Georgia healthy homes strategic plan : healthy homes and lead poisoning prevention program

Georgia Healthy Homes
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Healthy Homes and Lead Poisoning Prevention Program
Georgia Department of Public Health Environmental Health Section
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Contents
Executive Summary ................................................................................................................................................................ 4 Introduction............................................................................................................................................................................... 6 Why Do Healthy Homes Matter ....................................................................................................................................... 8 Housing and Health in Georgia An Overview of Existing Conditions ...........................................................11 Georgia Healthy Homes Strategic Planning Process ...............................................................................................16 Vision for Healthy Homes in Georgia ............................................................................................................................18 Key Strategies and Action Plans ......................................................................................................................................20 Sustainability Plan.................................................................................................................................................................28 References ................................................................................................................................................................................29 Appendix A Advisory Workgroup Members...........................................................................................................31 Appendix B Practical Vision Statement.................................................................................................33
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Executive Summary

The connection between housing and health is well established. Numerous housing-related health issues including asthma and respiratory illnesses lead poisoning and injuries remain major public health challenges in Georgia. A healthy homes approach is effective in reducing housing-related health hazards. This approach is organized around the "Seven Principles of Healthy Homes " which are

Keep it

1.

Dry

2.

Clean

3.

Safe

4.

Ventilated

5.

Pest-Free

6.

Contaminant-Free

7.

Maintained

Recognizing a need for a more integrated approach to improving housing-related health outcomes the Georgia Department of Public Health (DPH) embarked on a statewide healthy homes strategic planning process in the fall of 2012. DPH recruited key stakeholders to participate as members of the Healthy Homes Strategic Planning Advisory Workgroup (the Advisory Workgroup). The Advisory Workgroup represented collaboration between a diverse group of individuals representing local state and federal health programs social service agencies housing agencies realtors non-profits and advocacy organizations and many others. Through the strategic planning process the Advisory Workgroup members identified seven elements that describe their collective statewide vision for healthy homes. These seven vision elements and associated key strategies include

Vision Element 1 Comprehensive Strategies to Support Diverse and Engaged Stakeholders 1. Implement and launch a public relations strategy. 2. Design an organizational structure to advance the healthy homes initiative in Georgia. 3. Develop a healthy homes certification or "seal of approval."

Vision Element 2 Coordinated appropriate and effective marketing and education 1. Develop and disseminate quality targeted educational materials. 2. Identify legislative champions to support ongoing education with legislators. 3. Develop a strategic marketing and education plan with clear priorities. 4. Launch a public awareness and education campaign. 5. Identify funders to support educational and promotional materials.

Vision Element 3 Effective policies and strong enforcement 1. Educate and motivate the legislature to pass strong laws.

