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An evolving body of scientific evidence demonstrates solid relations between housing and health. The public health community is developing, testing, and implementing effective interventions that yield health benefits through improved housing quality. Public health agencies have valuable expertise and resources to contribute to a multisectoral approach to housing concerns.
Public health has a long albeit intermittent history of involvement in the housing arena, and this involvement is generally accepted by other housing stakeholders e. Housingrelated health concerns such as lead exposure and asthma are highly visible. The public is also concerned about the quality and accessibility of housing as affordable housing becomes scarcer. In this article, we describe some of the evidence linking housing conditions to health, place public health's role in addressing housing issues in an historical context, provide examples of contemporary local public health activities in the housing arena, and conclude with suggestions for public health action in the next decade.
An increasing body of evidence has associated housing quality with morbidity from infectious diseases, chronic illnesses, injuries, poor nutrition, and mental disorders. We present some of this evidence in the following section. Features of substandard housing, including lack of safe drinking water, absence of hot water for washing, ineffective waste disposal, intrusion by disease vectors e. In more recent years, epidemiological studies have linked substandard housing with an increased risk of chronic illness. Damp, cold, and moldy housing is associated with asthma and other chronic respiratory symptoms, even after potentially confounding factors such as income, social class, smoking, crowding, and unemployment are controlled for.
In , eleven million occupied homes in America had interior leaks and 14 million had exterior leaks. Old, dirty carpeting, often found in substandard housing, is an important reservoir for dust, allergens, and toxic chemicals. Pest infestations, through their association with asthma, provide another linkage between substandard housing and chronic illness.
Cockroaches can cause allergic sensitization and have emerged as an important asthma trigger in inner-city neighborhoods. Children with asthma who are sensitized and exposed to cockroaches are at elevated risk for hospitalization. Inadequate food storage and disposal facilities provide them with opportunities for obtaining food. Dead spaces in walls harbor pests and permit circulation among apartments in multiunit dwellings. Deviation of indoor temperature beyond a relatively narrow range has been associated with increased risk of cardiovascular disease.
Exposure to toxic substances found in homes can result in chronic health problems. The association of passive exposure to indoor tobacco smoke with respiratory disease is well documented. The importance of designing homes to prevent injuries has received long-standing attention, 60 especially with regard to reducing burns and falls. These hazards are frequently present in temporary accommodations provided to homeless women and young children. Recent analyses of longitudinal cohorts of children have examined the influence of childhood housing conditions on the subsequent development of chronic diseases.
A study conducted in Britain demonstrated modest associations of inadequate ventilation with overall mortality respiratory mortality was not specifically examined and type of water supply with coronary heart disease mortality, independent of other measures of deprivation. Lack of affordable housing has been linked to inadequate nutrition, especially among children. Relatively expensive housing may force low-income tenants to use more of their resources to obtain shelter, leaving less for other necessities such as food.
Substandard housing may also adversely affect mental health, although the evidence is more tentative. Excessive indoor temperature has been linked with irritability and social intolerance. High-rise buildings may inhibit social interaction because they lack common spaces. In summary, substandard housing affects multiple dimensions of health.
There is evidence that, in part, poor housing conditions contribute to increasing exposure to biological e. In addition, concerns about substandard housing and fear of homelessness are psychosocial stressors that can lead to mental health problems. Preliminary research has suggested that residents' perceptions of their homes e. For example, excessive noise common in poorly insulated housing units has been associated with sleep deprivation that leads to psychological stress and activation of the hypothalamic—pituitary—adrenal axis and sympathetic nervous system. These factors are major contributors to allostatic load the wear and tear accumulated by an organism as a result of physiological responses to environmental stressors.
Beyond the condition of the housing unit itself, the site of the home may be a determinant of health. Neighborhood-level effects on health have been documented; these include elevated rates of intentional injury, 79, 80 poor birth outcomes, 81 cardiovascular disease, 82 HIV, 83 gonorrhea, 84 tuberculosis, 85 depression, 86 physical inactivity, 87, 88 and all-cause mortality 89— 91 in neighborhoods of low socioeconomic status, independent of individual-level risk factors.
