Health Benefits of Green Public Housing: Associations With Asthma Morbidity and Building-Related Symptoms

A multi-city study of indoor air quality in green vs non-green low-income housing

OBJECTIVES

The condition of the home is a strong predictor of exposure to environmental contaminants, with low-income households being particularly vulnerable. Therefore, improving housing standards is a priority. Housing built to "green" standards, with improved building methods and materials, has been suggested to reduce contaminants. However, evidence is limited as to which contaminants are reduced. The Green Housing Study was conducted to address this issue. The study hypothesis was that housing built using green components has lower concentrations of environmental contaminants compared to conventional housing.

METHODS

A repeated-measures, 12-month cohort study was performed in three U.S. cities. Data were collected in the home at three time points throughout a year. The level of contaminants were estimated using air samples for particulate matter and black carbon, dust samples for aeroallergens and pesticides, and resident or study staff reporting evidence of mold. To investigate source(s) of PM2.5 and black carbon, multivariable models using stepwise variable selection were developed.

RESULTS

In adjusted generalized estimating equations (GEE) models, black carbon concentration (μg/m3) (β = -0.22, 95% CI = -0.38 to -0.06, p = 0.01), permethrin (OR = 0.28, 95% CI = 0.15-0.49, p < 0.0001), and reported mold (OR = 0.29, 95% CI = 0.13-0.68, p = 0.003) were significantly lower in green homes. Cockroach antigen was also lower in green homes (OR = 0.59, 95% CI = 0.33-1.08, p = 0.09), although not statistically significant. We found that 68% of PM2.5 was explained by dwelling type and smoking and 42% of black carbon was explained by venting while cooking and use of a gas stove.

CONCLUSIONS

This study provides quantitative data suggesting benefits of incorporating green building practices on the level of numerous environmental contaminants known to be associated with health. Occupant behavior, particularly smoking, is an important contributor to indoor air pollution.

Reduced prevalence of childhood asthma after housing renovations in an underresourced community

Background

Despite improvements in asthma symptom management and asthma morbidity, the prevalence of asthma in the United States remains high, especially in underresourced communities.

Objective

Our goal was to determine whether housing renovations affect the prevalence of asthma in an underresourced community.

Methods

The Fay Apartments (~800 units) in Cincinnati, Ohio, were renovated to "green building" standards between 2010 and 2012 and renamed the Villages at Roll Hill. The prevalence of asthma among 7-year-olds in the Villages at Roll Hill was determined by accessing Ohio Medicaid data for the years 2013 to 2021.

Results

In the first 6 years after the renovations (2013-2018), the prevalence of asthma among 7-year-olds in the community averaged 12.7%. In contrast, in postrenovation years 7 through 9 (2019-2021), the average prevalence of asthma was 5.9%. Logistic regression modeling for the log odds of asthma diagnosis in this age group was used to test the statistical significance of asthma prevalence for 2013-2018 versus for 2019-2021. The model resulted in demonstration of a significant (P < .001) reduction in asthma prevalence between 2013-2018 and 2019-2021.

Conclusions

The renovation of an underresourced community's housing resulted in a lower prevalence of asthma for 7-year-olds who were born after the renovations had been completed.

The HOME-Health (HOusing, environMEnt, and Health) Study; Description of a Danish natural experiment, designed as a longitudinal study with repeated measurements, providing internal- and external validity of the study

Background

The ambient and indoor environment are pivotal to our health. We spend most of our time indoors within our home, why our home is where we are most exposed to indoor pollutants and indoor air quality (IAQ). Populations within social housing areas are more vulnerable due to advanced age, co-morbidity and social economic status. Commonly, studies within social housing are cross-sectional, few Nordic longitudinal studies exist, and fewer studies combine quantitative and qualitative measurements in a mixed method approach.

Method

This research proposal provides an extensive detailed description of the design and methodology of the HOME-Health study. The study is a longitudinal study and is a natural experiment employing structured surveys, objective measurements of indoor air parameters, lung function test and qualitative semi-structured interviews. Data collection are conducted seasonally (winter and summer), before and after building energy renovation (BER).

Generalisability

The study population before BER (n = 432) was explored and found similar to the Danish social housing population in terms of age, gender, persons per apartment and migration status. Future analyses should be stratified by multi-family apartments and terraced houses.

Research aim

The aim of the HOME-Health study is to provide knowledge about residents' seasonal state of health, perception of indoor enviromental quality (IEQ), IEQ-related behaviours and practices, and objective measurements of IAQ before and after BER. By applying a design with repeated measurement before and after BER, and combining both objective and subjective quantitative as well as qualitative data the study is expected to create in-depth knowledge. Future results will provide evidence of both energy-savings and non-energy savings from different BER projects. Knowledge which are expected to benefit future renovation projects within social housing areas.

"How does your residential environment positively or negatively influence your well-being?": A multicase photovoice study with public housing tenants

Public housing aims to reduce social inequalities by providing affordable dwellings as a social policy. Anchored in an ecological perspective, the paper reports on a multicase photovoice study documenting public housing tenants' perceptions of how their residential environment influences their well-being. This design can provide a deeper understanding of the public housing environment to inform change at a programmatic level. To this end, 303 captioned photos were collected by 59 tenant-researchers at six sites in Québec (Canada). An in-depth cross-case analysis of the material led to two key themes with five subthemes each. In the Residential environment perceived as mostly positive theme, the subthemes were access to nature, community resources and services, positive relations among tenants, opportunities for participation, and specific aspects of their home. In the Negative aspects focused on life in public housing theme, the subthemes were strict regulations, lack of respect for tenants' needs, lack of intimacy, lack of proper maintenance, and conflicts between tenants. Findings highlight the dynamic interplay between the residential environment and public housing tenants' well-being. Two recurring programmatic issues are highlighted: problematic maintenance and limited opportunities for tenants' empowerment. Changes to address these concerns at the programmatic level of public housing could potentially increase tenants' well-being.

