Health Outcomes and Green Renovation of Affordable Housing

Transcription

1 Reserch Articles Helth Outcomes nd Green Renovtion of Affordble Housing Jill Breysse, MHS Dvid E. Jcobs, PhD Willim Weber, MArch b Sherry Dixon, PhD Crol Kwecki, MA, RN Susn Aceti, MSW Jorge Lopez, BS c ABSTRACT Objective. This study sought to determine whether renovting low-income housing using green nd helthy principles improved resident helth nd building performnce. Methods. We investigted resident helth nd building performnce outcomes t bseline nd one yer fter the rehbilittion of low-income housing using Enterprise Green Communities green specifictions, which improve ventiltion; reduce moisture, mold, pests, nd rdon; nd use sustinble building products nd other helthy housing fetures. We ssessed prticipnt helth vi questionnire, provided Helthy Homes trining to ll prticipnts, nd mesured ventiltion, crbon dioxide, nd rdon. Results. Adults reported sttisticlly significnt improvements in overll helth, sthm, nd non-sthm respirtory problems. Adults lso reported tht their children s overll helth improved, with significnt improvements in non-sthm respirtory problems. Post-renovtion building performnce testing indicted tht the building envelope ws tightened nd locl exhust fns performed well. New mechnicl ventiltion ws instlled (compred with no ventiltion previously), with fresh ir being supplied t 70% of the Americn Society of Heting, Refrigerting, nd Air-Conditioning Engineers stndrd. Rdon ws,2 picocuries per liter of ir following mitigtion, nd the nnul verge indoor crbon dioxide level ws 982 prts per million. Energy use ws reduced by 45% over the one-yer post-renovtion period. Conclusions. We found significnt helth improvements following low-income housing renovtion tht complied with green stndrds. All green building stndrds should include helth requirements. Collbortion of housing, public helth, nd environmentl helth professionls through integrted design holds promise for improved helth, qulity of life, building opertion, nd energy conservtion. Ntionl Center for Helthy Housing, Columbi, MD b University of Minnesot Center for Sustinble Building Reserch, College of Design, Minnepolis, MN c Southwest Minnesot Housing Prtnership, Slyton, MN Address correspondence to: Jill Breysse, MHS, Ntionl Center for Helthy Housing, Little Ptuxent Pkwy., Ste. 500, Columbi, MD 21044; tel ; fx ; e-mil <jbreysse@nchh.org> Assocition of Schools of Public Helth 64 Public Helth Reports / 2011 Supplement 1 / Volume 126

2 Helth nd Green Renovtion of Affordble Housing 65 Low-income fmilies re more likely to encounter environmentl helth nd sfety hzrds in their homes nd communities nd re, therefore, disproportiontely ffected by environmentl diseses. 1,2 Low-income children re eight times more likely to suffer from led poisoning, 3 nd childhood sthm rtes re higher in low-income communities. 4 Housing ffects helth directly nd indirectly, nd the burden of housing-relted diseses nd injuries is substntil. 5 Physicl, chemicl, nd biologicl exposures in the home tht produce dverse helth outcomes nd ssocited housing interventions hve been reviewed elsewhere. 6 9 Dt re needed to elucidte the complex links between helth, buildings, nd communities to enble building owners, community plnners, nd others to more confidently implement helth-bsed housing interventions. This study sought to determine whether renovting low-income housing using green nd helthy principles improved resident helth nd building performnce. Severl different green rting systems hve ppered recently, including Enterprise Green Communities Criteri, 10 U.S. Environmentl Protection Agency s (EPA s) Energy Str Plus Indoor Air Progrm (Indoor irplus), 11 nd Ledership in Energy nd Environmentl Design (LEED). 12 While such systems my improve helth, evidence to support this clim is sprse. The definition of green construction is fluid nd developing. These leding green building systems differ gretly with regrd to whether helth spects of green re required or optionl. For exmple, the Enterprise Green Communities stndrds used in the renovtion described in this study include severl required helth-relted specifictions, while LEED only provides certin number of optionl points for helth items. Although two erlier studies demonstrted significnt respirtory helth improvements in new green construction, 13,14 this is the first study to investigte whether renovting low-income housing using green principles improves resident helth. METHODS A three-building, 60-unit prtment complex in southwest Minnesot underwent substntil