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2. Identify and draft needed legislative authorities for healthy homes. 3. Develop persuasive data-driven arguments. 4. Convene convince and motivate the public and stakeholders to engage in dialogue with
their legislators. 5. Implement statewide code enforcement that is standardized effective and incorporates
healthy homes principles.
Vision Element 4 Comprehensive accurate and timely data tracking surveillance and evaluation.
1. Implement mandated reporting of healthy homes data to the Georgia Department of Public Health including hospital emergency room visits due to poisonings falls burns and asthma.
2. Coordinate the collection and management of healthy homes data to educate and inform policy makers and funders.
3. Develop comprehensive data tracking and surveillance networks.
Vision Element 5 Diverse resources and revenue generating mechanisms. 1. Communicate the return on investment for healthy homes activities with policy makers funders and other stakeholders. 2. Implement revenue generating requirements for contractors and property owners. 3. Collaborate with insurance providers to mandate healthy homes assessments and interventions for specific health care claims. 4. Conduct effective research to garner funding support for healthy homes. 5. Ensure efficient use of resources by establishing and strengthening partnerships.
Vision Element 6 Standardized processes and consistent implementation. 1. Identify common benefits and clear roles for all stakeholders to support collaborative participation. 2. Establish proper training standards quality control and certification processes. 3. Conduct cross-training of agencies and organizations statewide to ensure consistent approaches to identification and remediation of hazards. 4. Engage home visiting agencies in integrating healthy homes standards into their protocols.
Vision Element 7 Healthier Safer Homes for Generations.
- This vision element represents the culminating outcome that would result if the other six elements of the vision were realized.
Georgia has a number of existing assets to support these statewide healthy homes efforts. Building and maintaining extensive partnerships across a diverse range of stakeholders will be necessary for successful implementation of these key strategies. As a result of the strategic planning process Advisory Workgroup members agreed to sustain their collective relationship and provide continued direction and leadership for the activities identified in this strategic plan. Their leadership and commitment will assure Georgia s ability to respond collectively and individually to any budgetary and political changes ahead.
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Introduction
The Georgia Department of Public Health s Healthy Homes and Lead Poisoning Prevention Program (GHHLPPP) (formally known as the Georgia Childhood Lead Poisoning Prevention Program) has been in operation since 1992 under funding received from the Centers of Disease Control and Prevention in the form of cooperative agreement. Since then GHHLPPP has successfully worked to get Georgia s high risk children tested for lead poisoning while also identifying those who are lead poisoned and requiring case management and environmental follow up.
The key aims of GHHLPPP are to
Transition into a comprehensive Healthy Homes Program while continuing to monitor children for lead exposure and provide case management and environmental investigations for lead poisoned children
Develop and implement a strategic plan for the state to reduce or eliminate housing-related health hazards and to promote housing that is healthy safe affordable and accessible
Build a consortium of strategic partners to address unsafe and/or unhealthy housing conditions caused by housing-based hazards by leveraging resources and seeking sustainability in funding
Assure that follow up care and interventions are provided for vulnerable populations who are identified with housing-related health issues
Expand the GHHLPPP surveillance system to include not only blood lead levels but also environmental tests results and selected healthy homes variables
Consolidate existing related Department of Public Health (DPH) programs into a comprehensive Healthy Homes and Lead Poisoning Prevention Program
Work with housing agencies to enforce hazard reduction in inspected housing through existing HUD hazard reduction programs healthy homes local programs and housing code enforcement mechanisms
Engage our Environmental Justice and Faith Based Partners to educate the community concerning the dangers of housing-based hazards including lead poisoning and identifying vulnerable populations that may suffer the most from these health threatening sources of exposure
Contribute to DPH s mission of responsible health planning and improved health outcomes for the residents of Georgia
Expand GHHLPPP by adding staff training in healthy homes concepts and implementing interventions and referrals in response to the detection of housing-based health hazards
Reduce the overall cost of expensive medical responses to injuries and the exasperation of health conditions such as asthma by applying primary prevention principles to reduce housing-based hazards to reduce exposure prior to needing medical interventions
Employ indicator based evaluation techniques to evaluate every aspect of the program to increase efficiency and implement responsible health care planning and utilization of resources and
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Continue to train and credential existing Environmental Health Branch and local environmental health specialists in lead inspection techniques as well as Healthy Homes Practitioner principles.
Recognizing a need for a more integrated approach to improving housing-related health outcomes GHHLPPP assembled a Georgia Healthy Homes Advisory Committee with the mission to develop a strategic plan to direct and focus healthy homes initiatives for the State of Georgia. What follows is a comprehensive healthy homes strategic plan to be implemented by GHHLPPP within the program s key aims in conjunction with key partner agencies and organizations.
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Why Do Healthy Homes Matter
The connection between housing and health is well established. The U.S. Department of Housing and Urban Development (HUD) and the National Center for Healthy Housing (NCHH) have summarized a large body of scientific research demonstrating that numerous housing-related hazards pose a threat to human health (HUD 2011 NCHH 2009). These hazards are frequently grouped into four major categories based on the American Public Health Associations "Basic Principles of Healthful Housing" published in 1938
Physiological Requirements A number of indoor chemical contaminants including lead environmental tobacco smoke carbon monoxide (CO) radon volatile organic compounds (VOC) asbestos and pesticides pose serious threats to human health.
Psychological Requirements Poor lighting has been linked with depression and mood disorders such as seasonal affective disorder. Adequate lighting is important in allowing people to see unsanitary conditions and to prevent injury thus contributing to a healthier and safer environment. Noise can cause hearing impairment sleep disturbance negative cardiovascular and psycho-physiologic effects psychiatric symptoms and poor fetal development and can also reduce attention to tasks and impede speech communication.
Protection Against Infection Inadequate design and maintenance of housing can result in conditions that facilitate the growth of mold and bacteria as well as infestation of rats mice and other pests.
Protection Against Unintentional Injuries Inadequate and deferred maintenance of homes inadequate design of new homes and lack of important safety devices can result in preventable injuries illness and death in the home.
This section highlights three housing-related health issues that will require a coordinated housing- based approach as a key strategy asthma and respiratory health childhood lead exposure and unintentional injuries.
Asthma and respiratory health Asthma is a chronic disease in which the airways of the lungs become inflamed or narrowed resulting in disruptions to normal breathing patterns and significant health consequences. Asthma disproportionately impacts low-income families and people of color living in substandard housing because of the presence of pests mold environmental tobacco smoke and other asthma triggers. Mold pests and other allergens can trigger asthma which is the leading cause of school and work absences emergency department visits and hospitalizations in the United States (American Lung Association 2011). Asthma results in annual costs of $20.7 billion to the nation (American Lung Association 2011). Exposure to mold and dampness within homes contributes to an estimated 21% of all asthma cases in the United States (Mudarri & Fisk 2007). In addition dampness can lead to insomnia allergies headache cough and other respiratory health issues (Eggleston et al. 2005 Kercsmar et al. 2006). Chronic obstructive pulmonary disease (COPD) is the fourth-leading cause of death in the United States (CDC 2010). COPD may be exacerbated by environmental exposures including tobacco smoke and air pollutants. The highest COPD hospitalization rates are seen among older adults.
