Healthy Homes Lit Reviews Abstracts

I. Asthma
Brophy-Herb, Holly E., et al. "Key Theoretical Frameworks for Intervention: Understanding and Promoting Behavior Change in ParentInfant Feeding Choices in a Low-Income Population." The Journal of Primary Prevention 30.2 (2009). Brophy-Herb et al. discuss the effects of the introduction of solids in the infant diet before an appropriate age with emphasis on diet as choosen by low-income individuals. The affects discussed are limited to allergies (asthma), later-life weight issues, and diabetes. The authors propose that issuing The Infant Feeding Series (TIFS) as an educational, curiculum intervention tool could work to prevent some of these issues through providing mothers knowledge of solid food readiness cues. The project provides short term education and produces long-term outcomes. Brown, Amanda Savage, et al. "Family and Home Asthma Services across the Controlling Asthma in American Cities Project." Journal of Urban Health 88.S1 (2011): 100-112. This article reviews six of The Center for Disease Control and Preventions interventions key program variable and process indicators in an attempt to converge best practices within the Controlling Asthma in American Cities Project (CAAC). Each home in need of family and home intervention services (FHAS) received multicomponent (asthma self-management, social services, and coordinated care) and multitrigger environmental interventions. Implementation of the six interventions will be implemented through consideration of communities, coalitions, and programs. Brugge, Doug. (2010). How much evidence is enough? Assessing home asthma research. Journal of Public Health Management and Practice. 16(5): S21-23. There is growing evidence that certain environmental interventions both benefit and pose risks to the health of those who receive them. Brugge advocates for movement towards determining the appropriate level of evidence required before recommending an intervention. Using home asthma research as a case study for his analysis, Brugge finds that the perceived success of many environmental interventions may be due to the social engagement of households in the intervention. As a result, Brugge calls for a greater examination of the social component of environmental interventions. This will assist in identifying which elements have little or no contribution to the desired benefits and thus reduce intervention costs and invasiveness. Bruzzese, Jean-Marie, et al. "School-based Asthma Programs." Journal of Allergy and Clinical Immunology 124.2 (2009): 195-200. This article focuses on the limitations of screening tools and school-based interventions in relation to the necessity that is identifying specific districts where asthma morbidity and prevalence are highest and there is no existing access to asthma care. Strategies are reviewed, including: improved access to care, self-management skills in school, improvement of school personnel asthma management skills. Improvement can take place, however, due to a greater importance placed on curriculum, health issues are often secondary. Bryant-Stephens, T. (2009). Asthma disparities in urban environments. Journal of Allergy and Clinical Immunology. 123(6): 1199-1206. Asthma disproportionately affects minority and low-income populations. Studies reveal that compared with white children, rates of asthma prevalence, morbidity and mortality are higher among African American and Latino children who live in low-socioeconomic status urban environments. This article outlines the health care and environmental disparities underpinning this disproportionate burden of asthma, and identifies components of asthma interventions that may close this gap.

Bryant-Stephens, T. et al. (2011). Brief report of a low-cost street-corner methodology used to assess inner-city residents awareness and knowledge about asthma. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 88(1): S156-162. Abstract: Bryant-Stephens, T. et al. (2009). Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma. American Journal of Public Health. 99(S3): S657-S665. Effective asthma management includes both quality health care and environmental trigger avoidance. Current national asthma guidelines highlight symptom control as a function of asthma management. This article explores the impact on asthma symptom control of a home-based educational and environmental intervention delivered in an urban setting by community health workers. Butz, A. M., et al. "A Randomized Trial of Air Cleaners and a Health Coach to Improve Indoor Air Quality for Inner-City Children With Asthma and Secondhand Smoke Exposure." Archives of Pediatrics and Adolescent Medicine 165.8 (2011): 741-48. Using a randomized controlled trial and a randomized study database, an air cleaner and health coach were used to test the effectiveness of reducing the symptoms of asthma and other aspects of its prevalence. The study was conducted at the John Hopkins Childrens Center and homes of children, with 126 children in the Baltimore area. Carter, M.C. et al. (2001). Home intervention in the treatment of asthma among inner-city children. Journal of Allergy Clinical Immunology. 108(5): 732-737. the use of allergen avoidance as a treatment for asthma among inner-city children. Children were randomized into an active avoidance group, a placebo avoidance group, and a second control group for which no home visits occurred until the end of the first year. Results showed a significant decrease in acute visits for asthma among the children in the active avoidance and placebo groups, although there was no significant difference between the two. Overall, the authors find that home visiting positively influences the management of asthma among lowerincome and impoverished families. Dixon, S.L. et al. (2008). An examination of interventions to reduce respiratory health and injury hazards in homes of low-income families. Environmental Research. 109 (2009): 123-130. The authors evaluated whether combining asthma trigger reduction with housing structural repairs, device disbursement and education in low-income households with children would improve self-reported respiratory health and reduce housing-related respiratory health and injury hazards. Homes enrolled in the study received a baseline assessment, intervention, and another assessment approx. 3-4 months post-intervention. On average, 8 injury hazards and 3.3 respiratory health hazards were observed in the home at baseline, while four months later, they had decreased to 2.2 and 0.9, respectively. Furthermore, 97% of parents reported their homes were safer and 96% said the respiratory health of their asthmatic children improved post-intervention. Etzel, Ruth A. "How Environmental Exposures Influence the Development and Exacerbation of Asthma." Pediatrics 112.1 (2003): 233-39. This article emphasizes and reviews the impacts that environmental exposures have on asthma exacerbations and prevalence. The aspects of asthma triggers reviewed that are of particular importance include: outdoor air pollutants, tobacco smoke, and dust mites. Etzel questions the specific roles each aspect plays in either increased exacerbations and thus clusters, and asthma prevalence. Intervention techniques are then offered against exposure. Greenwood, V. (2011, April 14). Why are asthma rates soaring? Scientific American. Retrieved from http://www. scientificamerican.com/article.cfm?id=why-are-asthma-rates-soaring For many years, researchers have looked to the hygiene hypothesis to understand the surge in global asthma rates over the past three decades. The hypothesis argues that improved sanitary conditions deprive the immune system of the ability to develop differing, highly effective defenses to infectious agents. The body thus launches an attack against harmless particles that results in an allergic reaction and the classic signs of asthma. While data supports

