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Appendices

Appendices
page 186 Appendices
page 187

Appendix 1.1 Resources

Neighborhood and Community Health and Safety Issues 

Issue Resource

Brownfields EPA: http://www.epa.gov/brownfields/

 The Brownfields and Land Revitalization Technology Support Center:

 http://www.brownfieldstsc.org/

Built Environment CDC: http://www.cdc.gov/nceh/ehs/Topics/BuiltEnvironment.htm

Climate Change EPA: http://www.epa.gov/climatechange/

 National Oceanic and Atmospheric Administration: http://www.noaa.gov/climate.html

Disaster Planning FEMA: http://www.ready.gov/america/index.html

 CDC: http://emergency.cdc.gov/

Extreme Cold and Heat CDC: http://emergency.cdc.gov/disasters/winter/

 CDC: http://emergency.cdc.gov/disasters/extremeheat/

Flood Cleanup http://www.fema.gov/hazard/flood/aftrfld.shtm

 National Center for Health Housing: 

 http://www.centerforhealthyhousing.org/FloodCleanupGuide_screen_.pdf

Indoor Air Quality http://www.epa.gov/iaq/homes/retrofits.htm

Natural Disasters FEMA: http://www.ready.gov/america/index.html

 My Emergency Planning Kit and My Emergency Widget—to get online updates on disasters

 CDC: http://emergency.cdc.gov/disasters/

Neighborhood Safety National Crime Prevention Council:

 http://www.ncpc.org/topics/home-and-neighborhood-safety

Noise Pollution EPA: http://www.epa.gov/air/noise.html

Outdoor Air Quality EPA: http://www.epa.gov/air/

Rural Housing USDA Rural Development Housing and Community Facilities Programs: 

 http://www.rurdev.usda.gov/rhs/

Violence CDC: http://www.cdc.gov/ViolencePrevention/index.html

Water Quality EPA: http://www.epa.gov/safewater/

Workforce/Green Jobs http://www1.eere.energy.gov/wip/retrofit_guidelines.html

Workplace Hazards Occupational Safety and Health Administration: http://www.osha.gov/

 National Institute for Occupational Safety and Health: http://www.cdc.gov/niosh/

 NIEHS: National Clearinghouse for Worker Safety and Health Training 

 http://tools.niehs.nih.gov/wetp/

Appendices
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Appendix 1.2 Case Study

Opportunity Council, Bellingham, WA

Weatherization Partnership

Program Overview 

Purpose. The purpose of the project was to 

address the needs of children with asthma 

living in low-income housing by reducing 

environmental triggers.

Target Population. The program targeted very 

low-income families with children, from birth to 

age four, and home-based child care programs 

served by Opportunity Council weatherization 

and home rehabilitation programs. The target 

households included Native American children, 

who have an exceptionally high prevelance of 

asthma, and recently-settled immigrants from 

the Ukraine. The target area was comprised 

of four counties in the northwest corner of 

Washington State.

Partnerships. The Opportunity Council provided 

leadership for this initiative. As a community 

action agency they are responsible for multiple 

programs and community services including 

child care, early childhood education, homeless 

and transitional housing, health care, and 

community information and referral services.

Program partners included Northwest Clean 

Air Agency (the regional air pollution authority), 

Whatcom County Health Department, City 

of Bellingham Community Development 

Department, Opportunity Council Head 

Start, and Childcare Resource and Referral 

programs. In collaboration with over 30 public 

and private organizations, the Opportunity 

Council conducted a two-year public education 

campaign focusing on healthy homes 

interventions.

Community Involvement. The Indoor Air 

Coalition of Whatcom County (IACWC) served 

as the steering committee for the project and 

focused on defining the target population as 

they served to leverage. 

Planning. Partner agencies serving the target 

population coalesced to implement the healthy 

homes program. Opportunity Council Head 

Start program recruited families who were 

receiving weatherization program services. 

The Northwest Clean Air Agency has the 

ability to assess in-home hazards in low-income 

households where children with asthma lived.

Interventions

Recruitment. Families were enrolled using the 

following eligibility criteria on a “first come, first 

served” basis:

• Income: The participant family income needed 

to be 125 percent of poverty or less.

• Health: Family or child care providers must 

have at least one child clinically diagnosed 

with asthma. Households with indoor cigarette 

smoking or pets were not eligible.

• Home conditions: The dwelling needed to be 

in a condition such that reasonable repairs or 

weatherization measures and available funding 

could address imminent hazards. 

• Home ownership: Program participants (both 

families and child care providers) had to be 

homeowners.

Interventions. Healthy homes program services 

include:

• Pre- and post-renovation air and dust samples.

• Pre- and post-renovation education to help 

families identify and control asthma triggers.

• Weatherization services, including enhanced 

ventilation systems and pollutant mitigation.

• Supplies for the families, including green 

cleaning kits, HEPA vacuums, walk-off mats, 

and mite-proof bedding covers.

• Training of Head Start home visitors, child care 

monitors, health department staff, and other 

community social service providers in asthma 

trigger prevention and the “Seven Steps to a 

Healthy Home” model.

• Dissemination of information to the 

weatherization network regarding Healthy 

Home principles. 

Appendices
page 190

• Two tools created to support the interactive 

curriculum:

 How Your House Works, which is based on 

the “house as a system” approach.

 Home Asthma Reduction Training 

Workbook, a tool to help families create a plan 

to reduce asthma triggers in their home.

Program Staff. The program used the 

Opportunity Council’s in-house weatherization 

staff for all repairs except where specialty 

contractors, such as electricians, plumbers, and 

HVAC installers, were needed. All in-house staff 

received training on healthy homes concepts, 

program parameters, and other topics. 

Systems and Policies

The Opportunity Council in collaboration 

with ICF Consulting and Tohn Environmental 

Strategies developed the Weatherization Plus 

Health model and related protocols and training 

for Department of Energy Weatherization 

Assistance Programs (WAP). 

Funding and Leverage

Funding Sources: 

• HUD Healthy Housing Demonstration grant.

• Weatherization program funding and technical 

expertise was leveraged.

• A private donor committed $100,000 per year 

in support of energy efficiency retrofits. 

Program Costs. The average cost to combine 

the weatherization program with healthy homes 

interventions is estimated at $5,620 per housing 

unit, with a range of $1,500–$6,000.

Evaluation and Outcomes

Housing Outcomes. The visual assessment 

tool was used to evaluate housing units postrenovation. The tool covered observations of 

mold and moisture, pest and pesticide use, 

presence of carbon monoxide detectors, 

condition of appliances, lead-based paint 

hazards, environmental tobacco smoke, 

poisoning, and fire hazards. 

Northwest Air Pollution Authority and 

Opportunity Council staff collected pre- and 

post-renovation dust tape lifts, air samples, 

and carpet dust samples. While the results of 

post-testing varied, in aggregate there were 

noticeable improvements in the reduction 

of dust levels in most home and child care 

environments. 

Health Outcomes. Family members reported on 

children’s health, asthma status, family health 

maintenance, and home cleaning practices 

at baseline and follow-up visits. The program 

reported that frequency of unit turnover had 

decreased in housing units receiving healthy 

homes program services.

Sustainability

Under the current expanded program, the 

Opportunity Council continues to follow the 

Weatherization Plus Health Model, using private 

sector leverage to cover the additional costs of 

the health-related assessments and additional 

upgrades. This is possible mainly because of 

the existing infrastructure of the weatherization 

program. Homes asthma trigger reduction 

strategies have been integrated into the existing 

weatherization and housing rehabilitation 

program production systems. With funding from 

the American Recovery and Reinvestment Act 

of 2009, the Opportunity Council has expanded 

its on-line training resources through its Building 

Performace Center. It has also become an 

accredited training provider through the U.S. 

Department of Energy. 

Best Practices

• Integrating the resources of a Community 

Action agency that offers weatherization, 

Head Start, child care resource and referral, 

and home visiting to serve the same target 

group.

• Leveraging existing weatherization funding 

with Healthy Homes grants.

Appendices
page 191

Appendix 1.3 Case Study

Baltimore City Health Department

Transitioning from Lead to Healthy Housing 

Program Overview

Purpose: In 2007, the U.S. Centers for Disease 

Control and Prevention (CDC) chose the 

Baltimore City, Maryland Health Department’s 

Childhood Lead Poisoning Prevention Program 

(CLPPP) to transition from a lead program to 

a comprehensive Healthy Homes Program. 

The Healthy Homes Demonstration Project 

pilot’s goal was to develop, implement, and 

evaluate a cost-effective, outcome-focused, 

replicable model for transitioning from an urban 

childhood lead poisoning prevention program to 

a comprehensive healthy homes program. The 

program aimed to reduce lead exposure, asthma 

risks, injury risks and hazards, carbon monoxide 

poisoning, and fire morbidity and mortality.

Target Population: The program targeted 

children with elevated blood levels (EBL) and 

children aged 0–6 years and pregnant women 

living in housing with hazards identified through 

its Primary Prevention Initiative (PPI).

Partnerships: CDC, University of Maryland, 

Coalition to End Childhood Lead Poisoning, 

Health Care Access.

Community Involvement: The Health 

Department obtained input through a variety of 

different mechanisms: 

• One-on-one meetings with various individuals 

and organizations across the city, including 

community organizations, community leaders, 

and government agencies.

• A newly developed healthy homes advisory 

board.

• Focus groups with representatives of the 

target population.

The program relied on input from clients for 

ongoing feedback. During baseline visits, field 

staff asked clients about their home and family 

priorities. The staff used the client-identified 

needs to devise a specific and appropriate 

action plan for each client. 

Planning. A pilot team of two field staff 

representatives, field staff supervisors and 

managerial staff, was formed to draft, discuss, 

and revise the assessment forms, protocols, and 

education materials. In developing the protocols 

for the program, the pilot team cyclically reviewed 

scientific studies and other healthy homes 

protocols and approaches, analyzed Baltimore City 

health and housing data, and received feedback 

from field staff. After piloting the protocols and 

assessment forms in ten healthy homes visits, the 

pilot team integrated feedback from staff to create 

the final documents. The program also relied 

heavily on field staff with lengthy home-visiting 

experience to shape the protocol, resources, 

supplies, and assessment form.

During the first year of the transition, the 

program developed new protocols, assessment 

forms, referral resources, and completed 90 

hours of staff training. Extensive evaluation 

occurred after the first year, showing statistically 

significant health outcomes. Stage two of the 

transition required additional ongoing work, 

including applying for funds to expand services, 

building a career ladder for health department 

staff, implementing a quality improvement 

initiative, and expanding community outreach. 

Milestones during the transition year included: 

1. Convening the pilot team;

2. Initiating a broad range of trainings for the 

project staff;

3. Finalizing the healthy homes protocols and 

two assessment forms (visual and medical);

4. Training the entire staff on the protocols and 

assessment forms; and

5. Staff-wide expansion of the program.

Interventions

Recruitment. Children with elevated blood 

lead levels are automatically reported to the 

Health Department’s Healthy Homes Division for 

case management due to mandated reporting 

laws. Families under case management were 

Appendices
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automatically included in the pilot. Additional 

cases came from maternal and infant nursing 

home visiting programs serving high-risk 

pregnant and post-partum women. 

Interventions. All families received two initial 

home visits (a visual assessment conducted by a 

sanitarian and a health educational assessment 

conducted by a community health worker) and 

one follow-up visit after three months.

Staff members educated families during home 

visits and provided education materials and healthy 

homes supplies. Topics addressed included lead 

and carbon monoxide exposure, fire hazards, 

moisture/mold and pest problems, indoor smoking, 

ventilation, physical hazards, and easy accessibility 

to pesticides. Supplies included books for children, 

roach disks, caulk, non-toxic cleaning supplies, cribs, 

covered trash cans, and outlet covers. 

The environmental team made referrals to the 

Baltimore City Fire Department for free smoke 

alarm installation and to the Coalition to End 

Childhood Lead Poisoning for legal advocacy, 

relocation assistance, and lead abatement. In 

addition, the program worked with Baltimore 

City Maternal and Child Health on the Safe Sleep 

Initiative. Through this initiative, the program 

installed cribs in homes where children under one 

year old had no safe place to sleep. 

During both the initial and the follow-up 

assessments, caseworkers asked clients to 

identify any concerns they had with their home 

and/or family. Then using the client-identified 

issues, caseworkers developed an appropriate 

action plan. During follow-up visits, field staff 

paid attention to client-identified issues and used 

them as reference points. 

Program Staff. In May 2006, the Baltimore City 

Health Commissioner announced the appointment 

of the first major U.S. City Assistant Commissioner 

for Healthy Homes in the nation. From 2006–2009, 

the Health Department’s Healthy Homes Division 

was comprised of 60 staff members working on 

five healthy housing programs and initiatives, 

including an integrated healthy homes inspection 

and health services program, a fire safety initiative, 

a lead abatement funding program, and an 

integrated pest management (IPM) pilot program 

in housing units owned by the Housing Authority 

of Baltimore City.

Staff attended approximately 90 hours of 

training in the first year. Staff attended didactic 

and interactive training seminars on home 

environmental health topics, childhood lead 

poisoning prevention, lead-safe work practices, 

and behavioral health. Additional topics covered 

at the trainings included community resources, 

injury prevention, safe sleep, water testing, 

blood-borne pathogens, mold prevention, carbon 

monoxide poisoning, fire safety, and IPM. 

Funding and Leverage

Funding Sources. CDC, HUD, EPA, State of 

Maryland, and City of Baltimore. 

Evaluation and Outcomes

The program had statistically significant changes 

in health and housing outcomes:

• At the initial visit, 50 percent of the homes 

showed evidence of smoking and only 37 

percent at the follow-up visit (90 percent 

statistically significant).

• At the initial visit, 58 percent of infants had 

their own cribs and 89 percent had their 

own cribs at the follow-up visit (95 percent 

statistically significant).

• At the initial visit, 65 percent of families 

reported smoking indoors and only 45 percent 

reported indoor smoking at the follow-up visit 

(99 percent statistically significant).

• At the initial visit, 33 percent of homes 

“appeared clean,” and 54 percent of homes 

“appeared clean” at the follow-up visit (99 

percent statistically significant).

• At the initial visit, 36 percent of homes were 

free of garbage or debris and 68 percent 

of homes were free of garbage or debris at 

the follow-up visit (99 percent statistically 

significant).

Sustainability

The Health Department’s Healthy Homes 

Division served as a key consultant in the city’s 

receipt of major Weatherization funds. Healthy 

homes priorities are being incorporated into 

weatherization services city-wide.

Appendices
page 193

CDC has produced a report titled Healthy 

Homes Transition Report—A Study of the 

Baltimore City Healthy Homes Division for use 

by other jurisdictions as they evolve from single 

issue lead poisoning prevention programs to 

more comprehensive healthy homes programs.

Best Practices

• Conducting focus groups to assess the 

perspective of program participants directly 

impacted by the transition.

• Using client-identified needs to help prioritize 

issues and create an appropriate action plan.

Appendices
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page 195

Appendix 1.4 Case Study

Boston Public Health Commission & Boston Inspectional 

Services Department

Health Care and Housing Code Enforcement Partnership

Partnerships. Boston’s Public Health 

Commission works with the City of Boston 

Inspectional Services Department, Boston 

Medical Center, Boston Housing Authority, 

Boston Urban Asthma Coalition, Children’s 

Hospital Boston, and Committee for Boston 

Public Housing and Medical Legal Partnership. 

These partners worked together to envision the 

on-line system, implement a pilot project and 

evaluate, monitor and expand the program.

Interventions

Recruitment. Doctors, nurses and other 

healthcare professionals located at hospitals and 

health centers.

Interventions. The program enforces the 

State Sanitary Code Chapter II: Minimum 

Standards of Fitness for Human Habitation 

(Massachusetts Housing Code). Inspections 

may result in issuance of a notice of violation, 

with a maximum time to correct the violation. 

Common asthma triggers covered by the Code 

include the presence of cockroaches, rodents, 

excessive moisture or mold, damaged, wet or 

dirty carpets, excessive heat or absence of heat, 

among other issues.

Program Staff. The program structure includes 

a program coordinator employed by the Boston 

Public Health Commission who works closely 

with housing inspection staff from ISD. This 

system capitalizes on integrating core functions 

of the two city agencies. ISD inspectors conduct 

all the inspections and the Boston Public Health 

Commission manages the program, conducts 

outreach to the health institutions, program 

evaluation and communications.

