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Compelling scientific evidence suggests that a strong association exists between housing-related hazards and the health and safety of their residents. Health, safety, and environmental hazards (such as asthma and allergy triggers), unintentional injury hazards, lead-based paint hazards, and poor indoor air quality are interrelated with substandard housing conditions. This article describes a Healthy Homes initiative to address these hazards in a coordinated fashion in the home, rather than taking a categorical approach, even in the presence of multiple hazards. It also provides an overview of Oklahoma's Healthy Homes initiative and its pilot project, the Tulsa Safe and Healthy Housing Project, which is currently administered in Tulsa in collaboration with Children First, Oklahoma's Nurse-Family Partnership program. This pilot project seeks to open new areas of research that can lead to a greater understanding of environmental health issues related to substandard housing in the United States, which will eventually make homes safer and healthier.
In 1999, the U.S. Department of Housing and Urban Development (HUD) launched its Healthy Homes Initiative (HHI) to address diseases, injuries, and unhealthy conditions related to substandard housing.1,2 The HHI is a comprehensive approach to address a broad range of housing deficiencies and hazards in a coordinated fashion rather than taking a categorical approach to health and safety hazards in the home, even in the presence of multiple issues.2,3
Several federal agencies, including the Centers for Disease Control and Prevention (CDC), have turned their attention to the HHI and have begun collaborating with HUD to investigate the causal relationships between housing and health.2 On June 9, 2009, then Acting Surgeon General Steven K. Galson issued The Surgeon General's Call to Action to Promote Healthy Homes.3,4
In response to the shift in focus of federal agencies to the HHI, the Oklahoma Childhood Lead Poisoning Prevention Program (OCLPPP) also began developing the capacity to meet this challenge. In partnership with the National Center for Healthy Housing (NCHH) and East Central University in Ada, Oklahoma, OCLPPP has offered the course Essentials for Healthy Homes Practitioners five times since May 2008. This two-day course is designed for professionals who routinely visit clients in their homes. The training is focused on reviewing Healthy Homes issues and challenges, including what conditions must be present to make a home healthy and how to recognize visible environmental health and safety hazards. In November 2008, OCLPPP offered another Healthy Homes course, Launching a Healthy Homes Initiative, targeted toward health and housing leaders and decision makers seeking to establish Healthy Homes programs and activities in their communities.5
In partnership with NCHH, the National Environmental Health Association (NEHA) offers the Healthy Homes specialist certification to recognize health and housing professionals with expertise in the area of Healthy Homes.6 As of June 18, 2010, 531 individuals—including 18 from Oklahoma—have been certified since 2007, when the credential was first offered.
These courses have put OCLPPP on the path to solidifying Healthy Homes alliances and providing the basis for skills development in specialized areas of environmental hazards identification and control to approximately 300 health and housing professionals in Oklahoma.
In 2009, CDC selected OCLPPP as one of six sites in the nation for its two-year Healthy Homes pilot project, Building Strategic Alliances for Healthy Housing Pilot. Oklahoma's project, the Tulsa Safe and Healthy Housing Project, is currently administered in collaboration with Children First (C1), Oklahoma's Nurse-Family Partnership (NFP) program and a longtime partner of OCLPPP.
Both C1 and OCLPPP are housed within the Oklahoma State Department of Health. OCLPPP has been providing training on childhood lead poisoning and its prevention to C1 nurses for the past five years, as part of their required continuing education. Several C1 nurses have attended the Essentials of Healthy Homes for Practitioners course.
The C1 program is based on the NFP initiative, a highly acclaimed, evidence-based community health and nurse home-visitation program with partnering sites in 32 states.7 The NFP initiative meets the congressionally established Top Tier evidence standard.8
C1 registered nurses provide services to first-time mothers and their families during pregnancy and up to two years after the child is born.9 To enroll in the program, clients must be ≤29 weeks pregnant and meet the same income eligibility criteria as required for the Special Supplemental Nutrition Program for Women, Infants, and Children and Medicaid. These young, low-income C1 clients are likely to have poor birth outcomes due to a combination of multiple factors including age, race/ethnicity, high-risk behaviors, socioeconomic status, lack of health insurance, and environmental exposures. The impact of substandard and inadequate housing and living conditions on this population, who are already at high risk for adverse health outcomes, can be significant.
During the first year, 25 C1 nurses in Tulsa will attend the National Healthy Homes Training Center and Network's (NHHTC) one-day course, Healthy Homes for Community Health Workers.5 The nurses will be trained on Healthy Homes principles and how to educate clients about the connection between health and housing (Figure). NHHTC's one-page assessment form, Visual Survey Report (VSR), has been adapted for the C1 nurses to collect information on visually evident structural problems and hazards during client visits.
OCLPPP will evaluate the completed VSR forms and select 25 eligible clients for an in-depth home assessment during the first year, based on factors identified through the VSR form, including housing age and hazards. Some of them will likely be Spanish-speaking, as a significant portion of Tulsa C1 clients are Hispanic (27% in 2009) and receive services from bilingual C1 nurses. These clients will receive Healthy Homes assessments from OCLPPP's bilingual case manager, who also holds NEHA's Healthy Homes specialist certification.
Community outreach programs, including home-visitation programs, can struggle with client retention, and C1 is no exception.10 However, the intensive level of support provided by highly trained and experienced registered nurses in guiding many low-income, first-time mothers during a challenging phase of their lives develops a trusted partnership between them, which can help in maximizing client retention.