this hypothesis for allergies, more recent evidence challenges this hypothesis for asthma and the link between high asthma rates and hygienic environments. The article outlines this evidence and presents alternative theories. Horner, S.D. (2006). Home visiting for intervention delivery to improve rural family asthma management. Journal of Community Health Nursing. 223(4): 213-223. This article focused on the use of home visits in an asthma self-management intervention, while describing the challenges with and possible solutions for implementing home visits in rural areas. While the study saw improved asthma management for all families, it also provided lessons in successful home visit intervention implementation. Although the challenges in making home visits in rural areas are similar to those experienced in urban areas, the lack of resources in rural areas may increase the value or benefit derived from such home visits. Kercsmar, C.M. et al. (2006). Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives. 114(8): 1574-1580. High exposure to allergens such as dust mite, cockroach, and mold have all been implicated in the development and exacerbation of asthma. This study explored the effects of remediation of the causes of home moisture and mold on asthma outcomes, hypothesizing that such a home environmental intervention would significantly decrease symptom days and health care use beyond what is achieved though a standard intervention alone. Overall, it seems that construction remediation combined with a medical/behavioral intervention produces significant reductions in symptom days and health care use for children with asthma living in homes with mold problems. Kinney, P.L. et al. (2002). On the front lines: An environmental asthma intervention in New York City. American Journal of Public Health. 98(1): 24-26. This study implemented an apartment-based intervention to reduce exposures to indoor allergens among children living with asthma in two areas in New York City with asthma morbidity and mortality that rank among the highest in the United States. Although the intervention phase was not yet complete at the time of publication, the authors believe that a report of their field experiences could possibly be useful to groups engaged in environmental intervention trials in urban areas. Klitzman, S. et al. (2005). A multihazard, multistrategy approach to home remediation: Results of a pilot study. Environmental Research. 99 (2005): 294-306. The authors evaluated a pilot home remediation intervention that addressed multiple home hazards, including lead, pests, mold, and safety hazards in a sample of 70 pre-1940 dwellings. As needed, participating homes received paint stabilization, dust lead cleaning, integrated pest management, mold cleaning, and safety devices. Significant reductions were achieved in the number of dwellings with three or more problems; high levels of dust lead on floors and window sills; homes with evidence of cockroaches or rodents; and fire, electrical, and/or fall hazards. The results of the pilot program demonstrate that a comprehensive approach to hazard remediation can be highly effective while overall improvements can be maintained. Krieger, J. et al. (2010). Housing interventions and control of asthma-related indoor biologic agents: A review of the evidence. Journal of Public Health Management Practice. 16(5): S11-S20. Subject matter experts systematically reviewed evidence on the effectiveness of housing interventions that affect health outcomes, primarily asthma, associated with exposure to moisture, mold, and allergens. Three of the 11 interventions reviewed had sufficient evidence for implementation: multifaceted, in-home tailored interventions for reducing asthma morbidity; integrated pest management to reduce cockroach allergen; and combined elimination of moisture intrusion and leaks and removal of moldy items to reduce mold and respiratory symptoms. Largo, T.W. et al. (2011). Healthy homes university: A home-based environmental intervention and education program for families with pediatric asthma in Michigan. Public Health Reports. 126(Supplement 1): 14-26. This study aimed to implement an in-home environmental public health program in order to improve health outcomes among asthmatic children. Families received four home visits during a six-month intervention, as program staff assessed home for asthma triggers and subsequently provided products and services to reduce exposures, along with providing asthma education to caregivers. Based on self-reported data gathered at baseline

and six months post-intervention, childrens asthma impacts were substantially reduced, and the proportion who sought acute, unscheduled health services decreased by more than 47%. Largo, T, et al. (2011). Healthy homes university: A home-based environmental intervention and education program for families with pediatric asthma in Michigan. Public Health Reports. 126: 14-26. Healthy Home University, an in-home environmental and educational intervention program to address asthma, was implemented to improve asthma in children from low-income families in Lansing, Michigan from 2005 to 2008. Families received four visits over a six month intervention period. Review of the intervention results revealed statistically significant reductions in asthma severity. Authors cannot solely attribute these outcomes to the intervention due to reliance on self-reported data and the lack of a control group. Lin, S. et al. (2004). An evaluation of the asthma intervention of the New York State Healthy Neighborhoods program. Journal of Asthma. 41(5): 583-595. This article evaluated the Healthy Neighborhoods Program (HNP) intervention, which uses home visits to identify asthmatics, assess asthma morbidity and management, and identify environmental triggers. The purpose of the evaluation was to assess the impact of the intervention for the 1997-1999 funding cycle and the first year of the 2000-2002 funding cycle by analyzing the rate of self-reported hospitalizations and three intermediate outcome measurements. Overall, the HNP intervention seems to be successful in reducing asthma morbidity, as measured by a decrease in hospitalization rates post-intervention, in addition to having success in reducing in-home cockroach infestation. Maas, Tanja et al. "Cochrane Review: Mono and Multifaceted Inhalant And/or Food Allergen Reduction Interventions for Preventing Asthma in Children at High Risk of Developing Asthma." Evidence-Based Child Health: A Cochrane Review Journal 5.3 (2010): 1385-450. Maas et al sought genetic asthma prevention through environmental influence education intervention using the PREVASC model. The interventions were applied within the examinations of mono and multi-faceted interventions of inhalant and food allergen exposure, specifically breastfeeding and tobacco smoke. The hygiene, supplementation of poly-unsaturated fatty acids, and viruses and bacteria and probiotics hypotheses are all reviewed to add perspective to the main focus. Mendell, M.J., Mirer, A.G., Cheung, K., Tong, M., & Douwes, J. (2011). Respiratory and allergic health effects of dampness, mold, and dampness-related agents: A review of the epidemiologic evidence. Environmental Health Perspectives, 119(6): 748-756. Many studies have shown consistent associations between indoor dampness or mold and respiratory or allergic health effects, although causal links remain unclear. The authors conducted an updated, comprehensive review of available epidemiologic evidence on qualitative assessments of dampness or mold factors and new synthesis of evidence on quantitative measurements of microbiologic factors. They conclude that evident dampness or mold had consistent positive associations with multiple allergic and respiratory effects. Parker, E.A. et al. (2007). Evaluation of community action against asthma: A community health worker intervention to improve childrens asthma-related health by reducing household environmental triggers for asthma. Health Education and Behavior. The article describes the evaluation of a community-based participatory research, community health worker intervention to improve childrens asthma-related health by reducing household environmental triggers for asthma. Children likely having persistent asthma and residing on the eastside or southwest Detroit were recruited to receive a home-visiting intervention by a CHW. Home visits were effective in improving some aspects pertaining to lung function, health care utilization, and medication use and in changing some behaviors related to environmental trigger reduction. However, it was less effective in reducing measured dust allergen concentrations. Somerville, M, I Mackenzie, P Owen & D Miles. (2000). Housing and health: Does installing heating in their homes improve the health of children with asthma. Public Health. 114: 434-439. Studies have consistently demonstrated a link between damp and moldy housing and respiratory symptoms in adults and children. At the time of this article however, no known studies had examined whether asthma

morbidity may be lowered by reducing the presence of asthma and mold in the house. This study seeks to do so by installing central heating in the homes of children with previously diagnosed asthma, finding that such an intervention has the potential to significantly improve childrens asthma symptom management and reduce the amount of school days lost due to asthma. Takaro, T.K. et al. (2011). The breathe-easy home: The impact of asthma-friendly home construction on clinical outcomes and trigger exposure. American Journal of Public Health. 101(1): 55-62. The authors assessed the effect of a breathe-easy home, or BEH, on asthmatic childrens number of symptom days, urgent care visits, quality of life, and exposure to indoor environmental triggers. They hypothesized that living in a BEH would produce further benefits than those offered by asthma-control interventions alone. Compared with such families, those who moved into a BEH experienced additional improvements in multiple clinical outcome and trigger exposure measures. However, when the two studies are compared, these improvements are only statistically significant for night-time symptoms. It is suggested, although not proven based on the evidence presented, that BEH intervention has added benefits further than those from in-home asthma interventions alone. Ungar, Wendy J., et al "Socioeconomic Factors and Home Allergen Exposure in Children With Asthma." Journal of Pediatric Health Care. 24.2 (2009): 108-115. This study used a cross-sectional analysis of data and 845 children with asthma as well as multiple linear regression to find the link between sociodemographic factors and in which ways failure to reduce sources of allergens is prominent. Logistic regression assessed a relationship between the socioeconomic status of the household and exposure to tobacco smoke. Van Asselt, L. "Review : Interactions between Domestic Mites and Fungi." Indoor and Built Environment. 8.4 (1999): 216-20. Asselt identifies an often overlooked ecologic dependency relationship between dust mites and fungi (mold) in homes. For example, fungi may provide vitamins and sterols that serve as the nutrients needed for the D. phagoides pteronyssinus mite type (most commonly related to asthma) to survive. This relationship makes transfer of micro-organisms into clean food possible. Asselt concludes that fungicides are imperative to the reduction and control of domestic mites. Warman, Karen, et al. "Modifiable Risk Factors for Asthma Morbidity in Bronx Versus Other Inner-City Children." Journal of Asthma 46.10 (2009): 995-1000. This article seeks to make light of the reasons why children in the Bronx have higher asthma mobidity risks that children in other inner-city US states. 1772 (265 from the Bronx) children ages 5-11 years old with persistent asthma in 8 sites (1 Northeast, 2 South, 2 Midwest, 2 West, and the Bronx) participated in a cross-sectional study regarding persistent asthma and its relationship to housing conditions. Williams, S.G. (2006). Does a multifaceted environmental intervention alter the impact of asthma on inner-city children? Journal of the National Medical Association. 98(2): 249-260. The authors evaluated the impact of a multifaceted environmental and educational intervention on indoor allergen levels and childrens asthma severity. This study used an experimental design, and participants were randomized into either an intervention or delayed intervention group, with the former receiving dust mite covers, a professional house cleaning, and having roach bait and trays placed in their homes. Despite low retention limiting comparisons between groups, the evidence found that the intervention resulted in decreased dust mite allergen levels and improved median Functional Severity Scores in the intervention group. Wickman, M., E. Melen, N. Berglind, S. Lennart Nordvall, C. Almqvist, I. Kull, M. Svartengren, and G. Pershagen. "Strategies for Preventing Wheezing and Asthma in Small Children." Allergy 58.8 (2003): 742-47. The authors conducted a Prospective birth cohort study (BAMSE) from 1994 to 1996 with 4089 children aged 2 years and under. The study sought to assess the results of compliance with preventative allergy guidelines on wheezing and asthma in households in Stockholm with families having various lifestyles (tobacco, home dampness,