The Boston Public Health Commission and 

Boston Inspectional Services Department cosponsored annual inspector trainings to increase 

awareness and skills addressing housing 

conditions that contribute to asthma. Program 

staff has also received training in safe pest 

control practices.

Program Overview

Purpose. Breathe Easy at Home (BEAH), 

a program of the Boston Public Health 

Commission and Boston Inspectional Services 

Department and the Boston Inspectional 

Services Department, is a web-based service 

system designed to allow clinicians to make online referrals for housing code inspections for 

their patients with asthma.

Target Population. BEAH targets children and 

adults with asthma living in public or private 

rental housing in Boston neighborhoods with 

high rates of asthma and multifamily rental 

housing. Physicians, nurses, social workers 

and other health workers identify and refer 

their patients in need of environmental asthma 

trigger reduction in their homes.

Model. BEAH is an on-line system for referring 

Boston residents with asthma for housing code 

inspections. Online referrals originate from 

clinical sites. Home inspections are conducted 

by the Boston Inspectional Services Department 

(ISD) inspection staff. Boston ISD enforces 

the Massachusetts housing code in the city 

of Boston. The program is managed out of 

the Boston Public Health Commission, whose 

program coordinator works with the program 

advisory board to undertake planning, outreach 

and recruitment and evaluation. Referring 

clinicians receive electronic updates on the 

status, findings and resolution of the case. 

Inspections may result in issuance of a notice 

of violation, with a maximum time to correct 

the violation. The “correction order” specifies 

the violations that must be remedied to resolve 

the case and a required time frame. A case is 

closed when the violation is corrected. Common 

asthma triggers covered by the Massachusetts 

state sanitary code for housing include presence 

of cockroaches, rodents, excessive moisture or 

mold, damaged, wet or dirty carpets, excessive 

heat or absence of heat among others.

Appendices
page 196

Systems and Policies

The program enforces the Massachusetts 

Housing Code, officially titled the State 

Sanitary Code Chapter II: Minimum Standards 

of Fitness for Human Habitation. Inspections 

are conducted by Boston ISD’s Housing 

Inspection Division. This healthy homes 

program leverages an existing regulation and 

enforcement infrastructure and uses staff whose 

job responsibilities were broadened to focus on 

asthma triggers.

Funding and Leverage

The program is dependent on extensive 

leveraged resources from the Boston 

Inspectional Services Department. Financial 

support is also provided by the City of Boston, 

Boston Public Health Commission, which has 

secured grants to support the program pilot and 

supplement city funds for program coordinator 

support.

Evaluation and Outcomes

Evaluation includes:

• Focus groups with ISD inspectors for feedback 

and recommendations on program needs.

• Interviews with clients to capture satisfaction 

and information on environmental and health 

benefits of the program.

• Interviews with clinician referrers on utility 

and ease of the on-line system and program 

benefits.

• Program measures such as housing conditions 

cited, case resolution rates and timelines.

• Overall referral numbers and by referring 

institution and neighborhood.

• Health outcome evaluation in planning stage.

Sustainability

This program has been institutionalized 

within the ISD and the Boston Public Health 

Commission and uses the current housing code. 

It is not dependent on grant funding.

Best Practices

• Community-based organizations advocated 

for local efforts on housing issues that impact 

asthma management.

• Collaboration with the key housing agencies 

in the City of Boston resulted in a sustainable 

service systems and policy change.

• Strong relationships with health care 

institutions facilitated awareness of housing 

concerns and their impact on the patients’ 

health.

• Building on existing infrastructure makes 

the program less dependent on external 

fundraising.

Appendices
page 197

Appendix 1.5 Case Study

Case Western Reserve University School of Medicine 

Swetland Center for Environmental Health

Healthy Homes and Babies Program (Cleveland, Ohio) 

Program Overview

Purpose. The purpose of the program is 

to provide home health and injury hazard 

assessments and interventions to pregnant 

women, infants, and geriatric patients. The 

program also provides the opportunity for 

physicians-in-training to learn about housingrelated health hazards by participating in the 

environmental assessments of their patients’ 

homes. 

Target Population. The target area included the 

City of Cleveland and its first-ring suburbs. The 

program targeted homes with young infants as 

a prevention measure and the elderly to support 

independent living and aging in place.

Partnerships. The Swetland Center for 

Environmental Health at Case Western Reserve 

University School of Medicine provided 

leadership for the program. Partners include 

the Departments of Pediatrics and Family 

Medicine and the Center for Geriatric Medicine 

at the University Hospital’s Case Medical Center, 

Environmental Health Watch (EHW), a grassroots 

community-based nonprofit organization, 

Community Housing Solutions, a nonprofit 

affordable housing organization, and the Lead 

Programs of the Cleveland Department of 

Public Health and the Cuyahoga County Board 

of Health. The program provided follow-up 

referrals to weatherization, home repair lead 

hazard control grant programs as needed. 

Community Involvement. Neighborhood 

Leadership Institute (NLI) organizes and 

manages a Community Advisory Board to bring 

community concerns and suggestions to the 

program. NLI offers a 14-week training program 

in partnership with Cleveland State University 

for community residents who wish to improve 

their grassroots advocacy and leadership skills.

Planning. This project evolved from existing 

partnerships related to lead poisoning 

prevention and healthy homes. As these partner 

organizations became more familiar with each 

other’s strengths and service areas, they were 

able to identify a variety of program needs and 

resources. The long term partnership between 

Case Western Reserve University, EHW, and 

the city and county health departments was 

significant in gaining political support and 

funding. Demonstration programs and technical 

studies were used to pilot the assessments and 

interventions.

Interventions

Recruitment. Medical residents recruited 

their pregnant, infant, and elderly patients for 

participation in the project and accompanied the 

EHW inspector to their patients’ homes for the 

assessment. 

Interventions. The assessment included an 

occupant interview, visual assessment of paint 

condition, collection of dust and soil samples 

for lead analysis, tap water and refrigerator 

temperature measurements, observations of 

child/elderly fall and injury hazards, infant’s 

sleep environment, and visual evidence 

of smoking, mold, roaches, rodents, dust 

mites, pets, pesticides, space heaters, faulty 

combustion appliances, and the presences of 

smoke and carbon monoxide (CO) detectors. 

Four types of interventions were provided: (1) 

health and safety items; (2) low-level repairs/ 

improvements; (3) referral to other programs 

for higher-level repairs or improvements; and 

(4) a written plan for behavioral changes that 

the family agreed to make. These plans were 

expected to be reinforced by the medical 

resident in future visits. 

1. Health and safety items: A standard and a 

variable set of health and safety items were 

provided to the families, differing somewhat 

for the infants and elderly, and tailored to the 

specific needs found in the health-oriented 

home inspection. The standard items included 

allergen vacuum, fire extinguisher, smoke 

Appendices
page 198

and CO detectors, digital thermometer 

(mercury thermometers are removed from the 

household for proper disposal to eliminate 

breakage risk), door mats, and cleaning 

supplies. In addition, site specific items were 

provided, depending on the hazards found. 

2. Low-level building interventions: Based 

on the inspection and the lead sampling 

results, EHW home environmental specialists 

conducted low-level building repairs, 

modifications, and hazard remediation. 

These were limited interventions that 

could be performed by EHW staff in rental 

properties without the owner’s permission. 

The interventions included installation of 

safety items, environmental cleaning to reduce 

lead dust and other contaminants, moisture 

reduction measures, and integrated pest 

management (IPM).

3. Referral for building interventions: Based 

on the paint condition and lead dust 

sampling results, referrals were made to 

the City of Cleveland and Cuyahoga County 

Lead Hazard Control Programs. For other 

repairs and weatherization, referrals were 

made to Community Housing Solutions and 

weatherization program. EHW staff worked 

with the families and the landlords to establish 

eligibility and complete application forms. 

EHW’s Affordable Green Housing Center 

has also developed a set of no cost/low-cost 

recommendations for electricity, gas, and 

water use reductions for low-income housing. 

4. Education and behavioral change: During the 

inspection, families were educated about their 

role in reducing home health hazards. Medical 

residents reinforced these recommendations 

in the clinic setting.

Interventions for frail elderly clients focused 

primarily on fall prevention, IPM, lighting, and 

addressing deferred maintenance and clutter. 

Electrical repairs were one of the most frequent 

referrals due to the age of the housing and the 

medical equipment needs of the elderly clients.

Systems and Policies

The program developed referral networks 

with multiple health and housing programs in 

the community and facilitated the application 

process to assure comprehensive services to 

families and homes in need.

Funding and Leverage

Funding Sources. HUD Healthy Homes 

Demonstration grant funding was matched 

with in-kind support provided by Case Western 

Reserve University. As the program expanded, 

private funds were leveraged to partner with 

HouseCalls, a program designed to serve frail, 

home-bound seniors. The project received 

another HUD Healthy Home Demonstration 

grant to support a Healthy Homes and Patients.

Program Costs. Pediatric home inspections and 

interventions averaged $927 (ranging from $509 

to $4197), and geriatric home inspections and 

interventions averaged $577 (ranging from $247 

to $936). Visits for pediatric patients were more 

expensive in direct costs because additional 

health and safety items were required. 

Sustainability

The program is being brought to the Greater 

Cleveland Asthma Coalition with the goal of 

obtaining Medicaid reimbursement for home 

visits as a cost-effective means to achieve the 

health benefits of prevention.

Project staff believes that the residency 

training component could be replicated in any 

community where a connection exists with an 

organization that provides home assessments 

and/or interventions. 

Best Practices

• The inspector used a personal data assistant 

(PDA) to conduct the visual assessment. 

As technology has evolved, the program 

converted to an Access database and a tablet 

PC for data collection. The computerized 

assessment guided the inspection through 

each area of the house, documented building 

and behavioral conditions, explained 

the related hazard, provided drop-down 

alternatives to enter observations, and 

listed available corrective actions and 

who would perform the action (e.g., EHW, 

family, physician, owner), transforming the 

inspection process and assessment tool into 

Appendices
page 199

an educational opportunity for the medical 

resident and the family member. The action 

plan was computer-generated, based on the 

assessment data.

• An established relationship between the 

patient and doctor eased the process of 

scheduling home visits, resulting in a much 

lower rate of cancellations and “no shows.” 

• The program demonstrated that medical 

residents benefit from participating in home 

inspections of their patients. The doctors 

reported that the experience influenced their 

practice of medicine, resulting in a more 

focused environmental history-taking.

Appendices
page 200 Appendices
page 201

Appendix 1.6 Case Study 

Children’s Mercy Hospitals and Clinics

Clinic/Medical Partnership (Kansas City, Missouri)

Overview

Purpose. The purpose of the Children’s Mercy 

Hospital Environmental Health Program (CMHEHP) is to create healthy and sustainable 

indoor environments for children wherever 

they spend time. The program has four focus 

areas: patient-centered environmental health, 

health provider education and training, safe 

and healthy school and childcare programs, and 

community education and training programs. 

Through extensive collaborations with a wide 

variety of stakeholders the CMH-EHP is able to 

offer unique and comprehensive environmental 

health services that might impact families within 

the community through different communitybased channels. Once concerns for a pediatric 

patient are identified, the CMH-EHP staff can 

offer multiple services and resources addressing 

exposure-related health issues in any setting 

where the patient spends time.

Target population. The CMH-EHP worked with 

asthmatic children two to 17 years old.

Partnerships. Program partners include Kansas 

City, MO Health Department Lead Poison 

Prevention Program; Kansas Department of 

Health and Environment’s Healthy Homes and 

Lead Hazard Control Program; Metropolitan 

Energy Center; Wyandotte County, KS, Health 

Department; EPA’s Indoor Environment, 

Environmental Justice , and Children’s Health 

Protection Departments in Region 7; MidAmerica Pediatric Environmental Health 

Specialty Unit (MAPEHSU); and 60 other 

community organizations. CMH-EHP is also a 

member of the Healthy Indoor Environments 

Coalition of the Heartland.

Interventions

Recruitment. Families may be referred by their 

private physician or through the entire hospital 

information system via an internal environmental 

consult process or by contacting the program 

staff directly. Families are asked to enroll in a 

four to six month healthy home program that 

involves from three to six visits. Some aspects 

of the program are research-related and require 

participation in an informed consent process.

Interventions.

• Depending on the severity of a patient’s health 

condition families are offered one of two levels 

of participation; basic and advanced. In either 

case, home assessments are conducted to 

both educate families on healthy home best 

practices and to identify any issues about the 

home and its maintenance that represent a 

significant hazard or might be contributing 

to health problems of the occupants. 

Interventions are comprehensive but usually 

focused on controlling environmental irritants 

and allergens, including asthma triggers, 

sources of lead exposure, and safety and injury 

prevention. For patients with significant health 

issues, an advanced home environmental 

health assessment that includes environmental 

monitoring and sample collection is performed 

to more specifically identify sources of 

contaminants. This information is then used 

to identify targeted interventions to eliminate 

contaminant sources and exposure.

• All families who agree to participate in the 

program receive a healthy home kit that 

includes cleaning supplies, safety supplies 

and healthy home supplies including a HEPA 

vacuum, furnace filters, allergen bedding, a 

pocket hygrometer,

• For families receiving advanced home 

assessment services, a list of targeted 

interventions is developed and resources are 

identified to address the concerns identified. 

A case review takes where members agree 

to a list of interventions related to one of five 

healthy home domains; airflow and ventilation, 

allergens and dust, moisture control, chemical 

exposure and safety and injury prevention. 

Community partners oversee the intervention 

work and a follow up assessment is performed 

to verify that any contaminant sources have 

been removed and the family has begun the 

process of changing behavior to create a 

healthier home.

Appendices
page 202

Program Staff. The project utilizes a program 

manager, an office coordinator, environmental 

hygienists and environmental health 

coordinators (e.g., respiratory therapists, health 

educators, advocates), and social workers. 

Environmental hygienists are trained in-house on 

environmental health, environmental assessment 

protocols, indoor environmental hazard 

measurements and sampling techniques, basic 

building science, and healthy homes and school 

practices. Training is supplemented through 

outside education opportunities. Environmental 

health coordinators are trained in environmental 

health, asthma, and safe and healthy home and 

school practices. They also serve as the primary 

educators in all settings. Some training is 

provided by outside sources.

Systems and Policies

Partial Medicaid reimbursement has been 

received for some home assessment service. 

CMH-EHP is currently working with a state-wide 

stakeholder group in Missouri to establish a 

policy for Medicaid reimbursement for all home 

environmental health assessment services.

A relationship between Missouri Legal Aid 

and the program staff enables advocacy for 

families on home environmental problems, code 

violations, lease disputes, or other issues that 

impede the families’ ability to make changes in 

their homes.

The program is currently exploring expanding 

services through community partners to 

assist elderly adults with home environmental 

concerns.

Funding and Leverage

Funding Sources. Funding has been secured 

from HUD, EPA, MAPEHSU, corporate sponsors, 

and health insurance reimbursement.

School-based services are paid for through 

annual contracts with individual districts.

Because of the mission of Children’s Mercy 

Hospitals and Clinics to serve the community 

and benefit all children, many services are inkind or services fees are negotiated down to a 

level families indicate they can afford.

Program Costs.

• Basic home environmental health assessments 

include a visual assessment and healthy home 

education and case management: $100 to 

$300 per home.

• Advanced home environmental health 

assessments include a visual assessment, 

healthy home education and case 

management, Environmental Measurements 

and Sample collection and analysis: $500 to 

$800 per home, depending on the number of 

environmental samples collected, if any.

The program charges a fee for a home 

assessment. Attempts are made to obtain 

reimbursements from health insurance 

companies, including Medicaid and HMOs. In 

some cases, families pay for the service out 

of pocket, and in other cases, a family can 

negotiate the fee down to little or nothing.

Leveraged resources. The CMH-EHP partners 

with the two area lead hazard control programs, 

two local weatherization programs, small home 

repair programs, and some neighborhood 

associations to fund housing repairs. They 

are currently working with local Habitat for 

Humanity programs to develop volunteer efforts 

to benefit families in need of assistance with 

healthy home issues.

EPA funds are used for an Asthma-Friendly 

Child Care Program for home-based child care 

operations. This program supports assessments 

of home-based child care.

The CMH-EHP also receives financial support 

from private companies:

• Allergy Zone provides furnace filters and 

N95 masks to all families participating in the 

Healthy Home Program.

• Mission Allergy provides significant discounts 

on allergen encasement for mattresses and 

pillows.

• True Value hardware stores provide special 

pricing on healthy home supplies.