Several features of these neighborhoods may contribute to poor health. Air quality may be poor because of their proximity to sources of vehicle exhaust emissions such as major roads, bus depots, airports, and trucking routes. Yet it is possible to design neighborhoods to promote health by considering sidewalk and street design, the presence of green spaces and recreational sites, and the location of schools, work, and shopping within walking distance of homes. When 5-year-old Jose and his 3-year-old sister Maria suddenly developed breathing problems, their doctor was puzzled.
The usual medical treatments didn't work, and the symptoms persisted even after their mother followed instructions to rid the apartment of rugs, dust, and cockroaches. The pediatrician initially disregarded the mother's frustration with her neighbor's smoking—until she realized that the smoke flowed right into Jose and Maria's apartment through a large hole in the living room wall. Social dimensions of neighborhoods also affect health. Sampson and colleagues examined the relation between collective efficacy a combination of trust, social cohesion, and informal social control and violence in Chicago neighborhoods and concluded that rates of neighborhood violence were lower in areas with high collective efficacy.
Exposure to substandard housing is not evenly distributed across populations. People of color and people with low income are disproportionately affected. For example, Blacks and low-income people are 1. Disparities in asthma morbidity may be attributable, in part, to disproportionate exposure to indoor environmental asthma triggers associated with living in substandard housing. Clutter stemming from lack of storage space and hazardous cooking facilities also contribute to increased risk of injury from fire.
As housing and energy prices continue to climb, low- and moderate-income households make tradeoffs between having enough food, staying warm, and living in adequate housing, with resultant adverse effects on health. The notion of housing as a public health issue is not new. In the middle of the 19th century, pathologist Rudolf Virchow advised city leaders that poorly maintained, crowded housing was associated with higher rates of infectious disease transmission.
Interest in housing as a determinant of health has fluctuated in response to housing-related infectious disease outbreaks e. Later in the century, the sanitary reform movement was spurred by urban industrialization and growing class conflict. The depression and social unrest of the s brought renewed public health attention to housing. During the post—World War II period, a lack of affordable housing, exacerbated by the return of veterans and migration from the rural South, increased the prominence of the housing issue.
In the s through the s, activists addressed racial disparities in housing, the civil rights movement resulted in legislation prohibiting discrimination in housing, and indoor lead exposure became a major public health concern. Although a comprehensive history of public health involvement in housing is beyond the scope of this article, we next provide several illustrative examples. In the early s, the relation between housing conditions and health was recognized among public health practitioners in the United States — and Europe — and led to the rise of the sanitary reform movement.
Industrialization caused a rapid growth in urban populations that was not matched by a sufficient increase in adequate housing. Builders, eager to capitalize on the need for housing, built inferior housing in congested areas of cities. The response to this situation established the basis of public health action at the local and national levels and clearly established the link between public health and housing. In the United States, the sanitary reform movement was carried out by boards of health and in some cases by voluntary health associations consisting of physicians, public officials, and other civic-minded citizens.
These reforms succeeded in controlling the epidemics of infectious diseases. The recognition of lead-based paint as a health hazard is another important chapter in the history of public health involvement in housing. As early as , the health consequences of lead exposure were discussed in the medical literature. By the mids, there was strong evidence that lead poisoned those exposed to it and was especially harmful to children. It continued an aggressive campaign throughout the 20th century, providing free diagnostic tests for lead poisoning, inspecting houses, requiring the removal of lead by landlords, and mandating the inclusion of warning labels for lead-based paint.
Ultimately, the Consumer Product Safety Commission prohibited the use of all lead paint after Thirty years ago, our major emphasis was transferred from the physical environment to the individual. Today, we must shift our gaze from the individual back to the environment, but in a broader sense…to the whole social and economic environment in which the individual lives and moves and has his being. He therefore led the Hygiene and Public Health Committee in an examination of the components of healthy housing in terms of physical, physiological, and psychological needs.