pet ownership, etc.). Additionally, the study identified the difference in percentage during compliance between children with allergic heredity and those without.

II.

Lead

A. Lead-Hazard Control Interventions

Breysse, J. et al. (2008). Selecting a lead hazard control strategy based on dust lead loading and housing condition: II. Application of Housing Assessment Tool (HAT) modeling results. Journal of Occupational and Environmental Hygiene. 5: 540-545. This article illustrates the field application of the HAT proposed in Part I (Dixon et al, 2008), which assists practitioners in determining the minimum intervention intensity needed to reach acceptable one year postintervention dust lead levels. The HAT was used to predict one year post-intervention dust lead levels on a variety of housing conditions (poor or good) and baseline levels in order to determine the most effective and costeffective strategy to keep dust lead at lower levels. Dixon, S.L. et al. (2005). Effectiveness of lead-hazard control interventions on dust lead loadings: Findings from the evaluation of the HUD Lead-Based Paint Hazard Control Grant Program. Environmental Research. 98(2005): 303-314. From 1994 to 1999, the Evaluation of the US Department of Housing and Urban Development Lead-Based Paint Hazard Control Grant Program studied the intervention experiences of over 2800 homes in 11 states. Each interior intervention was categorized as (in order of increasing intensity): (a) cleaning/spot painting; (b) complete repainting; (c) complete repainting plus window treatments; (d) window abatement plus treatments to other components; (e) abatement of all lead-based paint hazards; or (f) abatement of all lead-based paint. The first intervention, cleaning/spot painting, did not prove effective at maintaining dust lead below baseline levels for 12 months. Findings demonstrate that a whole-building approach to lead-hazard control is most appropriate. Dixon, S. et al. (2008). Selecting a lead hazard control strategy based on dust lead loading and housing condition: I. Methods and results. Journal of Occupational and Environmental Hygiene. 5: 530-539. A methodology was developed to classify housing conditions and interior dust lead loadings, using them to predict the relative effectiveness of different lead-based paint hazard control interventions. Data from the National Evaluation of the HUD Lead Hazard Control Grant Program was used to create statistical models in order to identify a simple visual assessment of interior and exterior housing condition, referred to as a Housing Assessment Tool (HAT), which can predict effectiveness for a range of intervention intensities and baseline dust lead levels. Haynes, E. et al. (2002). The effect of interior lead hazard controls on childrens blood lead concentrations: A systematic evaluation. Environmental Health Perspectives 110(1): 103-107. The authors conducted a systematic review of randomized, controlled trials of low-cost lead hazard control interventions to determine the effect on childrens blood lead concentration. Four studies met inclusion criteria. Findings showed no significant difference in mean change in blood lead concentration for children by random group assignment (children assigned to the intervention group compared with those assigned to the control group). No significant difference between intervention and control groups was found in the percentage of children with blood lead 10 g. However, the interventions were associated with a reduction in the percentage of children who had blood lead concentrations 15 g/dL and 20 g/dL. Taha, T., M.S. Kanarek, B.D. Schultz, & A. Murphy. (1999). Low-cost household paint abatement to reduce childrens blood lead levels. Environmental Research 81: 334-338. This study examined the effectiveness of a low-cost abatement intervention on childrens blood lead levels. Blood lead was analyzed before and after abatement in 37 homes of children under 7 who had an initial blood lead level of 25-44 g/dL. A control group of children with similar age and blood lead ranges was retrospectively selected. After abatement, the intervention children saw statistically significant declines in blood lead, while the control

childrens levels did not decline significantly. Low-cost abatement and education are effective short-term interim controls. Wilson, J. et al. (2006). Evaluation of HUD-funded lead hazard control treatments at 6 years post-intervention. Environmental Research. 102(2006): 237-248. This study compared the relative effectiveness of lead hazard control (LHC) treatments after 6 years of the different classes of interventions used by HUD grantees, after controlling for such factors as housing conditions and characteristics and resident neighborhood characteristics. Findings from the 6-Year Extension study indicate that across all grantees and treatment strategies the treatments applied were effective at significantly reducing environmental lead levels on floors, window sills, and window troughs at least 6 years following the intervention.

B. Blood Lead Levels and Childhood Outcomes

Jusko, T.A. et al. (2008). Blood lead concentrations < 10 g/dL and child intelligence at 6 years of age. Environmental Health Perspectives. 116(2): 243-248. This study examines the association between early childhood blood lead levels and cognitive function, measured by an IQ test at 6 years old. The average blood lead level for study participants was 7.2 g/dL , and more than half never had a concentration of 10 g/dL or higher, the CDC definition of an elevated blood level. Children how had lifetime levels lower than 5 g/dL scored better on IQ tests than their counterparts who had lifetime levels between 5 and 9.9 g/dL .The authors find that childrens intellectual development and functioning is impaired by blood lead concentrations well below the CDC recommendations. Miranda, M.L. (2010). Early childhood lead exposure and exceptionality designations for students. International Journal of Child and Adolescent Health. 3(1): 77-84. In this paper, the authors explore whether early childhood blood lead levels are associated with membership in exceptionality designation groups, while further examining the racial and socioeconomic composition of these groups. End-of-grade testing data was evaluated to determine the impact of lead exposure across four groups: students with no exceptional status designated, students in advanced/gifted programs, students designated exceptional due to learning or behavioral classifications, and students designated exceptional for other reasons. The authors found that a low level of blood lead exposure can significantly increase the likelihood of LBED and EDO classifications, while decreasing the chance of admittance to advanced programs. Miranda, M.L. et al. (2009). Environmental contributors to the achievement gap. Neurotoxicology. 30(6): 10191024. Childhood lead exposure has been linked to a number of adverse cognitive outcomes. In previous work, the authors demonstrated a relationship between early childhood lead exposure and end-of-grade (EOG) test scores on a limited dataset. In this analysis, data from the North Carolina Childhood Lead Poisoning Prevention Program surveillance registry were linked to educational outcomes available through the North Carolina Education Research Data Center for all 100 counties in NC. The results from the previous study (Miranda et al., 2007) are backed up in this statewide assessment, demonstrating that lead exposure can explain part of the educational achievement gap between minorities and disadvantaged groups compared with middle- and upper-class whites. Miranda, M.L., Kim, D., Osgood, C. & Hastings (2011). The impact of early childhood lead exposure on educational test performance among Connecticut schoolchildren. Phase 1 report. D. Childrens Environmental Health Initiative. In this report, the authors use the analytical approach used in North Carolina (see Miranda et al., 2007, 2009, & 2010) as the basis for examining the association between blood lead levels and educational outcomes among CT children. Using the same methodology as the previous studies, the authors find similar results in Connecticut: early childhood lead exposure negatively affected CMT test scores in both reading and mathematics, while negative correlations were statistically significant at blood lead levels well below the current CDC blood lead action level of 10 g/dL.