• Mar-Beck Appliance provides reconditioned 

HEPA vacuums at a special price for the 

Healthy Home Program.

Appendices
page 203

Sustainability

School Partnership. CMH-EHP developed the 

School IEQ Program to provide training related 

to the indoor environment, asthma, and healthy 

schools to school district staff. This program also 

provides an environmental health assessment 

of school facilities. This effort led to two school 

districts signing contracts with the CMHEHP to provide indoor environmental health 

management programs. To date, the School IEQ 

Program had assessed over 1400 classrooms.

Training Center. CMH-EHP established a 

Healthy Homes Training Center for Region VII 

through a partnership with the National Center 

for Healthy Housing, the Kansas City, MO, 

Health Department, and the Kansas Department 

of Health and Environment’s Healthy Homes and 

Lead Hazard Control Program.

Center for Environmental Health. The program 

is in the process of converting from CMH-EHP 

into a Center for Environmental Health. The 

CMH-EHP addresses indoor environment issues 

in areas where children spend most of their time 

(e.g., schools, child care facilities, hospitals, and 

homes). The program offers training classes on 

indoor environmental health and asthma for 

physicians, clinicians, school nurses, home health 

staff, social workers, public health workers, child 

care providers, code enforcement inspectors, 

and families.

Best Practices • Patchwork funding from a variety of sources 

including private donations.

• Comprehensive care coordination based 

on routine communication between 

environmental health coordinators, health care 

providers, school nurses, and families.

• A comprehensive, school-based program that 

focuses on the safety of the environment and 

classroom-based and hands-on healthy homes 

training. Staff receives regular training to keep 

their knowledge current.

Appendices
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page 205

Appendix 1.7 Case Study 

Esperanza Community Housing Corporation

South Los Angeles Healthy Homes Program

Program Overview

Purpose. The purpose of this program was to 

prevent lead exposure in pregnant women and 

children under six years, reduce asthma triggers 

for families living in substandard housing 

without jeopardizing their tenancy, and create 

systemic changes in health and housing agencies 

by demonstrating that healthy housing is an 

important health intervention.

Target population. The program targeted lowincome families in 13 census tracts in South 

Central Los Angeles with a particular focus on 

families with children under age six at high risk 

for lead poisoning and other consequences of 

substandard housing.

Partnerships. Esperanza Community Housing 

Corporation (Esperanza) collaborated with St. 

John’s Well Child and Family Center (St. John’s) 

and Strategic Actions for a Just Economy 

(SAJE) in leading this project. The Los Angeles 

Healthy Homes Collaborative, an association 

of community-based organizations committed 

to eliminating environmental threats in homes 

and communities spearheaded the code 

enforcement aspect of this project. Additional 

partners were the Los Angeles Community 

Action Network (LACAN), Inner City Law, 

Los Angeles Housing Department City Code 

Enforcement Program, and Eisner Pediatric & 

Family Medical Center.

Community Involvement. Esperanza was 

founded as a result of a four-year organizing 

effort by community residents in the Figueroa 

Corridor of South Central Los Angeles. 

Esperanza’s project staff are a team of 

Promotoras de Salud (community health 

promoters) specializing in healthy homes 

interventions. They are community residents 

who are graduates of Esperanza’s six-month 

intensive Community Health Promoters Training, 

followed by years of specialized training in lead 

dust sampling, lead-safe work practices, and 

Healthy Homes related protocols. The program 

was designed entirely with their input as they 

were from the community and knew first-hand 

the needs and housing conditions of the families 

in the neighborhood.

Interventions

Recruitment. Families were identified and 

recruited through:

• Referrals from the St. John’s Well Child and 

Family Center;

• Tenant-organizing activities by SAJE; and

• Door-to-door outreach to other families living 

in the buildings visited by the Healthy Homes 

Team as a result of any referral.

Interventions. The program is a coordinated, 

tri-discipline approach involving: (1) community 

outreach, in-home environmental assessment, 

and education; (2) tenant rights and 

displacement prevention; and (3) progressive 

clinical monitoring of environmentally-caused 

illness and injury.

The housing interventions included an initial 

home visit, administration of the Health and 

Housing Survey, education and management 

of housing conditions, and monitoring of home 

environmental triggers. Lead dust samples, 

moisture meter readings, and cockroach 

sampling were conducted. Families participating 

fully in the data collection procedures received 

a Bucket Cleaning Kit. The kit contained a mop, 

gloves, baking soda, vinegar, two rags, and 

a spray bottle, as well as Healthy Homes and 

poison prevention material.

Program Staff. The project utilized a project 

manager and data analyst (both trained 

Promotoras), Esperanza executive director, 

finance director, and a team of Healthy Homes 

Promotoras, community organizers, tenant 

organizers at SAJE, clinicians, and a part-time 

evaluation consultant. Most of the Esperanza 

team were certified lead sampling technicians 

and had years of training in lead-safe work 

practices and integrated pest management.

Appendices
page 206

Systems and Policies

Esperanza’s work, as part of the Los Angeles 

Healthy Homes Collaborative, has resulted in 

important State Policy: the development and 

enactment of Senate Bill 460, put into law 

January 2002. This law empowers and mandates 

both local code enforcement agencies and 

local health departments to stop unsafe work 

practices and makes the disruption of lead 

hazards a violation of both housing code.

The South Los Angeles Healthy Homes Program 

has focused on housing as a highly significant 

determinant of health, documenting negative 

health impacts of substandard housing and 

positive impacts of quality, affordable housing. 

As a result of this partnership our clinical 

partners have adopted a “zero-tolerance” for 

blood lead policy that has resulted in systems 

of universal testing of all children and universal 

reporting of all results to the Healthy Homes 

program.

The partnership between the Los Angeles 

Healthy Homes Collaborative and the City’s 

Systematic Code Enforcement Program (SCEP) 

has integrated healthy homes concerns into 

Los Angeles code enforcement activities. 

Community outreach workers, whether 

Promotoras or tenant organizers, work with the 

City Code Enforcement Inspectors to make their 

work more impactful, correctly focused on an 

expanded menu of housing code violations, and 

specifically beneficial (rather than threatening) 

to the tenants.

Funding and Leverage

Funding Sources. HUD and in-kind services from 

project partners.

Leveraged Resources. Leveraged financial 

support for the project totaled $1,500,000 for 

the three principal partners combined. St. John’s 

Well Child and Family Center also received a 

2009 Everychild Foundation Grant to continue 

the work of the collaborative. Both SAJE and 

Esperanza received funding from the California 

Endowment and California Wellness Foundation.

Housing units were also referred to the City of 

Los Angeles’ Lead Hazard Remediation Program.

Evaluation and Outcomes

Data Management. Significant emphasis was 

placed on data clean-up and quality in data 

entry. The Project Manager regularly supervised 

the data clean-up and provided follow-up 

training to staff as needed. The Project Manager 

also made quality assurance calls and visits to 

households following Promotoras’ home visits 

to ensure that project protocols were properly 

adhered to.

Health and Housing Outcomes. Participant 

awareness of lead hazards increased significantly 

as a result of this initiative. At baseline, 30 

percent were aware that chipping and peeling 

paint can cause lead poisoning. At the time of 

the follow-up survey, this number increased to 

75 percent; by the time of the final survey, it had 

reached 94 percent.

Records kept by St. John’s on 550 asthma 

patients who are receiving intensive case 

management services revealed the following 

results:

• 80 percent reduction in the percentage of 

clients visiting the ER due to asthma.

• 67 percent reduction in the percentage of 

clients hospitalized due to asthma.

• 65 percent reduction in the percentage of 

clients visiting the clinic/doctor due to an 

asthma attack.

• 55 percent reduction in the number of school 

days missed because of asthma.

• 69 percent reduction in the percentage of 

children missing one or more days of school 

due to asthma.

• 100 percent of clients have had a routine 

asthma visit.

• 100 percent of clients have a written asthma 

action plan.

• 100 percent of working caregivers report 

reduction in the number of missed work days 

per month due to asthma (one or more missed 

work days).

• 68 percent of clients report daytime 

symptoms two days or fewer per month.

• 76 percent of clients report nighttime 

symptoms two days or fewer per month.

Appendices
page 207

• 73 percent of clients with persistent asthma 

symptoms taking controller medication.

• 47 percent reduction in treatments for vermin 

bites, cockroaches, and environmentallyassociated skin conditions.

• At the initial visit, more than half of the 

participants reported having cockroaches; by 

the final visit, only 14 percent reported having 

roaches.

Sustainability

• Advocacy is impacting policy change and 

enforcement of City housing codes.

• The health and human rights model 

championed by the South Los Angeles 

Healthy Homes Program is a key sustainability 

framework; the concept that having access to 

good housing and healthcare is a fundamental 

right and not merely a privilege. This framework 

is currently gaining traction in South Los 

Angeles, and influence in Los Angeles County.

Best Practices

• The use of Promotoras (representatives of 

the target community) in recruitment and 

enrollment, outreach, tenant education, and 

home visits. Promotoras served as the bridge 

for other health and housing agencies to 

gain entry to the home, such as the housing 

inspectors. The Promotoras’ involvement 

encouraged trust among community and 

organizations.

• Developed a team trained in both healthy 

homes protocols and comprehensive 

community health, such as domestic violence 

and tenants’ rights; cultivating relationships 

between local families and a cadre of 

community health leaders that helps build a 

stable community.

• Linked tenant environmental health education 

with referrals to tenants’ rights clinics and 

protections to prevent displacement.

• The “Medical Evidence Form” developed 

under our partnership allowed physicians 

to note environmentally-driven conditions 

that children manifest in clinical visits, such 

as elevated blood lead levels, vermin bites, 

rashes, and upper respiratory distress. The 

completed form triggers a visit to the home 

by health Promotoras who report back to the 

physician about the status of remediation for 

some of the housing conditions. The physician 

may send a letter to the landlord stating the 

effect of the housing conditions, considered 

code enforcement violations, on the health 

of the child and recommendations for 

remediation practices. This letter is only sent 

if there is an established relationship between 

the families and the tenant organizers to limit 

threats of eviction of tenants.

Appendices
page 208 Appendices
page 209

Appendix 1.8 Case Study

Public Health—Seattle and King County 

Evolution of a Healthy Homes Program 

CHW who resided in the same community as the 

families, the ability to individualize the training 

and interventions to the families’ needs, and the 

provision of resources to address the asthma 

triggers.

Second Stage. A second randomized 

controlled study compared the effect of asthma 

management education (that included both 

medical and environmental aspects of selfmanagement) and support provided by trained 

nurses in a clinic situation compared to in-home 

education and support by a nurse in combination 

with a CHW who made home visits. While 

both conditions led to improvements in many 

measures, the families served in their home 

CHW showed greater levels of improvement 

on a number of measures, with statistically 

significant improvements in behavioral changes, 

symptom-free days and caregiver quality of life.

Third Stage. Public Health Seattle and King 

County’s Better Homes for Asthma grant was 

designed to combine the CHW home visits 

of the earlier projects with remediation of 

structural conditions in the rental properties 

where the families with asthmatic children 

lived and test the marginal benefit of the 

renovation. The earlier studies showed that 

some of the environmental conditions identified 

as high-priority items in the family action plans 

were outside the family’s control, such as the 

temperature of hot water, the ability to remove 

carpets, mold that could not be controlled 

through cleaning alone, and roach infestation in 

multi-family apartment buildings.

This project intended to address those structural 

conditions in properties owned by the Seattle 

Housing Authority and private landlords and 

to determine whether there were additional 

benefits beyond the Community Health Worker 

one-year intervention. Due to the complexities 

of the human subjects application and 

contracting for renovations, this project was not 

completed.

Fourth Stage. The Seattle Breathe Easy 

Homes project was the next effort to address 

Program Overview

Better Homes for Asthma and Breathe Easy 

Homes represent later stages in the evolution 

of multiple initiatives conducted in Seattle/

King County. All of these projects addressed 

housing conditions of low-income children with 

diagnosed asthma. The first two NIEHS grants 

focused on the development of protocols for 

visual assessments and behavioral interventions 

conducted by Community Health Workers 

(CHW). The later Healthy Homes Projects 

received HUD funding and included renovations 

to the homes.

First Stage. The first study, a randomized 

controlled trial, compared two interventions:

1. Low intensity intervention: Consisting of a 

single home visit by a trained CHW, a home 

environmental assessment, preparation of a 

behavioral action plan for the household with 

priority actions jointly developed between 

a family member and the CHW, limited 

education on asthma triggers, and distribution 

of bedding encasements. This control group 

was offered the full range of high intensity 

services one year after the baseline visit.

2. High intensity intervention: Consisting of 

four to eight additional visits by the CHW after 

the baseline visit over the course of a year, an 

environmental assessment and action plan, 

distribution of a more comprehensive package 

of asthma-trigger supplies (allergy-control 

mattress and pillow covers, low-emission 

vacuums, door mats, cleaning kits, roach baits, 

rodent traps), referrals to smoking cessation 

clinics, free allergen skin-prick tests, and 

assistance with pest eradication and advocacy 

for improved housing conditions.

The study demonstrated that both groups 

benefited from the home visit experience, but 

that substantially greater improvements in 

caregiver quality of life scores and reductions in 

use of urgent care services were associated with 

the high-intensity intervention. The researchers 

attributed much of this success to the use of 

Appendices
page 210

childhood asthma triggers through structural 

intervention and in-home education and 

asthma management plans provided by CHW 

educators. Thirty-five (35) new units in the 

Seattle Housing Authority’s High Point HOPE 

VI redevelopment community were constructed 

as Breathe Easy units. In addition to meeting 

the Seattle BuildGreen design criteria, these 

units also included enhancements to the 

exterior envelope, foundation, interior finishing, 

flooring, and the ventilation system to reduce 

moisture infiltration and mold growth, provide 

smooth and easy-to-clean floors, reduce outgassing of building materials, increase fresh air 

exchange, and reduce allergy triggers related to 

landscaping.

BREATHE EASY HOMES

Program purpose: To provide new, affordable 

housing for low-income children with asthma 

and to assess whether this new housing 

provided more health benefits than achieved 

through the intensive CHW education and 

behavioral change program.

Target population: The target population was 

the High Point HOPE VI development in West 

Seattle. Families with children aged 3–17 with 

health-care provider diagnosis of persistent 

asthma, who agreed to meet all required criteria 

for documenting low-income status for residents 

of public housing, passed credit and background 

checks, and agreed to meet the lease 

requirements for living in the asthma-friendly 

units. The project had originally intended to limit 

enrollment to families that had lived in the High 

Point development before rehabilitation, but 

found that some residents chose not to return 

after relocation so recruitment was opened to 

others with asthma who qualified for subsidized 

housing.

Partnerships, agencies, coalitions, and 

community organizations: Public Health 

Seattle and King County (PHSKC), SimonFraser University, King County Asthma Forum, 

Seattle Housing Authority (SHA), and Enterprise 

Community Partners (for a later phase of the 

project to build an additional 25 Breathe Easy 

units).

How was the community involved in decision 

making, implementation, and evaluation? 

A community activist and resident of the 

High Point community raised the possibility 

of building asthma-friendly units during 

early discussions of the HOPE VI redesign. 

A community advisory board was active 

throughout the project.

Interventions

How were homes and families identified, 

recruited, and retained? The composition of 

the surrounding neighborhood changed from 

the time that the HOPE VI reconstruction was 

first discussed. At the time of recruitment, 

the majority of neighborhood residents did 

not speak English as their first language. 

Recruitment of the families was achieved 

through referrals from clinics, hospitals, 

physicians, community-based organizations, 

flyers, and word-of-mouth.

In order to be eligible for housing in the Breathe 

Easy units, the families had to agree to work 

with the program for one year before placement. 

Using the CHW model developed in previous 

projects, at baseline a CHW and translator 

conducted a visual assessment, collected dust 

samples from the child’s bedroom, and provided 

bedding covers and education. Subsequent 

home visits reinforced the educational and 

behavioral management plan.

Education and/or housing interventions: In 

addition to meeting the Seattle BuildGreen 

design criteria for all units in the High Point 

development, these units also included 

enhancements to the exterior envelope, 

foundation, interior finishing, flooring, and 

ventilation system to reduce moisture infiltration 

and mold growth, provided smooth and easyto-clean floors, reduced out-gassing of building 

materials, increased fresh air exchange, and 

reduced allergy triggers related to landscaping.

Systems and Policies

What policies, regulations, or government 

service systems supported or impeded the 

program’s effectiveness?