APHA has periodically updated these guidelines on healthy housing. Current public health efforts to improve housing conditions include a continuation of these historical activities as well as new strategies based on emerging issues such as indoor environmental quality. The development and enforcement of most housing codes are the responsibility of housing and construction departments.
Our health department, like most others, issues and enforces housing codes that address a limited set of concerns e. Local codes are based on national uniform codes that set minimal standards for new housing construction, fire safety, plumbing, and mechanical systems. However, these codes consider only a subset of the conditions that affect housing quality. For the most part, they do not address the maintenance or remediation of substandard conditions in existing buildings.
Many jurisdictions have promulgated general health and nuisance codes that allow public health to intervene in situations in which an immediate threat to health exists, although such codes are applied infrequently to substandard housing conditions. A major limitation on the usefulness of codes is the difficulty in implementing them. Resources for inspection and enforcement are spread across multiple agencies that lack adequate staff and do not coordinate efforts.
Another constraint is the current political climate, which favors market-based solutions and individual legal action rather than public sector regulation and enforcement. At the local level, recent guideline development has been directed at indoor mold contamination.
Some jurisdictions are using the more general health codes to address substantial mold contamination. The emergence of asthma as a major public health issue has led to renewed interest in improving indoor environmental quality and in integrating these newer efforts with ongoing work addressing other indoor health hazards such as lead and injury risk factors.
Our department and many other local health jurisdictions e. These projects provide education and resources to support household members in taking actions to improve the quality and safety of their home environments. The Seattle—King County Healthy Homes Project , employs community health workers who use a home environmental checklist to assess exposures, knowledge, and actions related to indoor asthma triggers and indoor chemical hazards.
The checklist guides the development of a specific, computer-generated home environmental action plan for each household. The community health worker makes 5 visits over 1 year in which she works with clients to carry out the action plan by offering education and social support, encouraging changes in habits e. The project's scope is being expanded to include injury hazards, and Healthy Homes projects in jurisdictions with higher prevalences of lead exposure have also integrated lead assessment and abatement.
I have a 6-year-old patient who presented with severe asthma no previous history; no previous symptoms recognized by mom after moving into a large multifamily dwelling. Public Health nurse described mold on walls, dripping faucets, one small window in the whole place, roach infestation, mom and 3 kids slept in one room on a mattress on the floor. In addition to community health workers, other public health workers promote Healthy Homes principles.
For example, the PHSKC Home Health Hazards Project trained public health nurses to conduct in-home environmental assessments and education to address fall hazards, infant and toddler safety issues, and indoor air quality. Limited resources have restricted the scope of most Healthy Homes projects to educating household members, asking them to take individual actions, and assisting them with minor repairs.
However, more substantial structural remediation is often necessary to reduce sources of exposure. Remediation is often not completed given the lack of landlord interest or of resources to make the improvements e. Several Healthy Homes projects, with support from the Department of Housing and Urban Development HUD , federal home loan programs, energy assistance grants, and other sources, are assessing the benefits of more aggressive structural remediation interventions. Examples of remediation activities include removing and replacing extensive mold- or water-damaged material, installing continuously operating whole-house exhaust ventilation systems, repairing plumbing leaks, and removing carpeting.
We have considered landlord—tenant issues in the development of this project. Owners agree that rent will not be increased as a result of remediation and that tenants will be guaranteed the right to remain for at least 24 months after remediation, unless they violate the terms of the initial rental agreement. Boston and Cleveland are completing similar projects. Additional support for lead control has come from the federal government. Congress enacted the Residential Lead-Based Paint Hazard Reduction Act of with the goal of eliminating lead-based paint hazard in all housing as expeditiously as possible and preventing further childhood lead poisoning.
