Numerous studies support a direct link between substandard housing and its direct impact on health and safety, which includes injuries within the home (Folger et al., 2017; Zaloshnja, Miller, Lawrence, & Romano, 2005), asthma (Hughes, Matsui, Tschudy, Pollack, & Keet, 2017), respiratory infections (Howden-Chapman et al., 2007; Wang, Engvall, Smedje, Nilsson, & Norback, 2017), mental health issues (Rollings, Wells, Evans, Bednarz, & Yang, 2017), and lead poisonings (Centers for Disease Control and Prevention, 2012), for which the public health system bears a substantial financial cost. In 2011 it was estimated that childhood asthma alone cost the U.S. $56 billion annually (Nunes, Pereira, & Morais-Almeida, 2017).
Effective housing interventions can mitigate the physical and financial outcomes associated with poor housing. Gould (2009) estimated the benefit of all U.S. lead-based paint hazard control efforts in a cohort of 27.97 million children [less than or equal to] 6 years of age in 2006 to be $200 billion-$325 billion. The study found that every dollar invested in lead paint hazard control results in a return of $17-$221.
In 1999, in response to a congressional directive over concerns about children's environmental health, the U.S. Department of Housing and Urban Development (HUD) launched the Healthy Homes Initiative to protect children and their families from housing-related health and safety hazards (HUD, n.d.). As a result of the Healthy Homes Initiative, HUD offered grants from the Office of Lead Hazard Control and Healthy Homes (OLHCHH) to facilitate the identification and correction of housing deficiencies in vulnerable communities.
The City of Henderson, a suburban area of metropolitan Las Vegas, was awarded an OLHCHH grant in 2013 with the University of Nevada, Las Vegas Department of Environmental and Occupational Health as a subgrantee. As a HUD grantee, the Healthy Home Rating System (HHRS) was used to assess hazards in the qualifying target-area housing and prioritize HUD-funded home remediation. The HHRS was adopted from a United Kingdom (UK) tool used to quantify the health impact of poor housing to inform policy and housing improvements (Roys, Davidson, Nicol, Ormandy, & Ambrose, 2010). This new approach identifies the presence of hazards in the home and the risk associated with each hazard (Stewart, 2002).
The purpose of this article is to assess the impact of OLHCHH efforts in a low-income population in Henderson, Nevada, by evaluating the reduction in hazards postremediation. Recommended improvements to the HHRS and challenges of implementing the HHRS will be discussed.
Data for the Henderson Lead Hazard Control and Healthy Homes Program were collected August 2013-April 2016 on homes in Henderson, Nevada. To qualify for the program, participants met housing and occupancy requirements. Homes had to be built before 1978, have at least one bedroom, be a permanent structure, and be located within city limits. Occupants also had to meet HUD's income guidelines, and owner-occupied dwellings had to have either a child
If both housing and occupancy requirements were met, homes had to contain a leadbased paint hazard (lead concentration [greater than or equal to] 1.0 mg/[cm.sup.2] and be in chipping, flaking, or peeling condition) to receive remediation work. Identification of a lead-paint hazard prompted a healthy homes visual assessment. It is important to note that there is no standard visual assessment tool to conduct OLHCHH housing assessments; therefore, each HUD awardee develops their own tool.
A certified healthy homes specialist (HHS) performed all visual assessments. The visual assessment evaluates 29 hazard categories identified in the HHRS (see Table 1 for a complete list of hazards), of which 6 were excluded from analyses because they were not adequately assessed during the healthy homes inspections. The excluded hazards were asbestos, biocides, radiation, uncombusted fuel gas, noise, and explosions.
Each of the 23 hazards retained for analysis were assessed throughout the dwelling's interior and exterior. The number of hazards was determined by 1) the dichotomous presence or absence of the 23 individual HHRS hazards identified in a home and 2) the total number of instances of each hazard identified throughout a home. Further, additional hazards identified during the construction process, which were not marked during the initial assessment, were later added to the visual assessment for that dwelling.
Hazards identified during the visual assessment were inputted into an HHRS scoring tool. The scoring tool computes a Hazard Score and Hazard Band for each of the 29 hazards. National averages for the likelihood and the spread of harm are based on data obtained from the UK. For instance, UK data were used to determine the likelihood of a certain condition in the home based on what you might expect to find considering the age of the home and type (HUD, 2014). The HHRS allows inspectors to make judgments on three factors: 1) the perceived likelihood that the identified hazard will cause harm requiring medical care within the next 12 months in vulnerable age groups, 2) the consistency of the likelihood of harm with the national average, and 3) the severity of possible health outcomes.
Once the inspector made these decisions, the Hazard Score was derived by multiplying the weighted class of harms by the likelihood of occurrence and the spread of harm (Figure 1). The higher the Hazard Score, the more likely and serious the outcome. The Hazard Band is based on the inspector's judgment, however, less emphasis is put on the numerical score, and more emphasis on the Hazard Bands that are derived (A-J), with J being the least dangerous and A being the most dangerous (HUD, 2014).
The Hazard Bands were used to prioritize hazards in need of remediation. After lead and healthy homes rehabilitation work were completed, the City of Henderson program manager performed a postconstruction walkthrough of each property to ensure work was completed...