Policies and Use of IPM Professional Services..........................................................................................page 113

Principle #4: Keep It Safe....................................................................................................................................................page 113

Key Principles of Injury Prevention............................................................................................................................page 113

Falls........................................................................................................................................................................................page 114

Review of the Evidence...............................................................................................................................................page 114

Structural Interventions..............................................................................................................................................page 115

Burns and Scalds..............................................................................................................................................................page 115

Review of the Evidence...............................................................................................................................................page 115

Structural Interventions..............................................................................................................................................page 115

Other Safety Interventions...........................................................................................................................................page 116

Principle #5: Keep It Contaminant-Free........................................................................................................................page 118

Asbestos..............................................................................................................................................................................page 118

Lead-Based Paint Hazards............................................................................................................................................page 118

Combustion Products....................................................................................................................................................page 118

Volatile Organic Compounds (VOCs)........................................................................................................................page 118

Radon Control ...................................................................................................................................................................page 119

Particulate Matter............................................................................................................................................................page 119

Second-Hand Smoke......................................................................................................................................................page 119

Occupational Take-Home Hazards............................................................................................................................page 120

Principle #6: Keep It Clean.................................................................................................................................................page 120

Review of the Evidence..................................................................................................................................................page 120

Structural Interventions.................................................................................................................................................page 121

Cleanable Surfaces.......................................................................................................................................................page 121

Carpets..............................................................................................................................................................................page 121

Heating, Ventilation, and Air Conditioning (HVAC) Systems.........................................................................page 121

Adopting a Smoke-Free Policy.................................................................................................................................page 122

Low-Toxicity Cleaners and Safe Use and Storage of Supplies and Equipment ......................................page 122

Portable Air Cleaners...................................................................................................................................................page 123

Principle #7: Keep It Maintained......................................................................................................................................page 123

Structural Interventions.................................................................................................................................................page 123

Routine Maintenance Schedule..................................................................................................................................page 124

Cleaning for the Control of House Dust Containing Lead ................................................................................page 124

Hoarding .............................................................................................................................................................................page 124

Energy Efficiency..............................................................................................................................................................page 125

Security................................................................................................................................................................................page 126

Resident Knowledge and Education.............................................................................................................................page 126

Introduction.......................................................................................................................................................................page 126

Keep it Dry..........................................................................................................................................................................page 126

Keep it Ventilated.............................................................................................................................................................page 126

Keep it Pest-Free...............................................................................................................................................................page 126

Keep it Safe.........................................................................................................................................................................page 127

Keep it Contaminant-Free.............................................................................................................................................page 127

Keep it Clean......................................................................................................................................................................page 127
page xi

Keep it Maintained ..........................................................................................................................................................page 127

Special Focus on Asthma ..............................................................................................................................................page 128

Chapter 6

Evaluating Your Program................................................................................................................................page 137

Considerations in Planning Evaluation.........................................................................................................................page 140

Setting the Stage..................................................................................................................................................................page 140

Building the Evaluation Team......................................................................................................................................page 141

Using Logic Models to Build the Evaluation Framework...................................................................................page 142

Assuring High Quality Data ..............................................................................................................................................page 144

Best Practices.....................................................................................................................................................................page 144

Common Problems.........................................................................................................................................................page 145

Measuring Success...............................................................................................................................................................page 146

Process Evaluation Measures.......................................................................................................................................page 146

Outcome Evaluation Measures...................................................................................................................................page 147

Health and Well-Being Outcomes...........................................................................................................................page 148

Housing Outcomes.......................................................................................................................................................page 149

Cost Measures................................................................................................................................................................page 149

Disseminating Findings......................................................................................................................................................page 151

Chapter 7

Program Sustainability......................................................................................................................................page 157

Deciding What to Sustain..................................................................................................................................................page 160

Tools for Sustainability .......................................................................................................................................................page 160

Funding Strategies...............................................................................................................................................................page 161

Strategies to Improve Organizational Capacity ........................................................................................................page 162

Expanding Partnerships.....................................................................................................................................................page 166

System-level Sustainability—Public Policy ................................................................................................................page 166

Final Notes on Sustainability............................................................................................................................................page 168

Glossary ................................................................................................................................................................................page 173

Abbreviations and Acronyms................................................................................................................................page 181

Appendices........................................................................................................................................................................page 185

Appendix 1.1: Resources—Neighborhood and Community Health and Safety Issues..............................page 187

Appendix 1.2: Case Study: Opportunity Council, Bellingham, WA, 

Weatherization Partnership..............................................................................................................................................page 189

Appendix 1.3: Case Study: Baltimore City Health Department, Transitioning from 

Lead to Healthy Housing...................................................................................................................................................page 191

Appendix 1.4: Case Study: Boston Public Health Commission/Boston Inspectional

Services Department, Health Care/Clinic and Code Enforcement Partnership.............................................page 195

Appendix 1.5: Case Study: Case Western Reserve University School of Medicine 

Swetland Center for Environmental Health, Healthy Homes and Babies Program......................................page 197

Appendix 1.6: Case Study: Children’s Mercy Hospitals and Clinics, Clinic/Medical 
page xii

Partnership .............................................................................................................................................................................page 201

Appendix 1.7 Case Study: Esperanza Community Housing Corporation,

Community-Based Initiative.............................................................................................................................................page 205

Appendix 1.8 Case Study: Seattle King County Health Department, Evolution of 

a Healthy Homes Program ...............................................................................................................................................page 209

Appendix 1.9 Case Study: Cincinnati Children’s Hospital Medical Center, Injury 

Prevention Program Model ..............................................................................................................................................page 213

Appendix 1.10 Case Study: Philadelphia Department of Public Health, Healthy 

Homes Child Care Program ..............................................................................................................................................page 215

Appendix 2.1: Potential Stakeholders and Their Assets.........................................................................................page 219

Appendix 2.2: Data Available from Different Sources............................................................................................page 223

Appendix 3.1: Available Educational Materials on Healthy Homes....................................................................page 227

Appendix 4.1: Housing and Health Assessment Tools for Use by HUD’s Healthy 

Homes Demonstration Programs..................................................................................................................................page 233

Appendix 5.1: Examples of Healthy Housing Criteria for Housing Rehabilitation 

and New Construction .......................................................................................................................................................page 239