green renovtion in , complying with the voluntry Enterprise Green Communities Criteri, 10 which cover eight renovtion res: integrted design process, loction nd neighborhood fbric, site, wter conservtion, energy conservtion, mterils nd resources, helthy living environment, nd opertions nd mngement. Of the housing improvements conducted, eight were helth-relted (Figure 1). We dministered structured helth interview to ssess self-reported helth sttus of prticipting dults nd children. The helth interview ws dpted from the Centers for Disese Control nd Prevention s (CDC s) nnul Ntionl Helth Interview Survey, 15 CDC s Behviorl Risk Fctor Surveillnce System, 16 nd the Ntionl Institute of Environmentl Helth Sciences Ntionl Survey of Led nd Allergens in Housing (sponsored in conjunction with the U.S. Deprtment of Housing nd Urbn Development [HUD]). 17 Figure 1. Helth-relted green housing rehbilittion fetures: Green Housing Renovtion Study, Minnesot, Green housing feture Rehbilition ction Ventiltion nd fresh ir supply Comply with ASHRAE Stndrd Instll ir-hndling units in ech prtment, with ducted supplies into bedroom nd living spce nd centrl return t the unit. Duct fresh ir from exterior to systems return duct. Off-gssing Use low-voc dhesives, finishes, nd pints. Rdon Conduct testing nd mitigte if indicted. Pest control Conduct integrted pest mngement. Tobcco smoke No smoking in common res Mold control No crpets in wet rooms Moisture control Instll kitchen nd bth exhust fns. Other green fetures Energy: Instll geotherml heting nd cooling system; instll high-performnce (U-vlue 0.32) windows; dd insultion to exterior wlls (existing R-vlue 11 plus 7.5 dded) nd to roof ssembly (R-vlue 48). Wter: Replce wter fixtures in kitchen nd bthroom, instll dul-flush toilets, nd instll low-wter clothes wshers. ASHRAE 5 Americn Society of Heting, Refrigerting, nd Air-Conditioning Engineers VOC 5 voltile orgnic compound Public Helth Reports / 2011 Supplement 1 / Volume 126

3 66 Reserch Articles Interviews were dministered one to four months fter residents moved into renovted prtments nd were repeted 12 to 18 months lter. We ssessed prerenovtion helth sttus through respondent recll t this interview, which included questions concerning housing chrcteristics, demogrphics, clening prctices, smoking history, respirtory helth, nd physicl injury. One dult per dwelling ws interviewed nd provided informtion on his or her helth nd the helth of other resident dults nd children. Study dt collection begn in November 2006 nd ws completed in September Time 0 (T0) refers to the residents recll of conditions in their old homes prior to renovtion; time 1 (T1) refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments; nd time 2 (T2) refers to the follow-up visit pproximtely 12 to 18 months lter. Following ech interview, residents received trining on mintining helthy home using HUD booklet focusing on methods of keeping housing dry, clen, pest-free, sfe, contminnt-free, ventilted, nd mintined. 18 Building performnce testing ws conducted in the third renovted building (the only one tht ws vcnt fter renovtion ws complete but before re-occupncy) to compre it with design criteri nd building stndrds. The renovted ir-hndling system ws designed to supply outdoor ir to individul prtments, insted of the pre-renovtion system, which supplied outdoor ir only through unplnned building envelope lekge. Airflow ws mesured with the ir hndler running continuously. Totl building shell lekge ws mesured using clibrted blower door, which ws lso used to test two prtments. Inlet irflow ws tested during opertion of the ir hndler, bthroom exhust fns, nd kitchen exhust fns. Kitchen nd bthroom exhust fn irflows were compred with design specifictions. Duct return irflows nd duct lekge from the totl ir-hndling system were evluted using duct blster. Interstitil pressures were mesured between rooms within individul units, with interior doors closed if rooms were positively pressured nd opened if neutrl or negtively pressured reltive to the min living spce. Pressure tests were conducted to determine if return ir within living res ws dequte. We plced three-dy rdon test dosimeters in 25 loctions in the three buildings before renovtion. After renovtion but before ny rdon mitigtion, lph-trck long-term (pproximtely 90-dy) rdon dosimeters were plced in 17 loctions in two buildings. After rdon mitigtion in two buildings, 90-dy dosimeters were plced in 26 loctions. Using Onset HOBO dt loggers (Onset Computer Corp., Bourne, Msschusetts), crbon dioxide (CO 2 ) levels were trcked in the