Although new CHW needed to be hired and 

trained, the process worked efficiently. The 

program also had experience working with nonEnglish speaking families and had translated 

Appendices
page 211

educational materials available. Healthy Homes 

I and II projects also prepared the project staff 

for unique cultural practices that might impact 

asthma (such as use of incense) and strategies to 

redirect those behaviors in culturally acceptable 

ways.

The High Point community had an active citizen 

base that was actively engaged in the “green” 

housing design process.

Funding and Leverage

Sources of funding: Healthy Homes Grant for 

enhancements, Hope VI for basic housing costs.

Leveraged resources: Additional Enterprise 

Community Partners funding for 25 units.

Evaluation and Outcomes

How were program services monitored 

and evaluated? The project used a pre-post 

with historical comparison group evaluation 

design. Clinical evaluation included a detailed 

assessment of asthma severity, medication 

and health services use, administration of the 

Juniper scale quality of life measurement, skin 

test sensitization, and a methacholine challenge.

This latter physiologic test is considered the 

most effective test for pulmonary function, 

airway sensitivity and a measure of the child’s 

current asthma activity. These evaluation 

measures were made at the beginning of the 

one-year CHW intervention in the old home. 

Additional data was collected after one year of 

working with the CHW in the old home, after 

participants moved to their new home, and after 

one year in the new home (three separate time 

points). This enabled a pre-post comparison 

between the established CHW intervention in 

the old home and the impact of the new home 

on the same asthma endpoints described in 

previous studies with the addition of the very 

sensitive methacholine challenge test.

The study showed:

• BEH residents’ asthma-symptom–free days 

increased from a mean of 8.6 per 2 weeks in 

their old home to 12.4 after one year in the 

BEH.

• The proportion of BEH residents with an 

urgent asthma-related clinical visit in the 

previous three months decreased from 62 

percent to 21 percent.

• BEH caretakers’ quality of life increased 

significantly.

• The BEH group improved more than did the 

comparison group, but most differences in 

improvements were not statistically significant.

• Exposures to mold, rodents, and moisture 

were reduced significantly in BEHs.

Best Practices Across All Programs

• Multiple asthma triggers need to be 

addressed for sustained health benefits. The 

studies continued to demonstrate the value 

of a comprehensive assessment and repairs 

tailored to observed asthma triggers, as 

opposed to a “one size fits all” approach.

• Homes specifically designed to reduce asthma 

triggers may add additional benefit than 

those obtained through CHW interventions 

alone and may be particularly desirable for 

clients who will have difficulties implementing 

the behavioral changes required in other 

interventions. More research is needed to 

understand the impact and role of asthmafriendly homes.

• Use of CHW and the need for systematic 

training: The CHWs served as role models to 

the community. They have proved effective in 

connecting with participants and gaining their 

trust. They helped families change behaviors, 

secure resources and ultimately improve 

control of their children’s asthma. CHWs also 

acquired marketable skills that are sustainable 

and transferable to other employment 

situations, such as client counseling. The 

program has continued to use and value the 

CHWs, as they were accepted and trusted by 

the community.

• Multiple CHW visits were important to 

facilitating residents’ behavioral change. 

Currently, the program recommends one 

intake visit, three follow-up visits and optional 

fourth and fifth visits if needed.

• Caregivers need resources and incentives 

to maintain a home-based asthma trigger 

reduction program. Distributing cleaning 

Appendices
page 212 Appendices

and other materials at baseline increased 

credibility of the project with the residents.

• The need for continuous quality improvement: 

A staff retreat, including all the CHW, was held 

to identify lessons learned and strategies to 

overcome obstacles for future projects.

• Home-visiting programs need sustainable 

sources of funding to assure continuity of 

services.
page 213

Appendix 1.9 Case Study

Cincinnati Children’s Hospital Medical Center

Injury Prevention Program Model 

homes, or trailer homes. Invitational letters were 

sent out to potential eligible mothers.

Interventions. Households enrolled, consented, 

and randomized to the intervention portion of 

the injury hazard control project underwent a 

comprehensive, standardized, and validated 

survey of all living spaces of the home, including 

stairways, finished basements, and attics 

(the IPV). Hazard counts and densities (i.e., 

number of hazards per area) were developed 

comprehensively for the indoor environment 

and by high exposure rooms (i.e., kitchen, main 

activity room, stairways, child’s bedroom, and 

bathroom).

Surveys and interventions were directed 

primarily at areas below one meter in height 

(i.e., 39 inches and the 75th percentile in height 

for a three-year-old male). The recommended 

interventions were reviewed with the mother 

who had the option of choosing in rank order 

from the most passive and durable safety device 

to the least passive and non-durable (e.g., a selfclosing and locking stair gate bolted to a wall as 

compared to a pressure-mounted stair gate).

Trained research assistants then installed 

all consumer safety devices suggested to 

and agreed upon by the enrolled mother 

(and landlord when the home was rented). 

Recommended devices not installed were noted 

and tabulated in the counts of hazards and 

hazard density during follow-up surveys.

Program Staff. Program staff included 

intervention technicians, home survey assistants, 

and phone survey assistants. They worked as 

teams. Staff was trained on the study protocols 

and survey forms and how to recognize child 

neglect and abuse.

Funding and Leverage

Funding Sources. National Institute of Child 

Health and Development (NICHD, National 

Institute of Environmental Health Sciences) and 

the U.S. Environmental Protection Agency.

Program Overview

Purpose. The purpose of this program was 

to reduce exposure to injury hazards in the 

homes of young children from birth through 

four years of age. This project developed and 

validated the Home Observations and Measures 

of the Environment (HOME) Injury Survey that 

identifies and remediates injury hazards for 

young children in the home. This project also 

tested an intervention in which injury hazards in 

homes were minimized through installation of 

multiple safety devices.

Target population. Homes of children less than 

five years of age, living in pre-1978 homes within 

a five-county study surrounding the City of 

Cincinnati, Ohio.

Partnerships. Cincinnati Children’s Hospital 

Medical Center, Center for Children’s 

Environmental Health, University of Cincinnati 

Department of Pediatrics, National Institute for 

Environmental Health and Safety (NIEHS), U.S. 

Department of Housing and Urban Development 

(HUD, U.S. Environmental Protection Agency 

(EPA), National Center for Injury Prevention and 

Control (NCIPC) at the U.S. Centers for Disease 

Control and Prevention (CDC), and National 

Institute for Child Health and Development 

(NICHD).

Planning. The HOME Injury Survey was 

developed by analyzing the leading 

residential mechanisms for emergency visits, 

hospitalizations and deaths for U.S. children and 

reviewing surveys used in other studies.

Interventions

Recruitment. Expectant mothers visiting any 

of five participating obstetrical practices for 

prenatal care were screened for potential 

eligibility. Expectant mothers had to be at least 

18 years of age, less than 19 weeks gestation, 

living in pre-1978 homes within the five-county 

study area encompassing the City of Cincinnati 

and not living in public housing, shelters, group 

Appendices
page 214

Program Costs. The intervention cost, on 

average, was $700–$800 per home:

• $300–$350 per home for consumer safety 

products.

• Two to three hours to install the consumer 

safety products properly, averaging $300–

$400 in labor costs per home.

Evaluation and Outcomes

This was the first trial of home safety to 

demonstrate both a reduction in injury hazards 

and subsequent, medically attended injury in 

enrolled children randomized to an intervention. 

The HOME Injury Survey correlated with 

reported risk factors for childhood injury 

(i.e., externally valid), including maternal 

depressive symptoms, household income, and 

maternal age. Four high-risk, high-exposure 

rooms (i.e., kitchen, main activity room, child’s 

bathroom, and child’s bedroom) identified by 

parents in previous reports were shown to be 

representative of similar injury hazards found 

throughout the entire household.

The primary outcomes for the study were a 

reduction in medically attended (i.e., office, 

clinic, or emergency visits) injuries for children 

from birth through three years of age in the 

intervention group as compared to the control 

group.

Maternal reports of injury events, phone calls, 

office visits, and emergency visits for residential 

injuries in their child were outcomes assessed 

in the first 24 months of the trial. The primary 

outcome measure for this analysis was an 

emergency visit for a residential injury. Maternal 

reports of emergency visits were verified by 

checking medical records using a countywide 

injury surveillance system.

HOME Injury Surveys were also conducted 

in homes of families randomized to the lead 

abatement portion of the trial at baseline, and 

annually throughout the four-year study period. 

Injury hazards were similar at baseline but did 

not change in this control group, and injury 

rates were significantly higher for preventable, 

medically attended mechanisms in the lead 

intervention group. Although lead intervention 

group children had geometric mean blood leads 

that were not different from control group 

children, they had better scores on cognitive 

and motor development as compared to control 

children.

The density of unintentional injury-related 

hazards (i.e., number of hazards per area) was 

found to be a more reliable and valid measure 

of childhood residential hazards than the total 

number of hazards.

Sustainability

The HOME Injury Survey, a 55-item tool to 

quantify unintentional injury hazards in the 

indoor environment of homes with young 

children, was identified as reliable, valid, and 

reproducible between different users and over 

time.

Best Practices

• Tailored interventions were developed (e.g., 

consumer safety product installation) based on 

family needs and hazards identified during the 

HOME Injury Survey.

• For replication purposes, it was found that 

complete and comprehensive installation of 

consumer safety products or built-in safety 

devices and mechanisms is more effective than 

education or provision of free or reduced-cost 

safety devices.

Appendices
page 215

Appendix 1.10 Case Study

Philadelphia Department of Public Health

Healthy Homes Child Care Program

Program Overview

Purpose. The objective of the Healthy Homes 

Child Care Program (HHCC) was to educate 

home-based child care providers about 

environmental health and safety issues in their 

homes and remediate lead-based paint and 

safety hazards.

Target population. Licensed child care providers 

in the City of Philadelphia in 18 zip codes. The 

project selected the geographic targets based 

on the large numbers of children with elevated 

blood lead levels, children with emergency room 

visits for asthma, and licensed family child care 

providers located in those areas. 

Partnerships. Key agencies included the 

Philadelphia Department of Public Health’s 

(PDPH) Childhood Lead Poisoning Prevention 

Program (CLPPP), National Nursing Centers 

Consortium (NNCC), Philadelphia Early 

Childhood Collaborative (PECC), the State 

of Pennsylvania Keystone Stars Initiative, 

Drexel University’s School of Public Health, 

Environmental Protection Agency’s Agency for 

Toxic Substances and Disease Registry (ASTDR), 

YMCA of Philadelphia, University of Pennsylvania 

Center for Community Partnerships, Nonprofit 

Finance Fund (NFF), AmeriCorps, Penn State 

Integrated Pest Management, Delaware Valley 

Association for the Education of Young Children, 

and Pest-Free Maintenance.

Community Involvement. The following 

agencies provided ongoing support and served 

as members of the project’s advisory board: 

Public Citizens for Children and Youth, United 

Communities of Southeast Philadelphia, the 

Philadelphia Fire Department, the American Red 

Cross, Easter Seals of Philadelphia County, the 

PA Department of Public Welfare, Philadelphia 

Department of Licenses and Inspections, the 

City of Philadelphia, National Center for Healthy 

Housing (NCHH), and Enterprise Community 

Partners (ECP).

Planning. In preparation for a grant application, 

members of the advisory board met to 

determine target activities and define eligibility 

for services. A variety of child care regulatory 

and licensing agencies also participated in the 

planning process.

The PDPH mapped lead poisoning, asthma 

and injury rates, income levels, locations of 

home-based child care providers, and other 

factors to determine optimal neighborhoods for 

services. It took one year to establish all policies, 

procedures, and interagency agreements. 

Interventions

Recruitment. Child care providers were 

recruited through partner agency referrals, 

including Keystone Stars child care quality 

improvement program. HHCC staff utilized the 

list of certified child care providers located in 

the 18 zip code target area. These providers 

received an invitation to attend an orientation 

meeting at a location in their community.

HHCC accepted individual providers on the basis 

of location, income-eligibility for HUD funding, 

and enrollment in the Keystone Stars program. 

Individual providers were enrolled on a “first 

come, first served” basis. If they had a child with 

an elevated blood lead level, asthma, or allergies 

in their care, they received a higher priority 

when interventions were scheduled.

Interventions. Child care providers attended 

Healthy Homes Orientation meetings at the 

start of the project to educate them about the 

“Seven Principles of Healthy Homes” and enroll 

them into the program. Additional workshops on 

topics such as infant and child first aid and CPR, 

emergency preparedness and “greening” your 

home-based day care were also provided.

The initiative involves (1) child care facility risk 

assessment, (2) tailored interventions, and 

(3) hazard remediation. Trained staff visited 

licensed home-based child care businesses 

and completed a comprehensive assessment 

in 150, tested for the presence of lead, and 

documented pest problems, asthma triggers, 

Appendices
page 216

food safety, as well as fire and carbon monoxide 

hazards. The assessment determined the 

remediations required for each unit, from the 

following options: 

• Safety Interventions: Railings, gates at the 

top and foot of stairs, repairs of stair treads 

and risers, gun locks, secure cubbies to walls, 

secure loose bathroom sinks and toilets, 

fencing and gates, hallway lighting, electrical 

outlets, baseboard repairs, rubber matting on 

exterior surfaces where children play, first aid 

kits, and smoke detectors.

• Respiratory Interventions: Exhaust fans, 

bathroom ventilation/air purifiers, carpet 

removed and replaced with tile, air 

conditioners, stove hoods and fans, and pest 

control. 

• Energy interventions: Awning repair, roof 

cornice replacement, new stack pipes, weather 

stripping, ceiling and wall repairs, door 

replacement/repair, and new stoves.

• Lead hazard control interventions: Paint 

stabilization, window replacement, door 

replacement, and smooth and cleanable 

flooring.

The PDPH Lead Abatement Services Supervisor 

used the combined results of the health and 

safety and lead risk assessment to prioritize 

repairs up to an established program funding 

cap. Eighty-five (85) homes were remediated.

All participants received a HHCC “Cleaning 

Bucket.” The Bucket included a variety of 

household cleaning supplies, such as nontoxic furniture polish and window and surface 

cleaners, rubber gloves, sponges, smoke 

detectors, water temperature gauge, and 

written information materials. Participants were 

instructed on cleaning methods to keep their 

home free of lead dust and allergens.

Program Staff. Key staff members included 

the Project Manager, the Health and Safety 

Coordinator, the Environmental Health Services 

Risk Assessor, and the CLPPP Lead Abatement 

Supervisor. All staff attended lead risk assessor, 

“Essentials for Healthy Homes Practitioners,” 

and lead clearance technician training courses.

Systems and Policies

The project integrated established procedures 

used in several projects, including the 

Philadelphia Lead Hazard Control Grant, the 

Philadelphia Healthy Homes/Home Safe Grant, 

the Lead-Safe Babies program, and the HomeBased Child Care Lead Safety Program.

Funding and Leverage

Funding Sources. HUD Office of Healthy Homes 

and Lead Hazard Control Healthy Homes 

Demonstration Grant and Lead Hazard Control 

Grants, and in-kind contributions from partner 

agencies.

Leveraged resources. 

• The Nonprofit Finance Fund provided 

$150,000 for safety-related repairs. 

• The YMCA supplied furnishings to the leadsafe relocation site.

Evaluation and Outcomes

The program administered a questionnaire 

to child care providers during the enrollment 

process and found:

• 67 (79 percent) had no safety gates at either 

the bottom or top of staircases to prevent 

child access to stairs;

• 53 (62 percent) had unsecured tall or heavy 

furniture;

• 47 (55 percent) had toxic cleaning supplies not 

in a secure location;

• 44 (52 percent) lacked a carbon monoxide 

monitor;

• 43 (51 percent) had non-intact painted 

surfaces; and

• 30 (32 percent) reported they did not test their 

smoke detectors regularly.

Appendices
page 217

Sustainability 

• Partnerships between CLPPP, PECC, NNCC, 

YMCA, NCHH, PA Keystone Stars, and 

Delaware Valley Association of the Education 

of Young Children. 

• This project demonstrated and developed a 

model for a home-based child care health and 

safety program that can be replicated in other 

jurisdictions.

Best Practices

• The rules of three regulatory agencies with 

the Childcare Environmental Rating Standards 

were combined to form the HHCC’s EHS 

Assessment Instruments, Weighted Hazard 

Scoring and Decision Protocol, and project 

evaluation tools. 