[Developing tools to study the health impact of urban transformations in high vulnerability contexts: the RUCAS study]

This article describes the design and characteristics of a questionnaire and an intradomiciliary observation tool developed to assess the housing-neighborhood-health relationship both cross-sectionally and longitudinally in the context of urban transformations carried out in populations of high socio-territorial vulnerability. The instruments were developed for the multi-method longitudinal study RUCAS (Urban Regeneration, Quality of Life and Health), a natural experiment aiming to assess the quality of life and health impact of a comprehensive Urban Regeneration Program in two social housing complexes in Chile. The design of the instruments followed four main stages: (1) narrative review of the literature to define the dimensions of the study, and of existing measurement instruments to identify appropriate items for measuring them; (2) content validation with experts; (3) pre-test; and (4) pilot study. The resulting questionnaire, composed of 262 items, considers the different stages of the life course and gender issues. The intradomiciliary observation tool (77 items) is applied by the interviewer. The instruments assess (i) characteristics of the current residential situation that are known to affect health and will be intervened by the program; (ii) dimensions of health potentially affected by the residential situation and/or by the intervention within the time frame of the study (4 years); (iii) other health and health-related conditions that are relevant, even if changes will not be modified within the time frame of the study; and (iv) relevant socioeconomic, occupational and demographic dimensions. The instruments have shown to be capable of addressing the multidimensionality of urban transformation processes in contexts of urban poverty in formal housing.

A home visit program for low-income African American children with asthma: Caregivers' perception of asthma triggers and a gap in action

PURPOSE

The goals are to gauge caregivers' knowledge of at-home asthma triggers and identify the areas on which educational campaigns can focus to alleviate a child's asthma symptoms.

DESIGN AND METHODS

Families with children with moderate to severe asthmatic symptoms who had been recently hospitalized or in the emergency room were invited to participate in a home visit program. As part of the home visit, caregivers of the asthmatic children were asked a series of questions on asthma triggers and the measures for eliminating the triggers (N = 218).

RESULTS

Findings show a gap between caregivers' perception of asthma triggers and the actions to mitigate or avoid such triggers.

CONCLUSIONS

Overall findings show that home environments were suboptimal for the management and control of child asthma conditions. Knowledge about home triggers as well as the actions and efforts by caregivers and landlords to mitigate these was found to be inadequate. Even when caregivers are aware of the presence of at-home triggers, actions to minimize exposure to the trigger do not always follow due to a lack of power, resource, and knowledge.

PRACTICE IMPLICATIONS

The findings raise the need for additional research to investigate the reasons for the lack of actions, advocacy for low-income families to live in a healthy environment, continued education and empowerment, and patient/caregiver-doctor partnership. Additionally, the provision of community support through community advocacy and training of culturally competent healthcare providers are needed for the successful management of pediatric asthma among African American children.

Mapping emergency department asthma visits to identify poor-quality housing in New Haven, CT, USA: a retrospective cohort study

BACKGROUND

Housing conditions are a key driver of asthma incidence and severity. Previous studies have shown increased emergency department visits for asthma among residents living in poor-quality housing. Interventions to improve housing conditions have been shown to reduce emergency department visits for asthma, but identification and remediation of poor housing conditions is often delayed or does not occur. This study evaluates whether emergency department visits for asthma can be used to identify poor-quality housing to support proactive and early intervention.

METHODS

We conducted a retrospective cohort study of children and adults living in and around New Haven, CT, USA, who were seen for asthma in an urban, tertiary emergency department between March 1, 2013, and Aug 31, 2017. We geocoded and mapped patient addresses to city parcels, and calculated a composite estimate of the incidence of emergency department use for asthma for each parcel (N_v × N_p/log₂[P], where N_v is the estimated mean number of visits per patient, N_p is the number of patients, and P is the estimated population). To determine whether parcel-level emergency department use for asthma was associated with public housing inspection scores, we used regression analyses, adjusting for neighbourhood-level and individual-level factors contributing to emergency department use for asthma. Public housing complex inspection scores were obtained from standardised home inspections, which are conducted every 1-3 years for publicly funded housing. We used a sliding-window approach to estimate how far in advance of a failed inspection the model could identify elevated use of emergency departments for asthma, using the city-wide 90th percentile as a cutoff for elevated incidence.

FINDINGS

11 429 asthma-related emergency department visits from 6366 unique patients were included in the analysis. Mean patient age was 32·4 years (SD 12·8); 3836 (60·3%) patients were female, 2530 (39·7%) were male, 3461 (57·2%) were Medicaid-insured, and 2651 (41·6%) were Black. Incidence of emergency department use for asthma was strongly correlated with lower housing inspection scores (Pearson's r=-0·55 [95% CI -0·70 to -0·35], p=3·5 × 10^-6), and this correlation persisted after adjustment for patient-level and neighbourhood-level demographics using a linear regression model (r=-0·54 [-0·69 to -0·33], p=7·1 × 10^-6) and non-linear regression model (r=-0·44 [-0·62 to -0·21], p=3·8 × 10^-4). Elevated asthma incidence rates were typically detected around a year before a housing complex failed a housing inspection.

INTERPRETATION

Emergency department visits for asthma are an early indicator of failed housing inspections. This approach represents a novel method for the early identification of poor housing conditions and could help to reduce asthma-related morbidity and mortality.

FUNDING

Harvard-National Institute of Environmental Health Sciences (NIEHS) Center for Environmental Health.

Housing and health in vulnerable social groups: an overview and bibliometric analysis

Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.

Unequal Housing Conditions And Code Enforcement Contribute To Asthma Disparities In Boston, Massachusetts

Housing quality is a primary determinant of asthma disparities by race and social class in the US. We sought to assess how housing code enforcement systems in Boston, Massachusetts, address tenants' reports of asthma triggers. After adjustment for income and other neighborhood characteristics, racial demographics were significantly associated with asthma trigger incidence. For each 10 percent decrease in neighborhood proportion of White residents, trigger incidence increased by 3.14 reports per thousand residents. These disparities persisted during the study period (from 2011 through 2021), and for mold, which is an established asthma trigger, regressions showed that racial disparities are widening. The municipal response also demonstrated disparities: In neighborhoods with the fewest White residents compared to neighborhoods with the most White residents, adjusted models showed a 17 percent (3.51 days) slower median time until cases (tenant requests for inspections to the Inspectional Services Department) were closed, a 14 percent higher probability of being flagged as overdue, and a 54.4 percent lower probability of a repair. We found evidence that in Boston, despite several healthy housing initiatives, current regulatory systems are insufficient to address disparities in access to healthy housing. To reduce disparities in asthma burden, stronger inspectional standards and further enforcement policies to increase landlords' accountability and support tenants' rights to have repairs made are essential.

