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Office of the Surgeon General (US). The Surgeon General's Call to Action to Promote Healthy Homes. Rockville (MD): Office of the Surgeon General (US); 2009.

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The Surgeon General's Call to Action to Promote Healthy Homes.

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3Promoting Healthy Homes through Prevention

Illnesses and injuries related to homes are not inevitable. Many housing hazards and the injuries and illnesses resulting from them can be reduced or eliminated by proper design of new construction, modification of existing home structures, and changes in housing-related behaviors. Successful prevention of housing-related disease and injuries through healthy homes depends on how architects, building inspectors, property owners, maintenance and remodeling workers, and residents incorporate healthy housing knowledge into their practices and into their day-to-day activities. Many simple changes can promote health and safety at home. In addition, housing interventions can also improve the availability, accessibility, and environmental friendliness of homes. This section presents well-documented, evidence-based interventions.

Improving Air Quality

Two effective ways to reduce indoor air pollution levels are to eliminate or reduce emissions from indoor sources and to improve ventilation. Usually the most effective method is to control emissions, for example by eliminating smoking, adjusting gas stoves to minimize emissions, using paints and coatings that emit low levels of volatile organic compounds, using low-emitting building materials such as wood products that emit low levels of formaldehyde, and using cleaning products that emit low levels of air pollutants. In typical houses, the 2007 American Society of Heating, Refrigerating and Air Conditioning Engineers standard (ASHRAE 62.2) requires a mechanical ventilation rate of about 50 cubic feet per minute or 25 liters per second; larger houses have a higher rate. In some cases, proper ventilation can also be achieved by opening windows and doors for a period of time each day and by using exhaust fans in kitchens and bathrooms (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2008).

Smoke-free Homes

The best way to maintain a smoke-free house is to refrain from smoking. In addition, adopting smoke-free rules in homes reduces involuntary exposure to secondhand smoke and improves health. Opening a window; sitting in a separate area; or using ventilation, air conditioning, or a fan cannot eliminate secondhand smoke exposure. The only way to fully protect yourself and your loved ones from the dangers of secondhand smoke is through 100% smoke-free environments (U.S. Department of Health and Human Services 2006).

Percentage of children ages 0–6 living in homes where someone smokes regularly (by poverty status) 2003

Percentage of children ages 0–6 living in homes where someone smokes regularly (by poverty status) 2003.

SOURCE: U.S. Environmental Protection Agency, Indoor Environments Division, National Survey on Environmental Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke

Carbon Monoxide Poisoning Prevention

Removing or controlling carbon monoxide sources in the home is the most important way to prevent carbon monoxide exposure. For example, gas generators, gas grills, and other fuel-burning appliances should never be operated in the house. Converting from wood stoves or kerosene heaters may decrease both carbon monoxide and particulates in the home, although this may not always be practical. In addition, installing and maintaining carbon monoxide detectors can prevent death and injury from carbon monoxide exposure (Centers for Disease Control and Prevention 2005c).

Radon Gas Mitigation

An active radon test determines whether radon gas results exceed the EPA action level of 4 pCi/L. EPA estimates that 6% of U.S. homes have average concentrations at or above the 4 pCi/L action level (U.S. Environmental Protection Agency undated a). Radon mitigation using a soil depressurization system can effectively prevent radon from entering the house and reduce the risk for lung cancer (U.S. Department of Health and Human Services 2005b). Incorporating radon-reducing features while building a home is less expensive than installing a radon-reduction system in an existing home.