living spce of four units for pproximtely 12 months post-renovtion. Funding limittions prevented testing more units. CO 2 dt were retrieved qurterly nd compred with the commonly used indoor ir qulity guideline of 1,000 prts per million (ppm) to determine if fresh ir ventiltion ws dequte We nlyzed utility bills to determine overll energy use nd crbon gs emissions before renovtion nd one yer fter renovtion. Totl nnul energy use (mesured in kilo British therml units per yer [kbtu/yr]) ws divided by the squre footge (ft 2 ) of the conditioned spce nd heting degree dys (HDD) to compenste for yerly wether fluctutions (kbtu/ HDD/ft 2 /yr). When utility bill dt were missing for individul prtments, we estimted energy use by using verge energy use for the sme unit type. For interview questions tht could be nswered either yes or no, we used McNemr s test to test the hypothesis tht the percent of people nswering yes to question ws different t two specific times. When ll people hd the sme responses t both times, the p-vlue could be clculted. The binomil test of proportion ws used to test the hypothesis tht the proportion of respondents with better helth ws different from the proportion reporting worse helth. For questions tht could be nswered with multiple list of options representing some order of intensity (e.g., whether generl helth ws very good/excellent, good, or fir/poor ), we used the Cochrn-Mntel-Henszel row men score test for ordinl vribles to test the hypothesis tht the mens t two specific times were significntly different. When compring interview dt t two different time periods, we first mtched dt for both prticipnts nd prtments. Sttisticl significnce ws defined s p,0.05 nd mrginl significnce s 0.05#p,0.1. We did not control for multiple testing. Results Thirty-one (31) of the 54 occupied units (57%) were enrolled in the study. Due to differing strt times for building renovtion nd the study, residents could not be interviewed before renovtion, so bseline dt were bsed on recll. At the initil visit, residents hd lived in their newly renovted prtments less thn one month to pproximtely four months. Housing dt for T0 nd T1 were gthered for 31 units. Interviewed dults from 29 prtments provided T0 nd T1 helth dt bout themselves, 21 other dults, nd 30 children younger thn 18 yers of ge residing in these prtments. Fifteen (52%) of the 29 prtments tht provided T0 Public Helth Reports / 2011 Supplement 1 / Volume 126

4 Helth nd Green Renovtion of Affordble Housing 67 nd T1 helth dt hd children. Residents in 18 of the 31 units greed to prticipte in the T2 follow-up visit, retention rte of 58%. The 18 interviewed dults provided T2 dt for themselves, six other dults, nd 17 children living in these prtments. Nine (50%) of the 18 prtments hd children t T2. Of the 17 children, two were 17 yers old t the T1 visit nd 18 yers old t the T2 visit. Demogrphic dt Study prticipnts were lrgely immigrnts of minority rce/ethnicity nd ll low-income (Tble 1). Less thn hlf (43%) of the dults but most (82%) of the children were born in the U.S. Most dults were either white (37%) or Africn (not Africn Americn) (35%). Men nnul household income ws $29,000. There were no sttisticlly significnt differences in resident demogrphics between T1 nd T2 (ll p.0.1). Adult helth More dults reported better vs. worse overll helth t T1 compred with T0 (34% vs. 7%; p50.042; Tble 2). Adult helth sttus ws better t T2 thn T1 (p50.052). Sixty-two percent reported tht dult helth ws very Tble 1. Demogrphic dt of prticipnts: Green Housing Renovtion Study, Minnesot, Initil interview (T1) Follow-up interview (T2) Chrcteristic N Result N b Result Born in the U.S. (n [percent]) Adults Children Age (in yers) (men) Adults Children Highest level of eduction (medin) Adults Children Femle gender (n [percent]) Adults Children Rce/ethnicity (n [percent]) Adults White/Hispnic White/non-Hispnic Africn Blck/Africn Americn Americn Indin/Hispnic Americn Indin/non-Hispnic Some other rce/don t know/hispnic Children White/Hispnic White/non-Hispnic Africn Blck/Africn Americn/Hispnic Blck/Africn Americn/non-Hispnic Americn Indin/Hispnic Some other rce/don t know/hispnic Public Helth Reports / 2011 Supplement 1 / Volume (43) 22 (82) th grde 7th grde 29 (58) 11 (37) 5 (10) 13 (27) 17 (35) 4 (8) 1 (2) 1 (2) 8 (16) 1 (3) 2 (7) 9 (31) 2 (7) 11 (38) 1 (3) 3 (10) (46) 14 (82) th grde c 6th grde 16 (67) 7 (44) 2 (9) 8 (36) 7 (32) 2 (9) 0 (0) 0 (0) 3 (14) 1 (6) 2 (12) 2 (12) 0 (0) 9 (53) 1 (6) 2 (12) Number of people living in ech prtment (men) Length of time in renovted home t T1 (months) (rnge) Lived elsewhere 12 months prior to T1 (n [percent]) 21 8 (38) NA NA Annul household income (medin) 8 $29,000 7 $28,000 Although some T1 dt were reported for 50 dults nd 30 children in 31 homes, some vlues were missing. b Although some T2 dt were reported for 24 dults nd 17 children in 18 homes, some vlues were missing. c Two residents tht were children t T1 were dults t T2. T1 5 time 1 (refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments) T2 5 time 2 (refers to the follow-up visit pproximtely 12 to 18 months fter people moved into the renovted prtments) NA 5 not pplicble

