Educating refugees to improve their home environmental health

Abstract

Rochester's Healthy Home was a hands-on home environmental health museum that educated over 3500 visitors between June 2006 and December 2009. The Healthy Home provided visitors with the tools, resources, and motivation to make their homes healthier by reducing environmental hazards. The Healthy Home focused on empowering low-income renters to protect their families from home health risks, but served a broad audience. Based on the Healthy Home's initial successes with diverse visitors, in 2009 the county health department provided funding for a six-month project to educate 200 recently arrived refugees. This report summarizes the project's innovative approach to home health education, presents evaluation data on impacts on refugees and other visitors, suggests implications for resettlement agencies, and provides guidelines for those interested in replicating this approach in their own community.

Introduction

Many refugees arriving in the United States face multiple health challenges. Some refugees’ health issues result from experiences in their home countries; others may develop once they arrive. Because refugees generally live in low-income housing, one source of health hazards may be housing in poor condition. Even when living in safe housing, however, refugees who lack experience with western-style homes may be at greater risk than native-born residents. In addition, limited English and health literacy may prevent some refugee families from learning how to safely use, clean, and maintain their new homes.^1-3

Childhood lead poisoning is one area in which refugees’ elevated risk from home environmental hazards has been well documented. This risk received particular attention after a Sudanese child died from lead exposure in her home in New Hampshire in 2000.² Several studies have suggested that refugee children may have excess risks of elevated blood lead levels from housing after arriving in the U.S., in addition to potential exposures from traditional ethnic products.^1,4,5 Not only do refugee children from certain regions arrive with a high rate of elevated blood lead levels, but once in this country they have a greater chance of experiencing increased blood lead levels (BLL) than non-refugee children.¹ This disproportionate risk may be due to cultural differences in behavior related to cooking and cleaning practices, lack of awareness of lead risks, or difficulty communicating with landlords.

Lead is just one of many potential hazards that refugees may encounter in their new homes – others include asthma triggers, carbon monoxide, and hazardous cleaning chemicals. While there are abundant educational materials on these topics, written materials may be of limited value to non-English speaking or low literacy refugees. Resettlement agencies that must cover a wide range of topics seldom emphasize home environmental hazards in their programs. For example, the Mercy Housing organization in Denver, CO developed highly visual housing guides and training programs for refugees; however, even these appropriately designed materials have limited coverage of environmental health hazards.⁶ As a result refugees may find themselves exposed to unfamiliar hazards in their homes and may lack the tools to address them because of gaps in knowledge.

The housing stock in Rochester, New York (population 200,000) has a high risk for lead hazards - 87% of homes were built before 1970, property values are low, and there is a high rental rate. ⁷ It is therefore not surprising that childhood lead poisoning rates have been among the highest in the state.^7,8 While other hazards like carbon monoxide, mold, and pests are more difficult than lead to identify at the community level, research elsewhere suggests they frequently co-occur in low-value older housing in poor condition.⁹

The City of Rochester has seen the number of refugees settled steadily increase over the past ten years. The major resettlement agency in Rochester, Catholic Family Center, served over 700 individuals in 2010. Although resettlement agencies strive to place refugees in safe housing, limited financial resources frequently force refugees to move to properties that may have a high risk of lead and other environmental hazards. Thus, refugees recently settled in Rochester may be at particular risk from home environmental health hazards.

Rochester's Healthy Home was an innovative community-university partnership dedicated to helping residents improve the environmental health of their homes.¹⁰ The Healthy Home responded initially to low-income residents’ and landlords’ need for education after Rochester passed a comprehensive lead law in 2005.^7,11 Because the Healthy Home's hands-on, interactive approach to home health education was found to be successful with low-income tenants, the partners speculated that it might be an effective approach for refugees. This report describes a refugee education program conducted by the Healthy Home in 2009.

This paper relies on a variety of sources, including project reports written by Healthy Home staff documenting their interactions with refugee visitors. During the refugees’ visits to the healthy home, they asked questions and gave feedback through interpreters to the Healthy Home staff, who recorded themes and specific comments. Interpreters also helped the visitors complete “action sheets” specifying how the refugees planned to use what they learned at the Healthy Home in their own homes. Interpreters recorded open-ended responses about the refugee visitors’ planned actions. For the purposes of this analysis, the first listed response was coded into seven different action categories (Table 1). Refugee visitors’ responses were compared with the responses of the non-refugee visitors to the Healthy Home; differences were examined using the Fisher's exact test.¹² Due to limited English literacy, the refugees were not asked to complete the Healthy Home's full written evaluation, a two-page survey that has been described elsewhere; however, qualitative comments were conveyed by interpreters.¹⁰ The University of Rochester Research Subjects Review board approved the use of this data for this practice report.