Miranda, M.L. et al. (2007). The relationship between early childhood blood lead levels and performance on end-of-grade tests. Environmental Health Perspectives. 115(8): 1242-1247. This study explores the potential relationship between early childhood lead exposure and educational achievement in elementary school. Low-level lead exposure has previously been linked to decreased performance on standardized IQ tests for school-aged children, and this study aims to determine whether lead exposure is also th related to achievement on end-of-grade testing for 4 grade students. The results suggest that the relationship between blood lead levels and such measures of educational achievement are significant, even with low exposure. National Toxicology Program. (2011). Draft NTP monograph on health effects of low-level lead. U.S. Department of Health and Human Services. Washington, DC: U.S. Government Printing Office. This report from the National Toxicology Program summarizes the evidence from epidemiological studies in order to determine the health effects associated with low-level lead exposure (as indicated by blood lead levels < 10 g/dL). The authors found evidence for a multitude of neurological, immune, cardiovascular, renal, and reproductive/developmental effects linked to low-level lead exposure in children and adults. They conclude that there is sufficient evidence for adverse health effects at levels not only below 10 g/dL, but also as low as 5 g/dL. Zhu, M., Fitzgerald, E.F., Gelberg, K.H., Lin, S., Druschel, C.M. (2010). Maternal low-level lead exposure and fetal growth. Environmental Health Perspectives, 118(10): 1471-1475. Limited epidemiologic studies have examined the association between maternal low-level lead exposure and fetal growth. In this study, the authors examined whether exposure < 10 g/dL was inversely associated with birth weight and directly associated with the risk of preterm birth and small for gestational age. They find that a lowlevel PbB was associated with a small risk of decreased birth weight with a dose-response relationship, although it was not found to be related to the risk for preterm birth or small for gestational age.

III.

Safety

DiGuiseppi, C. et al. (2010). Housing interventions and control of injury-related structural deficiencies: A review of the evidence. Journal of Public Health Management Practice. 16(5): S34-S43. Subject matter experts systematically reviewed evidence on the effectiveness of housing interventions associated with structural housing deficiencies. Three of the 17 interventions reviewed had sufficient evidence for implementation: installed, working smoke alarms; 4-sided isolation pool fencing; and preset safe hot water temperature. However, the authors find that these interventions could benefit from further testing across other locations, population demographics, etc. DiGuiseppi, C. & Higgins, J.P.T. (2000). Systematic review of controlled trials of interventions to promote smoke alarms. Archives of Disease in Childhood. 82: 341-348. The authors undertook a systematic review of controlled trials of smoke alarm promotion interventions. Overall, counseling and educational interventions had only a modest effect on owning an alarm or having a functional alarm, while counseling as part of primary care child health surveillance had a greater effect, although effects on fire related injuries were not reported in randomized trials. In two non-randomized trials, direct provision of free alarms significantly reduced fire related injuries, while media and community education interventions showed little benefit in non-randomized trials. The authors conclude that further evaluations of primary care education or alarm give away programs should be randomized controlled trials measuring injury outcomes. Dowswell, T. & Towner, E. (2002). Social deprivation and the prevention of unintentional injury in childhood: A systematic review. Health Education Research. 17(2): 221-237. The authors systematically reviewed relevant literature on social deprivation as it relates to the prevention of unintentional childhood injury. World literature between 1975 and 2000 was used for this review. However, they contend that few studies examined the impact of interventions on different social groups, therefore creating difficulty in the design and targeting of interventions to address inequalities in childhood injury rates.

Farrell, G. & Pease, K. (2007). Preventing repeat residential burglary victimization. In B. Welsh & D. Farrington (Eds.), Preventing Crime: What Works for Children, Offenders, Victims, and Places (161-176). Dordrecht: Springer. Farrell & Pease conduct a review of evaluations intended to prevent repeat residential burglary at 11 intervention sites, following the review methodology proposed by the Campbell Collaboration. The review suggests the need for further evaluation of efforts to prevent repeat residential burglary, with a focus on strong, locally appropriate preventive interventions, as well as more thorough implementation, as some residents are unable or unwilling to spend money on security improvements. Hatfield, P.M. et al. (2006). Validating self reported home safety practices in a culturally diverse non-inner city population. Injury Prevention. 12: 52-57. This study attempts to determine the validity of self-reports about the presence of safety devices and use of safety practices in the home, especially as it relates to preventing unintended injury in children. Documented limitations of self reports include the length of requested recall; clarity of questions and scale of potential answers; similarity of interpretations across a broad group of individuals; cultural context; and social conformity. After filling out a questionnaire, project staff conducted home inspections to confirm parental responses to 16 questions. Results determined that when reported in a face to face interview, the reported use of safety devices and practices by parents are generally reliable. Katcher, M.L. et al. (2006). Use of the modified Delphi technique to identify and rate home injury hazard risks and prevention methods for young children. Injury Prevention. 12: 189-194. The authors used the Delphi method to identify and prioritize home injury hazards and prevention methods for children under the age of six. Thirty four experts participated in at least one of the three rounds of questionnaires, where 126 home injury hazards were rated based on frequency, severity, and prevention of injury; and 204 behaviors and devices were rated by efficacy and feasibility. Fire arms in the home and pools were rated as the most significant hazards, while smoke alarms and safe water temperatures were rated as the most efficient/feasible preventative measures. This study demonstrates that it is possible to prioritize injury hazards and their corresponding interventions by enlisting a panel of experts comprising a diverse array of expertise and training through the Delphi method. Keall, M.D. et al. (2007). Association between the number of home injury hazards and home injury. Accident Analysis and Prevention. 40 (2008): 887-893. The study gathered detailed housing data that were thought to have an impact on the health and safety of the residents, testing a method for assessing houses, as well as approaches to linking housing quality and resident safety/health. For residents that suffered a reported injury, the authors found that approx. 25% had between seven and nine injury hazards in the home, while the majority, 75%, had ten or more. Despite the possibility for confounding factors, the authors found an estimated 22% increased injury risk for each home injury hazard. Kendrick, D. et al. (2008). Parenting interventions and the prevention of unintentional injuries in childhood: Systematic review and meta-analysis. Child: Care, Health, and Development. 34(5): 682-695. The purpose of this systematic review was to evaluate the effectiveness of parenting interventions in the prevention of childhood injury and increasing safety. Fifteen studies were included, 11 of which were home visiting programs and two of which were pediatric practice-based interventions. Overall, intervention arm families were shown to have a significantly lower risk of injury, while several studies found fewer home hazards, a safer home environment, and a greater number of safety practices undertaken by families in the intervention groups. Based on their findings, the authors assert that parenting interventions, most commonly provided within the home using multi-faceted interventions, appear to be effective in reduction of unintentional childhood injury. Lee, H.C. et al. (2008). Protecting older people from burglary: Prevalence of security devices in the homes of older adults in Perth, Western Australia. Journal of Housing for the Elderly 22(4): 335-347. This study utilizes a cross-section survey to determine the prevalence of security measures taken by older adults in Perth, Western Australia, to protect their homes from burglary. The authors recruited respondents from community organizations in WA. Findings showed that the groups most at risk of burglary, based on their lower