5 68 Reserch Articles Tble 2. Generl helth dt for dults nd children: Green Housing Renovtion Study, Minnesot, T1 T2 Chrcteristic N Count (percent) P-vlue N Count (percent) P-vlue P-vlue b Helth comprison: interviewed dult c Better Sme Worse Helth comprison: child c Better Sme Worse Generl helth sttus: dult Very good or excellent Good Fir or poor Generl helth sttus: child Very good or excellent Good Fir or poor (34) 17 (59) 2 (7) 7 (23) 19 (63) 4 (13) 7 (33) 10 (48) 4 (19) 9 (53) 6 (35) 2 (12) NA 21 NA 17 5 (28) 9 (50) 4 (22) 5 (33) 8 (52) 2 (13) 13 (62) 5 (24) 3 (14) 11 (65) 6 (35) 0 (0) NA NA NA NA P-vlue from the binomil test of proportion tht the percent with better helth is greter thn the percent with worse b P-vlue from the Cochrn-Mntel-Henszel row men score test (for ordinl vribles) tht there ws difference in the mens t T1 nd T2 c At T1 respondents were sked bout chnges from time 0. At T2 respondents were sked bout chnges from T1. T1 5 time 1 (refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments) T2 5 time 2 (refers to the follow-up visit pproximtely 12 to 18 months fter people moved into the renovted prtments) NA 5 not pplicble good/excellent t T2, compred with 33% t T1. Those reporting helth sttus s fir/poor decresed from 19% t T1 to 14% t T2. The percentge of dults reporting severl specific helth problems significntly improved from T0 to T1 (Figure 2) for sthm (p50.046) nd non-sthm respirtory problems (p50.030). Improvements in reports of non-sthm respirtory problems (p50.025) remined significnt from T0 to T2 (Figure 3). For dults, non-sthm respirtory problems included emphysem, hy fever, sinusitis, nd chronic bronchitis. Child helth More children hd better overll helth vs. worse helth t T1 thn T0, lthough the difference ws not significnt (23% vs. 13%; p50.476; Tble 2). Reports of generl child helth sttus did not significntly chnge when compring T1 to T2 (p50.206). The percentge of children with non-sthm respirtory problems improved from 33% to 15% between T0 nd T1 (p50.025) (Figure 2). For children, non-sthm respirtory problems included hy fever, sinusitis, chronic bronchitis, er infections, nd respirtory llergies. At T0 nd T1, only 7% of children reportedly hd doctor-dignosed sthm. Housing condition The mjority of people reported tht their newly renovted homes t T1 were esier to clen (p,0.001), more comfortble (p,0.001), nd sfer (p50.008) thn their old homes t T0; their neighborhood ws sfer (p50.021); nd their children plyed outside more (p50.059) (Figure 4). At T1, significntly fewer people reported tht their renovted homes hd mildew odor/musty smell (p50.020) or evidence of wter/dmpness (p50.083) (Figure 5). At T2, only one person reported dmpness, nd none reported mildew odors/musty smells (Figure 6). The percentge of residents reporting cockroch problem mrginlly improved t T1 compred with T0 (p50.083; Figure 5). From T0 to T1, the use of insecticides by either residents or extermintors/mintennce personnel significntly improved (p nd p50.003, respectively). At T2, only two people still reported hving cockroch problems, nd none reported using insecticides t home (Figure 6). The percentge of residents reporting mice/rt problems in the previous 12 months decresed from T0 to T2 (p50.046). From T0 to T1, fewer people reported smoke inside their homes due to incense, cigrettes, cigrs, pipes, Public Helth Reports / 2011 Supplement 1 / Volume 126