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Childhood lead exposure Housing conditions associated with increased risk of lead poisoning include chipping peeling and flaking paint on the exterior and interior of a home lead paint on friction-impact surfaces such as windows doors stairs and railings water leaks moisture problems and renovation of old houses without proper use of lead-safe work practices and clean- up. Childhood lead exposure remains a critical public health issue. Children are exposed to lead in their homes from deteriorating lead paint and the contaminated dust and soil it generates lead in water from leaded supply lines or plumbing and other sources. The connections between lead exposure and negative health impacts include neurological damage decreased IQ increased blood pressure anemia gastrointestinal issues stunted growth seizures coma and at very high levels death (Gould 2009 Fewtrell Pruss-Ustan Landrigan & Ayuso-Mateos 2004). Even low levels of lead exposure can have a lasting impact on a child s IQ likelihood of having a learning disability and educational attainment (Chandramouli Steer Ellis & Emond 2009 Miranda Kim Galeano Paul Hull & Morgan 2007 Miranda Maxson & Kim 2010). No safe blood lead level in children has been identified emphasizing the importance of primary prevention "a strategy that emphasizes the prevention of lead exposure rather than a response to exposure after it has taken place (Advisory Committee on Childhood Lead Poisoning Prevention 2012)." The CDC reference value for childhood lead exposure provides a way to compare an individual child s blood lead level to a population of children the same age (Advisory Committee on Childhood Lead Poisoning Prevention 2012). The current reference value is 5 micrograms of lead per deciliter of blood (g/dL) and will shift with population blood lead levels. More than 535 000 U.S. children ages 1-5 have BLLs greater than 5 g/dL (MMWR 2013).
Unintentional injuries Inadequate and deferred maintenance of homes inadequate design of new homes and lack of important safety devices can result in preventable injuries illness and death in the home (HUD 2011).The leading causes of death in the home are falls drowning fires poisoning suffocation choking and guns. Falls alone account for over half of all unintentional home injury deaths. Very young children and adults over age 70 are the most likely to be hurt at home. Poorly designed homes can also provide an unsafe or unsuitable environment for older adults and people with a disability. Because of falls many elders experience devastating consequences such as broken bones and head injuries. Each year approximately 18 000 injury deaths and 12 million non-fatal injuries occur nationally within homes (Runyan et al. 2005a Runyan et al. 2005b). Falls account for over half of all unintentional injury deaths within the home (Runyan et al. 2005b) fires drowning poisoning suffocation choking and guns are other leading causes of death in the home.
Using a Healthy Homes Approach
A substantial evidence base of effective interventions exists to address these housing-related health hazards through a healthy homes approach (U.S. Department of Housing and Urban Development 2011 National Center for Healthy Housing 2009). A "healthy home" is a home designed constructed maintained or rehabilitated in a manner that supports the health of residents. The healthy homes approach systematically and holistically identifies and addresses health and safety hazards in the home environment. Applying a healthy homes approach is more efficient than single issue-focused programs because it promotes cost-efficient housing interventions that address
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multiple interrelated health hazards. The healthy homes approach is organized around the "Seven Principles of Healthy Homes " which are Keep it
Dry Clean Safe Ventilated Pest-Free Contaminant-Free Maintained The healthy homes approach uses three interrelated strategies to address environmental hazards in the home (HUD 2011). These strategies include (1) Changes in structural conditions and building practices (2) modification of resident and property owners behaviors and (3) development or revision of policies legislation and service systems to enable healthy housing practices (HUD 2011). Extensive evidence exists to support the implementation of specific healthy homes interventions such as (NCHH 2009) Multi-faceted tailored asthma interventions Integrated pest management Moisture intrusion elimination Radon air mitigation through active sub-slab depressurization Smoking bans Lead hazard control Installation of working smoke alarms Pre-set safe temperature hot water heaters This evidence-base provides the foundation for the identified priority action strategies outlined in this plan.
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Housing and Health in Georgia An Overview of Existing Conditions
Today most Americans spend nearly 90% of their time indoors and mostly at home (EPA 2013). For many a home is considered a place of safety and comfort however there are potential hazards that can cause illness or injury. In 2009 the U.S. Surgeon General recognized the public health impacts of housing and issued a nationwide Call to Action to promote health in homes.
This section gives an overview about current trends in demographics housing quality indoor air quality asthma injury lead poisoning and emergency preparedness. This section also highlights current program capacity and activities.
Demographics
Georgia is home to a diverse population with a variety of cultures. According to the 2011 U.S. Census Estimate the state s estimated population for 2011 was 9.8 million. Of this total 46% of people are non-white or Hispanic and 16% of individuals live below poverty level. In Georgia 32% percent of households have one or more child 19% of households have one or more elderly residents and 15% of families are below the poverty level. Renters comprise approximately 35% of residents and 56% of renters and 28% of homeowners pay 35% or more of their income for housing.
Indoor Air Quality
Indoor air quality is linked with many health effects including asthma lung cancer chronic obstructive pulmonary disease and other diseases. Poor indoor air quality can not only affect health of adults and children but also a child s ability to learn.
In Georgia indoor air quality issues include carbon monoxide poisoning household chemical exposure airborne mold spores radon gases volatile organic compounds particulate matter allergens and environmental tobacco smoke. Based on January to October 2012 statewide inquiries the majority of calls to the Healthy Homes Program were related to health concerns from exposure to mold or mildew. Additionally 86% of those callers were renters.
The most common household pests in Georgia include ants cockroaches fleas spiders flies wasps rats bats mice and increasingly bed bugs (University of Georgia s College of Agricultural and Entomological Sciences 2013). Pests carry disease exacerbate asthma and create a nuisance when inside a home. The prevalence of pesticide use in response to these pest species has raised significant concern over the potential health effects associated with both acute and chronic exposure to these chemicals (http //portal.hud.gov/hudportal/documents/huddoc id D
OC_12484.pdf). The Georgia Department of Public Health
promotes Integrated Pest Management and safer alternatives to household chemicals to assist households with reducing pests and chemical gases inside the home. Commercial pest control and pesticide application is overseen by the Georgia Department of Agriculture and the Georgia Environmental Protection Division.
Tobacco smoke is the leading cause of lung cancer in the U.S. (CDC 2013). Each year approximately 150 000 people die from lung cancer in the U.S. and lung cancer is the cause of one
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of every six cancer deaths. In Georgia environmental tobacco smoke has been banned in many public buildings in Georgia under the Georgia Smokefree Air Act (2005) and ordinances exist which restrict smoking near public entrances.
As the second leading cause of lung cancer radon is another healthy homes concern in Georgia. The U.S. Environmental Protection Agency identified most of north Georgia as moderate to high potential for exposure to radon in homes. Over the last 25 years there were 1 632 homes in Georgia with a short-term radon level 4 pCi/L. When combined with smoking regularly a person s risk for lung cancer increases exponentially.
Maintaining good indoor air quality with proper ventilation is essential for reducing asthma and other respiratory diseases. Approximately 230 000 (9%) children ages 0-17 years
and 570 000 (8%) adults have asthma in Georgia (2010 Georgia BRFSS). Asthma is the second leading health problem among school-aged children. In the past year 38% of children in Georgia with asthma had an asthma attack in the past year and 14% of children with asthma had to visit an emergency room or urgent care (2010 Georgia Program and Data Summary on Asthma). It is estimated that hospitalization charges related to asthma totaled more than $132 million and ER charges related to asthma totaled over $63 million in Georgia (2010 Georgia Program and Data Summary on Asthma). In Georgia among children with asthma hospitalization rates are highest for those ages four and under (2010 Georgia Program and Data Summary on Asthma).