prevalence of specific home security devices, include older adults residing on rental properties, those who are living alone, and those who are over the age of 85. They conclude that individuals in these categories may be a priority for home security education or intervention. Lord, S.R., Menz, H.B., & Sherrington, C. (2006). Home environment risk factors for falls in older people and the efficacy of home modifications. Age and Ageing. 35(S2): ii55-ii59. The authors find that the existence of home hazards alone is insufficient to cause falls, and the interaction between an older persons physical abilities and their exposure to environmental stressors appears to be more important. Some studies have found that environmental hazards contribute to falls to a greater extent in older vigorous people than in older frail people. Household environmental hazards may pose the greatest risk for older people with fair balance, whereas those with poor balance are less exposed to hazards and those with good mobility are more able to withstand them. The review concludes that home hazard reduction is effective if targeted at older people with a history of falls and mobility limitations. Mack, K.A. & DeSafey Liller, K. (2010). Home injuries: Potential for prevention. American Journal of Lifestyle Medicine. 4(1): 75-81. Some of the leading causes of home injury deaths are falls, fire/burns, poisonings, choking/suffocations, and drowning; those most at risk are children and older adults. This article provides an overview of the risk factors for such injuries, and reviews the evidence for prevention by life stage. In the end, the authors recommend a set of best practices for home safety that health professionals should encourage. Posner, J.C., Hawkins, L.A., Garcia-Espana, F., & Durbin, D.R. (2004). A randomized, clinical trial of a home safety intervention based in an emergency department setting. Pediatrics. 113(6): 1603-1608. The authors assessed the effectiveness of an emergency department intervention on increasing home safety practices in caregivers for children under five. After a structured home safety survey, parents either received comprehensive home safety education and free safety devices or simply focused, injury-specific ED discharge instructions. Results showed that those who received the comprehensive education and devices demonstrated significantly higher average overall safety scores, along with significant improvements in poison, cut, and burn safety. Parents in the intervention group also reported greater use of safety devices. Overall, the educational and device disbursement intervention was effective in improving the home safety practices of caregivers of young children, while the ED was used effectively to disseminate home injury prevention information. Saegert, S.C. et al. (2003). Healthy housing: A structured review of published evaluations of US interventions to improve health by modifying housing in the United States, 1990-2001. American Journal of Public Health. 98(9): 1471-1477. This study characterized and evaluated the success of current public health housing interventions implemented in the United States. Two reviewers analyzed 72 articles selected from 12 online databases between the years of 1990 and 2001. The most common strategies employed a one-time treatment intervention aimed at environmental improvement, resident behavioral change, or both. While most studies reported statistically significant improvements, only 14% were deemed extremely successful by the reviewers. Schwebel, D.C. et al. (2010). The association of activity level, parent mental distress, and parental involvement and monitoring with unintentional injury risk in fifth graders. Accident Analysis and Prevention. 43 (2011): 848852. The authors analyzed the associations between activity level, parent mental health, and parent involvement and monitoring on injury risk of fifth-grade children in three U.S. areas. Bivariate and multivariate ordinal logistic regression models were employed to predict unintentional injury frequency of respondents, which demonstrated that greater activity level in children and greater parent mental distress are significant predictors of injury rates. Therefore, interventions to reduce unintentional childhood injuries must take these two variables into account, along with environmental factors. Shenassa, E.D. et al. (2004). Social disparities in housing and related pediatric injury: A multilevel study. American Journal of Public Health. 94(4): 633-639.

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The authors conducted an ecological analysis to determine whether housing characteristics mediated the associations between concentration of poverty and pediatric injury, concentration of racial minorities and pediatric injury, and whether the association between housing conditions and pediatric injury is independent of other risks. Both owner occupancy and age of housing mediated the association between concentrated poverty and injury risk, most significantly for the poorest areas. For concentration of racial minorities, only percentage of owner occupancy had some mediating effect. Overall, housing conditions were found to mediate, at least partially, the association between community characteristics and pediatric injury risk. Risk of pediatric injury associated with housing conditions was independent of other risks. Stone, K.E. et al. (2007). Home safety in inner cities: Prevalence and feasibility of home safety-product use in inner-city housing. Pediatrics. 120(2): e346-e353. The authors examined the self-reported and observed home safety practices in urban, low-income families either expecting a child or had an infant less than a year old, and who were enrolled in East Baltimores Healthy Start visiting program. Home safety practices of working smoke detectors on every level of the home, stair gates blocking the top of the stairs, and locked medication storage were higher by self-report than by investigator home observation. Overall, the implementation of recommended safety practices was low, and the structural design of urban homes may be a significant barrier to home safety-product use. Sznajder, M. et al. (2003). Home delivery of an injury prevention kit for children in four French cities: A controlled randomized trial. Injury Prevention. 9(3): 261-265. Home visits consisting of counseling and distribution of safety devices to prevent child injuries could help parents to adopt safe behavior. The authors tested an intervention in which both groups received counseling and educational pamphlets, but one group also received a kit containing safety devices and information. Between the initial visit and the second follow up, safety improvement was significantly higher in the group that received the kit, validating this injury prevention tool and its delivery method (subsidizing, home visits, and adapted devices) for a large scale use.

IV.

Chemical Exposure

A. Housing Interventions for Chemical Agents

Sandel, M. et al. (2010). Housing interventions and control of health-related chemical agents: A review of the evidence. Journal of Public Health Management Practice. 16(5): S24-S33. Panelists systematically reviewed evidence on the effectiveness of housing interventions that affect health outcomes associated with exposure to chemical agents. The review included both published literature and peerreviewed reports from the US Environmental Protection Agency. Four of the 14 interventions reviewed had sufficient evidence to demonstrate their effectiveness and are ready for implementation. Sufficient evidence suggests that certain chemical exposures in the home can be decreased by specific housing interventions, which could reduce rates of radon-induced lung cancer and poorer neurological development in children that is associated with pesticides and lead.

B. Pesticide Exposure and Childhood Outcomes

Bouchard, M.F. et al. (2011). Prenatal exposure to organophosphate pesticides and IQ in 7-year old children. Environmental Health Perspectives. This study examined the link between prenatal and postnatal exposure to organophosphate pesticides and cognitive abilities in children. Pesticide exposure was measured by the amount of diakyl phosphate metabolites in urine collected during pregnancy and from children at various points between six months and five years. At age seven, the children were given an IQ test. The authors found that prenatal but not postnatal DAP concentrations were associated with lower scores on the test and substandard cognitive development.

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Engel, S.M. et al. (2011). Prenatal exposure to organophosphates, paraoxonase 1, and cognitive development in childhood. Environmental Health Perspectives. Prenatal exposure to organophosphate pesticides has been shown to have a negative effect on child neurological development. As such, the authors studied the relationship between exposure, Paraoxonase 1 (PON1, a key enzyme in the metabolism of ops), and cognitive development measured at child age 1, 2, and 6-9 years. The findings suggest that cognitive development is negatively correlated to prenatal organophosphate exposure, particularly perceptual reasoning abilities. Rauh, V. et al. (2011). 7-year neurodevelopmental scores and prenatal exposure to Chlorpyrifos, a common agricultural pesticide. Environmental Health Perspectives. The authors hypothesize that prenatal exposure to chlorpyrifos (CPF) would be associated with neurodevelopmental deficits persisting into elementary school. This extends their previous finding that prenatal exposure to CPF was associated with neurodevelopmental problems at age 3. The study finds that prenatal exposure to CPF has significant negative correlations for working memory and full-scale IQ scores for seven-yearold children.

V.

Multiple Interventions (e.g. combined safety and lead, etc.)