6 Helth nd Green Renovtion of Affordble Housing 69 wood fires, or non-tobcco cigrettes (p50.025) (Figure 5). The percentge incresed slightly between T0 nd T2, but not significntly (p50.157) (Figure 6). Building performnce testing nd indoor CO 2 Blower door testing showed building ir lekge ws 0.38 cubic feet per minute per squre foot t 50 pscls (cfm/ft P) (Tble 3), higher thn the current stndrd for Minnesot single fmily housing of 0.24 cfm/ft P. 22 The men lekge in individul units ws 3.7 times greter thn tht for the building. Men fresh ir supply rtes to individul units were 21 cfm nd 29 cfm for two- nd three-bedroom units, respectively, pproximtely 70% of the Americn Society of Heting, Refrigerting, nd Air-Conditioning Engineers (ASHRAE) 62.2 stndrds of 30 cfm nd 39 cfm, respectively. 23 The men nnul level of CO 2 ws 982 ppm, slightly less thn the 1,000 ppm guideline. The men kitchen exhust fn high-speed irflow of 84 cfm ws slightly below ASHRAE s 100-cfm stndrd, but the men bthroom exhust irflow of 68 cfm exceeded ASHRAE s 50-cfm stndrd. The men mesured return irflow for tested ir hndlers ws 346 cfm, within 10% of mnufcturer-specified vlues. However, the men duct lekge ws 28 cfm/100ft P, more thn 3.5 times higher thn EPA s Indoor irplus new construction criterion of 6 cfm/100ft P. 11 The bedrooms were under positive pressure with the ventiltion system on, contrry to design specifictions. Rdon Of the 25 res hving pre-renovtion short-term rdon tests, seven hd rdon levels equl to or greter thn the EPA s 4-picocuries-per-liter (pci/l) ction level (Tble 4). 24 Becuse the renovtion included seling of ll bsement foundtion crcks, rdon mitigtion ws not included in the originl renovtion. But postrenovtion long-term mesurements conducted before rdon mitigtion yielded two of 17 tested res with levels greter thn 4 pci/l; therefore, rdon mitigtion Figure 2. Chnge in reports of specific dult (n=49) nd child (n=27) helth issues, pre-renovtion (T0) vs. immedite post-renovtion (T1): Green Housing Renovtion Study, Minnesot, Adult sthm (p50.046) Child sthm (p5na) Adult injury (p50.366) Child injury (p5na) Adult non-sthm respir. (p50.030) Child non-sthm respir. b (p50.025) For dults, non-sthm respirtory problems include emphysem, hy fever, sinusitis, nd chronic bronchitis. b For children, non-sthm respirtory problems include hy fever, sinusitis, chronic bronchitis, er infections, nd respirtory llergies. T0 5 time 0 (refers to the residents recll of conditions in their old home prior to renovtion) T1 5 time 1 (refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments) NA 5 not pplicble Public Helth Reports / 2011 Supplement 1 / Volume 126

7 70 Reserch Articles Figure 3. Chnge in reports of specific dult (n=22) nd child (n=13) helth issues, pre-renovtion (T0) vs. one yer post-renovtion (T2): Green Housing Renovtion Study, Minnesot, Adult sthm (p50.317) Child sthm (p5na) Adult injury (p50.na) Child injury (p50.083) Adult non-sthm respir. (p50.025) Child non-sthm respir. b (p50.317) For dults, non-sthm respirtory problems include emphysem, hy fever, sinusitis, nd chronic bronchitis. b For children, non-sthm respirtory problems include hy fever, sinusitis, chronic bronchitis, er infections, nd respirtory llergies. T0 5 time 0 (refers to the residents recll of conditions in their old home prior to renovtion) T2 5 time 2 (refers to the follow-up visit pproximtely 12 to 18 months fter people moved into the renovted prtments) NA 5 not pplicble Figure 4. Chnges in reports of generl housing condition (better vs. worse), pre-renovtion (T0) vs. immedite post-renovtion (T1): Green Housing Renovtion Study, Minnesot, T0 5 time 0 (refers to the residents recll of conditions in their old home prior to renovtion) T1 5 time 1 (refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments) Public Helth Reports / 2011 Supplement 1 / Volume 126

8 Helth nd Green Renovtion of Affordble Housing 71 Figure 5. Chnges in reports of specific housing conditions, pre-renovtion (T0) to immedite post-renovtion (T1): Green Housing Renovtion Study, Minnesot, Percent reporting housing condition T0 5 time 0 (refers to the residents recll of conditions in their old home prior to renovtion) T1 5 time 1 (refers to the first study visit, which occurred n verge of 67 dys fter people moved into the renovted prtments) Figure 6. Chnges in specific housing conditions, pre-renovtion (T0) to one yer post-renovtion (T2): Green Housing Renovtion Study, Minnesot, T0 5 time 0 (refers to the residents recll of conditions in their old home prior to renovtion) T2 5 time 2 (refers to the follow-up visit pproximtely 12 to 18 months fter people moved into the renovted prtments) Public Helth Reports / 2011 Supplement 1 / Volume 126