Asthma in the Americas: An Update: A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and American Thoracic Society

Asthma affects a large number of people living in the Americas, a vast and diverse geographic region comprising 35 nations in the Caribbean and North, Central, and South America. The marked variability in the prevalence, morbidity, and mortality from asthma across and within nations in the Americas offers a unique opportunity to improve our understanding of the risk factors and management of asthma phenotypes and endotypes in children and adults. Moreover, a better assessment of the causes and treatment of asthma in less economically developed regions in the Americas would help diagnose and treat individuals migrating from those areas to Canada and the United States. In this focused review, we first assess the epidemiology of asthma, review known and potential risk factors, and examine commonalities and differences in asthma management across the Americas. We then discuss future directions in research and health policies to improve the prevention, diagnosis, and management of pediatric and adult asthma in the Americas, including standardized and periodic assessment of asthma burden across the region; large-scale longitudinal studies including omics and comprehensive environmental data on racially and ethnically diverse populations; and dissemination and implementation of guidelines for asthma management across the spectrum of disease severity. New initiatives should recognize differences in socioeconomic development and health care systems across the region while paying particular attention to novel or more impactful risk factors for asthma in the Americas, including indoor pollutants such as biomass fuel, tobacco use, infectious agents and the microbiome, and psychosocial stressor and chronic stress.

Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis

IMPORTANCE

Social determinants of health (SDOH) correlate with pediatric asthma morbidity, yet whether interventions addressing social risks are associated with asthma outcomes among children is unclear.

OBJECTIVE

To catalog asthma interventions by the social risks they address and synthesize their associations with asthma-related emergency department (ED) visits and hospitalizations among children.

DATA SOURCES

PubMed, Scopus, PsycINFO, SocINDEX, CINAHL, and references of included full-text articles were searched from January 1, 2008, to June 16, 2021.

STUDY SELECTION

Included articles were US-based studies evaluating the associations of interventions addressing 1 or more social risks with asthma-related ED visits and hospitalizations among children. The systematic review included 38 of the original 641 identified articles (6%), and the meta-analysis included 19 articles (3%).

DATA EXTRACTION AND SYNTHESIS

Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The SDOH intervention clusters were identified by grouping studies according to the social risks they addressed, using the Healthy People 2020 SDOH framework. Random-effects models created pooled risk ratios (RRs) as the effect estimates.

MAIN OUTCOMES AND MEASURES

Patients with ED visits or hospitalizations were the primary outcomes. Subgroup analyses were conducted by an SDOH intervention cluster. Sensitivity analyses were conducted for each, removing outlier studies and studies failing to meet the minimum quality threshold.

RESULTS

In total, 38 studies were included in the systematic review, with 19 of these studies providing data for the meta-analysis (5441 participants). All interventions addressed 1 or more of the health, environment, and community domains; no interventions focused on the economy or education domains. In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%). In subgroup analyses, the health, environment, and community intervention cluster produced the lowest RR for ED visits (RR, 0.53; 95% CI, 0.44-0.64; I2 = 50%) and for hospitalizations (RR, 0.33; 95% CI, 0.20-0.55; I2 = 71%) compared with other intervention clusters. Sensitivity analyses did not alter primary or subgroup effect estimates.

CONCLUSIONS AND RELEVANCE

The results of this systematic review and meta-analysis indicate that social risk interventions are associated with decreased asthma-related ED visits and hospitalizations among children. These findings suggest that addressing social risks may be a crucial component of pediatric asthma care to improve health outcomes.

Current Status of Old Housing for Low-Income Elderly Households in Seoul and Green Remodeling Support Plan: Economic Analysis Considering the Social Cost of Green Remodeling

In this study, the economic feasibility of green remodeling (GR), which could improve the health, safety, and energy of elderly households considering social cost, was analyzed. As a result, the net present value of GR was ‘−10,267 USD (49.7%)’, which was found to be uneconomical compared to the total construction cost (20,981 USD, 100%) despite benefits of energy saving, carbon reduction, and air pollutant reduction. Based on this result, in order to expand GR for low-income elderly households, who cannot afford to perform GR, a GR support measure linked to the currently implemented energy conversion and old-age housing support policies was proposed. It allows the government to perform GR for low-income elderly households with 1/4 of the total construction cost. This result could revitalize GR to reduce greenhouse gas and contribute to housing stability for low-income elderly households who are vulnerable to COVID-19 and climate change.

Effects of mechanical ventilation on indoor air quality and occupant health status in energy-efficient homes: A longitudinal field study

Despite the growing interest in energy-efficient homes (EEHs), there is still a lack of evidence regarding whether the mechanical ventilation system of an EEH positively or negatively impacts indoor air quality (IAQ) and the health and wellbeing of occupants. This study aimed to evaluate the IAQ level and daily health symptoms of adults and children living in EEHs compared to conventional buildings over the course of one year. A two-way mixed analysis of variance was conducted to compare the level of IAQ between the two housing types. A binomial generalized linear mixed model (GLMM) and generalized additive mixed model was developed to investigate the association between IAQ and daily risks of symptoms. Differences in the daily prevalence of symptoms between the two housing types were assessed using a Poisson GLMM model. Overall, the indoor concentrations of particulate matter (PM₁₀ and PM_2.5), carbon dioxide (CO₂), and volatile organic compounds (VOCs) were lower in EEH after controlling for seasonality. The indoor temperature and relative humidity level were relatively constant in the EEH. We also found that an increased level of indoor air quality parameters, particularly CO_2, which is closely related to the indoor ventilation rate, was associated with the daily risk of eye fatigue, allergic rhinitis, and atopic dermatitis symptoms. Considering that EEH effectively reduced indoor air pollutants and IAQ improvement was associated with a reduction in the risk of individual symptoms, the IAQ improvement of EEH may have positively impacted occupants' health. Symptoms such as eye fatigue and skin dryness, which have been reported in previous studies as potential side effects of mechanical ventilation, were reported in this study; however, they were not found to be statistically significantly different from those reported in the conventional building.