Reducing Allergens and Asthma

Homes should be designed, operated, and maintained to prevent water intrusion and excessive moisture accumulation. Moisture can be controlled by repairing water leaks, installing suitable insulation to avoid condensation, and ventilating rooms properly. When water intrusion and moisture accumulation are discovered, the sources should be identified and eliminated quickly to reduce mold growth and to reduce infestations of cockroaches and rodents (Institute of Medicine 2004). Allergen levels can be controlled by vacuuming and cleaning hard surfaces. Mold growth should be eliminated in a way that limits the possibility of recurrence and that limits exposure of the occupants and persons conducting the remediation. Mold should not be cleaned using mixtures of ammonia and bleach, which may produce poisonous gas. Porous materials such as ceiling tiles, wall boards, and fabrics that cannot be cleaned should be removed and discarded (New York City Department of Health 2000; U.S. Environmental Protection Agency 2001). Because dead mold may still retain its allergic or toxic properties, replacing rather than cleaning is often the best mitigation option (Foarde 1998; Institute of Medicine 2000). In addition, frequent washing of plush toys and bedding, using mattress and pillow covers, and keeping pets out of bedrooms has been demonstrated to reduce exposure to allergens (Krieger et al. 2005).

Improving Water Quality

There are several important things to know about homes that are connected to small community water systems or that have a private well: build wells away from septic systems and other wastewater systems, do not use wastewater systems to dispose of toxic chemicals, and know when and how to test wells (Centers for Disease Control and Prevention undated). Steps for proper maintenance and protection of private wells include periodic inspection of exposed parts of the wells to identify missing or worn parts or cracks, annual disinfection using bleach or hypochlorite granules, and annual testing for bacteria and chemical contamination (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2006).

Reducing Harmful Chemicals

Pesticide Exposure Prevention

A safer alternative to exclusive reliance on chemical pesticides is integrated pest management (IPM). IPM uses the least toxic practical baits and insecticides, thus reducing both insect pests and reliance on chemical pesticides (Klitzman et al. 2005; Williams et al. 2006). Most household pests can be controlled by eliminating the pest’s habitat inside and outside the house, keeping pests out using building or screening techniques that prevent entry, eliminating food from areas where pests can make their homes, and, when necessary, using pesticides appropriately (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2006).

Household Chemicals and Medicines

A number of simple actions can help to assure that household chemicals including household cleaning products, pesticides, medicines, gasoline, car polishes, and pool-cleaning chemicals can be used safely. Eliminate dangerous chemicals that do not need to be in the house. Do not repackage chemicals. Be sure all chemicals are labeled, read the labels on all products, follow directions regarding use and disposal, and dispose of chemicals safely (U.S. Environmental Protection Agency undated d). Store household chemicals and medicines with “keep out of reach of children” labels in locked cabinets. Use childproof caps on prescription medications to protect children. Lock outbuildings that store chemicals such as automotive supplies, pool cleaners, and agricultural pesticides and fertilizers.

Improving Housing Structure and Design

How homes are designed, constructed, and maintained; their physical characteristics; and the presence or absence of safety devices can promote the health of residents. Housing structure has an impact on mental health and the occurrence of injuries and diseases, as well as promoting accessibility for elders and people with disabilities.

Preventing Injuries

Fall Prevention

By installing grab bars in bathtubs and showers and adding handrails and good lighting in stairwells, homes can be designed and constructed to protect elderly occupants from fall-related injuries. Many homes currently do not have these simple safety features. For example, 35% of homes with stairs do not have handrails (Marshall et al. 2005). Interventions that can help to prevent childhood fall injuries include window guards (Barlow et al. 1983); stair gates, balcony railings less than 4 inches apart, and window locks or guards for windows above ground level (McDonald et al. 2006).

Fire and Burn Prevention

The leading cause of residential fire deaths is smoking. Smokers should be advised to quit. When a fire occurs in a home with a functioning smoke alarm, the risk for death is decreased by 40%–50% (Ahrens 2004). To reduce the risk of deaths from fires, smoke alarm batteries should be checked regularly—for example, when clocks are reset to daylight or standard times. New home construction should include hard-wired smoke alarms that do not depend solely on battery power. Residential sprinklers may be a promising strategy to prevent deaths and injuries due to fires (Warda and Ballesteros 2007). Preparing and practicing a fire escape plan, especially teaching fire escape skills to children, can minimize injuries and death from fires (McDonald et al. 2006; Thompson et al. 2004).