Appendices
page 218 Appendices
page 219

Appendix 2.1

Potential Stakeholders and Their Assets 

 Type of Strengths and Assets Examples

 Organization

Anti-crime/block 

clubs; civic and 

neighborhood 

associations

• Knowledge of the territory

• Available nights and weekends

• Trust of the residents

• Understanding of community concerns

• Ability to generate crowds/participation 

at large events

• Institutional memory

• Relationship with local government as 

constituents

• Experienced as advocates

• Esperanza Community Housing Corporation, 

Los Angeles, CA

• King County, WA—High Point Community

Existing coalitions 

and task forces 

(health, housing, or 

Issue-focused)

• Shared interests

• Organizational structure and processes 

for decision-making

• Possible source of data, meeting space, 

personnel, funding

• Understanding of community concerns

• Institutional memory

• Relationship with local government as 

constituents

• Experienced as advocates

• Policy development and advocacy skills

• Interagency referral networks

• Los Angeles Healthy Homes Collaborative

• Indoor Air Coalition of Whatcom County, 

WA

• Coalition to End Childhood Lead Poisoning, 

Baltimore, MD

• King County, WA Asthma Forum

• Healthy Indoor Environment Coalition, 

Kansas City, MO

• Asthma Regional Council, Boston, MA

• Boston Urban Asthma Coalition, Boston, MA

• Robert Wood Johnson Funded Allies 

Against Asthma Coalitions

Local health 

departments 

or regulatory 

agencies 

• Leadership

• Ability to bring together multiple 

groups

• Access to other government resources

• Access to elected officials

• Funding

• Ability to enforce health and housing 

codes

• Source of meeting space, data, policies 

and procedures, staff, speakers

• Institutional memory

• Jurisdiction and legal enforcement 

tools

• Access to public officials and the media

• Ability to dedicate resources and link to 

existing healthy homes programs and 

service systems

• City of Los Angeles Code Enforcement

• Northwest Air Pollution Authority

• Philadelphia Department of Public Health 

Childhood Lead Poisoning Prevention 

Program

• Cleveland Department of Public Health and 

Cuyahoga County Board of Health Childhood 

Lead Poisoning Prevention Programs

• Public Health Seattle King County

• Baltimore City Department of Health 

Childhood Lead Poisoning Prevention 

Program, Baltimore City Healthy Homes 

Division, Baltimore City Health Homes 

Asthma Program, Baltimore City Maternal 

and Child Health Safe Sleep Initiative

• Kansas City Health Department, Kansas 

Department of Health and Environment 

Healthy Home and Lead Hazard Control 

Program

• Boston Public Health Commission, Division 

of Healthy Homes and Community Supports

Appendices
page 220

Parents’ groups 

(school-based or 

support groups 

associated with 

specific health 

condition)

 Type of Strengths and Assets Examples

 Organization

• Ability to “put a face” on the problem

• Passion

• Ability to generate crowds or 

participation at large events

• Direct experience with local conditions/

services

• Constituents of public officials and 

service agencies

• Meeting space, volunteers

• Boston Urban Asthma Coalition Parent 

Asthma Leaders

Local health, 

housing, or social 

service providers

Grassroots 

organizations 

and communitybased and nongovernmental 

organizations.

Community 

Action Agencies

• May be able to expand service delivery 

to address Healthy Homes concerns

• Institutional memory

• Subject matter expert

• Likely to be trusted in community

• Access to public officials and the media

• Ability to leverage resources, programs 

and service systems

• Many are weatherization assistance 

program subgrantees

• Esperanza Community Housing Corporation, 

Los Angeles, CA

• YMCA of Philadelphia and Vicinity

• Opportunity Council, Bellingham, WA 

weatherization program

• Environmental Health Watch, Cincinnati, OH

• Community Housing Solutions

• Seattle Housing Authority

• Boston Housing Authority

Police, fire, 

and EMS 

services

• Knowledge of the territory

• Present in target areas on nights and 

weekends

• May or may not understand community 

concerns

• Source of data, educational materials, 

speakers

• City of Philadelphia Fire Department

• Baltimore City Fire Department

Public officials, 

Political action 

organizations 

(parties, 

advocacy 

groups)

• Constituents

• Advocacy and policy skills

• Data

• Decision-making power

• Philadelphia Citizens for Children and Youth

• Los Angeles City Council

Academic/

universities

• Grant funding, staff (students and 

faculty), meeting space

• Subject matter expertise (housing 

construction, engineering, architecture, 

public health, public policy, law, 

medicine and nursing, nutrition, social 

work, counseling, education, media and 

marketing, management, finance)

• Skills in program design, data analysis, 

evaluation, mapping (usually have more 

sophisticated IT capabilities)

• Translator services

• Case Western Reserve, Schools of Medicine 

and Public Health, Cleveland, OH

• Drexel University, School of Public Health, 

Philadelphia, PA

• University of Pennsylvania, Center for 

Community Partnerships

• University of Washington

• Harvard School of Public Health

• Tulane University School of Public Health

• Tufts Medical School

• Boston University School of Public Health

Appendices
page 221

Organizations 

that represent or 

work with at-risk 

or vulnerable 

populations

 Type of Strengths and Assets Examples

 Organization

• Trust of the residents

• Ability to generate crowds or 

participation at large events

• Ability to “put a face” on the problem

• Passion

• Knowledge of local conditions/services

• Translator services (both language and 

the ability to describe experiences in 

terms that policy-makers understand)

• Constituents

• Advocacy and policy skills

• Esperanza Community Housing 

Corporation, Los Angeles, CA

• Strategic Actions for a Just Economy, Los 

Angeles, CA

• Neighborhood Leadership Institute, 

Cleveland, OH

• Youth Build

• AmeriCorps

• Missouri Legal Aid

Health care 

providers, clinics, 

hospitals, health 

care insurance

• Trust of the residents

• Knowledge of local conditions

• Data, staff, and funding 

resources

• St. Johns’ Well Family and Child Center; 

Eisner Pediatric Center, Los Angeles, CA

• Case Western Reserve University School 

of Medicine, Swetland Center for 

Environmental Health, Departments of 

Pediatrics and Family Medicine, and Center 

for Geriatric Medicine, Cleveland, OH

• National Nursing Centers Consortium, 

Philadelphia, PA

• Cincinnati Children’s Hospital Medical 

Center

• University of Cincinnati Dept. of Pediatrics

• Children’s Mercy Family Health Partners, 

Kansas City, MO

• Pediatric Environmental Health Specialty 

Unit

Child Care 

providers, 

resource and 

referral agencies, 

early childhood 

education

• Required to meet standards for safe 

and sanitary facilities

• Access to target population

• Located in the target area

• Philadelphia Early Childhood Collaborative

• State of Pennsylvania Keystone Stars

• Head Start

• Children’s Environmental Heath Network

Property 

owners 

• Required to comply with health and 

building codes

• Leveraged funding for housing repairs

Realtors, 

landlord 

associations

• Access to rental property owners

• Ability to mobilize around public policy

Contractors • Training and certification for lead 

hazard control

• Integrated Pest Management, Inc., 

Philadelphia, PA

Appendices
page 222

Tenants’ rights 

organizations

 Type of Strengths and Assets Examples

 Organization

• Ability to organize to implement 

housing programs and advance public 

policy

• Access to the target population

• Familiar with housing issues in 

geographic target area

• Provide legal representation to tenants 

involved in landlord issues

• Esperanza Community Housing 

Corporation—Strategic Actions for a Just 

Economy (SAJE)

• Children’s Mercy Hospital—Missouri Legal 

Aid

Media (TV, radio, 

specialized 

media)

• Ability to raise awareness of healthy 

homes issues

• Advertise program services for 

recruitment purposes

• 2010 National Ad Council Campaign

• Tulane University’s New Orleans Healthy 

Homes Technical Study

Foundations and 

philanthropic 

organizations

• Provide funding

• Provide technical assistance in program 

design

• Serve as program partner

• Link to other community 

services

• Nonprofit Finance Fund, Philadelphia, PA

• W.K. Kellogg Foundation

• Annie E. Casey Foundation

• Robert Wood Johnson Foundation

Chambers of 

Commerce/

local financial 

institutions

• Identify program partners

• Private sector funding for healthy 

homes initiatives

• Metropolitan Energy Center, Kansas City, 

MO 

Appendices
page 223

Appendix 2.2Data Available from Different Sources

Types of Data National Data State-Level Data Local Data Neighborhood-Level Data

Demographic • U.S. Census: http://www.census.

gov/. Decennial census data can be downloaded by county, Congressional and legislative district, zip code, or census track/block. Quick Facts will compare localities to the state and national values for the indicators.

• U.S. Census also administers 

the more frequent American Community Survey, which estimates population, economic, and housing indicators by county subdivisions, Metropolitan Statistical Areas (SMAs), Congressional districts, and other factors between decennial censuses. These estimates are derived from surveys of households in geographic areas with 20,000 or more inhabitants. The most recent data are from 2005–2007 surveys.

• State Offices of Planning 

often track population changes on key economic and demographic features. State offices of Planning also have extensive Geographic Information System (GIS) capabilities.

• City and county plans 

for comprehensive development, zoning, and sustainability often contain demographic projections for neighborhoods, as well as projections for services. The larger communities will have GIS capabilities.

• Local universities, 

especially departments of public health or sociology may have the ability to generate this data.

• Windshield (or drive-by) 

surveys are quick methods to identify areas where services are delivered and the characteristics of the population who use them at different times of the day.

• Community meetings and 

focus groups can service as vehicles to identify groups in need of services.

• Interviews with key 

informants from the community.

Health Status, Health Care Consumption, Quality of Life

• Healthy People 2010:http://www.

healthypeople.gov/. Environmental Health Mid-course review: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA08TOC.htm. Injury and Violence Mid-course review: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA15TOC.htm. Respiratory Disease Mid-course review: http://www.healthypeople.gov/data/midcourse/pdf/FA24.pdf. Access to Quality Health Care Services Mid-Course review: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA01TOC.htm.

• State Healthy People 2010 plans: 

http://www.healthypeople.gov/Implementation/stateplans.htm.

• U.S. Centers for Disease 

Control and Prevention, National Environmental Public Health Tracking Network: http://ephtracking.cdc.gov/showStateTracking.action.

• National Survey of Children’s 

Health, 2007 State Profiles Pages: http://www.nschdata.org/Content/States.aspx?rid=5. The 2007 survey contains data on neighborhood safety and family mental health ratings.

• Local health department 

annual reports.

• National Association of 

Counties, Healthy Counties Database identifies strategies used in other locations to address obesity, nutrition, and housing: http://www.naco.org/Template.cfm?Section=New_Technical_Assistance& Template=/cffiles/healthy counties/search.cfm.

• Community surveys can 

assess perception of community needs and knowledge of health behaviors. These can be administered by neighborhood associations to their members, or at community events, such as health fairs. Models for these surveys can be found at (1) Enterprise Community Partners: Step- by-Step Tutorials: http://www.enterprisecommunity.org/resources/tutorials/resident_services/design_process.asp; 

Appendices
page 224 Types of Data National Data State-Level Data Local Data Neighborhood-Level Data

• Healthy People 2020: http://www.

healthypeople.gov/2020/about/default.aspx

• America’s Children: Key National 

Indicators of Well-Being, 2009: http://www.childstats.gov/americaschildren/index.asp.

• U.S. Centers for Disease Control 

and Prevention, National Health Information Survey (NHIS): http://www.cdc.gov/nchs/nhis.htm.

• U.S. Centers for Disease Control 

and Prevention U.S. Department of Health and Human Services, National Health and Nutrition Examination Survey (NHANES): http://www.cdc.gov/nchs/nhanes/nhanes_products.htm.

• U.S. Centers for Disease Control 

and Prevention, National Health Care Surveys (NHCS): http://www.cdc.gov/nchs/nhcs.htm.

• U.S. Centers for Disease Control 

and Prevention, Behavioral Risk Factor Surveillance System: http://www.cdc.gov/brfss/.

• National Health Statistics Reports

provide national summary data from a variety of health-related surveys, including NHIS, NHANES, and BRFSS: http://www.cdc.gov/nchs/products/nhsr.htm.

• U.S. Centers for Disease Control 

and Prevention, Injury Prevention and Control: Data and Statistics (WISQARSTM) provides a webbased injury statistics query and reporting system http://www.cdc.gov/injury/wisqars/index.html

• U.S. Environmental Protection 

Agency, America’s Children and the Environment. http://www.epa.gov/envirohealth/children/.

• BRFSS Selected Metropolitan/

Micropolitan Area Risk Trends (SMART): http://apps.nccd.cdc.gov/BRFSS-SMART/.

• Healthy States webpage 

from the Council of State Governments: http://www.healthystates.csg.org/.

• Agency for Health Care Research 

and Quality—Health Care, Cost, and Utilization Project: http://www.ahrq.gov/data/hcup/; state in-patient and ambulatory care data and 2008 State Snapshots http://statesnapshots.ahrq.gov/snaps08/index.jsp?menuId= 1&state=NY.

• Robert Wood Johnson 

Foundation, Commission to Build a Healthier America, State-by-State Data: http://www.commissiononhealth.org/StateByStateData.aspx.

• Annie E. Casey Foundation, Kids 

Count website: http://datacenter.kidscount.org/data/bystate/Default.aspx provides state, county, and selected locality data on a variety of health and social indicators.

• National Governors Association, 

“Shaping a Healthy America” website reviews state-level demographic and health data and provides model best practices implemented in the states: http://www.nga.org/portal/site/nga/menuitem.9123e83a1f6786440ddcbeeb501010a0/?vgnextoid=fbdb2f2d98ac6110VgnVCM1000001a01010aRCRD.

(2) CDC’s and the National Association of City and County Health Officials’ Community Environmental Health Assessment Protocol for Assessing Community Excellence in Environmental Health (PACE-EH) Guidebook: http://pace.naccho.org/DownloadPage.asp.

Appendices
page 225

Characteristics of the Housing Stock, Neighborhood conditions, Transportation systems, Quality 

Types of Data

of housing stock

National Data State-Level Data Local Data Neighborhood-Level Data

• American Housing Survey (AHS): 

http://www.census.gov/hhes/www/housing/ahs/ahs.html.

• National Center for Healthy 

Housing, State of Healthy Housing webpage: http://www.nchh.org/Policy/State-of-Healthy-Housing/Supporting-Documentation.aspx—provides an easy-to use comparison of 20 indicators from the AHS incorporated into two general indices of housing (Basic Housing and Healthy Housing). This enables users to compare more than 40 Metropolitan Statistical Areas (MSAs) on a variety of factors including interior and exterior deterioration, pests, and heating issues. The indices also allow users to compare within the MSA central city v. areas outside the central city, and owner-occupied v. rental properties. 

• American Planning Association, 

Health Communities Through Collaboration website: http://www.planning.org/research/healthy/index.htm

• American Planning Association, state 

chapters contact information: http://www.planning.org/chapters/#1

• National Association of Counties, 

Healthy Counties Database, “Built Environment”: http://www.naco.org/Template.cfm?Section=New_Technical_Assistance&Template=/cffiles/healthycounties/search.cfm provides program models that address housing development and transportation planning related to obesity reduction, greenways, school safety, transportation corridors, open space preservation.

• National Conference of State 

Legislatures (NCSL), Healthy Community Design and Access to Healthy Food Legislative Database: http://www.ncsl.org/IssuesResearch/ EnvironmentandNaturalResources/Healthy CommunityDesign and AccesstoHealthy Foo/tabid/13227/Default.aspx.

• Association of State and Territorial 

Health Officials (ASTHO), Built and Synthetic Environment website contains the ASTHO Smart Growth Toolkit with models for legislative action and policy development: http://www.astho.org/programs/environmental-health/built-andsynthetic-environment/.

• Every community 

that receives federal rehabilitation funding must submit a Consolidated Plan to HUD every three to five years and must update that plan annually. The Plan will include information on key housing problems and plans for use of funds to address these problems.

• The National Association 

of Housing and Redevelopment Officers (NAHRO).

• National Association 

of Counties Indoor Air Quality Project, which ended in 2007, developed a CD with model practices, fact sheets, educational campaigns, and other materials related to mold, asthma, radon, ETS, and school indoor air quality: http://www.naco.org/Template.cfm?Section=New_Technical_Assistance& Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=62&Content ID=14017.

• National Association of 

County and City Health Officers (NACCHO) provides a variety of Healthy Community Design toolkits that can be used by professionals and community residents to assess neighborhood fall hazards and other hazards: http://www.naccho.org/toolbox/veritysearch/search.cfm?keywords=&p=Healthy+Community+Design+Toolkit%7C14&st=ALL&x=68&y=14.