9 72 Reserch Articles Tble 3. Building ventiltion performnce results: Green Housing Renovtion Study, Minnesot, Ventiltion system Minimum Mximum Men Design criterion Design criterion reference Building shell lekge (cfm/ft P) (n51) NA 0.38 NA 0.24 Minnesot Single-Fmily Housing Stndrd Unit lekge (cfm/ft P) (n52) NA NA Rtio of building lekge to unit lekge NA NA Crbon dioxide (ppm) 253 2, ,000 Indoor Air Qulity benchmrk Fresh-ir supply (cfm) Two-bedroom unit (n514) Three-bedroom unit (n510) ASHRAE ASHRAE 62.2 Kitchen exhust (cfm) (n523) ASHRAE 62.2 Bthroom exhust (cfm) (n524) ASHRAE 62.2 Duct lekge (cfm/100ft P) (n512) EPA 2007 Duct return irflow (cfm) (n512) Within 10% of mnufcturer dt sheets Mnufcturer dt sheet specifictions Within-unit interstitil pressure for ll tested bedrooms (P) (n558) NA NA Within-unit interstitil pressure for bedrooms without ir hndlers in living room (P) (n546) NA NA ASHRAE 62.2 ventiltion rte is clculted ccording to the following eqution: (number of bedrooms 1) (7.5 cfm) (squre feet 0.01 cfm). cfm 5 cubic feet per minute ft 2 5 squre foot P 5 Pscl NA 5 not pplicble ppm 5 prts per million ASHRAE 5 Americn Society of Heting, Refrigerting, nd Air-Conditioning Engineers EPA 5 Environmentl Protection Agency ws dded. The mitigtion utilized the existing foundtion drin tile nd sub-slb plumbing long with fn-powered exterior verticl stcks to vent soil gs outdoors. Post-mitigtion long-term verge rdon levels were 0.7 pci/l, with no test results exceeding 4 pci/l. Energy use The nnul complex-wide post-renovtion combined electric/nturl gs energy use ws 5.05 BTU/HDD/ ft 2 /yr compred with 9.76 BTU/HDD/ft 2 /yr for prerenovtion, 48% reduction. Without considering HDD, the totl combined one-yer post-renovtion electric nd nturl gs energy use ws 39.3 kbtu/ ft 2 /yr (Figure 7; October 2007 through September 2008). This result, while well below the pre-renovtion energy use of 72.4 kbtu/ ft 2 /yr, ws 56% higher thn the Architecture 2030 Chllenge benchmrk of 25.4 kbtu/ft 2 /yr set for U.S. Midwest residentil projects of five or more units. 25 Differentition of energy use intensity by end use could not be determined due to overlpping end use from the sme sources. Electricity use combines household use with ll heting, cooling, nd ventiltion energy. DISCUSSION Primry drivers of the green building movement re improved energy conservtion nd reduced crbon emissions. In the 1970s, some of the first energy efficiency efforts yielded mjor indoor ir-qulity problems. 26 By contrst, this study yielded improvements in energy efficiency, helth, nd indoor environmentl qulity. However, retrofitting ventiltion systems in buildings tht previously relied solely on building lekge for fresh ir supply is difficult. Even the most well-designed renovtion needs post-renovtion commissioning, including building performnce testing. Public Helth Reports / 2011 Supplement 1 / Volume 126

10 Helth nd Green Renovtion of Affordble Housing 73 Tble 4. Rdon testing results (pci/l): Green Housing Renovtion Study, Minnesot, Test result Minimum Mximum Averge N (percent) of results 4 pci/l Short-term test results, pre-construction (n525) (28) Long-term test results, post-construction/pre-mitigtion (n517) (12) Long-term test results, post-construction nd post-mitigtion (n526) (0) 4 pci/l 5 Environmentl Protection Agency ction level pci/l 5 picocuries per liter Study dt suggest tht hd the buildings chieved the full ASHRAE-specified fresh ir rtes, verge CO 2 levels, which were only brely below the benchmrk of 1,000 ppm, my hve been lower. Results lso suggest tht the benefits of improved housing for low-income households likely include significnt helth cost reductions nd could contribute to helth-cre cost continment, not to mention reduced suffering from voidble illnesses. Limittions This study hd severl limittions. First, it ws difficult to discern whether helth improvements were due to the nture of green renovtion vs. norml renovtion. In Minnesot nd other jurisdictions, most federl- nd stte-ssisted renovtions re mndted green, mking this distinction less importnt. Another limittion ws tht one dult nswered the helth questions for children nd other dults in the prtment, potentilly introducing bis. Culturl differences between interviewers nd interviewees my hve cused misunderstnding of some questions. While 14 households required no trnsltion services, the rest did. Self-reported helth t two points in time my be subject to recll bis nd uncertinty, especilly becuse, due to the timing of study funding, residents interviewed hd to recll pre-renovtion helth nd housing informtion just fter renovtion ws complete. Although evidence indictes tht recll reports were resonbly well-correlted with ctul helth, 27 future studies should endevor to find funds for rehbilittion nd reserch simultneously so tht bseline dt cn be gthered before renovtion begins. For the building performnce testing, the fct tht fresh-ir delivery ws lower thn design specifictions