Successful strategies to decrease burns include reducing the temperature in water heaters to 120°F; installing hot water temperature limiters at the faucet; using roll-up cords for electric coffee pots; installing covers on electrical outlets; and using pots, pans, and kettles designed to be less likely to tip and spill hot liquids (Staunton et al. 2007).

Drowning Prevention

Drowning at home can be prevented by having proper fencing around swimming pools. When combined with self-closing and self-latching gates, four-sided fencing provides a passive intervention that prevents unintended access to pools by small children (Quan et al. 2007). To help prevent drowning, parents should be within arms length of children who are bathing or playing around water (Committee on Injury, Violence, and Poison Prevention 2003).

Suffocation and Strangulation

Parents and caregivers should be aware of the types of objects that pose a strangulation or suffocation risk for children and become familiar with methods to reduce this risk. Infants should be placed on a firm sleep surface, such as a safety-approved crib mattress, and soft objects or loose bedding should not be placed in a crib. Loop window blind and drapery cords should be tied up out of reach or the ends should be cut and retrofitted with safety tassels. The inner cords of blinds should be fitted with cord stops.

Firearm Injury Protection

To prevent firearm injuries and deaths, firearms should be stored locked and out of reach of children and should be equipped with trigger locks. These simple measures are often not taken. For example, in an estimated 13% of U.S. homes with firearms, those firearms are loaded and unlocked (Miller et al. 2005).

Preventing Elevated Lead Levels

Lead hazard control or elimination in residences has been evaluated and can reduce the likelihood that additional children will suffer elevated blood lead levels (Brown et al. 2001; U.S. Department of Housing and Urban Development 1995). Policies can also limit lead exposure from other sources, such as consumer products.

Improving Mental Health

Home design elements can foster improved mental health. For example, building designs with window placement that allows adequate light and views of natural landscapes may improve psychological well being (Ulrich 1984; Wells 2000). Home design elements that increase the probability of social interaction among neighbors—for example, front porches—can enhance social cohesion and support (Buka et al. 2003). Crowding in housing units can be prevented by providing an adequate supply of affordable homes. Certain design features such as greater ceiling height (Savinar 1975), windows (Desor 1972), brighter lighting, and visual distractions such as pictures on walls (Bell et al. 2001) can help reduce the perception of crowding (Baum and Valins 1979). Other factors, such as social support, can help reduce the negative impact of crowding (Lepore et al. 1992). Efforts to build social support may be a useful adjunct to design solutions.

Remedying Structural Deficiencies

When enforced, housing and building codes have resulted in better constructed and maintained buildings and in improved health. For example, strict housing code enforcement has been demonstrated to reduce the likelihood of death in residential fires (Cummins and Jackson 2001) and lead poisoning in homes where lead-poisoned children live (Brown et al. 2001). A large number of programs, codes, and regulations exist that have the potential to influence changes in the environmental conditions in homes. The development of clear design standards increases the potential to address a wider range of health hazards through building and housing codes. Incorporating public health considerations into the planning process will maximize the opportunities for healthy building and development.

Improving Accessibility

Designing and remodeling using wide doorways and building entrances without steps can help older persons and those with disabilities remain connected with their communities. Creating an adequate supply of homes accessible for elders and for people with disabilities will result in significant public health improvements. Following universal design guidelines or meeting minimum accessibility requirements, including easier visits to families and friends for elders and people with disabilities—also known as visitability—could improve safe accessibility to homes and to communities.

Encouraging Safe and Healthy Behaviors

Individual resident behavior and prevention patterns with regard to home hazards contribute to health and safety at home. Behaviors that affect health result from the interplay of many economic, social, and cultural factors. Still, changing behaviors is not easy, even when people are aware of the effects of certain behaviors on personal health or the health of their families. Behavior change needs to be understood in the context of large systems—social systems, cultural systems, education systems, and the public health system.