Beatley, N. (2011, March). Green housing = Improved health: A winning combination. Retrieved from http://www.nchh.org/Portals/0/Contents/green_build_symposium_r3.pdf. There is strong evidence supporting the benefits of green building in terms of energy efficiency and environmental impacts. Additionally, an increasing number of studies document the health benefits of green building programs. In this examination of various case studies of green and healthy housing projects, the author reports improved health outcomes for residents, in addition to a reduction in triggers such as mold and mildew and improved feelings of safety from residents. Dixon, S.L. et al. (2008). An examination of interventions to reduce respiratory health and injury hazards in homes of low-income families. Environmental Research. 109 (2009): 123-130. The authors evaluated whether combining asthma trigger reduction with housing structural repairs, device disbursement and education in low-income households with children would improve self-reported respiratory health and reduce housing-related respiratory health and injury hazards. Homes enrolled in the study received a baseline assessment, intervention, and another assessment approx. 3-4 months post-intervention. On average, 8 injury hazards and 3.3 respiratory health hazards were observed in the home at baseline, while four months later, they had decreased to 2.2 and 0.9, respectively. Furthermore, 97% of parents reported their homes were safer and 96% said the respiratory health of their asthmatic children improved post-intervention. Jacobs, D.E. et al. (2010). A systematic review of housing interventions and health: Introduction, methods, and summary findings. Journal of Public Health Management Practice. 16(5): S5-S10. Subject matter experts systematically reviewed evidence on the effectiveness of specific housing interventions in improving health. The panelists reviewed housing interventions associated with exposure to biological and chemical agents, structural injury hazards, and community-level interventions. This article highlights the projects research methods and general findings, although the specific evidence reviews are not included. The authors find that while many housing interventions had negative health outcomes, some specific interventions demonstrated improvement in health outcomes. Klitzman, S. et al. (2005). A multihazard, multistrategy approach to home remediation: Results of a pilot study. Environmental Research. 99 (2005): 294-306. The authors evaluated a pilot home remediation intervention that addressed multiple home hazards, including lead, pests, mold, and safety hazards in a sample of 70 pre-1940 dwellings. As needed, participating homes received paint stabilization, dust lead cleaning, integrated pest management, mold cleaning, and safety devices. Significant reductions were achieved in the number of dwellings with three or more problems; high levels of dust lead on floors and window sills; homes with evidence of cockroaches or rodents; and fire, electrical, and/or fall

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hazards. The results of the pilot program demonstrate that a comprehensive approach to hazard remediation can be highly effective while overall improvements can be maintained.

VI.

Energy Efficiency

BE Harrington, B Heyman, N Merleau-Ponty, H Stockton, N Ritchie and A Heyman. (2005). Keeping warm and staying well: Findings from the qualitative arm of the Warm Homes Project. Health and Social Care in the Community. 13: 259267. Fuel poverty, the ratio of required fuel cost to disposable income, is a significant challenge associated with living in energy-inefficient housing. Very little research, however, has explored residents experiences and understanding of fuel poverty. The Warm Homes Project investigates the nature of fuel poverty, strategies for addressing it, and the associated impact on family health. The findings suggest that there is significant variation in expectations of those in fuel poverty about staying warm, and in their understanding of the relationship between warmth and health. Howden-Chapman, P, A Matheson & J Crane et al. (2007). Effect of insulating existing houses on health inequality: Cluster randomised study in the community. BMJ. 334: 460. The Housing, Insulation and Health Study seeks to determine whether insulating existing houses increases indoor temperatures and improves occupants health and wellbeing. Rather than intervening at the individual level, by for example providing individuals with more clothes, this intervention sought to fit insulation into houses under the premise that this could be a more practical and cost effective approach. The article outlines the results of this study, which found that modest investment in insulation per house led to significant improvements in the populations self reported health and a lower risk of children having time off school or adults having sick days off work. Howden-Chapman P, J Crane, A Matheson, H Viggers, M Cunningham, T Blakely, et al. (2005). Retrofitting houses with insulation to reduce health inequalities: aims and methods of a clustered community-based trial. Social Science Medicine. 61:2600-10. There is growing evidence that the indoor environment, including insulation and temperature, has a substantial effect on the health and economic well-being of residents. There is however, relatively little research on the costeffectiveness of retrofitting houses with insulation. The Housing Insulation and Health Study examines the costeffectiveness of such an intervention in low-income communities in New Zealand, finding that the present discounted value of the health, energy and CO2 emissions savings are twice the cost of retrofitting insulation. Kuholski, K, Tohn, E, & Morley, R. (2010). Healthy energy-efficient housing: Using a one-touch approach to maximize public health, energy, and housing programs and policies. Journal of Public Health Management and Practice. 16(5): S68-S74. Programs addressing home health and energy efficiency have historically operated in categorical silos that fail to reflect these interventions shared challenges and benefits. This leads to disjointed service delivery and the inefficient use of limited resources. The authors identify how each field of interventions achieves in certain areas, health and economic outcomes that the other also pursues. They subsequently advocate for the integration of home health and energy efficiency into a one-touch approach to home interventions. Richardson G, Eick SA. (2006). The paradox of an energy-efficient home: is it good or bad for health. Community Practitioner. 79(12):397399. Energy efficiency measures in homes can substantially improve the health and economic well-being of residents. This article outlines how the indoor environment impacts health and outlines the changes that arise following the introduction of energy efficient measures in houses. The authors argue that residents need to adapt their lifestyles to this new indoor environment so as to sustain improvements and mitigate the potential negative effects of these changes to the built environment. Somerville, M, I Mackenzie, P Owen & D Miles. (2000). Housing and health: Does installing heating in their homes improve the health of children with asthma. Public Health. 114: 434-439.

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Studies have consistently demonstrated a link between damp and moldy housing and respiratory symptoms in adults and children. At the time of this article however, no known studies had examined whether asthma morbidity may be lowered by reducing the presence of asthma and mold in the house. This study seeks to do so by installing central heating in the homes of children with previously diagnosed asthma, finding that such an intervention has the potential to significantly improve childrens asthma symptom management and reduce the amount of school days lost due to asthma.

VII. Neighborhood-Level Interventions

Lindberg, R, Shenassa, E, Acevedo-Garcia, D, Popkin, S, Villaveces, A & Morley, R. (2010). Housing interventions at the neighborhood level and health. A review of the evidence. Journal of Public Health Management and Practice. 16(5): S44-52. This article reviews evidence for the health benefits of ten interventions aimed at improving the neighborhood environment and increasing access to safe and affordable housing. The authors find 1 intervention, The Housing Voucher Choice Program, to be effective and ready for implementation. The other nine reviewed interventions are found to require further field evaluation or research. These however, do appear to lend support for the health, social and economic benefits of neighborhood-level housing interventions.

VIII. Economic Costs of Housing Related Interventions

Mason, J., & Brown, MJ. (2010). Estimates of costs for housing-related interventions to prevent specific illnesses and deaths. Journal of Public Health Management and Practice. 16(5): S79-S89. An economic analysis of housing-related interventions can inform the more efficient use of limited resources as well as the development of more effective interventions. Review of the published costs of specific housing-related health outcomes and interventions both highlights and challenges the cost effectiveness of common interventions for asthma and indoor agents, lead poisoning, CO poisoning and lung cancer related to radon. The authors also identify substantial gaps in research assessing the costs and economic impacts of interventions. Gaps in evaluating the effectiveness of interventions currently supported by anecdotal evidence alone are also identified.

IX.

Editorials and Case Studies

Brown, M.J., Ammon, M., & Grevatt, P. (2010). Federal agency support for healthy homes. Journal of Public Health Management Practice. 16(5): S-90-S93. While various federal agencies have promoted health by addressing problematic housing conditions, in the past different agencies have focused on specific aspects of healthy housing rather than one holistic and integrated program. Interagency collaboration is essential for successful outcomes, and all recognize that no agency has all of the necessary resources or expertise for implementation of a national healthy homes agenda. Thus, HUD, the EPA, and the CDC have come together with the Departments of Health and Human Services, Energy, and Agriculture; the National Institutes of Standards and Technology and Environmental Health; and the Office of the Surgeon General to form an interagency group to promote the implementation of healthy homes policies at the federal and local levels. Maring, E, Jones, BJ, & Shenassa, E. (2010). Making the transition from lead poisoning prevention to healthy homes: A qualitative study. Journal of Public Health Management and Practice. 16(5): S53-S59. As childhood lead poisoning rates decline in many cities, a number of programs aimed at reducing lead poisoning are adapting a more comprehensive Healthy Homes approach. In 2007, the CDC selected Baltimore Citys Childhood Lead Poisoning Prevention Program (CLPPP) to pilot this shift. Using this transition as a case study, the article provides useful qualitative insight into the challenges and associated needs emerging in the transition from a Lead Poisoning Prevention to Healthy Homes program. The recommendations are not measured for their effectiveness nor are they universally applicable to contexts outside of Baltimore.