Confinement, Comfort and Health: Analysis of the Real Influence of Lockdown on University Students during the COVID-19 Pandemic

The COVID-19 pandemic forced the population worldwide into lockdown. The purpose of this study was to assess the impact of this measure on the health and comfort of university students and the role that the characteristics of the home may have played. It is essential to differentiate between the terms comfort and health both from the medical and architectural perspectives, as there are differences between the two concepts that are, nonetheless, shared by both disciplines. An online survey was fulfilled by 188 medicine and architecture undergraduate students at the University of Seville, Spain. In terms of health, 89% suffered neuropsychiatric disorders (56% anxiety and 49% depression), 38% gained weight and 59% reported alcohol consumption. In relation to comfort, the majority rated their home positively, comfortable in terms of room temperature and noise at night, and they had a good relationship with cohabitants. However, those who did not have a balcony or terrace would have liked to have open spaces They would have also liked to increase the size of their bedroom, where they spent most of their time and where they studied. A built-up environment gave them a sense of being imprisoned, while those who enjoyed open spaces found a sense of peace. The absence of open spaces in the house, the environment and the impossibility of making the most frequently used spaces more flexible may have had negative impacts on the health and comfort of university students during confinement.

Pyrethroid exposure among children residing in green versus non-green multi-family, low-income housing

BACKGROUND

There is growing concern about children's chronic low-level pesticide exposure and its impact on health. Green building practices (e.g., reducing leakage of the thermal and pressure barrier that surrounds the structure, integrated pest management, improved ventilation) have the potential to reduce pesticide exposure. However, the potential impact of living in green housing on children's pesticide exposure is unknown.

OBJECTIVE

To address this question, a longitudinal study of pyrethroid metabolites (3-phenoxybenzoic acid [3-PBA], 4-fluoro-3-phenoxybenzoic acid [4-F-3-PBA], trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane carboxylic acid [trans-DCCA]) in first morning void urine, collected from 68 children from New Orleans, Louisiana residing in green and non-green housing was conducted.

METHODS

Children were followed for 1 year with three repeated measures of pesticide exposure. Generalized estimating equations examined associations between housing type (green vs. non-green) and urinary pyrethroid metabolite concentrations adjusting for demographic and household factors over the year.

RESULTS

Ninety-five percent of samples had detectable concentrations of 3-PBA (limit of detection [LOD]: 0.1 μg/L); 8% of 4-F-3-PBA (LOD: 0.1 μg/L), and 12% of trans-DCCA (LOD: 0.6 μg/L). In adjusted models, green housing was not associated with statistically significant differences in children's 3-PBA urinary concentrations compared to non-green housing.

The impact of energy retrofits on pediatric asthma exacerbation in a Boston multi-family housing complex: a systems science approach

BACKGROUND

Pediatric asthma is currently the most prevalent chronic disease in the United States, with children in lower income families disproportionately affected. This increased health burden is partly due to lower-quality and insufficient maintenance of affordable housing. A movement towards 'green' retrofits that improve energy efficiency and increase ventilation in existing affordable housing offers an opportunity to provide cost-effective interventions that can address these health disparities.

METHODS

We combine indoor air quality modeling with a previously developed discrete event model for pediatric asthma exacerbation to simulate the effects of different types of energy retrofits implemented at an affordable housing site in Boston, MA.

RESULTS

Simulation results show that retrofits lead to overall better health outcomes and healthcare cost savings if reduced air exchange due to energy-saving air tightening is compensated by mechanical ventilation. Especially when exposed to indoor tobacco smoke and intensive gas-stove cooking such retrofit would lead to an average annual cost saving of over USD 200, while without mechanical ventilation the same children would have experienced an increase of almost USD 200/year in health care utilization cost.

CONCLUSION

The combination of indoor air quality modeling and discrete event modeling applied in this paper can allow for the inclusion of health impacts in cost-benefit analyses of proposed affordable housing energy retrofits.

Understanding the Role of Standards in the Negotiation of a Healthy Built Environment

A growing number of international standards promote Healthy Built Environment (HBE) principles which aim to enhance occupant and user health and wellbeing. Few studies examine the implementation of these standards; whether and how they affect health through changes to built-environment design, construction, and operations. This study reviews a set of sustainability and HBE standards, based on a qualitative analysis of standard documents, standard and socio-technical literature on normalization and negotiation, and interviews with 31 practitioners from four geographical regions. The analysis indicates that standards can impact individual, organizational, and market-scale definitions of an HBE. Some changes to practice are identified, such as procurement and internal layout decisions. There is more limited evidence of changes to dominant, short-term decision-making practices related to cost control and user engagement in operational decisions. HBE standards risk establishing narrow definitions of health and wellbeing focused on building occupants rather than promoting broader, contextually situated, principles of equity, inclusion, and ecosystem functioning crucial for health. There is a need to improve sustainability and HBE standards to take better account of local contexts and promote systems thinking. Further examination of dominant collective negotiation processes is required to identify opportunities to better embed standards within organizational practice.

Prioritising Housing Maintenance to Improve Health in Indigenous Communities in NSW over 20 years

Many studies document the relationship between housing quality and health status. Poor housing in Aboriginal communities continues to be linked to the compromised health status of Aboriginal Australians. The New South Wales (NSW) Housing for Health (HfH) program has been assessing and repairing Aboriginal community housing across the state for 20 years using a standardised intervention methodology that aims to improve the health of Aboriginal people in NSW by improving their living environments. Items are tested and repairs are prioritised to maximise safety and health benefits and measured against 11 Critical Healthy Living Priorities (e.g., safety, facilities for washing people and clothes, removing waste and preparing food). Descriptive analysis of data collected pre- and post-intervention from 3670 houses was conducted to determine the effectiveness of the program. Analysis demonstrated statistically significant improvements in the ability of the houses to support safe and healthy living for all critical healthy living priorities post-interventions. Trend analysis demonstrated the magnitude of these improvements increased over 20 years. In 24 communities (n = 802 houses) where projects were repeated (5-17 years later), results indicate sustainability of improvements for 9 of 11 priorities. However, the overall condition of health-related hardware in Aboriginal community housing across NSW pre-intervention has not significantly changed during the program's 20 years. Results suggest a systematic lack of routine maintenance and quality control continues to be the overwhelming cause for this lack of improvement pre-intervention. Our evaluation of the HfH program demonstrated that fidelity to a standardised housing testing and repair methodology to improve residents' safety and health can have sustainable effects on housing infrastructure and associated health benefits, such as a 40% reduction in infectious disease hospital separations. Housing and health agencies should collaborate more closely on social housing programs and ensure programs are adequately resourced to address safety and health issues.