The Pediatric Environmental Home Assessment form developed by NHHTC has been adapted to collect baseline data on general housing characteristics, home environment, sleep environment, home safety, and indoor pollutants during the home assessments. Additionally, tools such as carbon monoxide meters, carbon dioxide meters, moisture meters, lead-dust test kits, and borescopes will be used during home assessments to determine the presence of certain hazards. Following assessment and identification of health and safety hazards, C1 nurses will provide families appropriate low-cost health and safety items, including smoke alarms, carbon monoxide alarms, safety latches, nonslip area-rug pads, safety gates, night-lights, bathroom spout covers, infant bath pads, bathroom safety kits, anti-scald devices, oven locks, sticky mats for doorways, table edge guards, window guards, furnace filters, crawling-insect traps, humane mouse traps, crib mattress encasements, and steam vacuums. These items were chosen specifically because they can easily be transported to another residence if the family moves. C1 nurses will provide installation assistance and will educate families on how to reduce exposure to housing and safety hazards by following the seven Healthy Homes principles (i.e., keep it dry, clean, ventilated, pest-free, safe, contaminant-free, and maintained).5
OCLPPP will develop a client-specific action plan for the client and the C1 nurse assigned to the client based on the home-assessment findings. The action plan will identify areas of concern inside the home and goals the family can set to improve the environmental safety of their homes. Achievement of these goals will serve as a source of positive reinforcement for the family as they begin developing a feeling of security about their success in improving their health, as well as their housing-safety profile.
Assistance will be provided in connecting families with community and government programs for services beyond the project resources. OCLPPP has been allied with partners such as the city of Tulsa's Working in Neighborhoods department, the Tulsa Health Department's Environmental Health Services division, the American Lung Association of the Central States, and the Community Action Project of Tulsa County.
The Working in Neighborhoods department includes a Neighborhood Inspections section, which enforces nuisance and zoning ordinances to help maintain the highest level of safety and health standards in neighborhoods, and a Housing section, which oversees the city's housing assistance programs and property maintenance enforcement. The Working in Neighborhoods department offers grant and loan programs to owner-occupants of low to moderate income who reside in the city of Tulsa. Areas of service include lead-based paint, electrical, plumbing, security (doors and windows), roofs, heating, interior issues, and weatherization.
The Tulsa Health Department's Environmental Health Services division inspects existing structures to ensure and enforce certain minimum building standards that must be in place if the structure is occupied or used. The standards include, but are not limited to, requirements pertaining to sanitation, maintenance, and electrical, mechanical, and plumbing systems.
The American Lung Association of the Central States offers a variety of programs in Tulsa and throughout the central U.S. states to prevent, protect against, and control lung diseases in adults and children. Some of the programs currently offered in Tulsa include Breathe Smart from the Start, Freedom from Smoking, and Not on Tobacco.
The Community Action Project of Tulsa County is a comprehensive anti-poverty agency with a history of providing a variety of services to low-income individuals and families, including access to safe and affordable housing in Tulsa County, including the city of Tulsa. The agency is a charter member of NeighborWorks, a national network of more than 230 community-based organizations in 50 states dedicated to creating healthy communities. As the primary designated Head Start agency for Tulsa County, the Community Action -Project has 14 Early Head Start and Head Start centers in Tulsa.
Three months after the initial home assessment, C1 nurses will conduct a follow-up home visit with the client to administer a three-month follow-up survey individually designed for that client, based on the specific hazard reductions completed. Additional follow-up visits can be provided as needed.
After putting the infrastructure in place for the Tulsa Safe and Healthy Housing Project in year one, OCLPPP will expand the Healthy Homes assessment and hazard-reduction activities from 25 to 50 at-risk homes in year two. A refresher course in healthy housing principles will be offered to the C1 nurses, and partnerships and collaborations will be enhanced for the continuation of the project. Referral networks and services provided through community and government programs will be expanded where appropriate.
Data collected during initial and follow-up visits will be entered into a Microsoft® Access database and regularly monitored to guarantee that comparable data are collected.
Anticipated challenges include landlord-tenant issues and the possibility of rental clients suffering retaliatory eviction after reporting a problem needing remediation to the landlords. OCLPPP will refer these clients to the Tulsa Health Department's Environmental Health Services for environmental inspections. Clients can potentially be protected from retaliatory eviction if health and safety hazards are identified and documented in environmental inspection reports.
Other concerns could be maintaining contact with highly mobile clients and loss to follow-up, although the close association of C1 nurses with the clients can keep the retention rates higher.
Finally, the three-month follow-up visits could prove insufficient, as research has shown that greater beneficial effects are found in home-visitation programs of longer duration.11
Evaluation measures have been developed to demonstrate the project's progress and intended health and housing improvement. Data collected from initial and follow-up visits will be compared and analyzed to determine improvements in the health and housing-safety profile of the family. Improvements may include behavior changes, such as reducing or eliminating sources of pest infestation and proper storage of hazardous household products, or reduction in the severity of asthma symptoms.
The Tulsa Safe and Healthy Housing Project has the potential to open up new areas of research that can lead to greater understanding of best practices to make homes healthier and safer in the U.S. On March 23, 2010, the Patient Protection and Affordable Care Act was signed into law. The Maternal, Infant, and Early Childhood Home Visiting Program, which was created as part of the Act to support evidence-based programs focused on improving the well-being of families with young children, was also modeled on the NFP initiative. Both C1 and OCLPPP's Tulsa Safe and Healthy Housing Project are multidimensional, holistic programs focusing on various aspects of the family's health and safety. It seems reasonable that such a partnership, characterized by evidence-based preventive interventions, with the potential to yield quantifiable health, social, and economic benefits to families and communities, should be expanded not only in Oklahoma but also across the country.
The project was supported by Cooperative Agreement #1U88EH000570-01 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the author and do not necessarily represent the official views of CDC.