Table 1.

Follow-up actions planned by Healthy Home visitors

	Non-refugee visitors (N= 1504)	Refugee visitors (N=93)
Contact a resource agency	5.5%	0%*
Make physical changes in my home(s)	27.8%	33.3%
Talk to my landlord	3.1%	1.1%
Change household cleaning habits	32.6%	39.8%
Change other behaviors related to home hazards	18.8%	11.8%
Teach/share information with others	8.5%	9.7%
Other	3.8%	4.3%

^*Difference between non-refugee and refugee visitor responses significant at p=.05 based on Fisher's exact test

Refugee Education at Rochester's Healthy Home

The Healthy Home opened in July 2006 as an interactive “museum” to provide free, hands-on education about home environmental health hazards, demonstrate low-cost methods for reducing these hazards, and develop individualized action plans for visitors’ homes. The Healthy Home addressed lead paint, asthma triggers, mold, toxic chemicals, safety risks, and other home hazards. ¹⁰ Core partners included the University of Rochester and the Southwest Area Neighborhood Association, along with an Advisory Council comprised of over 30 additional community, government, and academic organizations. The Healthy Home focused on the needs of low-income tenants living in the City of Rochester. During its three and a half years in operation, the Healthy Home welcomed over 3,500 visitors, over half of whom resided in the six city zip codes with the highest historical rates of lead poisoning.⁸

The Healthy Home started with a small pilot grant from the University of Rochester's Environmental Health Sciences Center. The partnership obtained additional funding from the USEPA, state health and environment agencies, local governments, churches, and local foundations. In 2009, the Healthy Home received a $15,000 grant from the county health department to train refugees about lead poisoning prevention and healthy homes. An additional grant from a local church provided free cleaning kits for participating refugee families.

The Healthy Home partnered with Catholic Family Center (CFC), a non-profit agency that provides refugee resettlement services in Rochester. Healthy Home and CFC staff worked together to adapt Healthy Home tours to the refugees’ needs. For example, because CFC staff noted cultural differences in food storage and cleaning methods, Healthy Home staff designed hands-on activities to address these issues. Rather than translate materials into multiple languages, the partners trained CFC interpreters as Healthy Home tour guides. The project employed same-culture tour guides for each group of refugee visitors to help overcome language and cultural barriers to learning effective ways of reducing hazards in their homes.

Each two-hour visit started with an interactive tour that provided information on the Rochester Lead Law, other health and housing policies, and the rights and responsibilities of tenants and landlords. The tour was followed by training in healthy housekeeping, healthy food preparation and storage, reducing moisture and mold, safe use and storage of cleaning chemicals, using smoke and carbon monoxide detectors, and integrated pest management. Hands-on activities included baiting and setting mousetraps, two bucket mopping, hand washing, placing food in storage bins, and a “fire drill” in which visitors heard a smoke alarm and practiced evacuating safely.

Over a six-month period, 149 refugees toured the Healthy Home. As part of the project, nine interpreters and around 80 staff and service providers received extensive healthy homes training so they could continue to share this information in their ongoing work with refugees. Visitors included Burmese, Bhutanese, Somali, and Sudanese refugees. In addition, several group trainings were held at the CFC building using a “healthy home on the road kit” of hands-on activities, for refugees who were not able to visit the Healthy Home in person. Thirty refugee youth were also trained at the Rochester City School District's Refugee Academy.

Findings of the Refugee Education Project

Feedback from the refugee visitors indicated that they learned about a wide range of hazards during their Healthy Home tours, and based on this knowledge made specific plans to improve the environmental health of their homes. According to their recorded “action plans” (Table 1), 39.8 % of refugee visitors planned to change their cleaning habits and another third planned to make physical changes to reduce hazards in their homes. The nature of the physical changes planned by refugee visitors differed qualitatively from those of non-refugee visitors. The majority of refugees planned physical changes related to pest control, while non-refugee visitors listed varied actions such as buying new or covering pillows, using child safety locks, changing furnace filters, and reducing clutter. For behavioral changes, refugees mentioned actions like turning on bathroom fans and washing hands with soap, which they learned about the importance of for the first time while visiting the Healthy Home. Non-refugee visitors tended to mention more actions, like planning to inspect appliances more often, taking a Lead Safe Work Practices class, or not allowing smoking inside the home.