Health and Habitability in the Solar Decathlon University Competitions: Statistical Quantification and Real Influence on Comfort Conditions

Medicine and architecture are disciplines with the main objectives of satisfying the fundamental needs of human beings: health, comfort, well-being, safety, and ensuring an acceptable quality of life in a sustainable habitat. In both areas of knowledge, the advances and the most innovative proposals in the fields of research and teaching are focused on transversal knowledge and the use of learning methods through problem solving (learning by doing). The student competitions called "Solar Decathlon" are focused on the development of these concepts, in which prototypes of sustainable and, as far as possible, healthy social housing are tested. In these university competitions, the design of energy-efficient and comfortable living environments that contribute to the health of the occupants are encouraged; however, the methodology for evaluating the "comfort conditions" stipulated in the competition rules considers only parameters that can be monitored by sensors. For this article, the prototypes presented by the "Solar Decathlon Team of the University of Seville" to the editions of said competition held in Latin America and Europe (in 2015 and 2019, respectively) are being studied. The present research starts from the fact that the unique consideration of measurable indices (such as temperature, humidity, etc.), is clearly insufficient when it comes to evaluating the real conditions of habitability and comfort that a domestic architectural space presents. For this reason, a theoretical-practical analysis is carried out by means of surveys, with the final objective of determining a methodology for evaluating comfort-complementary to that of the competition-which assesses other relevant issues and which, in short, takes into account the repercussion on people's health. From our analysis, we conclude that at least these two methodologies should be used to evaluate comfort because they are individually considered incomplete in terms of the data provided by each one of them. The survey-based methodology provides complementary information on comfort and health that could be taken into account in future editions of Solar Decathlon.

A Community Development Program and Reduction in High-Cost Health Care Use

Adverse housing and neighborhood conditions influence child health. The Healthy Neighborhoods Healthy Families community development initiative was established in 2008 to address housing, education, employment, and other neighborhood-level, child health-influencing factors on the south side of Columbus, Ohio, with the goal of improving child health and well-being. In this article, we discuss the path from advocacy to outcomes analysis in this initiative and assess changes in high-cost health care use by children in the target area over the first decade of implementation. Change in health care use was measured by using a difference-in-differences approach comparing emergency department visits, inpatient stays, and inpatient length of stay in the intervention neighborhood and a propensity score-matched, pooled comparator neighborhood in the same city. The baseline and follow-up periods were August 2008 to July 2010 and August 2015 to July 2017, respectively. Findings from this analysis reveal that compared to 2 pooled comparison neighborhoods, the intervention neighborhood trended, nonsignificantly, toward greater decreases in inpatient stays and emergency department visits and smaller increases in length of stays. These results suggest that our community development activities may be influencing health care use outcomes, but in the early years of the intervention relative changes are modest and are variable based on the definition of the intervention and comparator neighborhoods. Lessons learned in expanding from advocacy to analysis include the importance of building multidisciplinary teams that can apply novel approaches to analysis, moderating expectations, and retaining focus on the broader social context.

Pruning chemicals from the green building landscape

Green building design has substantially minimized environmental impacts by reducing energy consumption compared with traditional buildings. Yet, it is not uncommon for a green building to meet the highest criteria for energy efficiency and be built with materials that contain chemicals hazardous to occupant health. Because of this discrepancy in achieving holistic sustainability, the architecture/engineering/construction (AEC) industry has never been more interested in occupant health and well-being than it is today. At the same time, numerous scientific studies have documented exposures to and associated health effects of chemicals used in building materials. Opportunities to translate environmental health research so that it is useful to the AEC community exist across the landscape of healthier buildings. For example, research can be conducted to prioritize building material and chemical combinations to demonstrate how green building certification systems, government building codes, and the building products marketplace can increase energy performance while also addressing the greatest chemical exposures and health impacts. In order for scientific research to be used to create and support healthier environments, researchers should design and translate their research with this landscape in mind and should consider experts in the AEC industry as ambassadors for change. We provide key examples of how scientists have promoted healthy building practices and highlight additional research opportunities.

Structural and Social Determinants of Health in Asthma in Developed Economies: a Scoping Review of Literature Published Between 2014 and 2019

Purpose of Review

Using the WHO Conceptual Framework for Action on the Social Determinants of Health, this review provides a discussion of recent epidemiologic, mechanistic, and intervention studies of structural and social determinants of health and asthma outcomes covering the period from 2014 to 2019.

Recent Findings

A majority of studies and interventions to date focus on the intermediary determinants of health (e.g., housing), which as the name suggests, exist between the patient and the upstream structural determinants of health (e.g., housing policy). Race/ethnicity remains a profound social driver of asthma disparities with cumulative risk from many overlapping determinants. A growing number of studies on asthma are beginning to elucidate the underlying mechanisms that connect social determinants to human disease. Several effective interventions have been developed, though a need for large-scale policy research and innovation remains.

Summary

Strong evidence supports the key role of the structural determinants, which generate social stratification and inequity, in the development and progression of asthma; yet, interventions in this realm are challenging to develop and therefore infrequent. Proximal, intermediary determinants have provided a natural starting point for interventions, though structural interventions have the most potential for major impact on asthma outcomes. Further research to investigate the interactive effect of multiple determinants, as well as intervention studies, specifically those that are cross-sector and propose innovative strategies to target structural determinants, are needed to address asthma morbidities, and more importantly, close the asthma disparity gap.

Household energy efficiency and health: Area-level analysis of hospital admissions in England

INTRODUCTION

Fuel poverty affects up to 35% of European homes, which represents a significant burden on society and healthcare systems. Draught proofing homes to prevent heat loss, improved glazing, insulation and heating (energy efficiency measures) can make more homes more affordable to heat. This has prompted significant investment in energy efficiency upgrades for around 40% of UK households to reduce the impact of fuel poverty. Despite some inconsistent evidence, household energy efficiency interventions can improve cardiovascular and respiratory health outcomes. However, the health benefits of these interventions have not been fully explored; this is the focus of this study.