GEORGIA

US

Lifetime asthma among adults Lifetime asthma among children

11.5% 14.5%

13.5% 12.6% (38 states)

Asthma ED visit rate per 10 000 residents

54.5

55.4

Asthma hospitalization rate per 10 000 residents 11.6

14.4

% of children who missed one or more days of school due to asthma

54%

Lead Exposure
Georgia has nearly 300 years of housing history and many of Georgia s historic homes contain lead- based paint. Throughout Georgia 39% of homes are pre-1978 and 8% are pre-1950. Within a two year period (2010-2012) GHHLPPP identified 206 homes with confirmed interior or exterior lead hazards that are directly linked to poisoned children.
Risk indicators establishing housing as high risk include location in an urban area high numbers of rental housing and numbers of Medicaid children as an indication of socioeconomic status. Risk indicators were originally used to identify childhood lead poisoning risk but can be applied to healthy homes risk factors as well due to building condition and housing disparities.

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Fig. 1. (above) Map of high-risk housing counties 2010. In 2011 there were 120 797 children less than 6 years old tested for lead poisoning (Georgia Department of Public Health 2011). Of these children 5 361 were found to have a blood lead level of 5 micrograms per deciliter (mcg/dL) or greater and 778 were found to have a blood lead level of 10 micrograms per deciliter (mcg/dL) or greater. Among the cases of lead poisoning 70% are managed care children (Georgia Department of Public Health 2011).

GHHLPPP identified several counties throughout the state that pose a high-risk for lead poisoning based on lead screening data including

Bibb Carroll Chatham Cobb Crisp DeKalb
Dougherty

Fulton Gwinnett Hall Laurens Muscogee Richmond
Whitfield

Fig. 2. Map of high-risk counties identified by blood lead screening data 2010
Injuries
Injuries in Georgia cause an average of 4 750 deaths per year. Fall-related injuries are the leading cause of hospitalizations in Georgia. Poisoning and falls are the 3rd and 4th leading cause of injury death in Georgia for all ages respectively. The majority of fires occur in residential homes. Injury- related hospitalizations cost nearly $668 million in hospital charges per year (GA Vital Statistics Data & Georgia Injury Prevention Strategic Plan 2010-2015).
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Age-Adjusted Death Rate Georgia 2010

0

5

Motor Vehicle... Suicide
Poisioning Falls
Homicide All Other... Suffocation Fire and Smoke... Drowning Accidental Shooting Leagal intervention

3.4 2.3 1.2 1.2 0.5 0.1

7.4 6.3

10

15

12.8 11.2 9.6

Emergency Preparedness
Georgia has its share of tornadoes severe storms floods power outages and fires. Emergencies and natural disasters can affect people s most basic needs food water shelter and safety. Emergencies such as these increase the risk of perishable food temperature and humidity control housing structural integrity flood related mold fires and carbon monoxide levels inside the home.
In 2011 Georgia had 67 tornadoes and three floods with 151 individuals injured (GEMA 2012.) With national attention being drawn to climate change the Georgia Department of Public Health recognizes the impact that severe weather damage can have on homes and residents. "Ready Georgia" provides information about disaster preparedness at home and a checklist for what to include in an Emergency Preparedness "Ready Kit". The checklist includes
Water-One gallon per person per day for at least 3 days for drinking and sanitation. Food-At least a 3-day supply of non-perishable food. Can opener-For food if kit contains canned food. Radio-Battery-powered or hand crank radio and a NOAA Weather Radio with tone alert
and extra batteries for both. Face mask-To help filter contaminated air and plastic sheeting and duct tape to shelter in
place. Moist towelettes garbage bags and plastic ties-For personal sanitation. Wrench or pliers-To turn off utilities. Local maps flashlight extra batteries first aid kit and whistle.
By promoting these Ready Kits residents can prevent illness and injury in the home during and after disasters occur.
Current Program Activities
Since 2004 the Georgia Healthy Homes and Lead Poisoning Prevention Program (GHHLPPP) has monitored blood lead levels conducted household environmental investigations for sources of lead and in 2011 began enforcing lead hazard abatement for rental units with lead hazards.
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GHHLPPP collects and manages information on blood lead testing through the Georgia Department of Public Health s State Electronic Notifiable Disease Surveillance System (SENDSS.) This system serves as a data sharing system that provides the capacity for laboratories to report results of blood lead testing and for GHHLPPP to conduct case management on lead poisoned children. GHHLPPP works with Georgia s Medicaid Program overseen by the Georgia Department of Community Health to ensure that children at the highest risk of lead poisoning are screened and receive the appropriate attention and advises the Medicaid Program about testing and follow-up of Medicaid children for lead exposure. GHHLPPP also works with the Head Start programs throughout the state to ensure that all Head Start children are tested for lead which is a federal Centers for Medicare & Medicaid Services requirement and oversees case management and follow-up for lead elevated children in the Maternal Child Health Program (MCH). Since 2011 GHHLPPP has expanded its childhood lead poisoning prevention services to include providing information about other potential hazards around the home. As part of the expanded lead program incorporating CDC s Healthy Homes initiative in Georgia GHHLPPP offers information about other household hazards such as indoor air quality and unintentional injuries. In 2012 the program conducted a healthy homes needs assessment to determine environmental health education materials needs and has developed several health education materials for distribution to the general public. The program has trained twenty-one local Environmental Health Specialists throughout Georgia as healthy homes practitioners. Several brochures on various healthy homes topics have been made available to every public health district in Georgia.
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Georgia Healthy Homes Strategic Planning Process
The Georgia Department of Public Health (DPH) embarked on a statewide healthy homes strategic planning process in the fall of 2012. DPH partnered with the National Center for Healthy Housing (NCHH) to help facilitate the strategic planning process. DPH recruited key stakeholders to participate as members of the Healthy Homes Strategic Planning Advisory Workgroup (the Advisory Workgroup). The Advisory Workgroup represented collaboration between a diverse group of individuals representing local state and federal health programs social service agencies housing agencies realtors non-profits and advocacy organizations and many others. A complete list of the Advisory Workgroup members is provided in Appendix A. The roles and responsibilities of the Advisory Workgroup members were to (1) participate in the strategic planning process through in-person meetings and review of materials (2) provide leadership for the implementation of the vision and strategies developed by the Advisory Workgroup and (3) advise DPH by ensuring that the outcomes of the strategic planning process resonate among diverse sectors sharing and disseminating the outcomes of the process and keeping DPH apprised of activities and programs that may be of value to other Advisory Workgroup members. NCHH facilitated two meetings of the Advisory Workgroup. The first meeting was held in October 2012 in celebration of National Childhood Lead Poisoning Prevention Week and Child Health Month. At this meeting DPH staff presented summary information on health and housing conditions in Georgia. NCHH presented model initiatives and strategies from across the United States that Georgia could consider as it works to implement a comprehensive healthy homes approach. Participants then articulated their visions for healthy homes in Georgia and developed a collective practical vision statement for healthy homes. At the second meeting held in December 2012 participants reviewed and reflected on the synthesized practical vision statement identified at the first meeting. Breakout groups then worked to identify priority strategies for achieving the vision developed at the first meeting and developed action plans for the first year of plan implementation. Figure 1 provides an overview of the strategic planning process.
Figure 1 Georgia Healthy Homes Strategic Planning Process
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Meeting evaluations suggest that the planning process was highly successful and well-received by participants. Of those who responded to the October 2012 meeting evaluation 100% of participants felt their input was "very much" considered and incorporated at the meeting. Eighty-three percent of participants felt the practical vision statement developed "very much" resonated with their organization and 17% felt that it "somewhat" resonated with their organization. Fifty-seven percent of participants anticipate staying "highly involved" and 43% anticipate staying "somewhat involved" in the implementation of the plan.