Federal funds are now provided to state and local health departments to determine the extent of childhood lead poisoning, screen children for elevated blood lead levels, help ensure that lead-poisoned infants and children receive medical and environmental follow-up, develop neighborhood-based efforts to prevent childhood lead poisoning, and safely remove lead from houses. Local health departments offer indoor environmental quality assessment of homes through visual inspection and, in some cases, through quantitative measurement of exposure to biological contaminants and toxic substances such as pesticides and heavy metals.
They also provide education on reducing exposure. One barrier to developing effective housing policy is the lack of information on housing quality at the community level. Although the US Census Bureau's American Housing Survey collects housing quality data for larger metropolitan areas every 6 years, smaller-area data for most municipalities and neighborhoods are not available. A few municipal housing departments collect supplemental local data e. We are unaware of any American local health jurisdictions that systematically collect and analyze local data related to housing and health, although some have in the past.
More than one-half of their annual health reports include a discussion of housing issues. Public health agencies frequently offer clinical assessment and management services to homeless shelter clients. Some of these agencies are responsible for operating shelters. Efforts to return the homeless to stable housing or to prevent eviction in the first place are less common. For example, the San Francisco Department of Public Health purchases buildings and renovates them for supportive housing for homeless or near-homeless people with substance abuse, mental health, or other chronic health conditions.
This activity requires the patching together of multiple funding sources from the state and local levels. The program has decreased the use of hospital-based acute care health services. Typically public health agencies do not build, maintain, or own housing stock; nor do they design housing developments or issue building permits. To promote healthy housing, they must collaborate with other entities who are more directly involved in the housing sector.
Our Healthy Homes Project works with the local public housing authority to increase its awareness of the impact of housing conditions on asthma.
The housing authority moved Healthy Homes clients to the top of its waiting list and offered housing that met Healthy Homes criteria. For clients already living in public housing units, the agency immediately repaired unhealthy conditions, gave priority to eradication of roaches, and moved the tenant to a more suitable unit e. The project also refers clients to local weatherization programs that have resources to improve ventilation and energy efficiency.
The New York City Department of Health is partnering with the housing authority to implement a pilot integrated pest management project to reduce exposure to pesticides and cockroach antigens. The Boston Healthy Homes Project works with a community development corporation to arrange grants to low-income home owners for remediation of conditions with adverse health effects. It is developing a decision-making tool to assist housing rehabilitators in incorporating affordable modifications that improve respiratory health.
The health authority in Cornwall, England used National Health Service funds to install central heating in homes that were damp and inhabited by children with asthma. An uncontrolled evaluation demonstrated significant reduction in dampness in children's bedrooms and in asthma morbidity. Public health workers support individuals and communities seeking better housing. For example, when public health staff assisted Healthy Homes participants in asking their landlords to make repairs, the tenants' requests were often more adequately addressed than when tenants tried on their own.
Home visitors from the New York City Department of Health assist tenants by encouraging landlords to correct hazardous conditions before enforcement action is initiated. Some local health departments have successfully advocated with local elected officials and agencies on behalf of increasing the availability of affordable, healthy housing. Public health workers have supported the efforts of community organizations fighting for improved housing conditions. Public health advocates can point to evidence demonstrating that residents of substandard housing who move to improved living environments enjoy better health outcomes.
Low-income seniors who moved from deteriorated, single-room, roach-infested apartments with inadequate kitchen and bath facilities into a new, well-designed senior apartment building with a senior center had lower mortality and improved self-reported health status after 8 years than a comparison group who were eligible to live in the new building but did not move.
Public health agencies provide information to the public regarding ways to make homes healthier and safer. They participate in distribution of smoke detectors, offer educational resources in print and on Web sites regarding indoor environmental quality, and help with efforts to eliminate hazardous wastes and toxins from homes. Public health workers continue to build on a long tradition of engagement with housing and health issues. Many of the efforts we have described are yielding benefits, although most are small in scale relative to the need.
Expansion of capacity is an important priority and is dependent on securing adequate resources. We conclude by suggesting what this expanded capacity might look like and what it might accomplish. Refinement of housing codes to reflect current knowledge of healthful housing is urgently needed. Continued and expanded efforts by the committee will help to include public health practitioners in such national endeavors.