Appendix 5.2: Healthy Homes Maintenance Checklist...........................................................................................page 245

Appendix 6.1: Special Considerations in Human Subjects Research.................................................................page 247

Appendix 6.2: Developing a Healthy Housing Program—Logic Model DRAFT ...........................................page 249

Appendix 6.3: Evaluation Design Strategies...............................................................................................................page 251

Appendix 6.4: Window Replacement Cost-Benefit Analysis................................................................................page 253

Appendix 7.1: Federal Government Resources..........................................................................................................page 257

Appendix 7.2: Comparison of Regulatory Approaches to Healthy Homes.....................................................page 259
page 1

Introduction

Focus of the Manual 

Manual Development

Impact of Housing on Health

Health Issues Commonly Addressed by Healthy Homes Programs

Housing Conditions that Pose a Risk to Health Status

Vulnerable Populations

What is Healthy Housing?

Seven Principles of Healthy Homes

Pathways to Healthy Housing

A Variety of Program Approaches

Characteristics of Successful Healthy 

Homes Programs

1
page 2 Introduction
page 3

The Healthy Homes Program Guidance Manual (manual) offers guidance and tools to help users establish or improve healthy homes programs. It covers a broad 

range of practical information that will be of interest to organizations, programs, and 

individuals concerned about the need for healthy housing, including:

• Government health, housing, or community 

development departments

• Community-based organizations

• Community development corporations 

• Weatherization or energy efficiency programs

• Academic institutions

• Hospital or medical clinics

• Health care or housing finance agencies

• Organizations that serve special populations, 

such as seniors, immigrants or the disabled

• Advocacy organizations

Suggested tools, techniques, and systems in 

this manual represent practices identified as 

effective, efficient, and realistic. The seven 

chapters mirror specific features of successful 

healthy homes programs. 

Healthy homes programs are more efficient 

than single focus programs because they 

promote cost-efficient housing interventions that 

address multiple health hazards that are often 

interrelated. This comprehensive approach can 

increase the availability of affordable housing, 

raise housing values, and improve health 

outcomes by reducing costs associated with 

uncoordinated housing improvements.1, 2

Focus of the Manual 

Many factors at the neighborhood and community 

level affect the health and safety of the home 

Key Messages

The manual offer guidance and tools to 

help establish or improve healthy homes 

programs.

• Healthy homes programs are defined by 

their comprehensive approach toward 

multiple residential health hazards.

• Each principle in the “Seven Principles of 

Healthy Homes” impacts multiple sources 

of exposure.

• There is no “one size fits all” in designing 

healthy homes programs.

• Healthy homes programs encompass 

multiple strategies and models.

1

Introduction
page 4

environment. This manual focuses on the home 

environment and does not specifically address the 

neighborhood or community-at-large, or issues 

such as natural disasters, the built environment, 

and outdoor air quality. Appendix 1 contains a list 

of resources related to these broader concerns.

Substandard housing is more likely to contain 

environmental hazards, and owners and renters 

of these properties are less likely to have 

the resources to prevent or remediate these 

problems. Given these realities, the manual 

concentrates largely on assuring health and 

safety in economically distressed housing and 

promoting cost-effective interventions for 

affordable housing. It is important to note, 

however, that no income group is immune to 

health hazards found in housing. Healthy homes 

programs should assure that their efforts are 

viewed as community-wide priorities when they 

reach to the larger community.

Two companion documents can be used with this 

manual: the Healthy Homes Reference Manual 

and the Healthy Homes Inspection Manual. 

Both provide data and recommendations on 

specific hazardous conditions that may be found 

in substandard housing. The Healthy Housing 

Reference Manual details how specific housing 

conditions relate to disease and injury.3 The 

Healthy Homes Inspection Manual addresses the 

broad range of housing deficiencies and hazards 

and describes elements of a home inspection.4

Manual Development

The U.S. Department of Housing and Urban 

Development (HUD) Office of Healthy Homes and 

Lead Hazard Control (OHHLHC) established its 

Healthy Homes program in 1999. Since that time 

over 100 Demonstration and Technical Studies 

grants have been funded. This manual is intended 

as a “best practices” document that assembles 

the cumulative knowledge that OHHLHC and 

other members of the healthy homes (HH) 

“community” have acquired about effective 

healthy homes program practices. OHHLHC used 

several methods to develop this manual: 

• An expert panel representing subject matter 

experts from around the country provided 

advice and peer review. 

• Relevant literature, documents and healthy 

homes grantee reports were examined to 

identify best practices. 

• Stakeholder interviews were conducted 

with healthy homes professionals in the 

field to further document best practices, 

programmatic challenges and barriers, and 

address information gaps.

• Case studies were developed to describe 

model healthy homes programs and their 

strategies.

The case studies located in Appendix 1, provide 

examples of various healthy homes program 

models. 

Impact of Housing on Health 

The connection between housing and health is 

well established. Structural defects, indoor air 

quality, exposure to toxic chemicals and biologic 

contaminants, and injury hazards are known to 

affect the health and safety of residents. These 

conditions can impact or cause lead exposure, 

asthma and allergies, and unintentional injuries; 

they may also contribute to the development 

of cancers, cardiovascular disease, and other 

illnesses.

Paradoxically, the health and housing agencies 

charged with addressing these issues are 

frequently separate organizations, resulting 

in decreased effectiveness in combating 

overlapping problems. For example, health 

departments are responsible for addressing 

the health effects of exposure to environmental 

contaminants while building or housing code 

enforcement agencies have the authority to 

correct structural deficiencies that may cause 

illness.