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Meyer, P.A. (2010). Healthier homes for a healthier nation. Journal of Public Health Management Practice. 16(5): S1-S2. Although the evidence supporting the link between housing and health has been increasing, the evidence demonstrating effective interventions to protect health against specific hazards has lagged. While many programs conduct home visits for a single health issue, healthy homes approaches addresses residents health and safety risks holistically. Furthermore, the panel reviews of specific housing interventions associated with exposure to biological and chemical agents, structural injury hazards, and neighborhood level interventions can be used by programs planning on adopting a healthy homes approach. Neltner, Tom. (2010). National healthy homes training center and network: Building capacity for healthy homes. Journal of Public Health Management and Practice. 16(5): S75-78. In 2003, the National Center for Healthy Housing (NCHH) entered into a cooperative agreement with the CDC to host and manage the National Healthy Homes Training Center and Network. The creation of such a center emerged out of federal governments increasing awareness of the inefficient and counterproductive use of resources related to the hazard by hazard approach to healthy homes. The Center is now an integral part of the federal governments healthy homes initiative and encompasses a wide range of web resources, training partners and courses. While this review outlines the Training Centers services, it does not evaluate their efficacy.

X.

Home Assessment Tools

Keall M, Baker MG, Howden-Chapman P, Cunningham M, Ormandy D. (2010). Assessing housing quality and its impact on health, safety and sustainability. Journal of Epidemiology and Community Health. June, 2010. An effective, evidence-based housing quality-assessment tool is essential to support housing improvement. Such a tool must link practical measures of housing conditions to their effects not only on health, but also safety and sustainability. The development of a tool must consider issues such as scope, practical administration and detailed content relating to the outcomes areas and dwelling features included in the analysis. This article provides guidance on the development of such a tool. Nicol, S., Roys, M., Davidson, M. et al. The real cost of poor housing. This paper reports on the outcome of a research project sponsored by the BRE Trust to develop a method of quantifying the health cost benefit of housing interventions, and the dis-benefits of leaving housing stock as it is. The model uses data from the English House Condition Survey to illustrate the various scenarios and improvement options. The model enables the total cost of poor housing in English homes to be estimated at over 600 million per year, while the total cost to society each year may be greater than 1.5 billion. Ormandy, D. Energy efficiency, health, and housing standards in England. Standards for existing housing in England have contained only minimal requirements, despite the clear evidence showing that low indoor temperatures have a negative impact on the physical and mental health of occupants and contribute to numbers of excess winter deaths. The minimum standard in effect until 2004, the Housing Fitness Standard, largely ignored thermal insulation and made only superficial heating requirements, masking the scale of the problem. However, the introduction of a new health based method for assessing housing conditions, the Housing Health and Safety Rating System, has highlighted the scale of the problem and provided a means to tackle it, although the financial resources and political will necessary for the improvements is questionable. Ormandy, David. (2010). Shifting the focus from defects to the effects of defects. Open House International. 35(2): 60-66. The English governments adoption of the Housing Health and Safety Rating System (HHSRS) marked a substantial shift from the previous focus on the built environment to a new emphasis on the potential threats to health and safety of the built environment. This approach allows for the ranking and comparison of hazards, and allows for estimations of the cost of poor housing in England. Using this approach, it has been estimated that poor housing costs Englands national health service approximately 600 million pounds a year.

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Stewart J. (2002). The housing health and safety rating system - a new method of assessing housing standards reviewed. Journal of Environmental Health Research. 1(2):35-41. Prior to its replacement, Englands standard of fitness for housing (the Fitness Standard) was under intense criticism regarding its failure to address hazards likely to cause severe harm. This article outlines the failures of the Standard and discusses the development of the now current approach to assessing housing conditions in England. This approachthe Housing Health and Safety Rating System, comprises a system of assessing rather than a fixed standard, and accounts for both the likelihood and severity of known hazards. University of Warwick Institute of Health. (2006). Health hazards in the home environment: A risk assessment methodology. Healthy Building Conference, Lisbon, Portugal, 4-8 June, 2006. Due to identified deficiencies in the Fitness Standard, Englands national housing standard, the Ministry of Housing commissioned the Warwick Law School to develop a new housing rating tool in July 1998. This risk assessment methodology, the Housing Health and Safety Rating System (HHSRS), has been developed to capture the likelihood and severity of the potential hazard, as well as the range of possible outcomes resulting from its occurrence. The hazard also allows for the comparison of hazards within and across dwellings. This article reviews the evolution of English housing standards and principles and the associated development of the HHSRS.

XI.

Integrated Pest Management

Brenner BL, Markowitz SB, Rivera M, Romero A, Weeks M, Sanchez E, et al. (2003). Integrated pest management in an urban community: A successful partnership for prevention. Environmental Health Perspectives. 111:1649 1653. Integrated pest management (IPM) is an alternative to conventional, chemical-based pest control. Few studies of IPM have been undertaken in urban cities. This article examines the success in reducing cockroach infestation and indoor exposure to chemical pesticides, of an IPM program implemented in East Harlem, New York City. The authors find that IPM, individually tailored at the household level, can significantly reduce cockroach infestation by more than 50% in urban households for at least a 6 month period. Eggleston, P.A. et al. (2005). Home environmental intervention in inner-city asthma: A randomized controlled clinical trial. Annals of Allergy, Asthma, & Immunology. 95(6): 518-524. Airborne pollutants and indoor allergens are found to increase asthma morbidity in inner-city children, so a reduction in exposure should improve asthma outcomes. The authors test this theory with a randomized controlled trial of a home-based intervention to reduce allergen and particulate exposures. While the intervention found reductions in home pollutants, notably in PM concentrations, the intervention was found to only have a modest impact on morbidity. Kass, D., et al. (2009). Effectiveness of an integrated pest management intervention in controlling cockroaches, mice, and allergens in New York City public housing. Environmental Health Perspectives. 117(8): 1219-1225. The authors implemented and evaluated an integrated pest management program compared to traditional pest control. IPM or control status was assigned to entire buildings rather than particular participating residences, and conditions were evaluated at baseline, 3 months, and 6 months. Compared with controls, IPM apartments had significantly lower counts of cockroaches at 3 months and greater success reducing or sustaining low counts of cockroaches at 3 and 6 months. IPM was also associated with lower cockroach allergen levels, decreased pesticide use, and increased resident satisfaction with building services. Overall, the study finds that a single IPM visit was more effective than the regular application of pesticides alone. Levy, J.I., D. Brugge, et al. (2006). A community-based participatory research study of multifaceted in-home environmental interventions for pediatric asthmatics in public housing. Social Science & Medicine. 63(8): 21912203. Pest infestation is a major problem in urban, low-income housing and may contribute to elevated asthma prevalence and exacerbation rates in such communities. However, there is poor understanding of the effectiveness of integrated pest management (IPM) efforts in controlling pediatric asthma, or of the interactions among various