• The Alliance for Healthy 

Homes (AFHH) Community Environmental Health Resource Center provides a number of hazard assessment tools that community residents can use: http://www.afhh.org/res/res_cehrc.htm.

• American Association for 

Retired Persons (AARP) Livable Communities: An Evaluation Guide provides tools for residents to use to assess affordability, design, access to services, et cetera: http://assets.aarp.org/rgcenter/il/d18311_communities.pdf.

Appendices
page 226 Appendices Types of Data National Data State-Level Data Local Data Neighborhood-Level Data Energy-Related • U.S. Department of Energy’s Residential Energy Consuption Survey (RECS): http://www.eig. gov/consuption/residential. • The U.S. Energy Information Administration (EIA) administers the Residential Energy Consumption Survey (RECS) to a nationally representative sample of housing units. Energy characteristics on the housing unit, usage patterns, and household demographics are collected. This information is combined with data from energy suppliers to these homes to estimate energy costs and usage for heating, cooling, appliances, and other end uses. Data from the 2009 RECS are tabulated for the four census regions, the nine census divisions, and 16 states. Note: Please note that URLs can change and that these web addresses were accurate at the time the Guidance Manual was published.
page 227

Appendix 3.1

Available Educational Materials on Healthy Homes

Free and available for reproduction from PDF

Source Document/ Website link Purpose

 website name

U.S. Department of 

Housing and Urban 

Development, Office 

of Health Homes 

and Lead Hazard 

Control, Outreach 

website

Help Yourself to a 

Healthy Home 

http://www.hud.gov/offices/

lead/library/outreach/

How2Maintain HealthyHome_

booklet.pdf

58 pages. Comprehensive 

overview for program staff 

and clients. Available in 

English and Spanish.

How To Maintain a 

Healthy Home

http://www.hud.gov/offices/

lead/library/outreach/

How2Maintain HealthyHome_

booklet.pdf

Seven pages. 2006 

Alameda County 

brochure. Appropriate for 

distribution to families.

Making Homes Healthier for 

Families webpage

http://www.hud.gov/offices/

lead/healthyhomes/index.cfm.

pdf

Link to two pages. Healthy 

Homes Maintenance 

Checklist. Also contains links 

to seven web pages that 

provide guidance for families 

on allergies, asthma, carbon 

monoxide, Integrated Pest 

Management, lead, mold, 

and radon.

How to Make Your 

Own Green Cleaning 

Materials

http://www.hud.gov/offices/

lead/library/outreach/

How2Make GreenCleaning.pdf

One page. Alameda 

County Lead Poisoning 

Prevention, adapted from 

Toxics Use Reduction 

Project, U. of Mass. 

Lowell. Appropriate for 

distribution to families.

Asthma Triggers 

Checklist

http://www.hud.gov/offices/

lead/library/outreach/Asthma 

TriggersChecklist_Eng.pdf

One page. Alameda County 

Healthy Homes Project. 

Appropriate for distribution 

to families. In English and 

Spanish.

U.S. Department of 

Agriculture, National 

Institute of Food 

and Agriculture, 

Healthy Indoor Air 

for America’s Homes 

website

Healthy Indoor Air 

for America’s Homes 

website

http://www.csrees.usda.gov/

nea/family/in_focus/housing_

if_epa.html

web site under development

Consumer awareness 

educational campaign 

for use by agricultural 

extension agents and 

community leaders.

Appendices
page 228

Source Document/ Website link Purpose

 website name

U.S. Environmental 

Protection 

Agency

EPA’s Indoor 

Environmental Media 

Campaigns webpage

http://www.epapsa.com/ Asthma and radon PSAs in 

English and Spanish.

Indoor Air Quality 

Publications webpage

http://www.epa.gov/iaq/

pubs/index.html

Variety of publications, 

including Care for Your 

Air: A Guide for Indoor Air 

Quality.

The Inside Story: A 

Guide to Indoor Air 

Quality

http://www.epa.gov/iaq/

pubs/insidest.html

Overview of key indoor air 

quality threats with links 

to resources and technical 

publications. Useful for 

program planners.

Indoor Air Quality 

House: Care for Your Air 

webpage

http://www.epa.gov/iaq/

iaqhouse.html

Interactive tour of a home 

that highlights common 

environmental triggers. 

Helpful for families.

Asthma Awareness Month 

planning materials 

planning kit

http://www.epa.gov/asthma/

awm/index.html#Event 

Planning Kit

Asthma Environmental 

Checklist

http://www.epa.gov/asthma/

pdfs/home_environment_

checklist.pdf

Eight page checklist and 

action plan for families.

Dusty the Asthma Goldfish 

and His Asthma Triggers 

Funbook

http://www.epa.gov/asthma/

pdfs/dustythegoldfish_en.pdf

Funbook in English and 

Spanish.

IAQ Tools for Schools: 

Managing Asthma in the 

School Environment

http://www.epa.gov/iaq/

schools/pdfs/publications/

managing_asthma.pdf

Overview of the IAQ Tools 

for Schools Program.

Radon webpage http://www.epa.gov/radon/

index.html

Includes A Citizen’s Guide to 

Radon and media campaign 

toolkits for Living Green 

and Healthy Starts from the 

Ground Up. 

Indoor Air Plus webpage http://www.epa.gov/

indoorairplus/index.html

Guidance for contractors 

who wish to meet Energy 

Star and additional healthy 

housing criteria for national 

certification.

Carbon Monoxide 

webpage

http://www.epa.gov/iaq/

co.html

Pesticides and 

Integrated Pest 

Management

http://www.epa.gov/

pesticides/ipm/index.htm

Includes IPM in Schools 

toolkit.

Appendices
page 229

Smoke Free Homes 

and Cars Program 

publications website

http://www.epa.gov/

smokefree/publications.html

Includes links to English 

and Spanish versions of 

Secondhand Smoke and the 

Health of Your Family and 

the Smoke Free Pledge kit.

Source Document/ Website link Purpose

 website name

Ground Water and 

Drinking Water 

webpage

http://www.epa.gov/safewater/ Consumer information on 

drinking water, well head 

protection, water treatment 

in emergency situations, lead 

in drinking water.

Healthy Homes Webpage http://www.cdc.gov/

HealthyHomes/

This site offers health and 

safety tips about the home 

structure and land and things 

to do at home to protect 

health and lower risks for the 

leading causes of death.

Air Pollution and 

Respiratory Health 

webpage

http://www.cdc.gov/nceh/

airpollution/links.htm

Links to CDC and other 

agency publications on 

asthma, carbon monoxide, 

outdoor air quality.

Carbon Monoxide 

Poisoning webpage

http://www.cdc.gov/co/ Includes PDFs in multiple 

languages of You Can 

Prevent Carbon Monoxide 

Poisoning.

Asthma webpage http://www.cdc.gov/asthma/ Includes Asthma-friendly 

schools initiative toolkit.

Mold webpage http://www.cdc.gov/health/

mold.html

Includes Protect Yourself 

from Mold.

Childhood Lead 

Poisoning webpage

http://www.cdc.gov/co/ Publications, prevention 

tips, data and surveillance, 

policy, training tools.

U.S. Consumer 

Products Safety 

Commission 

http://www.cpsc.gov/nsn/nsn.

html

Resources on Child Safety, 

Fire Safety, Carbon 

Monoxide, Older Adults, 

Drowning Prevention and 

ATV Safety. 

Indoor Air Quality 

Publications webpage

http://www.cpsc.gov/cpscpub/

pubs/iaq.html

Includes 28 CPSC fact sheets 

on asbestos, carbon monoxide, lead, mercury, paint 

strippers, cleaning of air humidifiers, use of generators. 

Many available in English 

and Spanish.

Emergency Supply List http://www.ready.gov/

america/_downloads/checklist.

pdf

List of additional items to 

add to an emergency supply 

kit.

Appendices

U.S. Centers for 

Disease Control and 

Prevention (CDC)

Neighborhood Safety 

Toolkit

Ready America 

website (Federal 

Emergency 

Management Agency)
page 230

Source Document/ Website link Purpose

 website name

Outreach materials for 

media

http://www.safekids.org/

media/

Collection of media 

documents, including 

research and reports and 

press statements.

Safe Kids USA Outreach materials for 

parents

http://www.safekids.org/

parents/

Informational and 

preventive campaign for 

parents. Categorized 

by age. Includes safety 

resources in links.

Outreach materials for 

educators

http://www.safekids.org/

educators/

Collection of safety-related 

materials and activities 

for educators to adapt for 

school-room use.

Outreach materials for 

media

http://www.safekids.org/

media/

Collection of media documents, including research 

and reports and press 

statements.

Safety Resources By Risk 

Area Website

http://www.safekids.

org/safety-basics/safetyresources-by-risk-area/

Contains fact sheets and 

other materials by the 

following topics: Bicycling 

and Skating, Car Seats, 

Boosters and Seat Belts, 

Choking, Suffocation 

and Strangulation, Falls, 

Drowning, Fire, Burn and 

Scalds, In and Around Cars, 

Pedestrian, Playground, 

Poison, Sports and 

Recreation, and Toys.

Appendices

Make A Plan http://www.ready.gov/america/

makeaplan/index.html

Directions on how to make a 

family emergency plan.

Be Informed webpage http://www.ready.gov/america/

beinformed/index.html

Webpage providing information on many emergency 

types such a Biological threats, 

blackouts, earthquakes, fire, 

flood, severe weather, tsunamis, radiation, and disease.

Safety Resources By Risk 

Area Website

http://www.safekids.org/

safety-basics/safety-resourcesby-risk-area/

Contains fact sheets and 

other materials by the following topics: Bicycling and 

Skating, Car Seats, Boosters 

and Seat Belts, Choking, 

Suffocation and Strangulation, 

Falls, Drowning, Fire, Burn 

and Scalds, In and Around 

Cars, Pedestrian, Playground, 

Poison, and Toys. 
page 231

Source Document/ Website link Purpose

 website name

American Red Cross Preparedness Fast 

Sheets

http://www.redcross.org/

portal/site/en/menuitem.86f46

a12f382290517a8f210b80f78a0

/?vgnextoid=92d51a53f1c3711

0VgnVCM1000003481a10aRCR

D&vgnextfmt= default

Comprehensive fact 

sheets for preparation 

of the following topics: 

Earthquake Safety, Fire 

Prevention & Safety, Flood 

Safety, Flu Safety, Heat 

Wave Safety, Hurricane 

Safety, Landslide Safety, 

Pet and Disaster Safety, 

Power Outage, Taking 

Care of Emotional Health, 

Thunderstorm Safety, 

Taking Care of People with 

the Flu, Tornado Safety, 

Wild Fire Safety, and Winter 

Storm Safety. Available in 

Spanish, Arabic, Chinese, 

French, Haitian-Creole, 

Korean, Tagalog and 

Vietnamese.

American Lung 

Association

Protecting Your Air at 

Home webpage

http://www.lungusa.org/

healthy-air/home/protectingyour-air-at-home/

Includes annual State of 

the Air report.

Appendices
page 232 Appendices
page 233

Appendix 4.1

Housing and Health Assessment Tools for Use by Healthy 

Homes Programs

This document provides additional information 

on leading tools and methods that can be used 

by Healthy Homes Demonstration programs 

to select appropriate interventions and help 

evaluate their effectiveness. The tools are based 

on the following unranked criteria:

1. Comprehensiveness

2. Validated/Used in Published Evaluation

3. Practicality and Ease of Adapting to Local 

Conditions

4. Potential Burden on Occupant and Inspector

Because local programs and conditions differ, 

there is no single best tool that can currently be 

applied universally. Each has its own strengths 

and weaknesses. Healthy homes programs 

should evaluate these tools and methods to 

determine which elements can be adapted to 

their programs and local conditions. Appendix 

6.2 contains extensive literature describing 

how each tool was developed. This list is not 

intended to cover the pros and cons of all tools 

that could be used by healthy homes programs, 

only those offering the greatest promise at this 

time.

Healthy Housing 

Inspection 

Manual, 2008

http://www.

cdc.gov/nceh/

publications/books/

inspectionmanual/

default.htm

High

AS, GH, HC, IS, MM, 

OP, PA, TC

No (earlier 

version used 

in HUD 

Programs)

Low Medium

NCHH Survey for 

Housing-Related 

Disease and 

Injury—Adaptation 

of the CDC 

National Health 

Interview Survey 

National Center for 

Healthy Housing 

http://www.nchh.org

High

AS, GH, HC, IS, 

MM, OP, PA, TC

Evaluation 

pending 

(used in two 

previous 

studies)

Medium Medium

Asthma Control 

Questionnaire—

Measuring quality 

of life in children 

with asthma

http://ajrccm.

atsjournals.

org/cgi/reprint/162/4/ 

1330

(Juniper Quality of 

Life Survey)

Medium

AS

Validated Medium Low

Asthma Therapy 

Assessment 

Questionnaire—

For health 

professionals only

http://www.asthma 

controlcheck.com/

asthma_control/

asthma controlcheck/

hcp/index.jsp

Medium

AS

Validated Low High

Table 1. Comparison of Leading Healthy Housing Assessment Tools

Tool Name Link or Source Comprehensiveness/ Validation/ Practicality Burden Topics Used in and Ease of (see key below) Published Adaptation Evaluation

Asthma Control 

Test—Measuring 

asthma control of 

persons 12 years 

of age and older

http://www.quality 

metric.com/WhatWeDo/

DiseasespecificHealth 

SurveysAsthmaControlTest 

%20%20 %20ACT/tabid/ 

190/Default.aspx

Medium

AS

Validated Medium Medium

Appendices
page 234

Table 1. Comparison of Leading Healthy Housing Assessment Tools (continued)

Tool Name Link or Source Comprehensiveness/ Validation/ Practicality Burden Topics Used in and Ease of (see key below) Published Adaptation Evaluation

Childhood 

Asthma Control 

Test—Measure 

of asthma control 

of children 4–12 

years of age

http://download.

journals.elsevierhealth.

com/pdfs/journals/ 

0091-6749/PIIS 

0091674907001674.pdf

Medium

AS

Validated Medium Low

Asthma Core 

Care-giver 

Survey—Allies 

Against Asthma

http://asthma.umich. 

edu/mediaeval_

autogen/core_

caregiver.pdf

Medium 

AS

Uses Juniper 

plus other 

questions

Medium Low

EPA Asthma 

Home 

Environmental 

Checklist

http://www.epa.gov/

asthma/pdfs/home_

environment_checklist.

pdf 

Medium

MM, PA,OP

No High Low

SeattleKing County 

HomeBASE

http://www.kingcounty.

gov/healthservices/

health/chronic/asthma/

homebase/

questionnaires.aspx

High

AS, HC, IS, MM, PA, 

OP, TC

Evaluation 

published

(prev. 

edition)

Medium Medium

Cuyahoga 

County Mold and 

Moisture Project: 

Visual Assessment 

and Testing

http://www.ehw.org/

Healthy_

House/HH_VAT.pdf

High

HC, MM, PA, OP, TC

Evaluation 

published

High Medium

Home Moisture 

Audit

http://www.ehw.org/

Healthy_House/HH_

Moist_Audit.htm

Medium

MM

No Medium Medium

Allergen Trigger 

Screening 

Questions—

NCHH

National Center for 

Healthy Housing 

http://www.nchh.org

Low

HC, MM, PA

Evaluation 

publication 

pending

High Low

Assessment 

Questions for 

Environmental 

and Other 

Factors that can 

Make 

Asthma Worse—

NIH

http://www.nhlbi.

nih.gov/guidelines/

asthma/06_sec3_

comp3.pdf

(Figure 3-17)

Low 

MM, PA, OP

No High Low

Community 

Environmental 

Health Resource 

Center

http://www.cehrc.org/

res/res_cehrc.htm

Medium

HC, MM, OP, PA

Evaluation 

publication 

pending

High Low

Pediatric Environmental Health 

Assessment

http://www.

healthyhomes training.

org/Nurse/PEHA_ 

Start.htm

Medium

HC, IS, MM, OP, PA, 

TC

No High Low

Appendices
page 235

Table 1. Comparison of Leading Healthy Housing Assessment Tools (continued)

Tool Name Link or Source Comprehensiveness/ Validation/ Practicality Burden Topics Used in and Ease of (see key below) Published Adaptation Evaluation

Housing Health 

and Safety Rating 

System (UK)

http://www.

communities.gov.

uk/documents/

housing/pdf/property 

questionnairegeneral.

pdf

Medium

HC, MM

No Medium 

(May only be 

applicable to 

UK Housing)

--

LARES http://www.euro.

who.int/Housing/

LARES/20080506_3

High

AS, GH, HC, IS, MM, PA, 

TC

Evaluation 

published

Low (May only 

be applicable 

to European 

housing)

--

Survey Topic Key: AS: Asthma Symptoms and Health Effects; GH: General Health; HC: Housing Conditions—

General; IS: Injury/Safety Conditions; MM: Mold/Moisture; OP: Other Pollutants/Irritants; PA: Pests/Animals; and TC: 

Temperature/Comfort 

Appendices
page 236 Appendices
Appendices page 237
page 238 Appendices
page 239

Appendix 5.1

Examples of Healthy Housing Criteria for Housing 

Rehabilitation and New Construction

The two sets of criteria for housing rehabilitation 

and new construction provided here include 

information reprinted from:

• Enterprise Green Community Criteria (2008) 

http://www.practitionerresources.org/cache/

documents/666/66641.pdf; and

• EPA Indoor airPLUS Construction 

Specifications (2009) http://www.epa.gov/

indoorairplus/construction_specifications.html.