According to HUD’s 2007 American Housing 

Survey,5 almost six million households live with 

moderate or severe physical housing-related 

problems. Although anyone can suffer from a 

housing-related illness and injury, certain groups 

such as children, the elderly, or individuals 

with chronic illnesses and disabilities are more 

susceptible. These problems disproportionately 

affect lower-income families and specific racial 

and ethnic groups.6

Introduction
page 5

Health Issues Commonly 

Addressed by Healthy Homes 

Programs

The high morbidity and costs of housingrelated childhood lead poisoning, asthma, 

and unintentional injuries have garnered the 

attention of government agencies and a range 

of experts. Both the HUD Healthy Homes 

Strategic Plan, and the Surgeon General’s Call to 

Action on Healthy Homes identify health-related 

housing conditions as high priorities. Their 

concern is prompted by the following evidence:

Lead Exposure: Lead-based paint and lead 

contaminated dust are the main sources of exposure 

for lead in U.S. children. Childhood lead poisoning 

results in lower IQ, learning, behavioral and attention 

problems and, in severe cases, death. According to 

the Centers for Disease Control and Prevention (CDC), 

approximately 250,000 U.S. children ages one to five 

years old (2005–2006) had blood-lead levels greater 

than the level at which CDC recommended at that 

time. CDC has recently adopted a reference value of 

five micrograms of lead per deciliter for children’s 

blood lead levels.8a Although lead affects children 

from all social and economic levels, those living at or 

below the poverty line in older housing (especially 

homes built before 1940) are at the highest risk for 

exposure. There are an estimated 11.8 million housing 

units built before 1940 and 22.9 million built before 

1978 with significant lead based paint hazards.8

Preventing lead poisoning in children results in cost 

savings in lost production, medical care, and special 

education.

Asthma: Asthma affects approximately 23 

million Americans. Children under the age of 18 

make up over a third, or almost seven million of 

the affected population.9, 10 Asthma particularly 

affects economically distressed families and 

minority populations living in substandard 

housing. Asthma is the leading cause of school 

and work absences, emergency room visits 

and hospitalization and incurs an estimated 

annual economic cost of $20.7 billion to our 

nation11. Common allergens and other asthma 

triggers found in the home, such as dust mites, 

cockroaches, rodents, mold, and pet dander, 

can trigger asthma symptoms. Other common 

triggers include environmental tobacco smoke 

Introduction

Deteriorated lead-based paint on housing exterior
page 6

and nitrogen oxides from gas stoves.

Unintentional Injuries: Injuries and deaths from 

falls, fire, drowning, poisoning, suffocation, and 

choking occur often at home. These injuries are 

now the leading cause of death and disability 

among children younger than 15 years old, and 

also disproportionately affect the elderly.12

Unintentional home injuries cost society at least 

$222 billion per year in medical costs.

Housing Conditions that 

Pose a Risk to Health Status

In response to the prevalence of these diseases 

and conditions, both the Surgeon General’s 

Call to Action to Promote Healthy Homes and 

HUD’s Healthy Homes Strategic Plan identified 

the need to address the following housing 

deficiencies:

• Interior Chemical Contamination: Air quality 

is compromised by CO and other combustion 

byproducts, environmental tobacco smoke, 

radon, volatile organic compounds (VOC), and 

allergens. Improper use of pesticides, and 

unsafe storage of cleaning and pool chemicals 

are additional common home health hazards. 

The proper use, maintenance, and venting of 

heating systems and cooking appliances can 

decrease exposure to CO and other products of 

combustion. Lead hazard reduction is effective 

in reducing lead exposure in children. Safe 

chemical storage, radon testing and mitigation, 

use of low VOC alternatives, selection of the 

least toxic pesticides, and enforcement of indoor 

smoking prohibitions can successfully protect 

individuals from harmful exposures. 

• Interior Biological Contamination: Because 

Introduction

Question: How many unhealthy housing conditions can you identify in this picture?

Answer: Mold, sharp objects, possible lead-based paint hazards, and possible pests.

(This photograph was taken in New Orleans—post hurricane Katrina—in November of 2005.)
page 7

damp conditions in the home facilitate the 

growth of mold, bacteria, dust mites and 

other pests, it is important to address interior 

and exterior sources of excess moisture. 

Effective solutions include sloping soil so 

water drains away from foundations, repairing 

and redirecting downspouts, fixing leaks, 

exhausting kitchen and bathroom vents to the 

outside, and adequately ventilating homes.

• Structural and Safety Defects: Deferred 

maintenance of old homes, inadequate design 

of new construction, and lack of safety devices 

can result in injury, illness, and poor health. 

Window guards, stair railings, smoke and 

carbon monoxide (CO) alarms, and reducing 

the temperature of hot water heaters have all 

been demonstrated to reduce morbidity and 

mortality.

Vulnerable Populations

HUD’s Healthy Homes Strategic Plan clarifies the 

extent to which certain populations are affected 

more significantly by health and housing 

problems. The burden of housing hazards 

disproportionately affects certain age groups, 

races, ethnicities, and varies geographically.

• Pregnancy: The many stages of fetal 

development present the opportunity 

for developmental harm. Environmental 

exposures during pregnancy can be 

detrimental to both the pregnant woman and 

her unborn baby. Such exposures include 

cleaning products, pesticides, chemicals in 

plastics, tobacco smoke, mold, and lead.

• Age: In general, children are more susceptible 

to environmental toxins due to their developing 

organs and nervous systems. They inhale 

more air, drink more water, and eat more on 

a body weight basis than adults. The normal 

hand-to-mouth and exploratory behavior of 

young children and babies makes them more 

vulnerable to environmental hazards, especially 

to contaminants in dust. Since they may spend 

up to 80 to 90 percent of their time indoors, the 

importance of minimizing possible dangers is 

clear.13

Even older persons in good health may 

experience increased health risks from 

exposures to environmental pollutants. As we 

age, our bodies can become more susceptible 

to environmental hazards (e.g., CO, tobacco 

smoke, temperature extremes) that can worsen 

chronic or life-threatening conditions. Older 

adults are also more prone to housing-related 

injuries such as falls. Proper housing design 

can help prevent some of these episodes such 

as injuries and falls, and help seniors remain 

in their homes and function independently 

rather than moving to assisted living facilities 

or nursing homes. The U.S. Environmental 

Protection Agency’s (EPA) Aging Initiative 

contains more information on these alternatives 

(www.epa.gov/aging/index.htm).

• Race, Ethnicity, and Income: Low-income, 

minority populations are more likely than 

the general population to live in homes with 

structural defects and environmental hazards 

and lack the resources to assure a safe and 

healthy living environment. When housing 

costs consume a disproportionate share of 

income, families have little left over for other 

basic needs, including food, heat, and health 

care.14, 15 It is hard to be healthy in a home 

without heat, and hard to be healthy when you 

have to choose between heating and eating. 