It may also be useful for national organizations, expert panels, and local health departments to develop guidelines rather than codes. I just witnessed the reunification of a young mother with her 3 children in a homeless shelter. The family had previously lived together in an overcrowded apartment with other extended family members. When the 3 children ages 2, 5, and 6 all tested high for lead, the mother voluntarily signed the children over to custody of the Department of Social Services so they could be placed in a lead-free home.
The mother then tried and failed to find safe and affordable apartment for her family; moving to a shelter became her only chance to live with her children in safety. She is now homeless, searching for affordable housing, with little hope for securing a unit. At least her children have their mother back.
Boston Medical Center Web site. Accessed March 1, Revised codes and enhanced guidelines can lay the groundwork for an expanded public health role in housing quality consultation, education, and enforcement. Local public health agencies need guidelines in order to respond to concerns about housing quality brought to them by the public, community organizations e. These agencies must have the capacity to assess whether units meet standards, to educate property owners and builders about how to implement guidelines, and to impose sanctions if standards are not met.
Some owners of substandard property, especially landlords who own only a few units, lack the resources to improve their properties.
'Inadequate housing and health: an overview', Int. J. Environment and Ineichen, B. () Homes and Health How Housing and Health Interact, E&FN Spon. Poor housing conditions are associated with a wide range of health Exposure to toxic substances found in homes can result in chronic health problems. High -rise buildings may inhibit social interaction because they lack common spaces.
Public health can take the lead in advocating for policies and resources to assist them. Evidence is accumulating that Healthy Homes programs yield measurable health benefits. These programs are popular with the public and current capacity cannot meet demand. Options for expansion include increasing program staffing and incorporating Healthy Homes activities into the regular duties of other home visitors e. Advocating for payment by health insurers for some of these activities in the context of health assessment and education for patients with asthma may help fund this expansion.
Many state and local health departments produce community health assessment reports, yet few include measures of housing quality and resident satisfaction with housing. Special reports that describe housing status in more detail, using qualitative as well as quantitative methods and incorporating visual documentation of housing conditions, could be powerful tools to focus attention on housing issues.
Such assessment data could be invaluable for housing advocates attempting to improve housing in their communities.
For example, the documentation in prose and photos by Jacob Riis of tenement conditions in New York City in the late s helped intensify the tenement reform movement. A single public health agency cannot achieve the goal of ensuring access to healthy housing and building healthy neighborhoods. For example, the revision of housing codes and development of guidelines discussed above will require collaboration with other government agencies that regulate housing construction, tenants, community housing advocacy groups, nonprofit housing organizations, community development corporations, builders, home owners, landlords, architects, and urban planners.
Public health representatives can participate in local planning processes and offer consultation to housing agencies and developers.
They can encourage the use of Health Impact Assessment , methods to consider the health implications of new construction and zoning decisions. They can encourage development of policies and actions that incorporate the principles of healthy housing into housing construction and maintenance. They can advocate for the design of healthy communities that offer opportunities for physical activity, social interaction, and community building activities.
Public health workers can collaborate with community housing advocates by providing them with assessment data, offering technical assistance e. Working closely with advocates and residents, public health workers can also develop culturally appropriate educational materials that explain healthy housing guidelines. Closer collaboration with public housing agencies will protect the health of the most vulnerable populations. Partnering to make public housing units safe and healthy, supporting health promotion and community building activities, and developing mechanisms to identify children whose health is adversely affected by housing conditions and to rehouse them promptly are only some of the possibilities.
Public health workers should take the lead in advocating for housing policies that ensure access to affordable, healthy housing units and the elimination or remediation of unhealthy housing stock. Burridge and Ormandy note:. The deficiencies in the housing stock will not be remedied by the waving of some legislative wand. At best, legal intervention can provide some normative standards for fiscal or coercive action, and a framework for intervention. Deeper solutions lie in the political arena.