57% of Advisory Workgroup
members plan to stay highly
involved in the implementation of the strategic
plan

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Vision for Healthy Homes in Georgia

The Advisory Workgroup members identified seven elements that describe a collective statewide vision for healthy homes in response to the question "What do we want to see in place in Georgia in 3-5 years as a result of collaboration among health housing and education programs " The practical vision statement resulting from this exercise is detailed in Appendix B. The resulting seven vision elements are as follows
1. Comprehensive strategies to support diverse and engaged stakeholders 2. Coordinated appropriate and effective marketing and education 3. Effective policies and strong enforcement 4. Comprehensive accurate and timely data tracking surveillance and evaluation 5. Diverse resources and revenue generating mechanisms 6. Standardized processes and consistent implementation 7. Healthier safer homes for generations

After generating their collective vision the Advisory Workgroup members identified key obstacles to achieving it.

Obstacles to the Vision

A number of important obstacles surfaced including limited knowledge and misinformation about healthy housing among decision-makers and as a result a lack of prioritization of healthy homes. Advisory Workgroup members also identified un- mobilized resources as an obstacle to a collaborative statewide healthy homes approach. The current undeveloped legal authority to support healthy homes in Georgia is another barrier. Finally the Advisory Workgroup pinpointed language and cultural barriers competing priorities and political opposition as important obstacles to address.

Key Obstacles Un-mobilized and unidentified
resources Political opposition Cuts to existing funding streams Competing priorities Language and cultural barriers Undeveloped authority Limited knowledge and
misinformation Inconsistent data and reporting Unidentified stakeholders Limited outreach to under-
represented groups

Assets and Opportunities to Support the Vision

Despite these existing barriers Advisory Workgroup members identified a number of existing assets that will support Georgia in its statewide healthy homes efforts. Georgia has strong expertise in key healthy homes content areas and significant research and data capacity. The local presence of the Centers for Disease Control and Prevention and regional offices of the Environmental Protection Agency and Department of Housing and Urban Development bring capacity historical knowledge

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and credibility to the Georgia Department of Public Health s healthy homes work. Advisory Workgroup members felt that the new statewide network of partners brought together to develop this strategic plan provides exciting opportunities for stronger collaboration among state and local agencies and organizations. Finally the state will be able to leverage Advisory Workgroup members existing connections with the real estate sector contractors and local communities to ensure successful implementation of the strategic plan.
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Key Strategies and Action Plans
Taking into account the existing assets strengths and obstacles for achieving healthier homes in Georgia the Advisory Workgroup developed specific strategies to advance each element of the state s vision for healthy homes. The Advisory Workgroup determined that the seventh vision element - Healthier safer homes for generations represents the culminating outcome that would result if the other six elements of the vision were realized. Therefore the Advisory Workgroup did not identify specific strategies or conduct action planning for this vision element.
The key strategies include
Vision Element 1 Comprehensive Strategies to Support Diverse and Engaged Stakeholders 1. Implement and launch a public relations strategy. 2. Design an organizational structure to advance the healthy homes initiative in Georgia. 3. Develop a healthy homes certification or "seal of approval."
Vision Element 2 Coordinated appropriate and effective marketing and education. 1. Develop and disseminate quality targeted educational materials. 2. Identify legislative champions to support ongoing education with legislators. 3. Develop a strategic marketing and education plan with clear priorities. 4. Launch a public awareness and education campaign. 5. Identify funders to support educational and promotional materials.
Vision Element 3 Effective policies and strong enforcement. 1. Educate and motivate the legislature to pass strong laws. 2. Identify and draft needed legislative authorities for healthy homes. 3. Develop persuasive data-driven arguments. 4. Convene convince and motivate the public and stakeholders to engage in dialogue with their legislators. 5. Implement statewide code enforcement that is standardized effective and incorporates healthy homes principles.
Vision Element 4 Comprehensive accurate and timely data tracking surveillance and evaluation.
1. Implement mandated reporting of healthy homes data to the Georgia Department of Public Health including hospital emergency room visits due to poisonings falls burns and asthma.
2. Coordinate the collection and management of healthy homes data to educate and inform policy makers and funders.
3. Develop comprehensive data tracking and surveillance networks.
Vision Element 5 Diverse resources and revenue generating mechanisms. 1. Communicate the return on investment for healthy homes activities with policy makers funders and other stakeholders. 2. Implement revenue generating requirements for contractors and property owners. 3. Collaborate with insurance providers to mandate healthy homes assessments and interventions for specific health care claims.
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4. Conduct effective research to garner funding support for healthy homes. 5. Ensure efficient use of resources by establishing and strengthening partnerships. Vision Element 6 Standardized processes and consistent implementation. 1. Identify common benefits and clear roles for all stakeholders to support collaborative
participation. 2. Establish proper training standards quality control and certification processes. 3. Conduct cross-training of agencies and organizations statewide to ensure consistent
approaches to identification and remediation of hazards. 4. Engage home visiting agencies in integrating healthy homes standards into their protocols. Strategies and Action Plan Tables The following pages include the specific activities and success indicators to help move toward Georgia s vision for healthy homes. The tables include recommended first-year activities the lead organization and partners who are responsible for implementation and indicators of successful implementation.
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Vision Element 1 Comprehensive Strategies to Support Diverse and Engaged Stakeholders

Key Strategies

1. Engage and Recruit key healthy homes stakeholders throughout Georgia.

2. Design an organizational structure to advance the healthy homes initiative in Georgia.

3. Develop a healthy homes certification or "seal of approval."

First-Year Activities

Lead

Partners

Success Indicators

Organization(s) (Including but

not limited to)

Develop a sustainable healthy homes coalition led

Georgia Department of

Members of the There is an Georgia Healthy established

by the Georgia Department

Public Health

Homes Strategic coalition that is

of Public Health (DPH). The

(Healthy Homes Planning

successful in

coalition should

and Lead

Advisory

implementing its

o Identify a clear purpose and consistent message
o Set clearly defined roles and responsibilities
o Seek out key stakeholders who are not yet represented
o Identify a timeframe for ongoing meetings
o Seek resources to sustain the coalition.