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interventions and risk factors in these settings. The authors conducted a longitudinal, single-cohort communitybased participatory research intervention study. Interventions primarily consisted of IPM and related cleaning and educational efforts. Results demonstrated significant reductions in a 2-week recall respiratory symptom score and in the frequency of wheeze/cough, slowing down or stopping play, and waking at night. Longitudinal analyses of asthma-related quality of life similarly document significant improvements. Mir, D.F., Finkelstein, Y., & Tulipano, G.D. (2010). Impact of integrated pest management (IPM) training on reducing pesticide exposure in Illinois childcare centers. Neurotoxicology. 31(5): 321-326. Children are especially vulnerable to pesticides, as a result of physiological factors which facilitate absorption of chemicals and limit the ability to detoxify and eliminate them. This study assessed the direct and indirect impact of a formal IPM training program by surveying 3364 Illinois childcare centers. The survey found that training increased the level of confidence, positive attitudes, and implementation of IPM by childcare providers. Nalyanya, G., J.C. Gore, et al. (2009). German cockroach allergen levels in North Carolina schools: Comparison of integrated pest management and conventional cockroach control. Journal of Medical Entomology. 46(3): 420427. While the effects of various cockroach control strategies have been examined in homes, they have yet to be examined in schools. The aim of this study was to compare the effectiveness of an integrated pest management program to conventional pest control in managing German cockroach infestations and Bla g 1 concentrations in 13 public school buildings in North Carolina. The study found that IPM-treated schools had significantly less infestation and allergens than conventionally treated schools, and that food preparation and food service areas were primarily associated with cockroaches. Peters, J.L., et al. (2007). Efficacy of integrated pest management in reducing cockroach allergen concentrations in urban public housing. Journal of Asthma. 44: 455-460. This study evaluates the effectiveness of a combination of abatement measures, including industrial cleaning, integrated pest management, and mattress replacement, on reducing allergen concentrations and the factors affecting efficacy over months of follow-up. Findings demonstrated substantial reductions in Bla g 1 and Bla g 2 concentrations in the kitchen and in the asthmatic childs bed at six months post-intervention, although from there allergen concentrations increase. By 10 months post-intervention, there were still reductions from baseline, but they were not as significant as the 6 month measurement. The authors conclude that cockroach allergen can be reduced through intensive cleaning and IPM and, without further external intervention, reductions can be sustained for up to six months. Phipatanakul W, Cronin B, Wood RA, et al. (2004). Effect of environmental intervention on mouse allergen levels in homes of inner-city Boston children with asthma. Annals of Allergy, Asthma & Immunology. 92: 420425. Studies have demonstrated that allergen avoidance and trigger reduction improve asthma symptom management and assist in reducing asthma morbidity. Studies have also identified a high prevalence of mouse allergen in innercity homes of children with asthma. To date, there are no known published studies evaluating the success of an environmental intervention in reducing mouse allergen. This study seeks to examine whether integrated pest management (IPM) can reduce mouse allergen levels in mouse-infested, inner-city homes. Schweitzer, M. & B. Tonn. (2001). Non-energy benefits from the weatherization assistance program: A summary of findings from the recent literature. ORNL/CON-484, Oak Ridge National Laboratory, Oak Ridge, TN. Since it was established in 1976, the U.S. Department of Energys (DOE) Weatherization Assistance Program (WAP) has weatherized approximately five million units occupied by low-income residents. A national evaluation of the program, focusing mainly on its resulting energy and cost savings, was completed in 1993. This article builds on that evaluations smaller discussion of WAPs nonenergy benefits, and examines the substantial amount of research examining these benefits in the years following the evaluations publication. Sever, M.L. et al. (2007). Cockroach allergen reduction by cockroach control alone in low-income urban homes: A randomized control trial. Journal of Allergy Clinical Immunology. 120(4): 849-855.

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A 3-arm randomized controlled trial was conducted to determine the comparative effectiveness of pest control performed by professional entomologists and commercial companies. Homes were randomly assigned to a control group, the treatment 1 group (receiving entomologist intervention) or the treatment 2 group (receiving pest control from commercial firms). Results show that at 12 months follow up, treatment 1 homes had significant reductions in geometric mean trap counts and Bla g 1 concentrations compared with control and treatment 2 homes. W.J. Sheehan, P.A. Rangsithienchai, R.A. Wood, D. Rivard, S. Chinratanapisit and M.S. Perzanowski et al. (2010). Pest and allergen exposure and abatement in inner-city asthma: A work group report of the American Academy of Allergy, Asthma & Immunology indoor allergy/air pollution committee. Journal of Allergy and Clinical Immunology. 125: 575581. The prevalence of asthma has increased in developed countries, particularly in urban areas, in the past thirty years. Urban areas provide a unique setting for asthma due to certain environmental factors. This article examines literature regarding the link between exposure to rodent and insect allergens and inner-city asthma. Future research directions are also identified and include examining the link between allergen exposure and adult asthma, allergen exposure outside of the home, and strategies to maintain reduced exposure to indoor allergens. Wilson, J., et al. (2010). Housing and allergens: A pooled analysis of nine US studies. Environmental Research. 110: 189-198. The authors pooled nine US studies in order to identify evidence-based housing factors that should be included in home assessments of indoor asthma triggers. After adjusting the calculated odds ratios for numerous confounding factors, cracks or holes in walls, mold odor, housing built before 1951, single-family home with slab on grade, and rodent control/signs of rodents were associated with high cockroach, dust mite, and mouse allergen. Except for the age of dwelling, all of these risk factors provide opportunities for remediation that can be expected to improve asthma outcomes.

XII.

Cost-effectiveness

Brown, M.J. (2002). Costs and benefits of enforcing housing policies to prevent childhood lead poisoning. Medical Decision Making, 22, 482-492. Brown conducted a decision analysis using population-based data that compared the recurrence of childhood lead poisoning in 2 urban areas one with a strict enforcement of lead poisoning prevention housing policies, and one with a limited enforcement capacity. The area that employed the limited strategy had a 4.5 times greater risk of identifying additional cases of children with elevated blood lead levels within 5 years following identification of a lead-poisoned child in the same building, while strict enforcement as found to prevent additional cases, resulting in substantial savings from decreased medical and educational costs and increased productivity. Gould, E. (2009). Childhood lead poisoning: Conservative estimates of the social and economic benefits of lead hazard control. Environmental Health Perspectives, 117(7), 1162-1167. Gould conducts a cost-benefit analysis to determine the social and economic benefits to household paint lead hazard control compared with the costs needed to remedy these deficiencies. The article finds that each dollar invested in lead hazard control results in a return of $17-$221, or a net savings of $181-$269 billion. Since these returns are substantial, lead hazard control seems well worth the price, especially targeted early interventions in high-risk communities. Hakim, S. & Y. Shachmurove. (1996). Social cost benefit analysis of commercial and residential burglar and fire alarms. Journal of Policy Modeling 18(1): 49-67. The authors evaluate the net benefits yielded by residential and commercial burglar and fire alarm systems and find that the total benefits of burglar alarm ownership outweigh the costs for the combined and separate commercial and residential units. The cost-benefit analysis revealed that the total benefits are $180,042 greater than the total societal costs.

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Kattan, M. et al. (2005). Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma. Journal of Allergy Clinical Immunology. 116(5): 1058-1063. This report provides an economic analysis of the Inner-City Asthma Studys environmental intervention, which successfully reduced symptom days, unscheduled clinic visits, and the number of -agonist inhalers used per year. Incremental cost-effectiveness ratios were calculated, which found that the intervention cost was $27.57 per additional symptom free day (SFD). Despite the authors hypothesis, subgroup analysis showed that targeting the intervention to certain high-risk groups did not reduce the cost-effectiveness ratio. They conclude that, when the aim is to reduce symptom days and the associated costs, the intervention is cost-effective. Sullivan, S.D., Weiss, K.B., et al. (2002). The cost-effectiveness of an inner-city asthma intervention for children. Journal of Allergy and Clinical Immunology, 110(4), 576-581. The authors examined the cost-effectiveness alongside a randomized, controlled trail of a comprehensive social worker-based education program and environmental control in children with varying levels of baseline asthma severity. The intervention significantly reduced asthma symptoms, and when compared with usual care, the intervention improved outcomes at an average cost of $9.20 per SFD gained, which the authors conclude is costeffective. In three subgroups of children with severe asthma, the intervention was cost-saving. Wang, C. & Bennett, G.W. (2009). Cost and effectiveness of community-wide integrated pest management for German cockroach, cockroach allergen, and insecticide use reduction in low-income housing. Journal of Economic Entomology. 102(4): 1614-1623. The authors evaluated a community-wide integrated pest management program in two low-income apartment complexes in Gary, Indiana. The program included staff and resident education, monthly monitoring, and nonchemical and chemical pest treatment based on monitoring results. One complex was treated by licensed state entomologists from Purdue University (E-IPM group) while the other was treated by pest management professionals (PMPs) from a contractor (C-IMP group). The findings showed substantial reductions in cockroach infestation, allergen levels, and insecticide usage without significant differences between the groups. However, broad adoption of IPM programs and sustained effects hinge on cooperation and motivation from staff and residents.

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