Barriers, Challenges, and Potential Solutions Community participants had unpredicatble schedules that made it challenging to set appointments. Jobs, childcare, and family obligations made for unpredictable schedules and difficulty in setting appointments with participants. CHES learned to fix the next visit date before leaving the home, with confirmation and reminders leading up to the appointment. Eventually, a computer-based system for tracking home visits, assessment findings, client contact activities, and action plan implementation was developed. The community participants were extremely diverse, which made communicating difficult. As much as possible, CHES were matched to participants by ethnicity and language. Staff participated in a cultural competency training and had basic educational materials in many languages. Participants had issues that took precendence over asthma. Many participants struggled with inadequate income, risk of eviction, unemployment, child behavior probelms, teen suicide, and drug addiction. CHES and their coordinators identified appropriate community resources and linked participants with them. Sometimes these issues were beyond the CHES' ability and required sustained assitance and case management. CHES were often overburdened and overwhelmed. Many issues arose including rigid project protocols, daily logistical hassles of travel, arranging their own childcare, and working evening and weekends. There was high staff turnover. CHES need supervisory support when these things become overwhelming. Also, incentives such as conferences and helping them balance their client caseload would help alleviate quick turnover. Community volunteers were difficult to coordinate and were not extremely effective. Volunteers often did not share the same language or ethnicity with community participants which made it difficult to connect, or there was a reluctance to work in inner-city neighborhoods. Also, volunteers' schedules did not usually match the times that community participants were available to meet. General Lessons Learned Identify potential participants through their sources of medical care. The project collected lists of potential participants from community and public health clinics, hospitals, and emergency departments. This yielded the largest amount of eligible participants for the project. "Best practices" as described in traditional literature and guidelines for mitigating indoor exposures are difficult to implement in low-income households. Often, the solutions were expensive or not accessible to low-income communities, such as allergy-control bedding encasements and HEPA filters. Or recommended behavioral changes were impractical, such as pet washing in hot water, or difficult to sustain given all of the other demands on low-income communities. For long-term change, sustained support and resources are necessary. Strategies for improving indoor environmental quality must go beyond asking household members to take individual actions. Many low-income communities are renters, and actions around pests and mold need to be done on a managerial/owner level. Also, updating and enforcement of housing codes are needed and actionable only by government. | 