Poisoning Prevention Program)

Workgroup
Traditionally un- or under- represented communities trades and sectors.

strategies
A statewide healthy homes program is well- established and well known
A comprehensive public relations strategy is in place and is actively being

Establish a standardized definition of healthy homes for the state of Georgia and identify the key processes required to make a home healthy.

implemented.
Stakeholders have a common understanding of healthy homes.

Initiate the development of a comprehensive public

relations strategy.

Identify statewide and local spokespeople to support

healthy homes.

Proactively include under- represented groups

including rural and

environmental justice

communities.

Examine opportunities for engaging property owners

and contractors through a

certification or "seal of

approval" process.

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Vision Element 2 Coordinated appropriate and effective marketing and education.

Key Strategies

1. Develop and disseminate quality targeted educational materials.

2. Identify legislative champions to support ongoing education with legislators.

3. Develop a strategic marketing and education plan with clear priorities.

4. Launch a public awareness and education campaign.

5. Identify funders to support educational and promotional materials.

First-Year Activities

Lead

Partners

Success

Organization(s) (Including but

Indicators

not limited to)

Initiate development of a

Georgia

Health districts Marketing and

marketing and education strategic plan.

Department of Public Health

Maternal and child health

education strategic plan is

Use focus groups to develop effective messages for key target audiences such as families homeowners renters schools and child cares and apartment associations.
Develop targeted educational and marketing materials (e.g. pamphlets slide deck press releases etc.) for key audiences.
Inventory existing quality educational materials and develop an easily accessible list of resources.
Develop an easy to navigate multi-lingual website for the public and key stakeholders (key healthy homes issues what to do etc.)
Continue to provide healthy homes training statewide.
Develop a quality control process for healthy homes training to assure quality education.
Identify community champions.
Look for partners with interest in funding marketing and education (e.g. Home Depot

(Healthy Homes and Lead Poisoning Prevention Program)
Georgia Department of Early Care and Learning
Federal partners and regional offices Centers for Disease Control and Prevention Environmental Protection Agency and Housing and Urban Development

home visitors
Children First Program
Babies Can t Wait
Anti-smoking coalition
Housing authorities
Georgia Association on Young Children
Corporations Foundations
State agencies Voices for
Georgia s Children Families First
Family Connection Partnership
Resource and referral agencies
Safe Kids Georgia
Head Start

in place
Georgia is passing successful legislation to support healthy homes
Standardized messaging and materials are in place
Corporations provide significant funding to support consumer education efforts
Legislative champions are in place
Pre-post survey demonstrates increased awareness in public

Lowes).

Host educational forums.

Engage Georgia Public Broadcasting to educate the

public.

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Vision Element 3 Effective policies and strong enforcement.

Key Strategies

1. Educate and motivate the legislature to pass strong laws.

2. Identify and draft needed legislative authorities for healthy homes.

3. Develop persuasive data-driven arguments.

4. Convene convince and motivate the public and stakeholders to engage in dialogue with

their legislators.

5. Implement statewide code enforcement that is standardized effective and incorporates

healthy homes principles.

First-Year Activities

Lead

Partners

Success Indicators

Organization(s) (Including but

not limited to)

Identify existing Georgia

Georgia

Members of A clear defined

healthy homes requirements

Department of

the Georgia

strategy for

and identify gaps or deficiencies

Public Health

Healthy

strengthening

in these existing requirements.

(Healthy

Homes

healthy homes

Research and address existing barriers to healthy homes

Homes and Lead

Strategic Planning

policy is in place and actively being

policy development and

Poisoning

Advisory

implemented.

adoption.
Determine policy strategies to strengthen existing healthy

Prevention Program)

Workgroup

Meetings and contacts between key stakeholders

homes requirements and

and legislators are

address existing policy gaps and

tracked as a

deficiencies.

measure of

Identify contact and engage a comprehensive list of

dialogue with policy-makers.

stakeholders to support

Existing

statewide policy priorities.

requirements are

Initiate conversations with legislative champions to

fully enforced. Statewide code

identify key barriers to healthy

enforcement is in

homes policy development and

place.

adoption.

Host a legislative day to

encourage dialogue among the

public and policy-makers.

Develop a clear plan for enforcement of existing

requirements.

Initiative the development of

standardized statewide code

enforcement.

24

Vision Element 4 Comprehensive accurate and timely data tracking surveillance and evaluation.

Key Strategies

1. Implement mandated reporting of healthy homes data to the Georgia Department of Public

Health including hospital emergency room visits due to poisonings falls burns and asthma.

2. Coordinate the collection and management of healthy homes data to educate and inform policy

makers and funders.

3. Develop comprehensive data tracking and surveillance networks.

First-Year Activities

Lead

Partners

Success Indicators

Organization(s) (Including but

not limited to)

Establish effective and efficient Georgia

CDC

protocols for reporting required

Department of

Surveillance system has been

health information.

Public Health

assessed and

Inventory existing data and surveillance systems and initiate a plan for developing a comprehensive tracking and surveillance network.
Expand the GHHLPPP surveillance system to include not only blood lead levels but also environmental test results

(Healthy Homes and Lead Poisoning Prevention Program) OHIPGeorgia Department of Public Health

issues have been addressed
Successful collection of surveillance data
Comprehensive HH surveillance system is in place within the

and selected healthy homes

GHHLPPPP

variables.

Program and

being utilized.

25

Vision Element 5 Diverse resources and revenue generating mechanisms.

Key Strategies

1. Communicate the return on investment for healthy homes activities with policy makers

funders and other stakeholders.

2. Implement revenue generating requirements for contractors and property owners.

3. Collaborate with insurance providers to mandate healthy homes assessments and

interventions for specific health care claims.