Healthy homes programs need to promote 

energy security, food security and housing 

security and stability by ensuring access to 

fuel assistance, food stamps, health insurance, 

energy efficiency benefits and other resources.

• Geography: Some hazards are more common in 

certain geographic locations. For example, the 

potential for extreme weather conditions and 

disasters varies across the country. While radon 

gas levels are found in every state, some areas 

present higher risks for exposure than others.

Introduction
page 8

What is Healthy Housing?

A healthy home is a home designed, 

constructed, maintained, or rehabilitated in a 

manner that supports the health of residents.16 

This broad definition incorporates three 

interrelated strategies to control or eliminate 

environmental hazards and assure the health and 

safety of the home environment. The strategies 

involve:

• Changes in structural conditions and building 

practices; 

Community Testimonial: Emergency Department Visits

No Longer Routine

Imagine you are a mother living in a single 

room with your husband and five small children, 

four boys and one girl. The space you occupy 

with your family is infested with roaches and 

rats, and there is no central air to cool the 

hot summers, nor is there heat to warm the 

cold winters. The kids are constantly getting 

sick. Some are coughing, some have tummy 

aches, and others have colds that never end. 

You repeatedly find yourself in the emergency 

department in a desperate attempt to cure 

your child’s ills.

When you go home and get a moment to 

yourself, you feel ashamed because the living 

environment is causing your family pain. You 

are ashamed to invite family and friends for 

dinner because there is nowhere to sit. This was 

the story of Alejandra C. before she became 

a tenant of Esperanza Community Housing 

Corporation (Esperanza).

For 20 years, Alejandra had been a resident in 

South Central Los Angeles, moving from single 

room to single room with her husband and 

five children, which included her son Roberto. 

When he was in fifth grade Roberto remembers 

moving into a building on Estrella Avenue. 

Before Esperanza purchased and renovated the 

building, Roberto remembers the space being 

a little bigger than what they had been used 

to before but still not big enough for a family 

of seven, “There was no space,” he says. “Our 

parents, my brothers and sister all shared one 

room. It was hard to go to school and get ready 

in the morning.”

Now think back to when you were 11 years old 

and you wanted to bring your friends over. If you 

were Roberto this was unthinkable because of 

the lack of space. You show up to school with bug 

bites all over your arms, because the building 

you live in is infested with bed bugs. One day 

your mom says “We’re moving, they’re going to 

remodel the building.” You don’t even know who 

“they” are and you don’t know what exactly the 

move entails but you pack up and leave. 

Roberto had no idea that the next time he 

would move back into the building on Estrella 

Avenue, he would be walking into a completely 

renovated three-bedroom apartment. Alejandra 

says that the emergency department visits were 

officially over. Gone were the tummy aches 

and incessant coughs. The bed bugs had also 

vanished. The family is breathing easier and 

finding time to consistently go to school and 

stop missing work.

This is what it means to have healthy housing; 

this is what it means to transform a life through 

housing restoration. As Alejandra puts it,“ The 

newly remodeled building gave us our health 

back.” Now Alejandra and her children, including 

Roberto who is now 21, can enjoy the company 

of family and friends in their spacious apartment. 

Alejandra loves seeing Roberto and her other 

children fraternize in the living room. “Everybody 

works and goes to school....We’re all doing 

good,” she says as her face lights up.

Provided by Esperanza Community Housing 

Corporation

Introduction
page 9

• Modification of resident and property owners’ 

behaviors; and 

• Development or revision of policies, legislation 

and service systems to enable healthy housing 

practices.

This definition also exemplifies a comprehensive/

holistic approach rather than focusing on a single 

health issue, such as lead poisoning prevention, 

radon exposure or prevention of unintentional 

injuries.

Seven Principles of Healthy 

Homes

The comprehensive approach promoted by this 

manual incorporates multiple interventions, 

program activities, and resident actions to assure 

healthy homes. These actions are organized 

around the “Seven Principles of Healthy 

Homes” and necessary programmatic capacities 

related to planning, interventions, evaluation, 

and sustainability. The Seven Principles were 

developed by the National Center for Healthy 

Housing’s National Healthy Homes Training 

Center (www.healthyhomestraining.org), funded 

by HUD and CDC. 

The Seven Principles are:

Keep it:

1. Dry

2. Clean

3. Safe

4. Ventilated

5. Pest-Free

6. Contaminant-Free

7. Maintained

Because each principle has an impact on 

multiple sources of exposures, implementation 

of multiple principles can significantly reduce 

exposure to hazards. (See Table 1.1) Among 

the benefits of this comprehensive approach is 

the shared ownership of problems. Household 

residents, property owners, government 

agencies, industries, and communities all have 

a role to play in addressing these exposures. 

In addition, following the “Seven Principles 

of Healthy Homes” can lift individuals and 

programs from feeling overwhelmed by a 

daunting list of problems to feeling confident 

and energized. The principles offer clear 

direction for taking concrete action toward 

specific achievable ends.

Pathways to Healthy 

Housing

Healthy homes programs use multi-tiered 

approaches to improve the health and safety of 

the home environment.

Pathways

• Housing Interventions

• Individual Behavior Change

• Community Capacity Building

• Program Design Improvements

• Policy Development 

• Housing Interventions. Changes to the 

structure and safety of the home environment 

include lead hazard reduction, mold 

remediation, leak prevention, improved 

ventilation, integrated pest management, 

installation of smoke detectors and CO alarms, 

improved lighting, radon mitigation, and slip 

and fall prevention through modifications to 

stairs, entryways, and bathrooms.

• Individual Behavior Change. Residents or 

tenants and property owners need to become 

knowledgeable about the hazards and risks 

that may exist in their home, how to reduce 

them, and the importance of preventive 

maintenance.

• Community Capacity Building. Community, 

advocacy, and grass roots organizations are 

important partners in increasing community 

awareness and healthy homes intervention 

capacity, and in sustaining program activities. 

Target communities and the public at large 

need to be involved in designing, carrying out, 

and evaluating healthy homes activities. 