The only category of planned action in which refugees’ responses differed significantly from non-refugee visitors was “contact a resource agency.” Further exploration of this finding is important. Although many home environmental health hazards can be reduced through behavior change and simple actions, individuals often need support in addressing more complex hazards (e.g. calling a lead inspector). If refugees are particularly unlikely to contact resource agencies, efforts should be made to identify and address barriers to seeking additional support and/or provide tools refugees can implement without additional help. The apparent unwillingness of both refugee and non-refugee visitors to contact their landlords also warrants further exploration.

During the tours, interpreters provided feedback from the refugees (Text Box 2) about what they were learning. Based on these reports and action plan responses, the refugees appeared to be most concerned about pests, carbon monoxide, fire hazards, cleanliness and mold. Overall, the refugees’ responses to their Healthy Home tours suggested that conditions in U.S. housing differed significantly from their past living experiences. The Healthy Home taught refugees to recognize and mitigate health hazards that they might not have experienced in their home countries or in refugee camps. The Healthy Home also provided advice and resources to help the refugee visitors incorporate this new information into their daily lives.

Although resource limitations precluded systematic follow-up visits to refugees’ homes, CFC staff reported that when they informally visited families who had been to the Healthy Home, they saw improved cleaning, food storage, and other home health practices. In addition, interpreters reported that several families had shared information with friends and recommended they also visit the Healthy Home. After the Healthy Home closed, CFC staff continued to incorporate this information into trainings and home visits. The increased awareness of home environmental health hazards among CFC staff and consequent integration into their ongoing educational programs may be the most important lasting impact of this project.

Conclusions

The refugee health surveillance system has increased awareness of excess lead risk among refugee children.² However, because a wide range of home health hazards are more common in older housing in poor condition, refugee families may be at risk from home environmental health hazards in addition to lead.^9,13,14 These risks may arise both from the characteristics of refugee housing and their lack of experience with western-style housing. The Healthy Home refugee education program found that many visitors lacked basic knowledge and experience about how to live safely in their new homes. The Healthy Home's hands-on and home-like approach with education delivered by same-language tour guides appears to have been effective with this population. Because of this project's limited sample size and lack of follow-up home visits to confirm changes, further exploration of gaps in refugees’ knowledge and effective ways to equip refugees to live safely in U.S. housing would be valuable. However, the initial experience of this program suggests that resettlement organizations should prioritize both placing refugees in safe housing and educating refugees about how to reduce home environmental health hazards.

As suggested by Geltman, et al., insights about refugees’ elevated risks also suggest a need to focus on non-refugee immigrants who may be unfamiliar with U.S. housing.³ Integrated policy and programmatic efforts to improve housing quality are essential to reduce home environmental health risks; however, education also has a role to play.¹⁵ Rochester's Healthy Home provides a model for educating both refugee resettlement agencies and the people they serve about the importance of home environments to the health of newcomers to U.S. communities.

Text Box 1: Key Findings.

Many refugees are unfamiliar with common hazards found in typical U.S. housing, putting them at additional risk from home environmental health hazards like lead, mold, asthma triggers, household chemicals, radon, and carbon monoxide.

Refugee housing should be carefully inspected for potential hazards prior to placement of refugee families.

Resettlement agencies should help families acquire the knowledge to safely use, clean, and maintain their new housing, as well as to identify and avoid potential hazards in future housing choices.

Landlords who rent to refugees should be made aware that refugee families may need more education about basic home maintenance and operation than native-born tenants.

Text Box 2: Comments made by refugees after touring the Healthy Home.

“...(we learned) different and better ways of cleaning here that are different from back home.”

“In the camps we had a lot of dust, so for cleaning we just threw buckets of water at the floor and walls to keep down the dust, but now we know how to clean here.”

“We never knew anything about lead before today.”

“I have a fan in my bathroom but I never knew what it was for.”

“We didn't know the difference between a mouse and a rat and we were using mouse traps for rats; now we can use the right one.”

“We are used to just cleaning our hands off with water only if we can see they are dirty.”

Text Box 3: Tips for replication.

Partner with community, school, housing, health, academic, and government groups to provide local resources and referrals.

Make trainings as hands-on and realistic as possible, preferably in a typical apartment setting.

Assemble a “Healthy Home on the Road” kit including cleaning materials, pest controls, examples of chemicals, etc. to allow for hands-on demonstrations in classrooms or health fairs.

A “Guide to Replication,” “Virtual Tour of the Healthy Home” and other materials are available at: http://www2.envmed.rochester.edu/healthyhomes.html