4. Conduct effective research to garner funding support for healthy homes.

5. Ensure efficient use of resources by establishing and strengthening partnerships.

First-Year Activities

Lead

Partners

Success

Organization(s) (Including but

Indicators

not limited to)

Institute a healthy homes

Georgia

Health insurers Comprehensive

comprehensive database using a standardized tool to enable

Department of Centers for

Public Health

Disease Control

database is in place

return on investment calculations.
Identify opportunities to use resources more efficiently among agencies and organizations involved in strategic partnerships.
Approach medical insurance providers to begin dialogue regarding reimbursement for

(Healthy Homes and Lead Poisoning Prevention Program)
National Healthy Homes Training Center and Network Partners

and Prevention
Local colleges and universities
Members of the Georgia Healthy Homes Strategic Planning Advisory Workgroup

Georgia has calculated and communicated the return on investment for healthy homes
Increased training of professionals and property

healthy homes assessments and

owners in

interventions.

healthy homes

Partner with local colleges and

principles

universities to research

Dialogue with

implementable revenue

insurance

generating strategies.

providers

Identify incentives that could be used to support property owners

results in reimbursement

in remediating hazards.

mechanisms.

Launch coordinated training for contractors and property

New revenue generating

owners.

strategies are

Post a searchable online listing of all federal state and local

identified and implemented

funded healthy homes initiatives.

Create a fee-for-service home

visiting program with a sliding

scale payment structure.

26

Vision Element 6 Standardized processes and consistent implementation.

Key Strategies

1. Identify common benefits and clear roles for all stakeholders to support collaborative

participation

2. Establish proper training standards quality control and certification processes.

3. Conduct cross-training of agencies and organizations statewide to ensure consistent

approaches to identification and remediation of hazards.

4. Engage home visiting agencies in integrating healthy homes standards into their

protocols.

First-Year Activities

Lead

Partners

Success

Organization(s) (Including but

Indicators

not limited to)

Finish the Georgia Healthy

Georgia

Federal

Strategic plan

Homes Strategic Plan to

Department of

agencies

in place and in

provide a framework for collaboration and implementation.

Public Health and regional health

Home visiting agencies

operation One champion
from each

Align healthy homes

organizations

organization/

considerations across all

Members of the

agency is

entities and organizations.

Georgia Healthy

involved

Begin to develop quality control processes.

Homes Strategic Planning

Partners recognize

Initiate the identification of common benefits and clear

Advisory Workgroup

common benefits and

roles for stakeholders.

buy-in to

Identify a champion from each organization and agency

statewide efforts

involved in coordinated

Home visiting

healthy homes efforts across

agencies fully

the state.

integrate

Gain participation and buy-in from key stakeholders.
Establish a one-stop location

healthy homes standards into their protocols.

for application intake and

education.

Encourage and incentivize

information sharing among

partners.

Begin dialogue with home

visiting agencies.

27

Sustainability Plan
The 2012 Federal Budget cut CDC funds for lead/healthy homes by 94%. Several months into the process CDC officially notified GHHLPPP that there would be no funding beyond the first year. As a result this plan was developed with an assumption that the future GHHLPPP role in promoting and implementing the plan may be very limited. However Georgia has an extensive base of people programs and organizations that can contribute to healthy homes and communities with multiple existing community assets and resources identified. As of this writing many projects are being considered for reducing program costs and/or generating funds. These concepts are being evaluated for their effectiveness cost-benefit capacity barriers and sustainability. They include but are not limited to concepts with staff reduction and reassignment resource reallocation alternative activities reduction and generation of lower cost services. Care Management Organizations are being utilized to assist GHHLPPP with patient case management and Medicaid reimbursement for home inspections of elevated blood lead children. Additionally grant funding opportunities will be explored and applied for when deemed appropriate for this program s mission. To achieve the vision elements strategies and action steps developed extensive partnerships will be necessary for successful implementation. The Healthy Homes Advisory Committee represents a broad list of key stakeholders selected for their expertise specific focus and common direction. These consist of local state and federal governmental health and housing-related agencies private industry and non-governmental education and advocacy organizations. Advisory Committee members have common organizational goals and have indicated a commitment to work together to gain support for common objectives and implement the plan. As a result of the strategic planning process members agreed to sustain this relationship and serve to provide continued direction for GHHLPPP activities identified in this strategic plan.
28

References
Advisory Committee on Childhood Lead Poisoning Prevention. (2012). Low Level Lead Exposure Harms Children A Renewed Call for Primary Prevention. Available at http //www.cdc.gov/nceh/lead/ACCLPP/Final_Document_030712.pdf.
American Lung Association. (2011). Charles D. Connor Appropriations Testimony (Department of Health and Human Services - Summary of Programs) to the U.S. House of Representatives Subcommittee on Labor Health and Human Services and Education. Retrieved August 14 2012 from http //www.lung.org/get-involved/advocate/advocacy-documents/connor-appropriations- testimony.pdf
Chandramouli K. Steer C. Ellis M. & Emond A. (2009). Effects of early childhood lead exposure on academic performance and behaviour of school age children. Archives of Disease in Childhood 94 (11) 844-848.
Eggleston P. Butz A. Rand C. Curtin-Brosnan J. Kanchanaraksa S. Swartz L. et al. (2005). Home environmental intervention in inner-city asthma A randomized controlled trial. Annals of Allergy Asthma and Immunology 95 (6) 496-497.
Fewtrell L. Pruss-Ustan A. Landrigan P. & Ayuso-Mateos J. (2004). Estimating the global burden of disease of mild mental retardation and cardiovascular diseases from environmental lead exposure. Environmental Research 94 120-133.
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.
Kercsmar C. M. Dearborn D. G. Schluchter M. Xue L. Kirchner H. L. Sobolewski J. et al. (2006). Reduction in asthma morbidity in children as a result of home remediation aimed at moisture sources. Environmental Health Perspectives 114 (10) 1574-1580.
Miranda M. Kim D. Galeano M. Paul C. Hull A. & Morgan S. (2007). The relationship between early childhood blood lead levels and performance on end-of-grade tests. Environmental Health Perspectives 115 (8) 1242-1247.
Miranda M. Maxson P. & Kim D. (2010). Early childhood lead exposure and exceptionality designations for students. International Journal of Child Health and Human Development 3 (1) 77- 84.
Mudarri D. & Fisk W. (2007). Public health and economic impact of dampness and mold. Indoor Air 17 226-35.
National Center for Healthy Housing. (2009). Housing Interventions and Health A Review of the Evidence. Columbia MD National Center for Healthy Housing.
Portier C. (2012). The Latest Science on Lead s Impacts on Children s Development and Public Health. Testimony before the Committee on Environment and Public Works United States Senate . Available at http //epw.senate.gov/public/index.cfm FuseAction Files.View&FileStore_id c7b84ff9-468a- 4d92-8adc-c84aee2e6ff1.
29

