Healthy home environment assessments

Evidence Rating  
Scientifically Supported
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  

Healthy home environment assessments engage home visitors, often community health workers (CHWs), similarly trained asthma outreach workers, other professionals, paraprofessionals, or volunteers to assess and reduce environmental health risks within the home1, 2. Programs typically focus on improving asthma management via low cost changes such as improved ventilation, integrated pest management (IPM), and other forms of allergen control. Programs may also provide low emission vacuums, allergen-impermeable bedding covers, air filters, cleaning supplies, and supplies for roach abatement3, 4.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Reduced exposure to allergens

  • Reduced hospital utilization

  • Improved health outcomes

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Improved asthma management

  • Improved quality of life

  • Improved indoor air quality

What does the research say about effectiveness? This strategy is rated scientifically supported.

There is strong evidence that healthy home environment assessments encourage household behaviors that reduce asthma triggers and exposure to allergens5, 6, 7, 8, decrease use of urgent care and related health care costs2, 3, 6, 8, 9, 10, 11, 12, and improve health outcomes3, 4, 5, 6, 8.

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 hospital6 and urgent care center visits9, 10, and may also reduce the number of asthma-related doctor’s appointments13. Programs have been shown to improve asthma self-management, increase the number of asthma symptom-free days2, 5, 12, 14, 15, and can reduce activity restrictions for asthmatic children5, 9, 10. Programs improve quality of life2, 5, 12, 14, 15 and reduce school and work absences for asthmatic children and their caregivers5. Healthy home environment assessment programs have been shown to be beneficial in urban and rural areas11 and for people of color and people with low incomes5, 6.

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 control9, 10, 16, reduced environmental triggers, reduced emergency department visits, and generated significant Medicaid cost savings16.

Healthy home environment assessments improve user comfort through temperature and humidity adjustments and may reduce the presence of molds7. 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 participants13.

Economic evaluations indicate healthy home environment assessments achieve high cost savings largely due to averted urgent care clinic visits, emergency room visits, and hospitalizations2, 5, 8, 11, 15. 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 environment17. 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 settings11. As regulations around health care costs continue to evolve, home assessments may be increasingly covered by health insurance plans17. 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 services18.

How could this strategy advance health equity? This strategy is rated potential to decrease disparities: supported by strong evidence.

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 incomes5, 6, 7, 8. 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 outcomes25. Healthy home environment assessment programs alleviate allergy and asthma symptoms and reduce exposure to secondhand smoke for urban, minority children from families with low incomes6, as well as for asthmatic adults and children living in lower quality housing3, 4, and for those living in rural areas11. 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 control9, 10.

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 areas2, 26. Programs can also improve the home environment and respiratory health of asthmatic older adults with low incomes27. 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)28.

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 understanding10, 29. 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 hazards13.

What is the relevant historical background?

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 inequity28, 30. 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 202017, 28, 31.

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 neighborhoods32. By the 1960s, many urban neighborhoods and rural areas were suffering from the effects of disinvestment, concentrated poverty, and high segregation levels33. 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 segregation34. In the 1970s, heating oil prices skyrocketed in the U.S.35. 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 decades36.

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 sites37. 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 upgrades38. Residents may require connections with other housing assistance programs to make the more extensive, expensive repairs that may be recommended by home environment assessments39.

Equity Considerations
  • 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?
Implementation Examples

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 protocols19, 20. 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 environments1.

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 assessments21. 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 hazards22. 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 incomes2, 23.

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 program24.

Implementation Resources

Resources with a focus on equity.

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).

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

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.

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

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

Footnotes

* Journal subscription may be required for access.

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

2 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.

3 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.

4 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.

5 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.

6 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.

7 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.

8 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.

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

10 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.

11 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.

12 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.

13 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.

14 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.

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.

16 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.

17 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.

18 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.

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

20 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.

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

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

23 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.

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

25 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.

26 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.

27 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.

28 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.

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

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

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

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

33 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.

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

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

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

37 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.

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

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

Date Last Updated