Program Design Improvements. Healthy homes 

programs need to assess their capacity, monitor, 

and evaluate their performance, and make needed 

Introduction
page 10

Table 1.1 Relationships among the “Seven Principles,” recommended actions, 

reduced hazards, and outcomes

Principle Actions Hazard and Associated Health and 

 Contaminant Reduction Other Impacts

Keep It 

Dry

• Cockroaches

• Mold

• Rodents

• Lead-based paint

• Dust mites 

• Termites

• Injuries associated with 

slips, trips and falls

• Volatile organic 

compounds

• Reduction in 

asthma triggers and 

respiratory irritants.

• Reduction in risk 

for childhood lead 

poisoning.

• Reduced risk of 

injuries.

• Increased physical 

comfort and energy 

efficiency.

• Decrease in structural 

deterioration related 

to decay and pest 

damage.

Keep It 

Clean

• Cockroaches

• Rodents

• Contaminant residues 

in dust

• Injuries

• Reduction in 

asthma triggers and 

respiratory irritants.

• Reduction in risk 

for childhood lead 

poisoning.

• Reduced exposure to 

contaminants in dust.

Control dust and contaminants. 

Create smooth and cleanable surfaces.

Reduce clutter. 

Store food in pest-resistant containers.

Use wet-cleaning methods and HEPAequipped vacuum.

Address hoarding behavior.

Water Intrusion: Prevent water from 

entering the home through leaks in roofing 

systems, windows, and exterior shell. 

Drainage Problems: Control ground 

drainage to prevent intrusion in crawlspaces 

and basements. Address inadequate gutter 

and downspout systems.

Interior Leaks: Prevent plumbing or 

sewage leaks or overflows. 

Humidity: Control humidity from 

occupant behavior such as use of room 

humidifiers, and unvented clothes dryers.

Exterior Leaks: Respond to water intrusion 

and leaks, and correct condensation 

problems on walls, windows, and fixtures.

Keep It 

Safe

Store chemicals and medicines out of the 

reach of children. 

Add child-safety devices such as cabinet 

locks, electrical outlet covers and safety 

gates. 

Secure loose rugs and keep children’s play 

areas free from hard or sharp surfaces. 

Add grab bars in bath, two handrails on 

stairs, and other measures to prevent falls, 

especially for seniors. 

Install smoke and carbon monoxide alarms. 

Keep fire extinguishers charged and 

accessible. 

Assure adequate lighting.

Reduce clutter. 

Avoid circuit overloads and extension cords.

Keep water temperature below 120F. 

• Injuries associated with 

slips, trips and falls. 

• Fires

• Household chemicals, 

pesticides, and 

medicines. 

• Carbon monoxide 

poisoning

• Reduced exposure to 

chemicals and 

poisonings.

• Reduced risk of 

burns.

• Reduced risk of 

injury, especially 

to children and the 

elderly.

Introduction
page 11

Keep It 

Ventilated

Principle Actions Hazard and Associated Health and 

 Contaminant Reduction Other Impacts

Ventilate bathrooms and kitchens. 

Use whole house ventilation to provide 

fresh air. 

Use active ventilation systems to manage 

indoor moisture, provide occupant 

comfort. 

• Carbon Monoxide

• Formaldehyde

• Mold and Moisture

• Nitrogen Oxides

• Radon

• Volatile organic 

compounds

• Reduced respiratory 

irritation.

• Reduction in asthma 

triggers.

• Reduced chemical 

exposure.

• Reduced risk of lung 

cancer.

Keep It 

Pest-Free

Make the home less habitable for pests 

by identifying sources of water, food, and 

shelter. 

Remove harborage sites.

Seal cracks and openings throughout the 

home. 

Address overgrown vegetation.

Store food in pest-resistant containers. 

Monitor for pests and respond with 

integrated pest management approaches 

that prevent pests and use lower risk 

pesticides. 

• Cockroaches

• Mice

• Rats

• Ants

• Bed bugs

• Pesticides

• Reduction in 

asthma triggers and 

respiratory irritants.

• Decrease in bite-related 

injuries.

• Increased physical 

comfort.

• Protection of central 

nervous system.

Keep It 

ContaminantFree

Reduce contaminants coming into the 

home through purchasing decisions.

Limit spread of contaminants. 

Stop smoking or move smoking outside. 

Test for radon and, if needed, install a radon 

removal system.

• Environmental Tobacco 

Smoke

• Asbestos

• Formaldehyde

• Lead-based Paint

• Pesticides

• Radon

• Volatile and semi-volatile 

organic compounds

• Flame retardants

• Treated lumber

• Reduced risk of lung 

cancer.

• Reduced respiratory 

irritation.

• Reduced risk for 

childhood lead 

poisoning.

• Protection of central 

nervous system.

• Reduced 

developmental 

hazards.

Keep It 

Maintained

Inspect, clean and repair the home and 

its equipment at regular intervals. 

Change air filters and similar equipment. 

Respond to problems quickly before minor 

problems become more serious.

Use lead-safe work practices for deteriorated 

paint in homes built before 1978.

• All of the above • Reduced risk of lung 

cancer.

• Protection of central 

nervous system.

• Reduced asthma 

triggers.

• Reduced risk for childhood lead poisoning.

• Increased physical 

comfort and energy 

efficiency.

The contents of this table related to hazards and contaminants are not exhaustive. For more detailed information go to 

http://www.healthyhomestraining.org/Credential/Contaminant_Guide_4-20-09.pdf

Introduction
page 12

changes to assure effectiveness and cost-efficiency. 

It should be noted that expanding existing 

infrastructure or enhancing service systems may be 

more affordable and sustainable than creating new 

programs and services.

Policy Development. Passage, implementation, and 

refinements to specific laws, such as lead-based 

paint ordinances and housing codes, can advance 

and sustain healthy housing. Codes and ordinances 

require enforcement to be effective. Program policies 

such as cross-department and organizational referrals 

and partnerships can strengthen and expand healthy 

housing programs. 

A Variety of Program Approaches

There is no “one size fits all.” Individual healthy homes 

program goals, partnerships, health priorities and 

community assets will determine the design of each 

initiative. Urban and rural healthy homes programs 

often look very different based on unique hazards 

in their respective environments. Effective healthy 

housing programs are defined by the integration 

of health and housing services and usually include 

interagency partnerships that are reflective of federal 

priorities and practice.

