Healthy home environment assessments

There is strong evidence that healthy home environment assessments encourage household behaviors that reduce asthma triggers and exposure to allergens (Uchima 2019, Welker 2018, LeCann 2017, Jassal 2013), decrease use of urgent care and related health care costs (Welker 2018, Jassal 2013, Martin 2022, Martin 2021, Gomez 2017, Turcotte 2018, Campbell 2015, Kearney 2014), and improve health outcomes (Uchima 2019, Welker 2018, Campbell 2015, Jassal 2013, Krieger 2015).

Healthy home environment assessments conducted by community health workers (CHWs) or trained asthma outreach workers reduce children’s allergy and asthma symptoms, use of asthma medications, and asthma-related hospital (Welker 2018) and urgent care center visits (Martin 2022, Martin 2021), and may also reduce the number of asthma-related doctor’s appointments (Mankikar 2016). Programs have been shown to improve asthma self-management, increase the number of asthma symptom-free days (Uchima 2019, Turcotte 2018, Kearney 2014, Kapheim 2015, Margellos-Anast 2012), and can reduce activity restrictions for asthmatic children (Martin 2022, Martin 2021, Uchima 2019). Programs improve quality of life (Uchima 2019, Turcotte 2018, Kearney 2014, Kapheim 2015, Margellos-Anast 2012) and reduce school and work absences for asthmatic children and their caregivers (Uchima 2019). Healthy home environment assessment programs have been shown to be beneficial in urban and rural areas (Gomez 2017) and for people of color and people with low incomes (Uchima 2019, Welker 2018).

In Chicago and Boston, in-home asthma management, environmental trigger assessment, and remediation education by CHWs for families who have children with uncontrolled asthma improved asthma control (Martin 2022, Martin 2021, Marshall 2020), reduced environmental triggers, reduced emergency department visits, and generated significant Medicaid cost savings (Marshall 2020).

Healthy home environment assessments improve user comfort through temperature and humidity adjustments and may reduce the presence of molds (LeCann 2017). Programs can increase knowledge of home hazards and reduce them, including basement, roof, and plumbing leaks, particularly if program methods and materials are sensitive to low literacy levels and cultural differences among participants (Mankikar 2016).

Economic evaluations indicate healthy home environment assessments achieve high cost savings largely due to averted urgent care clinic visits, emergency room visits, and hospitalizations (Uchima 2019, Jassal 2013, Gomez 2017, Kearney 2014, Margellos-Anast 2012). Health care cost savings may increase if programs can identify patients with more severe allergies or asthma who may experience greater benefits from improvements to their home environment (Kennedy 2019). Low-intensity, healthy home environment assessment programs for people with asthma show greater cost reductions when services are targeted to those with the worst controlled asthma, including children and adults in rural and urban settings (Gomez 2017). As regulations around health care costs continue to evolve, home assessments may be increasingly covered by health insurance plans (Kennedy 2019). Additional research is needed to see how best to include CHWs as part of interdisciplinary teams of practitioners, how to support training efforts, and reimbursement for services (Coutinho 2020).

There is strong evidence that healthy home environment assessment programs have the potential to reduce disparities in housing quality and health outcomes, especially related to asthma and allergen exposure, between people of color with low incomes and white people with higher incomes (Uchima 2019, Welker 2018, LeCann 2017, Jassal 2013). Children from families identifying as minorities with low incomes residing in inner cities are more likely to have asthma and suffer from poorer asthma-related health outcomes (Giese 2019). Healthy home environment assessment programs alleviate allergy and asthma symptoms and reduce exposure to secondhand smoke for urban, minority children from families with low incomes (Welker 2018), as well as for asthmatic adults and children living in lower quality housing (Krieger 2015, Campbell 2015), and for those living in rural areas (Gomez 2017). A Chicago-based study of primarily Hispanic children with uncontrolled asthma from families with low incomes receiving in-home asthma care and environmental assessments also experienced improved asthma control (Martin 2022, Martin 2021).

Programs have been shown to improve home air quality and reduce urgent care admissions for families of color and those with low incomes in rural areas (Kearney 2014, Postma 2011). Programs can also improve the home environment and respiratory health of asthmatic older adults with low incomes (Turcotte 2019). Additional study is needed to see if older adults with asthma may benefit from additional follow-up visits by home visitors, generally community health workers (CHWs) (Turcotte 2020).