ws likely due to complex pressure differentils, mking ir more likely to be drwn from djcent units thn from outside. Although the building shell ws mde tighter, interior wlls were not seled during renovtion, potentilly cusing incresed odor or smoke migrtion between prtments, common postrenovtion resident complint. Duct lekge ws high becuse the contrctor filed to sel ech duct joint. These findings led to retrofits, which my hve cost Figure 7. One-yer post-intervention totl building energy consumption electricity nd nturl gs combined: Green Housing Renovtion Study, Minnesot, Energy consumption (kbtu/sq ft/yr) 2030 Chllenge benchmrk: 25.4 kbtu/sq ft/yr kbtu/sq ft/yr 5 kilo British therml unit per squre foot per yer Public Helth Reports / 2011 Supplement 1 / Volume 126

11 74 Reserch Articles less if implemented during the originl rehbilittion. Some ventiltion systems did not perform to design specifictions, likely due to limited equipment choices/ sizing options, budgetry constrints, nd existing building chrcteristics. Ventiltion design could be improved by using secondry energy-efficient fn in the fresh-ir duct to improve irflow volume nd n intermittent timer-cycling thermostt to ensure regulr fresh-ir delivery. The high positive pressures within ech unit could drive ir nd moisture into exterior wlls or ceiling ssemblies, potentilly cusing future deteriortion nd mold problems. In ech unit, the design tem instlled trnsfer grill linking bedrooms to the living spces, creting return pth nd equlizing pressure. Future projects with centrl ir return options should include jump-ducting or trnsfer grills with light nd coustic dmpening grills. At the design stge, no protocols existed for conducting rdon tests nd mitigtion in multifmily buildings. The Americn Assocition of Rdon Scientists nd Technologists is working to develop protocols for multifmily testing nd mitigtion. Minnesot hs dopted mndtory rdon construction techniques for single-fmily new construction, nd Minnesot Housing requires rdon-resistnt construction for new multifmily housing in EPA Rdon Zone 1. Hd rdon mitigtion been included in the originl renovtion insted of retrofitting, costs would hve been reduced. Overll, building performnce results demonstrte tht sufficient plnning t the design stge nd immedite post-renovtion testing re essentil to ensure tht building ventiltion works s intended. Building performnce testing results underscore the need for erly formtion of n integrted design tem (including rchitecture, engineering, environment, public helth, nd other expertise) to yield more cost-effective results. The sttisticl strength of future studies could be improved by lrger enrollment nd the use of both medicl dt nd self-reported dt to evlute helth outcomes. Although it would hve been preferble to ccount for the lck of independence of helth reports between residents in the sme prtment, this ws not possible due to the smll study smple size. Initil interviews indicted tht prticipnts were generlly in good helth t the strt of the study, possibly indicting tht helthier people greed to prticipte. A lrger smple size nd bseline popultion in poorer helth my hve shown dditionl helth improvements. CONCLUSIONS The green renovtion produced improvements in resident helth, prticulrly dults, whose overll helth, sthm, nd non-sthm respirtory problems significntly improved during the one- to four-month follow-up period. Adults non-sthm respirtory problems lso improved one yer post-renovtion. Children s non-sthm respirtory problems improved during the one- to four-month nd one-yer follow-up periods. Exposures to rdon declined, children plyed outside more, nd security nd ventiltion were improved. Energy use declined drmticlly. The renovtions yielded improved housing conditions, mking homes esier to clen, more comfortble, nd sfer both inside the prtment nd in the community. There were fewer moisture nd dmpness issues, little or no pest problems, nd less smoke indoors. All green housing stndrds should include helth-relted requirements. Integrted design tems could yield more sustinble, energy-efficient, nd helthy housing. The uthors cknowledge the following project prtners for their contributions to this study: the building residents nd property mngers, Southwest Minnesot Housing Prtnership, Minnesot Green Communities, Greter Minnesot Housing Fund, University of Minnesot Center for Sustinble Building Reserch, nd Ntionl Center for Helthy Housing. Study funding ws provided by the Blue Cross Blue Shield of Minnesot Foundtion, the U.S. Environmentl Protection Agency, nd Enterprise