The variety of efforts detailed below are useful to 

consider in designing or expanding a healthy homes 

program. In-depth case studies of selected program 

strategies can be found in Appendices 1.2–1.10.

Transitioning from a lead hazard control program to 

a healthy homes program

Because of the success and significant funding 

invested in lead poisoning prevention and lead 

hazard control programs, many localities have 

expanded into more comprehensive healthy 

housing programs that identify and reduce asthma 

triggers and injury risks and hazards. Transitioning 

from lead to healthy homes programs requires new 

partners, staff training, assessments/inspection 

protocols, and capacity to provide additional 

interventions such as moisture control, increased 

ventilation, integrated pest management (IPM) and 

injury prevention. 

Baltimore City Health Department expanded 

its urban childhood lead poisoning prevention 

program into a comprehensive healthy homes 

initiative by adding interventions to reduce asthma 

risks, injury hazards, carbon monoxide poisoning, 

and fire hazards. In 2006, the department 

established a Healthy Homes Division and 

appointed an Assistant Commissioner for Healthy 

Homes to focus on the impact of housing on 

health. The healthy homes program was developed 

through pilot testing of new tools and protocols, 

focus groups with community members, intensive 

staff training, and expansion of partners to leverage 

resources, receive and provide referrals for their 

clientele, and provide healthy homes training to an 

expanded group of community stakeholders.

Medical-Clinic partnerships

Similar to childhood lead poisoning prevention 

programs which services are based on specific 

health criteria (e.g., elevated blood-lead levels), 

many healthy homes programs identify families for 

interventions based on asthma diagnosis. In these 

instances, programs partner with hospitals, health 

plans, asthma clinics and/or community-based 

health centers to develop a referral system. The 

medical facility screens their patients and makes 

referrals to the healthy homes program for followup in the home. It is essential to assure a feedback 

loop so that the health and medical services 

provider is aware of healthy homes program 

services and coordination and medical support are 

assured. 

The City of Boston’s Breathe Easy At Home

program, while more than a medical-clinic 

partnership, is a web-based referral system 

that allows doctors, nurses, or other health 

professionals to refer patients with asthma for a 

home inspection. Inspections are conducted by 

the Boston Inspectional Services Department, 

which enforces the sanitary code for housing. 

Their trained Breathe Easy at Home inspectors 

identify asthma triggers such as mold and chronic 

dampness, leaks, pest infestations, drafty doors 

and windows, lack of heat, poor ventilation, and 

damaged carpeting. The inspectors also work with 

property owners to eliminate these poor housing 

conditions. The web-based system offers ongoing 

communication between medical, public health 

and housing partners on the status of the referral 

and case disposition. The Boston Public Health 

Commission manages the Breathe Easy Program

and provides families with educational home visits 

and help in managing their asthma if needed. 

These complementary services are provided by 

community health workers. 

Introduction
page 13

Medical-Legal partnerships

The medical-legal partnership is defined by 

combining preventive medicine and preventive 

law to address non-medical issues that influence 

health and housing. Legal issues affecting health 

and housing include problems related to public 

benefits, housing, and utilities, legal (immigrant) 

status, and personal and family stability. Because 

doctors and other health care providers are a 

trusted and credible resource for families, screening 

for legal issues in the clinical setting can help 

to detect and resolve legal problems. Pairing a 

medical partner with a legal partner—usually from 

legal aid or pro bono support from the local bar 

association or law school—can ensure that basic 

family needs are met and result in systems change.

Boston Medical Center is the home of the National 

Center for Medical-Legal Partnerships (MLP) (www.

medical-legalpartnership.org). This program was 

founded in 1993 to address housing conditions and 

the nutritional status of asthma patients. The MLP in 

Boston currently services 1,000 patient-families per 

year at six community health centers and provides 

training to health care providers. Other services 

include legal advice and assistance for patients/

families and advocates for improvements in the 

health care and legal service delivery systems. 

The Medical Legal Community Partnership

(MLCP) in Los Angeles is composed of St. John’s 

Well Child and Family Center and Esperanza 

Community Housing Corporation. The combined 

effort educates medical providers on the social 

determinants of health, provides legal advocacy 

to patients on non-medical issues affecting 

health status, and works strategically to bring 

about systematic change to improve the health 

of the community. Over a two-year period, the 

program opened 684 cases; one-third were 

related to health program eligibility and services, 

and two-thirds primarily related to such housing 

issues as habitability, evictions, affordability and 

foreclosures.

Education

Repeated home visits by health educators, even 

without structural interventions, can let residents 

know about specific health and safety hazards 

in their home environments and help them plan 

actions to reduce risks. Use of community health 

workers or community Promotoras de Salud with 

similar backgrounds as the residents increases 

trust, facilitates entry to housing units, and builds 

long-term relationships. Small scale incentives, 

such as distribution of smoke and carbon 

monoxide alarms, pest control products, and 

mattress and pillow covers, should be considered 

to reinforce and motivate behavior change. There 

are a myriad of existing home visitation programs 

that can be explored for incorporation of healthy 

homes education and assessment.

Seattle and King County Healthy Homes Project

compared a single home visit by a trained 

community health worker with a higher intensity 

intervention consisting of four to eight visits 

to homes of asthmatic children. The study 

demonstrated that both groups of residents 

benefited from the home visit experience, but that 

substantially greater improvements in caregiver 

quality of life and reductions in use of urgent 

medical care services were associated with the 

high-intensity services.

Esperanza Community Housing Corporation

(Esperanza) in south Los Angeles uses Promotoras 

de Salud who are residents of the target area to 

conduct community outreach, visual assessment, 

environmental sampling, education, tenant 

rights advocacy, clinic coordination, and referral 

to city and county code enforcement services. 

A promotora is a community health advocate 

who has been trained in a six month-long 

comprehensive community health curriculum 

followed by extensive training in healthy homes 

issues. Esperanza is truly a grassroots effort 

whose establishment resulted from an organizing 

campaign by community residents. With its clinical 

partner St. John’s Well Child and Family Center, 

Esperanza has developed a system in which 

clinicians can refer cases to a promotora for an 

environmental home visit and case management.