Runyan C. Casteel C. Perkis D. Black C. Marshall S. Johnson R. et al. (2005a). Unintentional injuries in the home in the United States Park I Mortality. American Journal of Preventive Medicine 28 73-79. Runyan C. Perkis D. Marshall S. Johnson R. Coyne-Beasley T. Waller A. et al. (2005b). Unintentional injuries in the home in the United States Part II Morbidity. American Journal of Preventive Medicine 28 80-87. U.S. Centers for Disease Control and Prevention (2010). Chronic Obstructive Pulmonary Disease. Retrieved October 11 2012 from http //www.cdc.gov/Features/COPD/index.html. U.S. Department of Housing and Urban Development. (2011). The Healthy Homes Program Guidance Manual. Washington DC U.S. Department of Housing and Urban Development. U.S. Environmental Protection Agency. (2003). EPA Assessment of Risks from Radon in Homes. Washington DC U.S. Environmental Protection Agency.
30

Appendix A Advisory Workgroup Members
John Armour City of Atlanta Dept.of Planning and Community Development Sandra Bell Georgia Community Action Ass.(GCAA) Weatherization Karon Bush West Central Health District GDPH Julia Campbell GDPH Healthy Homes Program Eileen Carrol HUD Simone Charles Georgia Southern University Ryan Cira Dekalb County Board of Health Mindy Crean GEPD Lead-Based Paint Program Tori Endres West Central Health District GDPH Fozia Eskew GA. Chapter of American Academy of Pediatrics Kim Grier GDHS Division of Aging Services Margaret Gunter North Central Health District GDPH Janice Hacker Georgia Bright From the Start Stephanie Hall GDPH Asthma Program Corby Hanna The Center for Working Families- Lead Safe Atlanta Deb Junkin Georgia Realtors Association Christy Kuriatnyk GDPH Healthy Homes Program Tom Laubenthal The Environmental Institute Beverly Losman Safe Kids Georgia Francesca Lopez GDPH Asthma Program Bonnie Maurras Leadnology Today Megan Popielarczyk Safe Kids Georgia Kenneth Ray GDPH Tobacco Use Prevention Penny Round GA Apartment Owners Association
31

Steed Robison Georgia Dept. of Community Affairs (DCA)- Housing Sanjeeb Sapkota CDC Jan Simmons GEPD Lead-Based Paint Program Jonnette Simmons HUD Gwen Smith GDPH Lead Hazard Control Program Forrest Staley GDPH Lead Hazard Control Program Chris Stevens State Fire Marshall s Office Yu Sun GDPH Healthy Homes Program Shawn Taylor Columbus HD Vector Control Tracy Teague GDPH Healthy Homes Program Lanii Thomas City of Atlanta Dept. of Planning & Community Development Pamela Turner UGA Jeremy Weir Private Lead Inspector Liz Wilde US EPA Melinda Ford Williams Georgia Dept. of Community Health State Medicaid Program
32

Appendix B Practical Vision Statement

Georgia Healthy Homes Strategic Planning Advisory Workgroup Practical Vision
What do we want to see in place in Georgia in 3-5 years as a result of collaboration among health housing and education programs

Healthier Safer Homes for Generations
Comprehensive Strategies to Support Diverse and Engaged Stakeholders
Coordinated Appropriate and Effective Marketing and Education
Effective Policies and Strong Enforcement
Comprehensive Accurate and Timely Data Tracking Surveillance and Evaluation

Make healthy homes principles second nature to all. Decrease poor health outcomes and injuries. Make all homes safe and healthy. Ensure that all children are free from lead and housing-related health
issues.
Develop an organizational chart that clarifies the roles and responsibilities of the diverse organizations involved.
Establish functioning multi-sector collaborations with champions (e.g. an association).
Encourage collaboration among health housing and education sectors to screen for follow up on and eliminate lead poisoning.
Create a fee-for-service home visiting program with a sliding scale payment structure.
Establish a broader coalition. Proactively include under-represented groups including rural and
environmental justice communities. Ensure community engagement to foster new programs and activities. Identify champions at local level. Coordinate access to materials and educational resources.
Market and effectively communicate the benefits and savings of the healthy homes approach for residents contractors and legislators.
Develop a comprehensive education campaign. Host educational forums. Increase awareness among families/consumers and agency officials. Provide access to resources to assist with housing improvements.
Conduct effective policy analysis planning and monitoring. Review and strengthen existing legislation. Establish effective policies. Implement statewide code enforcement that is standardized
effective and incorporates healthy homes principles. Develop a clear plan for enforcement.
Establish data processes and monitor outcomes. Develop comprehensive data tracking and surveillance networks. Identify and remediate gaps in data system processes. Collaborate with internal and external partners to share appropriate
data as needed. Establish effective and efficient protocols for reporting required
health information.

33

Georgia Healthy Homes Strategic Planning Advisory Workgroup Practical Vision
What do we want to see in place in Georgia in 3-5 years as a result of collaboration among health housing and education programs

Diverse Resources and Revenue Generating Mechanisms

Provide incentives for property owners and other stakeholders. Leverage funds with the private sector. Develop clear "selling points" to generate funding support. Provide low-cost home modification opportunities. Establish public/private partnerships to support affordable housing.

Standardized Processes and Consistent Implementation

Establish a one-stop location for application intake and education. Develop standardized language and a common definition for a healthy
home. Conduct standardized comprehensive home assessments. Cross-train stakeholders on techniques to achieve healthy homes. Train all programs working with young children on the effects of lead
and other healthy homes issues. Develop a web portal to assist stakeholders in sharing resources and
information. Encourage and incentivize information sharing among partners. Develop a central web resource for both internal and external
stakeholders.

34