• 2011 Green Community Standards 

http://www.greencommunitiesonline.org/

tools/criteria/

Enterprise Green Community Criteria (2008) 

Enterprise Community Partners’ Green 

Communities criteria for new construction and rehabilitation promote smart growth, public health, 

energy conservation, operational savings, and sustainable building practices in affordable housing 

design. As a result, the methods and materials referenced in the following pages enhance affordable 

housing and communities as a whole. In addition to 

increasing resource efficiency and reducing environmental impacts, green building practices can yield 

cost savings through long-term reduction in operating expenses. The benefits include improved energy performance and comfort, a healthier indoor 

environment, increased durability of building components, and simplified maintenance requirements. 

Alignment with LEED Criteria Mandatory Provisions

for Homes Rating and Eligibility Point 

System (LH) System

7.1

LH

Low/No Volatile Organic Compounds (VOC ) Paints and 

Primers

Specify that all interior paints and primers must comply 

with current Green Seal standards for low-VOC limits.

Mandatory

7.2

LH

Low/No VOC Adhesives and Sealants

Specify that all adhesives must comply with Rule 1168 of 

the South Coast Air Quality Management District. Caulks 

and sealants must comply with Regulation 8, Rule 51 of 

the Bay Area Air Quality Management District.

Mandatory

7.3 Urea Formaldehyde-free Composite Wood

Use particleboard and MDF that is certified compliant with 

the ANSI A208.1 and A208.2. If using non-rated composite 

wood, all exposed edges and sides must be sealed with 

low-VOC sealants.

Mandatory

7.4

LH

Green Label Certified Floor Coverings

Do not install carpets in below grade living spaces, 

entryways, laundry rooms, bathrooms, kitchens or utility 

rooms. If using carpet, use the Carpet and Rug Institute’s 

Green Label certified carpet, pad and carpet adhesives.

Mandatory (if providing 

floor coverings)

7.5a

LH

Exhaust Fans—Bathroom: New Construction and 

Substantial Rehabilitation

Install Energy Star-labeled bathroom fans that exhaust to 

the outdoors and are connected to a light switch and are 

equipped with a humidistat sensor or timer, or operate 

continuously.

Mandatory 

Healthy Living Environments

Appendices
page 240

7.5b

LH

Exhaust Fans—Kitchen: New Construction and 

Substantial Rehabilitation

Install power vented fans or range hoods that exhaust to the 

exterior.

Mandatory

7.5c Exhaust—FansKitchen: Moderate Rehabilitation

Install power vented fans or range hoods that exhaust to the 

exterior.

5

7.6a

LH

Ventilation: Except for Moderate Rehabilitation

Install a ventilation system for the dwelling unit, providing 

adequate fresh air per ASHRAE 62.1-2007 for residential 

buildings above three stories or ASHRAE 62.2 for single 

family and low-rise multifamily dwellings.

Mandatory

7.6b Ventilation: Moderate Rehabilitation

Install a ventilation system for the dwelling unit, providing 

adequate fresh air per ASHRAE 62.1-2007 for residential 

buildings above three stories or ASHRAE 62.2 for single 

family and low-rise multifamily dwellings.

10

7.7

LH

HVAC Sizing

Size heating and cooling equipment in accordance with the 

Air Conditioning Contractors of America Manual, Parts J 

and S, ASHRAE handbooks, or equivalent software.

Mandatory 

7.8 Water Heaters: Mold Prevention

Use tankless hot water heaters or install conventional hot 

water heaters in rooms with drains or catch pans with 

drains piped to the exterior of the dwelling and with nonwater sensitive floor coverings.

Mandatory

7.9a Materials in Wet Areas: Surfaces

In wet areas, use materials that have smooth, durable, 

cleanable surfaces. Do not use mold-propagating materials 

such as vinyl wallpaper and unsealed grout.

Mandatory

7.9b Materials in Wet Areas: Tub and Shower Enclosures

Use fiberglass or similar enclosure or, if using any form of 

grouted material, use backing materials such as cement 

board, fiber cement board or equivalent (i.e., not paper-faced).

Mandatory

7.10a Basements and Concrete Slabs: Vapor Barrier

Provide vapor barrier under all slabs. For concrete floors 

either in basements or on-grade slab install a capillary 

break of 4 four inches of gravel over soil. Cover all gravel 

with 6-millimeter polyethylene sheeting moisture barrier 

with joints lapped 1 foot or more. On interior below grade 

walls, avoid using separate vapor barrier or below grade 

vertical insulation.

Mandatory

7.10b

LH

Basements and Concrete Slabs—Radon: New 

Construction and Substantial Rehabilitation

In EPA Zone 1 and 2 areas, install passive radon-resistant 

features below the slab along with a vertical vent pipe with 

junction box available, if an active system should prove 

necessary. For substantial rehab, introduce radon-reduction 

measures if elevated levels of radon are detected.

Mandatory

Alignment with LEED Criteria Mandatory Provisions

for Homes Rating and Eligibility Point 

System (LH) System

Appendices
page 241

Alignment with LEED Criteria Mandatory Provisions

for Homes Rating and Eligibility Point 

System (LH) System

7.11 Water Drainage

Provide drainage of water to the lowest level of concrete 

away from windows, walls and foundations.

Mandatory

7.12

LH

Garage Isolation

Provide a continuous air barrier between the 

conditioned (living) space and any unconditioned garage 

space. In single-family houses with attached garages, 

install a CO alarm inside the house on the wall that is 

attached to the garage and outside the sleeping area, 

and do not install air handling equipment in the garage.

Mandatory

7.13

LH

Clothes Dryer Exhaust

Clothes dryers must be exhausted directly to the 

outdoors.

Mandatory

7.14

LH

Integrated Pest Management

Seal all wall, floor and joint penetrations with low-VOC 

caulking. Provide rodent-proof and corrosion-proof 

screens (e.g., copper or stainless steel mesh) for large 

openings.

Mandatory

7.15 Lead-Safe Work Practices: Rehabilitation

For properties built before 1978, use lead-safe work 

practices during renovation, remodeling, painting and 

demolition.

Mandatory 

7.16 Healthy Flooring Materials: Alternative Sources

Use non-vinyl, non-carpet floor coverings in all rooms.

5

7.17 Smoke-free Building

Enforce a “no smoking” policy in all common and 

individual living areas in all buildings. See full criteria for 

“common area” definition.

2

7.18

LH

Combustion Equipment: Includes Space and WaterHeating Equipment

Specify power vented or combustion sealed equipment. 

Install one hard-wired CO detector for each sleeping 

area, minimum one per floor.

Mandatory

Operations and Maintenance

8.1

LH

Building Maintenance Manual

Provide a manual that includes the following: a routine 

maintenance plan; instructions for all appliances, HVAC 

operation, water-system turnoffs, lighting equipment, 

paving materials and landscaping, pest control and other 

systems that are part of each occupancy unit; an occupancy 

turnover plan that describes the process of educating the 

tenant about proper use and maintenance of all building 

systems.

Mandatory

Appendices
page 242

Alignment with LEED Criteria Mandatory Provisions

for Homes Rating and Eligibility Point 

System System

8.2

LH

Occupant’s Manual

Provide a guide for homeowners and renters that explains 

the intent, benefits, use and maintenance of green 

building features, along with the location of transit stops 

and other neighborhood conveniences, and encourages 

additional green activities such as recycling, gardening 

and use of healthy cleaning materials, alternate measures 

for pest control and purchase of green power.

Mandatory

8.3

LH

Homeowner and New Resident Orientation

Provide a walk-through and orientation to the 

homeowner or new resident using the Occupant 

Manual from 8-2 above that reviews the building’s 

green features, operations and maintenance along with 

neighborhood conveniences.

Mandatory 

Notes:

(1) Standards are subject to change.

(2) LEED Rating System can be found at http://www.usgbc.org.

(3) Mandatory Provisions and Eligibility Point System: To be eligible for Green Communities grants, loans and 

tax credit equity through Enterprise, a project must comply with all of the mandatory provisions of the Green 

Communities criteria. In addition, new construction projects must earn 35 points from the Optional Criteria, 

while moderate rehabilitation projects must earn 30 points from the Optional Criteria.

(4) This table is a partial representation of the eight criteria.

EPA Indoor airPLUS Construction 

Specifications (2009)

These specifications for new construction 

were developed by the U.S. Environmental 

Protection Agency (EPA) to recognize new 

homes equipped with a comprehensive set 

of Indoor Air Quality (IAQ) features. They 

were developed with significant input from 

stakeholders, based on best available science 

and information about risks associated with IAQ 

problems, and balanced with practical issues of 

cost, builder production process compatibility, 

and verifiability. Although these measures were 

designed to help improve IAQ in new homes 

compared with homes built to minimum code, 

they alone cannot prevent all IAQ problems. 

Occupant behavior is also important. For 

example, smoking indoors would negatively 

affect IAQ and the performance of the specified 

Indoor airPLUS measures.

Appendices
Appendices page 243
page 244 Appendices
page 245

Appendix 5.2

Healthy Homes Maintenance Checklist

The following information is also available at 

http://www.nchh.org/Portals/0/Contents/Maintenance_Checklist2009.pdf

Appendices
page 246 Appendices
page 247

Appendix 6.1

Special Considerations in Human Subjects Research 

Since healthy homes programs affect human 

behavior and health as well as the condition 

of housing stock, evaluators should be familiar 

with special protections required under federal 

law whenever human subjects are involved in 

formal research activities. The U.S. Department 

of Health and Human Services (HHS) defines 

research and the protections of human subjects 

(45 CFR 46.102(d)) as:

... a systematic investigation, including 

research development, testing and 

evaluation, designed to develop or contribute 

to generalizable knowledge...Human subject 

means a living individual about whom an 

investigator (whether professional or student) 

conducting research obtains: 

(1) Data through intervention or interaction 

with the individual; or 

(2) Identifiable private information.

Common Rule. HHS oversees the protection of 

human subjects during the course of research 

via application of the “Common Rule” (45 CFR 

Part 46). Not all projects that collect information 

on individuals are subject to these protections. 

Informed Consent. Clients have a reasonable 

expectation of privacy for their health 

information. They also have a reasonable 

expectation of knowing the results of any 

interventions performed on their homes and the 

potential effects on their health and wellbeing. 

There are many mechanisms to address these 

concerns. At a minimum, enrollment information 

should specify what data will be collected on the 

household, who will have access to the data, how 

the participant can get obtain the information, 

and how they can withdraw from the project. 

This information needs to be contained in the 

consent to participate in the project.

Institutional Review Board. The Institutional 

Review Board (IRB) process represents further 

protection for clients. The IRB addresses 

data privacy, assures participant protection, 

sets standards for recruitment and retention, 

and requires that all program documents 

and procedures be reviewed by third parties 

with no direct interest in the outcome of the 

research. IRBs are usually attached to academic 

institutions but can also be housed at health 

departments, hospitals, and health insurance 

companies. If your project includes an academic 

partner to conduct third-party evaluation, 

they can facilitate preparation of the IRB 

application and support the approval process. 

It is important to note that many IRBs are more 

familiar with medical research and may need to 

be educated on public and community health 

interventions and evaluation.

The IRB review process includes expedited 

reviews for studies that involve minimum risk to 

human subjects, which usually describes healthy 

homes programs. In general, expedited reviews 

take between one and three months while 

full reviews can take longer. The recruitment, 

enrollment and informed consent forms are at 

the heart of much of the IRB review. Programs 

should take the time to understand their IRB’s 

requirements for consent and to build in time for 

approval as a part of project “start up.”

Health Insurance Portability and Accountability 

Act. If health-related data are collected, 

healthy homes programs will also need to 

determine what data will be shared internally, 

with program partners, the community at 

large, and with funders. Health Insurance 

Portability and Accountability Act (HIPAA) data 

protection requirements are likely to apply to 

any projects where health departments, health 

care providers, or health insurance agencies are 

involved. In many cases, these agencies will have 

their own required policies and training for data 

protection. (See Alliance for Healthy Homes. 

Overcoming Barriers to Data-Sharing Related 

to the HIPAA Privacy Rule: A Guide for State 

and Local Childhood Lead Poisoning Prevention 

Programs. June 2004. http://www.afhh.org/res/

res_pubs/HIPAA_CLPPP_June_2004.pdf). 

Resources

• HHS’s Office of Human Research Protections 

provides a variety of guidance materials on 

application of the Common Rule, including 

decision charts for individual projects. See 

Appendices
page 248

http://www.hhs.gov/ohrp/humansubjects/

guidance/decisioncharts.htm

• As a matter of good practice, all healthy 

homes project staff should undergo training 

on the protection of human subjects. Free 

training can be found at http://ohrp-ed.od.nih.

gov/CBTs/Assurance/login.asp. 

• The Agency for Healthcare Research and 

Quality (AHRQ) has developed a toolkit for 

informed consent in research that poses 

minimum risk: http://www.ahrq.gov/fund/

informedconsent/

Appendices
Appendices page 249

Appendix 6.2

Developing a Healthy Housing Program—

Logic Model

Assumptions and External Factors

Strengths, Weaknesses, Opportunities and 

Threats (SWOT) and Political, Economic, Social 

and Technological (PEST) Analyses
page 250 Appendices
page 251

One-group design

This design assesses people and/or housing 

units after the program has been completed 

based on assumptions of what the conditions 

were before the program began; there is no 

comparison with people who did not receive 

services. This design is least robust and provides 

the least evidence that the changes observed 

were the result of the program. Outcome data 

can be derived from health records and interviews.

Pre/post design

This design includes assessment of individuals 

and housing units prior to the implementation 

of interventions. Differences in health status and 

housing condition are quantified by comparing 

conditions at baseline and post-intervention. 

While preferable to a one-group design, the 

Asthma Health Outcomes Project reports that 

programs using this design, without a comparison group, were more likely to report positive, 

but possibly unreliable results due to biases such 

as the test itself, participant maturation and 

other confounding factors.

Time series design

This design includes a series of measurements 

on key health or housing outcomes and conducts measurements at periodic intervals from 

the beginning to the end of the program (often 

including more than one post-intervention measurement). Time series seeks to document the 

persistence of program effects.

Comparison group design 

The use of a comparison (control) group that did 

not receive program services results in the ability to measure impact without the high cost and 

complexity of a randomized controlled trial. A 

comparison group should be carefully selected 

to ensure that they are as similar to the intervention group as possible in all ways except for participation in the interventions. With demographic and other data on participants in both groups, 

statistical modeling can be used to control for 

small differences between the groups.

Appendix 6.3

Evaluation Design Strategies

Appendices
page 252 Appendices
page 253

Appendix 6.4

Window Replacement Cost-Benefit Analysis

Net Benefits of Lead-Safe 

Window Replacement

Lead safe window replacement costs, annual 

energy savings, and related market value 

benefits vary by housing unit size and the 

number of windows replaced. Lead hazard 

reduction benefits vary by age of housing and 

the average number of young children living in 

the housing unit each year. 

Table 1 shows average costs (per housing unit), 

benefits, and annual energy savings resulting 

from lead-safe window replacement in three 

homes of different sizes and types. This is 

followed by an explanation of how each average 

cost and benefit was determined and how 

specific lead and/or healthy homes programs can 

collect and track data to determine how their 

local program’s costs and benefits compare to 

these average values.