There is a pressing need for a public housing policy which embraces the perspectives of public health and the maintenance of a healthy national housing stock. Other arenas for advocacy include providing energy assistance for people with low income, expanding medical insurance coverage for items that make homes healthier e.
The extent to which these efforts will actually occur is dependent on the resources and organizational capacity of public health agencies. Staff already working on housing-related issues e. This team can develop a strategic plan to address housing issues in collaboration with other public health staff and external partners. Resources to implement local public health housing activities will come from a combination of local sources, federal agencies, and national foundations.
An important challenge is to develop sustainable and increased funding. Public health housing advocates may be able to interest the Centers for Disease Control and Prevention, other federal agencies, local housing developers, and health care payers in supporting their efforts. Political factors also influence the ability of public health to respond to housing issues. Substandard housing is an environmental justice issue. The inequitable socioeconomic distribution of substandard housing reflects underlying disparities in income, assets, and power.
Tenants are often powerless to improve their housing conditions in the context of the low vacancy rates, high rental costs, weak tenant protection laws, and politically influential landlord associations commonly found in American cities. Public health assets can help remedy this imbalance in power. Yet these circumstances also constrain public health practitioners, many of whom are reluctant to antagonize powerful local political interests and the elected officials who support them. The absence of organized community advocacy groups that can effectively balance landlords' influence further inhibits public health action.
The current political climate is not supportive of a proactive, regulatory approach to addressing housing issues. Moving beyond an advisory, incentive-based approach will require courageous public health officials who can ally themselves with supportive community organizations and local elected officials. Today, several issues drive the housing and health agenda: This new era of unaffordable housing and the health and social disintegration that accompanies it will demand further public health attention.
These issues, along with the growing interest in the return of public health to its roots in addressing social factors affecting health, are converging to establish housing as a priority public health issue. We have learned much in the past decade about how to make homes healthier places in which to live. Public health has a long history of promoting healthy housing.
In recent years, we have been less engaged. It is time for us to build on this groundwork and do our share in ensuring that everyone has a safe and healthy home. We thank the following colleagues for their thoughtful comments on drafts of this manuscript and for providing information about their valuable efforts in addressing housing and health issues in their communities: Krieger developed the initial concept for this manuscript. Both authors developed the final concept, reviewed relevant literature, and wrote the manuscript.
National Center for Biotechnology Information , U. Am J Public Health. Find articles by James Krieger.
Find articles by Donna L. Accepted January 28, This article has been cited by other articles in PMC. Abstract Poor housing conditions are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. Infectious Diseases Features of substandard housing, including lack of safe drinking water, absence of hot water for washing, ineffective waste disposal, intrusion by disease vectors e.
Chronic Diseases In more recent years, epidemiological studies have linked substandard housing with an increased risk of chronic illness. Traditional studies have often lumped many important components of the built environment into a blanket socioeconomic status variable. But this approach makes it nearly impossible to tease out specific housing and community characteristics related to disease.
So, although the traditional tools of environmental health science are still an important part of the mix, research endeavors in this area are now incorporating aspects of sociology, psychology, demography, urban planning, and architecture. Just as significantly, research efforts are reaching beyond the boundaries of the scientific community, embracing rapid translation of research into effective intervention and active collaboration with community members as central concepts in their research protocols.
Spatial analysis is one of the new tools being applied in attempts to quantify the relationship between health disparities and the built environment. One spatial analysis tool, geographic information system GIS technology, has long been in use in other areas such as city planning, demography, and epidemiology, but is now allowing environmental and public health researchers to characterize local environments at finely resolved geographic scales. More complete, accurate, and comprehensive geocoded data on resources within communities are becoming increasingly available from a growing number of sources such as governmental agencies, law enforcement agencies, and marketing researchers.
This allows researchers studying the built environment to look at communities in new ways. As part of a larger project examining neighborhood-level influences on mortality from all causes, Winkleby and her colleagues are preparing to publish results from two studies using GIS to link survey data with other information such as census data, health records, and site visits.