Experts suggest that home visitors from the same communities and cultural background as the families they care for may be better equipped to build trust and greater understanding (CG-Asthma, Martin 2021). Programs that are sensitive to the literacy levels and cultural perspectives of participants can help program staff share culturally relevant materials at appropriate literacy levels. Accessible materials are more likely to increase participants’ understanding of home hazards and their ability to reduce those hazards (Mankikar 2016).

A safe and healthy home means more than stable walls, a roof, and functional plumbing. Healthy homes must be free of lead paint and asbestos, heating and cooling systems must work properly, and plumbing must be free of toxic elements. Housing conditions have a significant impact on health, which is further amplified by both the surrounding physical environment and historical drivers of inequity (Turcotte 2020, NCHH-Learn). Most indoor allergens including mold, dust mites, insects, smoke, pets, rodents, and fungi can be found in homes. These allergens can also trigger asthma, a chronic health condition experienced by 25 million people, as of 2020 (Turcotte 2020, AAFA, Kennedy 2019).

In 1934, the Federal Housing Administration (FHA) was established with the premise that racial segregation protected property values for white neighborhoods. The FHA’s redlining policies were the most influential factor that entrenched racial residential segregation. Redlining denied people of color access to government-insured mortgages and labeled homes in neighborhoods where people of color lived as uninsurable, thereby guaranteeing that property values in those neighborhoods would be less than those in white neighborhoods (Kaplan 2007). By the 1960s, many urban neighborhoods and rural areas were suffering from the effects of disinvestment, concentrated poverty, and high segregation levels (Zdenek 2017). The Fair Housing Act of 1968 was passed to reduce housing discrimination, but it has not stopped housing discrimination against people of color or helped rebuild the marginalized neighborhoods created by residential segregation (Urban-Reynolds 2021). In the 1970s, heating oil prices skyrocketed in the U.S. (CRS-Perl 2019). Efforts to conserve energy at home through untested insulation materials or by sealing homes often created toxic environments where chemical and biologic pollutants and moisture builds up inside, unable to be removed by outside air. Many of these toxins are still present in older homes and have contributed to the ill health of residents for decades (CDC-US HUD-Healthy housing).

In the present day, formerly redlined neighborhoods remain more likely to include older homes in poorer condition. These homes generally have inefficient energy systems; lead paint, soil, or pipes; mold and other allergens; repair needs; challenges with heating and cooling; and more. Formerly redlined neighborhoods are often near sources of pollution, toxins, and other health hazards, such as coal-fired power plants or hazardous waste disposal sites (Braveman 2022). Healthy home environment assessments are intended to evaluate the status of homes with these challenges, taking the first steps towards improving housing conditions. Since property values for homes in formerly redlined neighborhoods remain low, residents with low incomes have fewer resources to use for repairs or energy efficient upgrades (Sanders 2020). Residents may require connections with other housing assistance programs to make the more extensive, expensive repairs that may be recommended by home environment assessments (US HUD-Healthy homes).

• What partnerships can healthy home environment assessment programs build with community organizations and social service agencies to reach households that can benefit the most?
• What financial support is available in your community for households with low incomes that receive assessments and need expensive repairs to create a healthy home? What additional assistance and follow-up support can programs provide for families after initial visits?
• How can programs work with landlords to ensure that rental properties are maintained and free of hazards?
• How can programs hire community health workers (CHWs) from the communities that are most in need of assistance to build trust among participants through cultural understanding and possible shared language?
• What efforts can your community make to invest in formerly redlined neighborhoods with older homes in disrepair? Can your local healthy home environment assessment program be incorporated into a multi-component initiative to improve housing quality and support homeownership in these neighborhoods?

Healthy home environment assessments programs are in place throughout the country. For example, Public Health—Seattle and King County in Washington State maintains one of the longest running asthma home visiting programs, which trains community health workers (CHWs) to conduct home visits focused on controlling asthma and offers numerous resources detailing their program’s protocols (King County-CHW asthma, Seattle-Asthma program). The Master Home Environmentalist Program (MHEP) launched by Washington’s American Lung Association, trains volunteers to identify health hazards in the home (e.g., dust, lead, household chemicals, mold, and other air pollutants), use low cost methods to reduce risks, and train families to improve their home environments (ALA-MHE).

The Minnesota Department of Health’s Asthma Program offers training, resources, and mentoring for local public health agencies interested in delivering asthma home-based services, including environmental assessments (MDH-Asthma toolkit). In Iowa, the Black Hawk County Health Department partners with Waterloo Community Development to run the Healthy Homes Program, which features home environment assessments targeting 29 health hazards (Black Hawk-Healthy homes). The Eastern Carolina Asthma Prevention Program’s Asthma Case Managers (ACM) provide education and resources to control asthma and allergen triggers in the home, largely to families with low incomes (ECAPP, Kearney 2014).