METHODS

In this cross sectional ecological study, we conducted two sets of analyses at different spatial resolution to explore population data on housing energy efficiency measures and hospital admissions at the area-level (counts grouped over a 3-year period). Housing data were obtained from three data sets covering housing across England (Household Energy Efficiency Database), Energy Performance Certificate (EPC) and, in the South West of England, the Devon Home Analytics Portal. These databases provided data aggregated to Lower Area Super Output Area and postcode level (Home Analytics Portal only). These datasets provided measures of both state (e.g. EPC ratings) and intervention (e.g. number of boiler replacements), aggregated spatially and temporally to enable cross-sectional analyses with health outcome data. Hospital admissions for adult (over 18 years) asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) were obtained from the Hospital Episode Statistics database for the national (1st April 2011 to 31st March 2014) and Devon, South West of England (1st April 2014 to 31st March 2017) analyses. Descriptive statistics and regression models were used to describe the associations between small area household energy efficiency measures and hospital admissions. Three main analyses were undertaken to investigate the relationships between; 1) household energy efficiency improvements (i.e. improved glazing, insulation and boiler upgrades); 2) higher levels of energy efficiency ratings (measured by Energy Performance Certificate ratings); 3) energy efficiency improvements and ratings (i.e. physical improvements and rating assessed by the Standard Assessment Procedure) and hospital admissions.

RESULTS

In the national analyses, household energy performance certificate ratings ranged from 37 to 83 (mean 61.98; Standard Deviation 5.24). There were a total of 312,837 emergency admissions for asthma, 587,770 for COPD and 839,416 for CVD. While analyses for individual energy efficiency metrics (i.e. boiler upgrades, draught proofing, glazing, loft and wall insulation) were mixed; a unit increase in mean energy performance rating was associated with increases of around 0.5% in asthma and CVD admissions, and 1% higher COPD admission rates. Admission rates were also influenced by the type of dwelling, tenure status (e.g. home owner versus renting), living in a rural area, and minimum winter temperature.

DISCUSSION

Despite a range of limitations and some mixed and contrasting findings across the national and local analyses, there was some evidence that areas with more energy efficiency improvements resulted in higher admission rates for respiratory and cardiovascular diseases. This builds on existing evidence highlighting the complex relationships between health and housing. While energy efficiency measures can improve health outcomes (especially when targeting those with chronic respiratory illness), reduced household ventilation rates can impact indoor air quality for example and increase the risk of diseases such as asthma. Alternatively, these findings could be due to the ecological study design, reverse causality, or the non-detection of more vulnerable subpopulations, as well as the targeting of areas with poor housing stock, low income households, and the lack of "whole house approaches" when retrofitting the existing housing stock.

CONCLUSION

To be sustainable, household energy efficiency policies and resulting interventions must account for whole house approaches (i.e. consideration of the whole house and occupant lifestyles). These must consider more alternative 'greener' and more sustainable measures, which are capable of accounting for variable lifestyles, as well as the need for adequate heating and ventilation. Larger natural experiments and more complex modelling are needed to further investigate the impact of ongoing dramatic changes in the housing stock and health.

STUDY IMPLICATIONS

This study supports the need for more holistic approaches to delivering healthier indoor environments, which must consider a dynamic and complex system with multiple interactions between a range of interrelated factors. These need to consider the drivers and pressures (e.g. quality of the built environment and resident behaviours) resulting in environmental exposures and adverse health outcomes.

A Review of Housing and Food Intersections: Implications for Nurses and Nursing Research

Study Background

Quality, accessibility, and affordability of housing and food are public health and nursing concerns. Yet, intersections between housing and food security are relatively understudied.

Purpose

The purpose of this article is to examine the evidence describing the relationship between food security and housing interventions, and second, describing specific opportunities for targeted strategies for nursing practice and research.

Methods

Arksey and O’Malley’s scoping review method was followed to search housing and food security research. A database search identified 46 studies that were mapped onto a social ecological theory to understand the micro, meso, exo, and macro interventions.

Results

Three major recommendations were identified. Micro-system recommendations include primary care screening for low-income groups. Meso- and exo-system recommendations focus on creating partnerships in research and enhancing social housing. Lastly, macro-system recommendations focus on challenging housing affordability standards. The major gap in the literature is addressing healthy housing.

Conclusion

Broadening housing interventions to include comprehensive approaches to meeting individuals’ needs offers more than simply packaging two interventions together. There is a significant moment in nursing in which nurses are witness to a paradigmatic shift in the ways to approach housing and food security.

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

Subsidized Housing and Adult Asthma in Boston, 2010-2015

OBJECTIVES

To examine whether subsidized housing, specifically public housing and rental assistance, is associated with asthma in the Boston, Massachusetts, adult population.

METHODS

We analyzed a pooled cross-sectional sample of 9554 adults taking part in 3 Boston Behavioral Risk Factor Surveillance System surveys from 2010 to 2015. We estimated odds ratios for current asthma in association with housing status (public housing development [PHD] resident, rental assistance [RA] renter, non-RA renter, nonrenter nonowner, homeowner as reference) in logistic regression analyses adjusting for year, age, sex, race/ethnicity, education, and income.

RESULTS

The odds of current asthma were 2.02 (95% confidence interval [CI] = 1.35, 3.03) and 2.34 (95% CI = 1.60, 3.44) times higher among PHD residents and RA renters, respectively, than among homeowners. We observed smoking-related effect modification (interaction P = .04); elevated associations for PHD residents and RA renters remained statistically significant (P < .05) only among ever smokers. Associations for PHD residents and RA renters remained consistent in magnitude in comparison with non-RA renters who were eligible for subsidized housing according to income.

CONCLUSIONS

Public housing and rental assistance were strongly associated with asthma in this large cross-sectional sample of adult Boston residents.

Energy savings, emission reductions, and health co-benefits of the green building movement

Buildings consume nearly 40% of primary energy production globally. Certified green buildings substantially reduce energy consumption on a per square foot basis and they also focus on indoor environmental quality. However, the co-benefits to health through reductions in energy and concomitant reductions in air pollution have not been examined.We calculated year by year LEED (Leadership in Energy and Environmental Design) certification rates in six countries (the United States, China, India, Brazil, Germany, and Turkey) and then used data from the Green Building Information Gateway (GBIG) to estimate energy savings in each country each year. Of the green building rating schemes, LEED accounts for 32% of green-certified floor space and publically reports energy efficiency data. We employed Harvard's Co-BE Calculator to determine pollutant emissions reductions by country accounting for transient energy mixes and baseline energy use intensities. Co-BE applies the social cost of carbon and the social cost of atmospheric release to translate these reductions into health benefits. Based on modeled energy use, LEED-certified buildings saved $7.5B in energy costs and averted 33MT of CO₂, 51 kt of SO₂, 38 kt of NO_x, and 10 kt of PM_2.5 from entering the atmosphere, which amounts to $5.8B (lower limit = $2.3B, upper limit = $9.1B) in climate and health co-benefits from 2000 to 2016 in the six countries investigated. The U.S. health benefits derive from avoiding an estimated 172-405 premature deaths, 171 hospital admissions, 11,000 asthma exacerbations, 54,000 respiratory symptoms, 21,000 lost days of work, and 16,000 lost days of school. Because the climate and health benefits are nearly equivalent to the energy savings for green buildings in the United States, and up to 10 times higher in developing countries, they provide an important and previously unquantified societal value. Future analyses should consider these co-benefits when weighing policy decisions around energy-efficient buildings.