Both studies suggest pathways by which disparities in the built environment can be related to disparities in health. Interestingly, the other study found that another characteristic of the physical environment in the deprived neighborhoods influenced an individual risk factor. Among several CEHI programs currently in progress, the farthest along is an initiative to prevent childhood lead exposure called Mapping for Prevention.
The group has created GIS-based lead exposure maps for 36 North Carolina counties and several other sites around the country using census data, blood lead screening data, and county tax assessor data to identify high-risk areas for lead poisoning. Once an exposure map has been developed, the researchers work with local health departments to selectively and proactively screen children for lead exposure, and to educate new parents who live in high-risk housing about how to prevent their children from being exposed. They also help housing departments identify ways to prioritize housing rehabilitation and lead abatement funding to address the housing at greatest risk for lead poisoning.
Miranda is convinced that the spatial component is vital: One of the most significant recent developments in efforts to characterize and ameliorate built environment conditions associated with health disparities has been the growing movement toward community-based participatory research CBPR , which has been largely pioneered and supported by the NIEHS through a variety of extramural grant programs.
CBPR studies focus on gathering and disseminating scientific knowledge about the interrelationships between the physical and social environments and health, and to identify, evaluate, and implement potential interventions—all with a distinct emphasis on active collaboration with residents and other stakeholders within the communities being studied.
These multidisciplinary projects generally draw from many resources to arrive at comprehensive understanding of the multifaceted dynamics at work in populations suffering health outcome disparities—including negative aspects of the built environment. Academic researchers from the University of Michigan are working directly with several community groups and health service providers to examine the contributions of the physical and social environments to both ethnic and socioeconomic disparities in risk factors for cardiovascular disease among the adult population of Detroit.
Data have been gathered in three demographically diverse Detroit neighborhoods that were initially selected because they were anticipated to vary in their concentrations of airborne particulate matter. Air quality monitoring confirmed this differential exposure. The researchers also surveyed neighborhood residents, collected blood and saliva samples to assess physiological indicators of cardiovascular risk and stress, and sent observers into the neighborhoods to evaluate the built and social environments in each area. Although the group is still analyzing the data, principal investigator Amy Schulz, a research associate professor of health behavior and health education at the University of Michigan School of Public Health, says they are seeing trends suggestive of variations in both cardiovascular disease risk factors and protective factors that play out for different racial and socioeconomic groups across areas of the city.
For example, they have noted variations in dietary intakes of fruits and vegetables in population groups within the city, and intend to analyze whether conditions in the built environments of the neighborhoods can predict those variations. Residents of the Detroit neighborhoods being studied have been involved at all stages of the project, including helping to design the survey as well as collect and analyze the data. Also, says Schulz, community involvement contributes to a very rich analysis whose results are more likely to lead to change.
Positive changes to the built environment that help reduce health disparities can and do emerge from these partnerships. Much of that effort has focused on the Barrio Logan, a low-income Latino community plagued by poor air quality due to heavy diesel truck traffic from a major regional freeway dissecting the community, and a troubling mix of industries and residences in close proximity to one another.
Armed with results of an informal community health survey that showed disturbing levels of asthma and other respiratory problems, the group convinced the California Air Resources Board to begin monitoring air quality in the community. EHC and the community are also working on changes to land use and zoning that will reduce the number of warehouses and industries that generate diesel truck traffic in residential areas.
The air monitoring also led to a direct intervention to help a family in distress. The group had identified a metal-plating shop on a residential street in Barrio Logan as a potential hazard, and asked for air samples to be collected in the immediate vicinity. Regulators previously had believed that an operation of that size that was basically in compliance would not pose much of a hazard.
However, once they sampled the air, they found high levels of emissions such as chromium-6, a highly toxic air pollutant, at the houses next door and across the street, says Williams. It turned out that one family living next door had a son with poorly controlled asthma.