The U.S. Environmental Protection Agency (EPA) offers guidance and resources for health care organizations interested in creating asthma home visiting programs, featuring materials on asthma-friendly homes and step-by-step instructions on setting up a program (US EPA-Asthma HV).

‡ Resources with a focus on equity.

ACEEE-Smarter House - American Council for an Energy-Efficient Economy (ACEEE). Smarter House: Reduce your impact and home energy breakdown.

ALA-MHE - American Lung Association (ALA). The Master Home Environmentalist (MHE) Program.

Clean Air-HEAL - Clean Air for Kids Partnership. Directions for the do-it-yourself home environmental assessment list (HEAL).

MDH-Asthma toolkit - Minnesota Department of Health (MDH). Asthma home-based services toolkit.

US EPA-Asthma HV^‡ - U.S. Environmental Protection Agency (U.S. EPA). Asthma home visit programs.

WAC^‡ - Children's Health Alliance of Wisconsin. Wisconsin Asthma Coalition (WAC). Home Walkthrough Program: Report and checklist to identify low and no-cost solutions to asthma triggers.

* Journal subscription may be required for access.

AAFA - Asthma and Allergy Foundation of America (AAFA). Asthma facts and figures.

ALA-MHE - American Lung Association (ALA). The Master Home Environmentalist (MHE) Program.

Black Hawk-Healthy homes - Black Hawk County Health Department, Iowa. Environmental health: Healthy homes program.

Braveman 2022 - Braveman PA, Arkin E, Proctor D, Kauh T, Holm N. Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling. Health Affairs. 2022;41(2):171-178.

Campbell 2015* - Campbell JD, Brooks M, Hosokawa P, et al. Community health worker home visits for Medicaid-enrolled children with asthma: Effects on asthma outcomes and costs. American Journal of Public Health. 2015;105(11):2366-2372.

CDC-US HUD-Healthy housing - Centers for Disease Control and Prevention (CDC) and U.S. Department of Housing and Urban Development (U.S. HUD). Healthy housing reference manual. Atlanta: U.S. Department of Health and Human Services; 2006.

CG-Asthma - The Guide to Community Preventive Services (The Community Guide). Asthma: Home-based multi-trigger, multicomponent environmental interventions children and adolescents with asthma.

Coutinho 2020 - Coutinho MT, Subzwari SS, McQuaid EL, Koinis-Mitchell D. Community health workers’ role in supporting pediatric asthma management: A review. Clinical Practice in Pediatric Psychology. 2020;8(2):195-210.

CRS-Perl 2019 - Perl L. The LIHEAP formula. Congressional Research Service (CRS) RL33275; 2019.

ECAPP - Eastern Carolina Asthma Prevention Program (ECAPP). Reduce asthma attacks, emergency department visits and asthma hospitalizations among rural, low income families with children with asthma.

Giese 2019* - Giese JK. Evidence-based pediatric asthma interventions and outcome measures in a healthy homes program: An integrative review. Journal of Asthma. 2019;56(6):662-673.

Gomez 2017* - Gomez M, Reddy AL, Dixon SL, Wilson J, Jacobs DE. A cost-benefit analysis of a state-funded healthy homes program for residents with asthma: Findings from the New York State Healthy Neighborhoods program. Journal of Public Health Management and Practice. 2017;23(2):229-238.

Jassal 2013* - Jassal MS, Diette GB, Dowdy DW. Cost-consequence analysis of multimodal interventions with environmental components for pediatric asthma in the state of Maryland. Journal of Asthma. 2013;50(6):672-680.

Kapheim 2015* - Kapheim MG, Ramsay J, Schwindt T, Hunt BR, Margellos-Anast H. Utilizing the community health worker model to communicate strategies for asthma self-management and self-advocacy among public housing residents. Journal of Communication in Healthcare: Strategies, Media and Engagement in Global Health. 2015;8(2):95-105.

Kaplan 2007* - Kaplan J, Valls A. Housing discrimination as a basis for Black reparations. Public Affairs Quarterly. 2007;21(3):255-273.

Kearney 2014 - Kearney GD, Johnson LC, Xu X, et al. Eastern Carolina Asthma Prevention Program (ECAPP): An environmental intervention study among rural and underserved children with asthma in Eastern North Carolina. Environmental Health Insights. 2014;8:27-37.

Kennedy 2019 - Kennedy K, Allenbrand R, Bowles E. The role of home environments in allergic disease. Clinical Reviews in Allergy and Immunology. 2019;57(3):364-390.