Community Prtners. REFERENCES 1. Jcobs DE. Environmentl helth disprities in housing. Am J Public Helth. In press Krieger J, Higgins DL. Housing nd helth: time gin for public helth ction. Am J Public Helth 2002;92: Blood led levels United Sttes, MMWR Morb Mortl Wkly Rep 2005;54(20): Mnnino DM, Hom DM, Akinbmi LJ, Moormn JE, Gwynn C, Redd SC. Surveillnce for sthm United Sttes, MMWR Surveill Summ 2002;51(1): World Helth Orgniztion. Report of the WHO technicl workshop on quntifying disese from indequte housing, Bonn, Germny, November Genev: WHO; Jcobs DE, Brown MJ, Beder A, Sucosky MS, Mrgolis S, Hershovitz J, et l. A systemtic review of housing interventions nd helth: introduction, methods, nd summry findings. J Public Helth Mng Prct 2010;16(5 Suppl):S Krieger J, Jcobs DE, Ashley PJ, Beder A, Chew GL, Derborn D, et l. Housing interventions nd control of sthm-relted indoor biologic gents: review of the evidence. J Public Helth Mng Prct 2010;16(5 Suppl):S Sndel M, Beder A, Brdmn A, Hughes J, Mitchell C, Shughnessy R, et l. Housing interventions nd control of helth-relted chemicl gents: review of the evidence. J Public Helth Mng Prct 2010;16(5 Suppl):S DiGuiseppi C, Jcobs DE, Pheln KJ, Micklide AD, Ormndy D. Housing interventions nd control of injury-relted structurl deficiencies: review of the evidence. J Public Helth Mng Prct 2010;16(5 Suppl):S Public Helth Reports / 2011 Supplement 1 / Volume 126

12 Helth nd Green Renovtion of Affordble Housing Enterprise Community Prtners. Enterprise Green Communities Criteri 2005 [cited 2009 Nov 30]. Avilble from: URL: Environmentl Protection Agency (US). Indoor irplus construction specifictions [cited 2009 Nov 30]. Avilble from: URL: U.S. Green Building Council, Ledership for Environment nd Energy Design (LEED). LEED rting systems [cited 2009 Nov 30]. Avilble from: URL: spx?cmspgeid Krieger J, Tkro TK, Song L, Beudet N, Edwrds K. A rndomized controlled tril of sthm self-mngement support compring clinic-bsed nurses nd in-home community helth workers: the Settle-King County Helthy Homes II Project. Arch Peditr Adolesc Med 2009;163: Leech JA, Rizenne M, Gusdorf J. Helth in occupnts of energy efficient new homes. Indoor Air 2004;14: Ntionl Center for Helth Sttistics (US) Ntionl Helth Interview Survey questionnire [cited 2011 Jn 18]. Avilble from: URL: ftp://ftp.cdc.gov/pub/helth_sttistics/nchs/ Survey_Questionnires/NHIS/2006/English 16. Centers for Disese Control nd Prevention (US). Behviorl Risk Fctor Surveillnce System [cited 2010 Jn 6]. Avilble from: URL: Ntionl Institute of Environmentl Helth Sciences. Ntionl Survey of Led nd Allergens in Housing (NSLAH) [cited 2011 Jn 18]. Avilble from: URL: clinicl/join/studies/riskssess/nslh.cfm 18. Deprtment of Housing nd Urbn Development (US). Help yourself to helthy home: protect your children s helth. Wshington: HUD, Deprtment of Agriculture (US) (in conjunction with the Coopertive Stte Reserch Eduction nd Extension Service); Shendell DG, Prill R, Fisk WJ, Apte MG, Blke D, Fulkner D. Associtions between clssroom CO 2 concentrtions nd student ttendnce in Wshington nd Idho. Indoor Air 2004;14: Erdmnn CA, Apte MG. Mucous membrne nd lower respirtory building relted symptoms in reltion to indoor crbon dioxide concentrtions in the 100-building BASE dtset. Indoor Air 2004;14 Suppl 8: Brtlett K, Mrtinez M, Bert J. Modeling of occupnt-generted CO 2 dynmics in nturlly ventilted clssrooms. J. Occup Environ Hyg 2004;1: ASTM Interntionl. ASTM Interntionl Stndrd E : stndrd specifiction for n ir retrder (AB) mteril or system for low-rise frmed building wlls, As incorported by reference in the Stte of Minnesot. Residentil Energy Code: codes dopted by reference. St. Pul (MN): Minnesot Office of the Revisor of Sttutes; Americn Society of Heting, Refrigerting, nd Air-Conditioning Engineers. ASHRAE Stndrd : ventiltion nd cceptble indoor ir qulity in low-rise residentil buildings. Atlnt: ASHRAE; Environmentl Protection Agency (US). A citizen s guide to rdon: the guide to protecting yourself nd your fmily from rdon. Wshington: EPA Indoor Environments Division; Architecture chllenge trgets: U.S. residentil regionl verges [cited 2009 Dec 15]. Avilble from: URL: Regionl.pdf 26. Sundell J. On the history of indoor ir qulity nd helth. Indoor Air 2004;14 Suppl 7: Miilunplo S, Vuori I, Oj P, Psnen M, Urponen H. Self-rted helth sttus s helth mesure: the predictive vlue of self-reported helth sttus on the use of physicin services nd on mortlity in the working-ge popultion. J Clin Epidemiol 1997;50: Public Helth Reports / 2011 Supplement 1 / Volume 126