Reducing Disparities in Access to Healthy and Safe Homes

Focusing on properties that pose the greatest health risks; that is, those properties that are older, low-income, or in substandard condition, will yield the greatest improvement in health outcomes. This will also help address the striking health disparities borne by low-income and minority families. Indeed, for all important exposures and health problems, it is essential to emphasize making improvements among the most affected populations as well as in the population as a whole. Existing funds and policies for “home improvement” programs may, for example, provide effective strategies for improving individual- and community-level health disparities.

Addressing Community Factors that Affect Health and Homes

Weather and Natural Disasters

Siting and design of homes can protect against adverse health effects related to weather and disasters. Although no building can be completely disaster-proof, good design and materials will minimize structural damage and will safeguard the lives of occupants during a major disaster or extreme weather event. Disaster resistance is best achieved by following modern building codes and standards. Urban planning and zoning can ensure that homes are not built in locations at high risk for specific types of disasters.

People can minimize their risk for disaster-related adverse health effects by learning about the types of disasters that are most likely to occur where they live. People can learn about the local warning signals and systems. Developing home response plans can also minimize health risks by, for example, maintaining a disaster survival kit with an adequate supply of water and necessary prescription medications. Communities can help minimize consequences of disasters by adequate response planning.

Finally, the responses of people to natural events should avoid harm to themselves or the environment. For example, portable generators or supplemental heating devices should be used appropriately so that they do not release deadly carbon monoxide. Proper installation and maintenance of heating and cooling systems can prevent hypothermia and hyperthermia (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2006) when temperatures are extremely cold or hot.

Noise

Noise abatement housing design strategies have been proposed but have been inadequately tested. However, reducing the sources of noise in and around the home and designing buildings to control the transmission of sound may reduce noise and its adverse health consequences. (Berglund et al. 1999).

Green Homes

A home can be built green or can be renovated to add green features. Individual homebuyers and builders can incorporate green features when siting the home, designing, building or renovating, and selecting materials.

Siting homes to maximize the benefits of sunlight can help reduce energy consumption and increase entry of natural light. Selection of construction materials and interior finish products with zero or low emissions can improve indoor air quality. Examples of nontoxic materials may include wheat-derived strawboard; natural linoleum made from jute and linseed oil; paints with few or no volatile organic compounds; and toxin-free insulation made from soybeans, recycled paper, or even old denim. Incorporating effective and efficient natural or mechanical ventilation systems may also reduce indoor air pollutants.

Cleaning practices, water use, and appliances also contribute to a green home. When building, renovating, and maintaining the home, people can use less-toxic materials such as paints, coatings, wood products, and cleaning supplies. Selecting new ENERGY STAR®-qualified appliances results in energy efficiency. Water can be conserved by using products with EPA’s WaterSense label. Many local and state governments, utility companies, and other entities across the country offer rebates, tax breaks, and other incentives for adding ecofriendly elements to homes.

Housing Instability and Homelessness

Preventing homelessness requires a communitywide approach to home instability and adaptation of successful models to local conditions. Communities where these and other approaches have been implemented have had substantial reductions in the number of homeless people (National Alliance to End Homelessness 2007). Targeting home subsidies to homeless families was found to have the greatest effect in reducing homelessness in several communities (Rog et al. 1995; Shinn et al. 1998; Stojanovic et al. 1999). Adults who are severely mentally ill require supportive services in conjunction with permanent homes. Mediation also has been shown to prevent homelessness—even in cases where a property owner has filed for eviction—by resolving the dispute and thus preventing eviction (Burt et al. 2007). Another commonly used approach to prevent homelessness is cash assistance for families with past-due rent.

Programs that improve home choices can also reduce home instability by providing families with the ability to access safe and healthy homes. In addition, some evidence indicates that moving from a neighborhood of concentrated poverty to a neighborhood with mixed income levels improves health and well-being. In one study, asthma and injury rates among children and behavioral problems among boys were significantly reduced in families that moved from public housing projects to more affluent neighborhoods (Katz et al. 2001). Other studies have found lower rates of obesity and improved mental health for adults and girls (Katz et al. 2001; Leventhal and Brooks-Gunn 2003; Orr et al. 2003).