Established and Emerging Environmental Contributors to Disparities in Asthma and Chronic Obstructive Pulmonary Disease

PURPOSE OF REVIEW

Multiple respiratory diseases, including asthma and chronic obstructive pulmonary disease (COPD), display significant socioeconomic and racial/ethnic disparities. The objective of this review is to evaluate the evidence supporting a link between disproportionate environmental exposures and these health disparities.

RECENT FINDINGS

Studies suggest that various co-occurring factors related to the home environment, neighborhood environment, non-modifiable individual factors, and individual behaviors and attributes can increase or modify the risk of adverse respiratory outcomes among socioeconomically-disadvantaged and racially/ethnically diverse populations. Pollutants in the home environment, including particulate matter, nitrogen dioxide, and pesticides, are elevated among lower socioeconomic status populations and have been implicated in the development or exacerbation of respiratory-related conditions. Neighborhood crime and green space are socioeconomically patterned and linked with asthma outcomes through psychosocial pathways. Non-modifiable individual factors such as genetic predisposition cannot explain environmental health disparities but can increase susceptibility to air pollution and other stressors. Individual behaviors and attributes, including obesity and physical activity, contribute to worse outcomes among those with asthma or COPD.

SUMMARY

The root causes of these multifactorial exposures are complex, but many likely stem from economic forces and racial/ethnic and economic segregation that influence the home environment, neighborhood environment, and access to healthy foods and consumer products. Critical research needs include investigations that characterize exposure to and health implications of numerous stressors simultaneously, both to guard against potential confounding in epidemiological investigations and to consider the cumulative impact of multiple elevated environmental exposures and sociodemographic stressors on health disparities.

Reporting to parents on children's exposures to asthma triggers in low-income and public housing, an interview-based case study of ethics, environmental literacy, individual action, and public health benefits

BACKGROUND

Emerging evidence about the effects of endocrine disruptors on asthma symptoms suggests new opportunities to reduce asthma by changing personal environments. Right-to-know ethics supports returning personal results for these chemicals to participants, so they can make decisions to reduce exposures. Yet researchers and institutional review boards have been reluctant to approve results reports in low-income communities, which are disproportionately affected by asthma. Concerns include limited literacy, lack of resources to reduce exposures, co-occurring stressors, and lack of models for effective reporting. To better understand the ethical and public health implications of returning personal results in low-income communities, we investigated parents' experiences of learning their children's environmental chemical and biomonitoring results in the Green Housing Study of asthma.

METHODS

The Green Housing Study measured indoor chemical exposures, allergens, and children's asthma symptoms in "green"-renovated public housing and control sites in metro-Boston and Cincinnati in 2011-2013. We developed reports for parents of children in the study, including results for their child and community. We observed community meetings where results were reported, and metro-Boston residents participated in semi-structured interviews in 2015 about their report-back experience. Interviews were systematically coded and analyzed.

RESULTS

Report-back was positively received, contributed to greater understanding, built trust between researchers and participants, and facilitated action to improve health. Sampling visits and community meetings also contributed to creating a positive study experience for participants. Participants were able to make changes in their homes, such as altering product use and habits that may reduce asthma symptoms, though some faced roadblocks from family members. Participants also gained access to medical resources, though some felt that clinicians were not responsive. Participants wanted larger scale change from government or industry and wanted researchers to leverage study results to achieve change.

CONCLUSIONS

Report-back on environmental chemical exposures in low-income communities can enhance research benefits by engaging residents with personally relevant information that informs and motivates actions to reduce exposure to asthma triggers. Ethical practices in research should support deliberative report-back in vulnerable communities.

The Potential for Proactive Housing Inspections to Inform Public Health Interventions

Municipal housing inspection data can inform planning, targeting, and evaluating interventions aimed at reducing housing hazards (lead paint, mold, pests, etc) that may affect residents' health. However, the potential of these data to inform public health initiatives is underexplored. We determined whether home health hazards identified by city inspectors during proactive inspections of single-family private rental housing are predicted by housing age, assessed value, or location in one of 26 geographic "inspector areas" in Rochester, New York. A comparison of linear mixed models, using housing inspector area as a random effect and assessment and construction year as fixed effects, shows that while a large proportion of variation (64%) in violations is due to housing stock, inspectors provide significant additional information about the presence of potential health hazards, particularly in the highest-risk housing stock. This suggests that inspector-generated housing hazard data may be valuable in designing public health interventions.

Chemical exposures in recently renovated low-income housing: Influence of building materials and occupant activities

Health disparities in low-income communities may be linked to residential exposures to chemicals infiltrating from the outdoors and characteristics of and sources in the home. Indoor sources comprise those introduced by the occupant as well as releases from building materials. To examine the impact of renovation on indoor pollutants levels and to classify chemicals by predominant indoor sources, we collected indoor air and surface wipes from newly renovated "green" low-income housing units in Boston before and after occupancy. We targeted nearly 100 semivolatile organic compounds (SVOCs) and volatile organic compounds (VOCs), including phthalates, flame retardants, fragrance chemicals, pesticides, antimicrobials, petroleum chemicals, chlorinated solvents, and formaldehyde, as well as particulate matter. All homes had indoor air concentrations that exceeded available risk-based screening levels for at least one chemical. We categorized chemicals as primarily influenced by the occupant or as having building-related sources. While building-related chemicals observed in this study may be specific to the particular housing development, occupant-related findings might be generalizable to similar communities. Among 58 detected chemicals, we distinguished 25 as primarily occupant-related, including fragrance chemicals 6-acetyl-1,1,2,4,4,7-hexamethyltetralin (AHTN) and 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethylcyclopenta[g]-2-benzopyran (HHCB). The pre- to post-occupancy patterns of the remaining chemicals suggested important contributions from building materials for some, including dibutyl phthalate and xylene, whereas others, such as diethyl phthalate and formaldehyde, appeared to have both building and occupant sources. Chemical classification by source informs multi-level exposure reduction strategies in low-income housing.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