Housing agency-based

Housing agencies can provide meaningful 

leadership for healthy housing initiatives. Location 

in a housing department can provide access to 

federal and state housing programs and funding 

such as Community Development Block Grants 

(CDBG) and the Weatherization Assistance 

Program. Key to the success of these programs is 

partnerships with public and private sector health 

Introduction
page 14

of Health (RIDOH), private licensed water testing 

laboratories, and the Ground Water Association 

comprised of licensed well drillers to assure 

the safety of well water. The program includes 

education of private well owners about the 

importance of regularly testing their well water, 

professional training and networking, and phone 

consultation. The RIDOH recently established 

regulations that require testing private wells at the 

sale of property or when a new well is installed.

State programs

In addition to city or county healthy homes 

programs that usually target specific high risk 

neighborhoods, state governments have begun 

to provide leadership for advancing healthy 

housing initiatives. Rhode Island has developed 

a five-year work plan to facilitate integration of 

state health and housing services and programs. 

Maryland builds healthy homes goals into its state 

and local sustainability plans. New York State has 

a Healthy Neighborhoods Program that provides 

home education on safety, pests, asthma triggers, 

and lead and visual assessment visits to selected 

neighborhoods. 

New York State Healthy Neighborhoods Program

(HNP) provides in-home assessments and 

interventions to improve the environmental health 

and safety of residents residing in high-risk target 

communities in ten counties. The HNP is delivered 

by local health departments and relies on a variety 

of strategies to recruit participants including doorto-door canvassing and referrals from other health 

and housing programs. Homes are assessed for 

hazards related to fire safety, lead poisoning, carbon 

monoxide poisoning, indoor air quality, pests/

vermin, mold and moisture, tobacco use, and other 

common environmental health issues. During the 

home visit, residents are provided with education, 

products, and referrals to help them correct or 

minimize each potential hazard. This approach relies 

heavily on strong local partnerships to ensure that 

resources are in place to help residents deal with the 

wide variety of environmental health and related 

social issues identified during a typical visit. Twentyfive percent of the homes are visited again after 90 

days to reassess conditions and to provide additional 

interventions as needed. A comprehensive program 

evaluation is underway.

Injury prevention programs

Introduction

programs and service providers.

The City of Phoenix Neighborhood Services 

Department provides leadership for a healthy 

homes program that leverages financial support 

through set-asides within their existing housing 

programs. The program established relationships 

to receive referrals of families with elevated blood 

lead levels, asthma, or injuries stemming from 

known or suspected housing hazards. Securing 

commitment from department leadership was 

central to achieving the program’s priorities. 

Significant problem solving occurred to integrate 

the need for timely health services with longer term 

and more comprehensive housing rehabilitation.

Elderly programs

Older adults have particular needs for safe and 

affordable home environments. Preventing 

unintentional injuries—especially falls and 

poisonings—through education, medication 

management support, and retrofitting homes for 

safety is especially critical for this population. Older 

adults often subsist on fixed incomes and may not 

have the financial resources for home repairs and 

rising utility costs. In addition to interventions such 

as installation of hand railings on stairs, grab bars 

in bathrooms and adequate lighting, community 

education programs can be highly effective in 

addressing home health and safety issues affecting 

seniors. Education should be provided at locations 

that are accessible and comfortable for older 

adults, allow time for adequate discussion, and 

provide options for additional services. The U.S. 

Department of Health and Human Services (HHS), 

HUD, and EPA are committed to promoting better 

ways for older adults to remain in safe and healthy 

homes and “age in-place.” 

Rural programs

Rural healthy homes programs focus on unique 

issues such as well water protection, household 

wastewater management including septic systems 

design, fertilizer and pesticide use and storage, and 

agriculture-related injuries. These programs also 

address typical issues like lead-based paint, radon, 

natural disasters, and mold and moisture.

The University of Rhode Island Cooperative 

Extension Water Quality Program works in 

cooperation with the Rhode Island Department 
page 15

Despite the fact that injuries are a leading 

cause of illness and death in the United States, 

home interventions to prevent injuries are 

often overlooked. Efforts aimed at addressing 

injuries include attention to fire safety through 

smoke alarms and escape plans, retrofitting 

homes to prevent falls, poisoning prevention 

through proper storage, and safety education.

Cincinnati Children’s Hospital Medical Center 

developed an injury prevention program as 

part of a larger research project targeted to 

homes of young children from birth through 

four years of age. This initiative is validating 

the benefits of its Home Observations 

and Measures of the Environment (HOME) 

Injury Survey, a 55-item tool that quantifies 

unintentional injury hazards in the indoor 

environment of homes with young children. 

After the injury assessment is completed, 

recommended interventions are reviewed 

with parents who participate in prioritizing 

interventions. Consumer product safety 

devices are then installed by project staff.

Child care programs

Based on the disproportionate burden of 

environmental hazards on children, home-based 

child care programs offer a strategic opportunity 

for healthy housing partnerships. Home-based 

child care programs located in high-risk target 

areas can be targeted for education and housing 

interventions to protect large numbers of children. 

Priority interventions may include lead hazard 

reduction, child safety installations such as railings 

and gates, assurance of product (toys) safety, crib 

safety, and safer cleaning products, and focus on 

asthma, allergies, and indoor air quality. 

The Philadelphia Department of Health’s Healthy 

Homes Child Care Program provided education 

and remediated lead and safety hazards in 

licensed home-based child care programs located 

in an area of the city with old and deteriorating 

housing stock serving low-income children. The 

Pennsylvania Department of Public Welfare’s Office 

of Child Development provided a list of certified 

child care providers located in the target area, and 

interagency agreements facilitated partnerships 

with the Philadelphia Early Childhood Collaborative 

and Pennsylvania’s Keystone Stars, which promotes 

quality improvement in early learning of schoolaged children. The project also integrated 

established procedures from Philadelphia’s Lead 

Hazard Control, Healthy Homes and Lead-Safe 

Babies Programs. Activities were aimed at safety, 

indoor air quality, energy efficiency, integrated 

Introduction
page 16

resources and train workers to advance a “whole 

house” strategy. Integrated green and healthy 

housing assessment and interventions focus 

on environmental health, safety and energy 

efficiency.