Window replacement costs and market value 

benefits: Window replacement costs and the 

associated average increase in a home’s market 

value are from Remodeling Magazine’s annual 

“Cost vs. Value”3 estimates. These are based 

on U.S. Department of Housing and Urban 

Development estimates from 1999 for replacing 

seven windows in an 800 ft2 attached home, and 

Remodeling Magazine’s estimates to replace 16 

windows in 1993 and 10 windows in 2005 (Alfano, 

2001–2005), all updated to 2005 dollars. The cost 

estimates include contractor and supplier labor, 

material, overhead, and profit. The average cost 

per window when a program engages in a large 

volume purchase may be lower than this retail 

cost. Higher home market values associated with 

new energy-efficient windows are mainly due to 

a 15 percent to 25 percent reduction in energy 

bills, an average increase in home value of $20 for 

every dollar per year in energy bill savings, and an 

appearance value of about $100 per window.4

Introduction

Cost-benefit analysis is an important tool 

for justifying program expenditures and can 

influence funding decisions made by federal, 

state, and local governments and foundations. 

Program activities are more likely to receive 

ongoing and/or increased funding if there is 

clear evidence that program benefits exceed 

program costs.

Regulatory analysis and academic studies have 

shown that window replacement combined with 

paint repair and lead-safe work practices yield 

public and private benefits that far exceed the 

costs of interventions.1 Window replacement, 

mainly to increase energy-efficiency, appears to 

explain a significant part of the decline in lead 

paint hazards in older homes from 1990–2000.2

New windows combined with home maintenance 

and reinvestment could explain why older homes 

in high-income neighborhoods are much less 

likely to have lead paint hazards than similar-age 

homes in low-income neighborhoods.

Lead-safe window replacement results in:

• Long-term energy savings when Energy Star 

windows are used to replace old, single-pane 

windows; 

• Elimination of lead hazards; and 

• Lower lead dust levels through specialized 

post-intervention cleaning and clearance 

testing. 

1

 U.S. Department of Housing and Urban Development, 

1999, Economic Assessment of the Final Rule on LeadBased Paint, Office of Lead Hazard Control, Washington 

DC; Nevin R. (2009) Energy-efficient housing stimulus 

that pays for itself (2010), Energy Policy 38:4–11; Nevin, 

R. and D. Jacobs. (2006), Windows of opportunity: lead 

poisoning prevention, housing affordability, and energy 

conservation, Housing Policy Debate 17(1), 185–207; 

Nevin, R., D. Jacobs, M. Berg, J. Cohen, (2008), Monetary benefits of preventing childhood lead poisoning 

with lead-safe window replacement, Environmental 

Research 106, 410–419.

2

 Jacobs, D. and R. Nevin (2006), Validation of a 20-year 

forecast of U.S. childhood lead poisoning: Updated 

prospects for 2010, Environmental Research, 102 (3), 

352–364.

3

 Alfano, S., Cost vs. Value Reports, Remodeling Online.

4

 Nevin, R. and G. Watson (1998), Evidence of rational 

market valuations for home energy efficiency, Appraisal 

Journal 66:401–09; Nevin, R., H. Gazan, C. Bender 

(1999), More evidence of rational market values for 

home energy efficiency, Appraisal Journal 67:454–60.

Appendices
page 254

Any lead or healthy homes program can track 

their own data on window replacement costs 

(including labor, material, and overhead) and 

develop comparable market value benefit 

estimates as follows:

• Obtain data on the average annual energy bill 

for each upgraded home (total annual cost for 

electricity, natural gas, and/or fuel oil);

• Assume that replacing single-pane windows 

with Energy Star windows reduces annual 

energy bills by 20 percent;

• Multiply that annual energy savings by 20, and 

add $100 per window replaced to estimate 

market value benefit. 

Paint stabilization costs and market value 

benefits: Regulatory analysis shows that 

approximately 95 percent of the cost of leadsafe paint stabilization is recovered through an 

increase in a home’s market value. Lead and/

or healthy homes programs can track their own 

cost information through contractor estimates 

or invoices (per housing unit) for this portion of 

the scope of work. This cost can be multiplied 

by 0.95 to develop a comparable market value 

benefit estimate.

Cleanup and clearance testing costs: The 

average cost for lead dust cleanup and clearance 

testing assumes whole-house cleanup and 

testing. Lead and healthy home’s programs can 

track their own data on cleanup and clearance 

testing costs through documenting contractor 

cost estimates and/or invoices for this portion 

of the work, inspector clearance testing costs 

based on time and materials, and laboratory 

analysis costs. 

Lead hazard reduction benefits: The health 

benefit of lead-safe window replacement is 

based on extensive regulatory analysis and 

research quantifying the value of increased 

average lifetime earnings associated with the 

prevention of preschool lead exposure. This 

benefit reflects the average loss of IQ due 

to lead exposure, and associated losses in 

education attainment and earnings. 

Appendices

Table 1 Lead-Safe Window Replacement Costs, Benefits, and Energy Savings

 800 ft2 Attached 1200 ft2 Detached 1800 ft2 Detached

 7 Windows 10 Windows 16 Windows

Costs

Window Replacement $6,118 $9,684 $15,494

Weighted Average Interior Paint Stabilization $146 $146 $146

Weighted Average Exterior Paint Stabilization $291 $291 $291

Specialized Cleanup $386 $510 $510

Lead Dust Clearance Testing $175 $219 $219

Average Cost $7,116 $10,850 $16,660

Annual Energy Savings (15%–25%) $130–216/yr $194–324/yr $292–486/yr

Market Value Benefits

Windows $5,485 $8,681 $13,890

Weighted Average Interior Paint Stabilization $144 $144 $144

Weighted Average Exterior Paint Stabilization $270 $270 $270

Average Market Value Benefit $5,899 $9,095 $14,304

Average Lead Hazard Reduction Benefit

Weighted Average in Pre-1940 Housing $6,847 $6,847 $6,847

Weighted Average in 1940–1959 Housing $2,847 $2,847 $2,847

Weighted Average in 1960–1977 Housing $632 $632 $632
page 255

Conducting Cost-Benefit 

Analysis

Table 2 illustrates how programs can track their 

program costs and benefits by collecting data 

on each home upgraded with lead-safe window 

replacement. These costs are based on collecting 

cost information for window replacement, paint 

stabilization, lead- dust cleaning, and clearance 

testing in each upgraded home. In summary:

• The benefit of window replacement in each 

home would equal $100 per window plus a 

20 percent reduction in that home’s average 

annual energy bill compared to the year prior 

to window replacement.

• The benefit of paint repair/stabilization in each 

home equals 95 percent of paint repair costs.

• The benefit of lead hazard reduction in each 

home equals $6,847 in a pre-1940 home, 

$2,847 in a home built from 1940–1959, and 

$632 in a home built from 1960–1977.

When the costs of window replacement, paint 

stabilization and lead dust cleanup are tracked for 

each home that is treated as a part of your lead 

or healthy homes program, costs-benefit analysis 

can be conducted as demonstrated in Table 2.

These benefits vary by the age of housing 

because lead paint hazards are more common 

in older housing. The benefit calculation 

also reflects the savings in pre-intervention 

risk assessment costs by using single-pane 

windows as a presumption of lead hazards. 

Almost all pre-1940 homes with single-pane 

windows have lead paint on window surfaces 

and/or lead dust hazards. Therefore, lead-safe 

window replacement in pre-1940 homes with 

single-pane windows almost always yields lead 

hazard reduction benefits for current and future 

resident children. 

About 40 percent of 1940–1959 homes and 10 

percent of 1960–1979 homes with single-pane 

windows have lead paint on window surfaces. 

This means 60 percent of 1940–1959 homes and 

90 percent of 1960–1979 homes with singlepane windows are less likely to have lead paint 

hazards, reducing the average lifetime earnings 

benefit of lead safe window replacement in 

these homes, although the benefits still exceed 

the costs. Lead safe window replacement in 

these homes still yields energy savings and 

market value benefits, including the market 

benefit of routine paint repair as needed.

Table 2 Program-Specific Lead-Safe Window Replacement Costs and Benefits

Costs

Window Replacement: Actual Installed Cost $

Paint Stabilization: Actual Cost $

Cleanup and Lead Dust Clearance Testing: Actual Cost $

Total Cost = A $ Sum of all homes

Market Value Benefits

Windows Market Benefit = $100/window + 

(20% of the previous year annual energy bill) x 20) $

Paint Stabilization Market Benefit = 95% of Actual Cost $

Total Market Value Benefit = B $ Sum of all homes

Lead Hazard Reduction Benefits

Pre-1940 units multiplied by $6,847 $

1940–1959 units multiplied by $2,847 $

1960–1977 units multiplied by times $632 $

Applicable Lead Hazard Reduction Benefit = C $ Sum of all homes

Net Benefits: B + C - A $

Appendices
page 256 Appendices
page 257

Appendix 7.1

Federal Government Resources

EPA/CDC/ATSDR Federal 

Grants Guide for Community 

Environmental and Public 

Health Activities 

The U.S. Environmental Protection Agency (EPA), 

U.S. Centers for Disease Control and Prevention 

(CDC) and the Agency for Toxic Substances and 

Disease Registry (ATSDR) are collaborating to 

achieve community environmental and health 

goals through a Memorandum of Understanding 

signed in July 2007. By leveraging their 

knowledge and resources, the three agencies’ 

goal is to maximize the help they offer 

communities, state governments and tribes. 

EPA/CDC/ATSDR Federal Grants Guide for 

Community Environmental and Public Health 

Activities, is a comprehensive document that 

provides information on funding in support of 

healthy homes activities.

http://www.epa.gov/air/care/documents/EPA_

CDC_ATSDR_Grants_Guide_web_061708.pdf

U.S. Department of Housing 

and Urban Development 

(HUD)

Office of Healthy Homes and Lead Hazard 

Control (OHHLHC): HUD’s OHHLHC 

established its Healthy Homes Program in 

1999 in response to a congressional directive 

to protect children and their families from 

housing-related health and safety hazards. The 

Healthy Homes Initiative builds upon HUD’s 

Lead Hazard Control programs by supporting 

efforts that address a variety of environmental 

health and safety concerns. OHHLHC grants 

focus on demonstrating and researching 

low-cost, effective home hazard assessment 

and intervention methods as well as public 

education.

http://www.hud.gov/offices/lead/hhi/index.cfm

Community Planning and Development:

HUD’s Community Development Block Grant 

(CDBG) program funds local governments to 

undertake a wide range of activities intended 

to create suitable living environments, provide 

decent affordable housing and create economic 

opportunities, primarily for persons of low and 

moderate income. CDBG and HOME Investment 

Partnership-funded housing programs are 

required to evaluate and reduce lead based 

paint hazards and comply with the federal 

lead-safe housing rule. Many jurisdictions 

use a percentage of these funds to support 

minor home repair, building inspection/code 

compliance, energy efficiency, public health and 

community capacity building initiatives.

http://www.hud.gov/offices/cpd/

communitydevelopment/programs/

U.S. Centers for Disease 

Control and Prevention (CDC)

Grant Funding: CDC supports healthy homes 

initiatives through two grant programs:

• Building Capacity in Environment Healthy 

Service Delivery and

• Building Strategic Alliances for Healthy 

Housing Pilot.

http://www.cdc.gov/HealthyHomes/ByAudience/

Programs_Comprehensive.html

Training: Through a cooperative agreement, 

CDC is the primary funder of the National 

Healthy Homes Training Center and Network 

(Training Center) operated by the National 

Center for Healthy Housing. The Training Center 

brings together public health and housing 

practitioners to promote practical and costeffective methods for making homes healthier. 

It also serves as a forum for exchanging 

information on new research and best practices.

http://www.nchh.org/Training/National-HealthyHomes-Training-Center.aspx

Appendices
page 258

Single Issue Programs: The CDC also advances 

healthy homes through single issue programs 

that provide funding, training and technical 

assistance. These include:

• Asthma Control;

• Carbon Monoxide Poisoning Prevention;

• Air Pollution and Respiratory Health;

• Injury Prevention;

• Healthy Aging;

• Environmental Health Services; and

• Smoking and Health.

http://www.cdc.gov/healthyhomes/ByAudience/

Programs_SingleIssue.html

U.S. Environmental 

Protection Agency (EPA)

Grant Funding: The EPA funds healthy homes 

through the following grant programs.

• Community Action for a Renewed 

Environment (CARE) Program

http://www.epa.gov/care

• Environmental Education Grant Program 

www.epa.gov/enviroed

• Environmental Justice Collaborative ProblemSolving Program 

http://www.epa.gov/compliance/

environmentaljustice/grants/ej-cps-grants.html

• Environmental Justice Small Grants Program 

http://www.epa.gov/compliance/

environmentaljustice/grants/ej-smgrants.html

• State Indoor Radon Grant Program 

http://epa.gov/radon/sirgprogram.html

National Childhood Asthma Media Campaign: 

EPA has developed media materials, including 

Public Service Announcements, video news 

releases, fact sheets and tips for managing 

asthma. Local healthy homes programs, in 

partnership with local media, can use the media 

campaign materials to raise awareness in their 

jurisdictions.

United States Department of 

Agriculture (USDA)

The Healthy Homes Partnership is a network 

of state coordinators that provide information 

about home health hazards and steps that 

can be taken to avoid them. The initiative is a 

partnership between the USDA and HUD. 

http://www.csrees.usda.gov/nea/family/in_

focus/housing_if_healthyhomes.html

U.S. Department of Energy

The U.S. Department of Energy’s (DOE) 

Weatherization Assistance Program (WAP) 

provides energy efficiency improvements to 

low income homes using the most advanced 

technologies and diagnostic testing protocols 

available in the housing industry. The energy 

conservation resulting from the efforts of states 

and local agencies decreases the cost of energy 

for families in need while ensuring the health 

and safety of their homes. WAP programs 

use advanced technologies, such as blower 

door directed air sealing that help ensure that 

sufficient building ventilation remains following 

air sealing. The incorporation of combustion 

safety testing, pressure diagnostics, and 

moisture mitigation under the umbrella of 

energy-related building science creates healthier 

homes. The WAP, operating in all 50 states, the 

District of Columbia, U.S. Territories, and Native 

American Tribes, comprises the largest group 

of home energy upgrade experts in the country 

(see: http://www1.eere.energy.gov/wip/wap.

html).

DOE’s Weatherization Plus Health initiative, 

implemented by the National Association for 

State Community Services Programs (NASCSP), 

is a national effort to comprehensively and 

strategically coordinate resources to improve 

the energy efficiency, health, and safety of low 

income homes. Weatherization Plus Health 

facilitates essential connections between 

energy efficiency and healthy home programs 

(see: http://nascsp.org/Healthy-Homes/776/

Weatherization-Plus-Health.aspx?iHt=47).

Appendices
page 259

Appendix 7.2 

Comparison of Regulatory Approaches to 

Healthy Homes

Housing/Property Health/ Landlord- Product Hazard

 Maintenance Sanitation Tenant Law Standards Management

 Code Code Law

National 

Requirements

Yes, for federallyassisted housing 

No, for other housing

No Lead disclosure 

and fair 

housing

Yes, for 

specific 

products 

and general 

standards.

Yes for specific 

hazards such as 

lead, asbestos, 

and pesticides.

State 

Requirements

Several states Several states Most States Yes, for 

pesticides. 

All must be 

consistent with 

federal.

Generally yes for 

specific hazards 

in addition to 

federal such as 

carbon monoxide 

and radon.

Local 

Requirements

Common except in 

rural areas

Common but 

limited scope

Common in 

large urban 

areas

Uncommon Larger 

community for 

specific hazards 

in addition to 

federal and state.

Current 

National 

Models

Yes, International 

Property Maintenance 

Code (IPMC)

No Yes, Uniform 

Residential 

Landlord and 

Tenant Act 

(URLTA)

Industry 

Consensus 

Standards

Federal 

government 

and some 

associations 

issue guidelines 

to address 

specific hazards.

For More 

Information

http://www.

healthyhomes training.

org/Codes/HQS.htm

http://www.

healthyhomes training.

org/Codes/IPMC.

htm

http://www.

healthyhomes 

training.org/

Codes/APHA.

htm

http://www.

healthyhomes 

training.org/

Codes/URLTA.

htm

http://www.

healthyhomes 

training.

org/Codes/

Product_Stds.

htm

http://www.

healthyhomes 

training.org/

Codes/Hazard_

Stds.htm

http://www.

healthyhomes 

training.org/

Codes/EPA_RRP.

htm

http://www.healthyhomestraining.org/Codes/Code_Table.htm

Appendices
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page 261
page 262