King County-CHW asthma - Public Health—Seattle and King County, Washington. Community health worker (CHW) asthma training.

Krieger 2015* - Krieger J, Song L, Philby M. Community health worker home visits for adults with uncontrolled asthma: The HomeBASE trial randomized clinical trial. JAMA Internal Medicine. 2015;175(1):109-117.

LeCann 2017 - Le Cann P, Paulus H, Glorennec P, et al. Home environmental interventions for the prevention or control of allergic and respiratory diseases: What really works. Journal of Allergy and Clinical Immunology: In Practice. 2017;5(1):66-79.

Mankikar 2016 - Mankikar D, Campbell C, Greenberg R. Evaluation of a home-based environmental and educational intervention to improve health in vulnerable households: Southeastern Pennsylvania lead and healthy homes program. International Journal of Environmental Research and Public Health. 2016;13(9):1-15.

Margellos-Anast 2012* - Margellos-Anast H, Gutierrez MA, Whitman S. Improving asthma management among African-American children via a community health worker model: Findings from a Chicago-based pilot intervention. Journal of Asthma. 2012;49(4):380-389.

Marshall 2020 - Marshall ET, Guo J, Flood E, et al. Home visits for children with asthma reduce Medicaid costs. Preventing Chronic Disease. 2020;17:190288.

Martin 2021* - Martin MA, Pugach O, Mosnaim G, et al. Community health worker asthma interventions for children: Results from a clinically integrated randomized comparative effectiveness trial (2016‒2019). American Journal of Public Health. 2021;111(7):1328-1337.

Martin 2022* - Martin MA. Children with uncontrolled asthma. American Journal of Public Health. 2022;112(4):e4.

MDH-Asthma toolkit - Minnesota Department of Health (MDH). Asthma home-based services toolkit.

NCHH-Learn - National Center for Healthy Housing (NCHH). Learn about healthy housing.

Postma 2011 - Postma JM, Smalley K, Ybarra V, Kieckhefer G. The feasibility and acceptability of a home-visitation, asthma education program in a rural, latino/a population. Journal of Asthma. 2011;48(2):139-46.

Sanders 2020 - Sanders A. Housing: Often overlooked but a critical pillar for older adults. Generations Journal. 2020;44(2).

Seattle-Asthma program - Public Health: Seattle & King County. Guidelines to Practice (G2P): Reducing Asthma Health Disparities through Guideline Implementation. Program works with clinics, health plans, and with patients in their homes to improve asthma care of children and adults.

Turcotte 2018* - Turcotte DA, Chaves E, Gore R, Adejumo KL, Woskie S. The impact of housing type on low-income asthmatic children receiving multifaceted home interventions. Public Health. 2018;164:107-114.

Turcotte 2019* - Turcotte DA, Woskie S, Gore R, Chaves E, Adejumo KL. Asthma, COPD, and home environments: Interventions with older adults. Annals of Allergy, Asthma and Immunology. 2019;122(5):486-491.

Turcotte 2020 - Turcotte DA, Woskie S, Gore R, et al. Sustainability of residential environmental interventions and health outcomes in the elderly. Asthma Research and Practice. 2020;6:13.

Uchima 2019* - Uchima O, Sentell T, Dela Cruz MR, Braun KL. Community health workers in pediatric asthma education programs in the United States: A systematic literature review. Children’s Health Care. 2019;48(2):215-243.

Urban-Reynolds 2021 - Reynolds K, Lo L, Boshart A, Galvez MM. Federal reforms to strengthen housing stability, affordability, and choice. Washington, D.C.: Urban Institute; 2021.

US EPA-Asthma HV - U.S. Environmental Protection Agency (U.S. EPA). Asthma home visit programs.

US HUD-Healthy homes - U.S. Department of Housing and Urban Development (U.S. HUD). Office of Lead Hazard Control and Healthy Homes. Healthy homes program.

WAC - Children's Health Alliance of Wisconsin. Wisconsin Asthma Coalition (WAC). Home Walkthrough Program: Report and checklist to identify low and no-cost solutions to asthma triggers.

Welker 2018* - Welker K, Nabors L, Lang M, Bernstein J. Educational and home-environment asthma interventions for children in urban, low-income, minority families. Journal of Asthma. 2018;55(12):1301-1314.

Zdenek 2017 - Zdenek RO, Walsh D. Navigating community development: Harnessing comparative advantages to create strategic partnerships. Chapter: The background and history of community development organizations. New York: Palgrave Macmillan; 2017.