Code enforcement partnerships

Housing codes originally dealt with health 

problems and were the responsibility of health 

departments to enforce. However, the reality 

is there will never be enough government 

funding to make all homes healthy. Updating and 

enforcing housing codes are effective ways of 

leveraging property owner and public resources 

and building sustainability of healthy homes 

programs. Any type of agency partnership will 

require cross-training of staff and will benefit 

from regular problem-solving meetings. Some 

municipalities focus their joint sessions on case 

reviews to build consensus on effective strategies. 

Other partnerships use different approaches. The 

aim is to avoid duplicating activities, coordinate 

mutual resources, and maximize the effectiveness 

of interventions. Partnership strategies include:

• Deputizing health department staff to enforce 

the housing code.

• Referring housing code violations observed 

during health department home visits to 

housing code enforcement officials. The two 

departments can then collaborate on carrying 

out needed work.

• Conducting joint health department and code 

inspection home visits to assess conditions and 

develop a collaborative response.

Introduction

pest management, and lead hazard control. Over 

a three-year period, more than 150 child care 

providers received intensive continuing education 

on safety, lead, pest management, and asthma, and 

50 child care homes were remediated.

Energy efficiency and weatherization partnerships

The U.S. Department of Energy funds 

Weatherization Assistance Programs that are 

managed by states through Community Action 

Agencies (CAA) to improve energy efficiency. By 

leveraging work with weatherization programs, 

health and housing departments can take 

advantage of weatherization staff expertise on 

how to address whole-house ventilation and 

other issues. In turn, weatherization staff and their 

recipients (e.g., low-income families) can benefit 

from comprehensive healthy housing assessments 

and interventions. 

The Opportunity Council of Bellingham, 

Washington, is a CAA which houses a 

weatherization and Head Start program. The 

organization targeted low-income families with 

children suffering from asthma and ten homebased child care providers who served those 

children for intensive education, weatherization, 

and rehabilitation. All staff, including 

weatherization professionals, Head Start, and social 

service home visitors, were trained on program 

elements. Families received specialized education 

on how the home functions as a system and were 

given supplies to use in the home to reduce asthma 

triggers (e.g., cleaning kits, HEPA vacuums, and 

other items). The homes benefited from enhanced 

ventilation and pollution mitigation services. Visual 

assessments and family interviews were conducted 

before and six months after renovation. The 

program reported improvements in the children’s 

asthma symptoms, and an unexpected benefit of 

reduced turnover in the units. The average cost of 

improvements was $5,600 per unit.

The Green and Healthy Homes Initiative (GHHI) is a 

project of the National Coalition to End Childhood 

Lead Poisoning with support from HUD and the 

CDC. It is a social innovation that breaks down 

funding restriction barriers between federal, state, 

local and philanthropic resources. A number of 

project sites are being funded by establishing new 

public-private foundation partnerships. The goal 

of GHHI is to align funding sources, coordinate 
page 17

The Columbus, Ohio Health Department has the 

authority to enforce housing codes. Because 

of limited staff capacity, they coordinate with 

the Columbus Department of Development to 

conduct joint inspections and enforce orders if the 

property owner isn’t initially responsive.

The Multnomah County, Oregon, Health 

Department used its Healthy Homes 

Demonstration grant to facilitate policy and 

systems changes that integrate healthy homes 

concepts into the daily work of government 

housing programs. The City of Gresham

established a program requiring annual 

inspections of rental housing units. The City of 

Portland Quality Rental Housing Workgroup

changed the city’s housing code and enforcement 

procedures. Multnomah County itself passed a 

resolution related to improving rental housing 

conditions in unincorporated areas of the county.

Characteristics of Successful 

Healthy Homes Programs

In addition to insights garnered from highfunctioning healthy homes programs, other 

documents identified key characteristics of effective 

programs.17, 18 These qualities include:

• Planning: Allow adequate time for community and 

program planning.

• Community Involvement: Involve the community 

in program planning, implementation, and 

evaluation.

• Clinic/Medical Connections: Engage hospitals 

and clinics as resources for identifying at-risk 

families in need of healthy homes interventions, 

monitoring, and education. Determine if a 

Pediatric Environmental Healthy Specialty Unit 

is located in your community. www.aoec.org/

PEHSU/index.html

• Leadership: Recognize that community and 

program leadership is crucial to effective healthy 

homes programs. Identifying program champions 

inside collaborating organizations is especially 

important. One inspired leader can make a 

difference.

• Partnerships and Coalitions: Build and maintain 

collaborations across a wide variety of 

multidisciplinary programs. Partnerships among 

healthy homes programs are mandatory to assure 

a comprehensive and sustainable approach. 

• Policy Development: Focus on the policies, 

legislative infrastructure, and building 

code changes and enforcement that can 

support healthy homes programs, enable 

structural changes to housing, and strengthen 

sustainability. 

• Evaluation: Plan for program evaluation 

during the program design phase. Regular 

data collection and analysis are central to 

assuring cost-effective health and housing 

outcomes and fidelity to program policies and 

procedures.

In addition to the above key characteristics, 

successful healthy homes programs must also 

focus on the following:

• Improvements in the Delivery of Services 

to Residents: Look for opportunities to make 

programmatic changes that can streamline 

intake processes and restructure service 

delivery systems to integrate interventions 

and better leverage the use of available 

resources for residents, such as by identifying 

and braiding federal, state, philanthropic, and 

other private sector resources.

• Sustainability: Make sustainability a 

fundamental component of the initial 

and ongoing program plans. Ultimately, 

sustainability involves learning from 

experience (ongoing evaluation), making 

decisions about which elements of the 

program to sustain, selecting the right 

strategies, and using the right tools to build 

support for your program.

Introduction
page 18

Chapter 1 References*

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2

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15 Cook, J., Frank, D., Casey, P., Rose-Jacobs, 

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16 U.S. Department of Health and Human 

Services, 2009. The Surgeon General’s Call to 

Action to Promote Healthy Homes. Office of 

the Surgeon General. Available: http://www.

surgeongeneral.gov/topics/healthyhomes/

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17 Center for Managing Chronic Disease. 2007. 

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*Websites were verified during the drafting of this document but may have changed.
page 20 Introduction
page 21

Notes
page 22 Introduction