Respiratory health effects of home dampness and molds among Canadian children. Cold and heat-related illnesses in the indoor environment. These agencies must have the capacity to assess whether units meet standards, to educate property owners and builders about how to implement guidelines, and to impose sanctions if standards are not met. Tradition holds that home is a haven, where people are protected and nurtured. They also help housing departments identify ways to prioritize housing rehabilitation and lead abatement funding to address the housing at greatest risk for lead poisoning.
The EHC continues to make such unhealthful mixed land uses a priority in its activities. Housing is perhaps the ultimate nexus between the built environment and health disparities, and it has been the focus of much recent research and intervention activity looking at new approaches to old problems. That renewed interest is being manifested at the national and international levels, as well as in the form of grassroots community action. In late , the World Health Organization convened its 2nd International Housing and Health Symposium at Vilnius, Lithuania, a conference designed to review the existing scientific evidence on housing and health relationships, and assess needs for further research.
The two-day gathering of more than experts from government, academia, the building sciences industry, and public interest groups focused on increasing attention to the issue of indoor air pollution, with the surgeon general and other participants calling for action to improve the health of Americans by improving indoor environments. At the local level, two of the many CBPR projects in progress around the nation demonstrate the multifaceted, collaborative approach being taken toward not only characterizing housing and health pathways, but designing, implementing, and evaluating interventions as well.
Both have come about in response to the high prevalence of asthma in low-income urban communities, with a special focus on improving the health and housing conditions of public housing residents. The collaboration has produced guidance for builders, architects, and others on ways to make both new construction and existing housing healthier. Participants are currently engaged in a four-year project to assess the effectiveness of HPHI asthma intervention programs in three public housing developments.
The interventions include installation of air filters, purchase of new mattresses, heavy-duty cleaning, integrated pest management, family education on controlling asthma triggers, and installation of building systems upgrades and modifications. The group published a study in the 7 December edition of the online journal Environmental Health: A Global Access Science Source reporting the results of a detailed baseline evaluation of 78 asthmatic children living in the three public housing developments.
Among other findings, the study showed that many of the children, although they had access to primary care physicians, were not receiving care according to professional asthma management guidelines, which include recommended medications, monitoring practices and equipment, and other measures.
Also, exposure to violence, which has been related to exacerbation of asthma symptoms, was a significant problem. Add those factors to substandard housing, high concentrations of local ambient air pollution, and other negative aspects of neighborhood built environments, and it starts to become clear why the prevalence and incidence of asthma has risen so sharply and disproportionately among low-income minority urban children. A CBPR project currently under way in Seattle known as the High Point Healthy Homes and Community Project is taking full advantage of a unique opportunity to simultaneously address built environment issues in the public housing context and gain useful knowledge about how comprehensive interventions can be used to improve the health and well-being of residents.
The Seattle Housing Authority is in the process of reconstructing its public housing stock, to replace old, deteriorating structures with town homes. One of the sites being updated is High Point, formerly a unit development, which is now being rebuilt as a 1,unit mixed-income community. The High Point Healthy Homes and Community Project is taking a multilevel approach to designing a public housing development to be a healthy, sustainable community. Developers are thoughtfully addressing a range of considerations, from design issues such as layout, walkability, and watershed protection, to the use of construction materials and practices that enhance indoor environmental quality.
This project of the local public health department, housing authority, social service providers, public housing residents, and the University of Washington, with funding from the NIEHS and HUD, is paying particular attention to the needs of families affected by asthma. Researchers will follow the families for a year before they move into the units to establish a baseline assessment of their asthma status, and then continue to follow them for a year after they move into their new homes, which are currently under construction the first families are scheduled to move in in fall It is slated to include walking paths and trails, mini-parks and one larger park, a grocery store, a public library, and a community health center, in hopes that these amenities will provide a built environment more conducive to health and social interaction.
A community-based education initiative is also under way, using trained teams of community residents called project action teams to teach their neighbors about basic principles of how to keep their homes and community healthy. David Jacobs, a HUD housing expert, sees wide-ranging potential in projects that quantify such benefits.