The Impact of Working in a Green Certified Building on Cognitive Function and Health

Thirty years of public health research have demonstrated that improved indoor environmental quality is associated with better health outcomes. Recent research has demonstrated an impact of the indoor environment on cognitive function. We recruited 109 participants from 10 high-performing buildings (i.e. buildings surpassing the ASHRAE Standard 62.1-2010 ventilation requirement and with low total volatile organic compound concentrations) in five U.S. cities. In each city, buildings were matched by week of assessment, tenant, type of worker and work functions. A key distinction between the matched buildings was whether they had achieved green certification. Workers were administered a cognitive function test of higher order decision-making performance twice during the same week while indoor environmental quality parameters were monitored. Workers in green certified buildings scored 26.4% (95% CI: [12.8%, 39.7%]) higher on cognitive function tests, controlling for annual earnings, job category and level of schooling, and had 30% fewer sick building symptoms than those in non-certified buildings. These outcomes may be partially explained by IEQ factors, including thermal conditions and lighting, but the findings suggest that the benefits of green certification standards go beyond measureable IEQ factors. We describe a holistic "buildingomics" approach for examining the complexity of factors in a building that influence human health.

Exploring factors associated with asthma-related emergency department visits among adults: A path analysis approach

BACKGROUND

Asthma is an expensive chronic lung disease that affects 7% of U.S. adults and results in as many as 1.8 million emergency department (ED) visits each year. Pharmacists play an important role in managing asthma, including assessing control and monitoring disease progression, educating the patient about the disease and associated treatments, and ensuring safe and cost-effective medication use. However, comprehensive studies that account for the complex relationships between factors impacting asthma-related ED visits are lacking in the adult asthma population.

OBJECTIVE

To explore the complex relationships between asthma control, medication use, co-morbid conditions, minority status, environment and asthma-related ED visits using a path analysis approach.

METHODS AND MATERIALS

Data for this study were obtained from the 2012 Behavioral Risk Factor Surveillance System's Asthma Call Back Survey. Current asthmatics 18 and older were included in the sample. Path analysis was used to evaluate the direct effects of the independent variables on asthma-related ED visits, as well as the indirect effects mediated through asthma control, health status, and daily use of inhaled corticosteroids.

RESULTS

Having controlled asthma (β = -0.153, p < 0.01) and good health status (β = -0.133, p < 0.01) were associated with significantly fewer ED visits. Good health status was associated with daily use of inhaled corticosteroids, which in turn was associated with better asthma control. Hispanic ED use was mediated by asthma control (β = -0.067, p < 0.05), while African American ED use was mediated by health status (β = 0.050, p < 0.05).

CONCLUSION

These findings suggest that there may be race/ethnicity specific factors that may be targeted to reduce asthma-related ED visits in minority populations.

INTEGRATING HEALTH INTO BUILDINGS OF THE FUTURE

The health and wellbeing of building occupants should be a key priority in the design, building, and operation of new and existing buildings. Buildings can be designed, renovated, and constructed to promote healthy environments and behaviors and mitigate adverse health outcomes. This paper highlights health in terms of the relationship between occupants and buildings, as well as the relationship of buildings to the community. In the context of larger systems, smart buildings and green infrastructure strategies serve to support public health goals. At the level of the individual building, interventions that promote health can also enhance indoor environmental quality and provide opportunities for physical activity. Navigating the various programs that use metrics to measure a building's health impacts reveals that there are multiple co-benefits of a "healthy building," including those related to the economy, environment, society, transportation, planning, and energy efficiency.

Environmental Perceptions and Health before and after Relocation to a Green Building

Green buildings are designed to have low environmental impacts and improved occupant health and well-being. Improvements to the built environment including ventilation, lighting, and materials have resulted in improved indoor environmental quality (IEQ) in green buildings, but the evidence around occupant health is currently centered around environmental perceptions and self-reported health. To investigate the objective impact of green buildings on health, we tracked IEQ, self-reported health, and heart rate in 30 participants from green and conventional buildings for two weeks. 24 participants were then selected to be relocated to the Syracuse Center of Excellence, a LEED platinum building, for six workdays. While they were there, ventilation, CO2, and volatile organic compound (VOC) levels were changed on different days to match the IEQ of conventional, green, and green+ (green with increased ventilation) buildings. Participants reported improved air quality, odors, thermal comfort, ergonomics, noise and lighting and fewer health symptoms in green buildings prior to relocation. After relocation, participants consistently reported fewer symptoms during the green building conditions compared to the conventional one, yet symptom counts were more closely associated with environmental perceptions than with measured IEQ. On average, participants had 4.7 times the odds of reporting a lack of air movement, 1.4 more symptoms (p-value = 0.019) and a 2 bpm higher heart rate (p-value < 0.001) for a 1000 ppm increase in indoor CO2 concentration. These findings suggest that occupant health in green and conventional buildings is driven by both environmental perceptions and physiological pathways.

Airborne Particulate Matter in Two Multi-Family Green Buildings: Concentrations and Effect of Ventilation and Occupant Behavior

There are limited data on air quality parameters, including airborne particulate matter (PM) in residential green buildings, which are increasing in prevalence. Exposure to PM is associated with cardiovascular and pulmonary diseases, and since Americans spend almost 90% of their time indoors, residential exposures may substantially contribute to overall airborne PM exposure. Our objectives were to: (1) measure various PM fractions longitudinally in apartments in multi-family green buildings with natural (Building E) and mechanical (Building L) ventilation; (2) compare indoor and outdoor PM mass concentrations and their ratios (I/O) in these buildings, taking into account the effects of occupant behavior; and (3) evaluate the effect of green building designs and operations on indoor PM. We evaluated effects of ventilation, occupant behaviors, and overall building design on PM mass concentrations and I/O. Median PM_TOTAL was higher in Building E (56 µg/m³) than in Building L (37 µg/m³); I/O was higher in Building E (1.3–2.0) than in Building L (0.5–0.8) for all particle size fractions. Our data show that the building design and occupant behaviors that either produce or dilute indoor PM (e.g., ventilation systems, combustion sources, and window operation) are important factors affecting residents’ exposure to PM in residential green buildings.