“Where Does the Damp Come From?” Investigations into the Indoor Environment and Respiratory Health in Boston Public Housing

“Where Does the Damp Come From?” Investigations into the Indoor Environment and Respiratory Health in Boston Public Housing

Hynes, H Patricia

The pain in our shoulder comes

You say, from the damp; and this is also the reason

For the stain on the wall of our flat.

So tell us:

Where does the damp come from?

A Worker’s Speech to a Doctor

Bertoldt Brecht

INTRODUCTION

BY the early 20th century the public health and housing professionals had identified associations between poor health as measured by increased infant mortality and infectious disease and poor housing as measured by overcrowding, dampness, poor ventilation, and inadequate toilet facilities (1,2, 3). In lobbying for improved housing conditions, reformers recognized that safe and healthy housing nourishes the human spirit as well.

Housing is not merely shelter against the elements, Dr. Ira Wile told the American Public Health Association (APHA) gathered in New Orleans in 1919, it is a “home . . . for thinking, active, living human beings” and “. . . a determiner of personal, family and communal health” (3). In concluding his address, the physician listed several policy-based steps necessary to secure healthy housing for the poor, among them: 1.) a recognition of the links between human health and hygienic housing; 2.) enforcing standards of housing maintenance and repair; 3.) determining proper sanitation within apartments to protect against disease; and 4.) supporting the provision of affordable housing and a minimum living wage congruent with the cost of living.

Health in its many kindred forms-the health of people and families; community health; healthy homes; and clean, secure neighborhoods-has proven to be a unifying ideal and organizing issue for more than a century. Between the years 1997-2000, we, our colleagues, residents of Boston public housing, and community organizations undertook several pilot studies to investigate associations between respiratory health and indoor housing conditions. We tested the feasibility of a suite of indoor environment interventions known or suspected to improve asthma and related quality of life outcomes (4,5,6,7). Our series of community-based studies has grown into a comprehensive research, intervention, and public policy project with testable hypotheses. We generated the hypotheses from our pilot study findings and they are consistent with other research on housing and indoor environment conditions that affect respiratory health, asthma morbidity, and quality of life (8,9,10).

Partnerships that originated in our pilot studies have grown into the Healthy Public Housing Initiative, a community-university-city collaborative designed to work with public housing residents in a joint effort to improve resident health and building conditions in public housing. The collaborative is comprised of individual public housing residents, the Boston Housing Authority (BHA), and the Committee for Boston Public Housing (a resident advocacy organization); Boston’s three public health degree granting programs at Boston University, Harvard University, and Tufts University; a pediatric asthma specialist at the Boston Medical Center; the Franklin Hill and West Broadway Tenant Task Forces; the Boston Public Health Commission; and specialists in energy efficiency and housing policy and finance. Residents and resident advocates are integral to decision-making about study design, choice of interventions, ongoing community health initiatives, and long-term policy-making. The collaborative engages in five main activities: 1.) to gather science-based information about housing conditions, particularly those conditions that affect their health-training and using residents of Boston public housing to do so; 2.) to hold forums in which we discuss with residents our research findings and their related health, housing, and social questions and concerns; 3.) to plan together, implement, and evaluate cost-effective interventions in apartments and buildings, health promotion program with residents, and training for maintenance and capital staff in selected “best practices”; 4.) to assess changes in resident health and empowerment as a result of observed building improvements and project participation; and 5.) to disseminate the results locally, at the state level, and nationally intending to influence policy on housing and health.

This article reviews and summarizes our significant research findings from four pilot studies that form the foundation of our larger intervention study design. We explicate the principles of community-based research that inform the research design and the project decision-making. The strengths of this model of research into health and housing are also discussed.

PILOT STUDIES IN BOSTON PUBLIC HOUSING

Background

We and our colleagues undertook the initial Healthy Public Housing studies in Boston in 1997-98 to document the public health condition of public housing developments and the health of their residents for two compelling reasons. First, the prevalence of asthma has been steadily increasing since 1980 in the United States (11). According to the Centers for Disease Control, the self-reported prevalence of asthma increased by 75% from 1980 to 1994, a trend found to be significant (p

The role of ambient air pollution in urban areas as a risk factor for asthma, particularly ozone, nitrogen dioxide, sulfur dioxide, and particulates, has been widely investigated (17,18,19). Recently, however, researchers have turned their attention to the role of indoor environmental risk factors, especially in homes and schools. Moisture and mold growth, pest infestation, dust mites, the building envelope, certain heating systems, inadequate ventilation, oxides of nitrogen, and exposure to cigarette smoke are among the factors studied (8,9,10,20,21,22, 23,24). The Institute of Medicine (IOM) recently published the results of a comprehensive review of studies undertaken to determine the strength of evidence regarding indoor exposures, asthma development, and asthma exacerbation (8). The following conclusions were drawn. Exposure to house dust mites causes susceptible children to develop asthma. Exposures to cat and cockroach allergens and house dust mites cause exacerbations of asthma in sensitized individuals. Exposure to environmental tobacco smoke is associated with the development of asthma in younger children and causes exacerbations in children and adults as well (less strong evidence for older children and adults). Other indoor pollutants which are associated more or less strongly with asthma exacerbation include: fungi or molds (strongly), NO^sub 2^ and NO^sub x^ (strongly), formaldehyde and fragrances (limited) (8). Thus, evidence is strong and compelling to support investigating the indoor housing environments of children at risk of asthma.

The second impetus for our initial studies arose from our appreciation of risk and resilience in public housing. Many of Boston’s poorest families live in public housing: The average household income for Boston Housing Authority residents is $11,250, 17% of Boston’s median household income. Thirty-eight percent of the 26,000 residents living in Boston public housing are children. We know that children are particularly vulnerable to certain environmental exposures (25) and that most early childhood injuries happen in the home (26). Boston public housing mirrors the sex and race trends for poverty in Boston and the United States (27,28). Seventy-two percent of households are headed by women (Communication with BHA Director of Planning, June 5, 2001). The resident population is 31% Black non-Hispanic, 22% White non-Hispanic, 35% Hispanic, 8% Asian, and 3% “other.”

Numerous studies have documented high rates of morbidity and mortality among low-income minorities, the urban poor, and residents of poor quality public housing (29,30,31,32). Other studies have amassed evidence that income inequality, as well as relative poverty, result in decreased life expectancy and higher morbidity (33). Inequality in the United States, as measured by the Gini coefficient for family income, rose 14% between 1973 and 1991 and did not decrease during the 1990s. The post-World War II reduction in poverty, growth of the middle class, and decline in inequality has reversed during the past 25 years (34).

Even with the burden of poverty and deteriorating social conditions for the poor (28), public housing remains a prime locus for environmental health intervention for positive and strategic reasons. Housing developments elect “tenant task forces” that wield some power in decisions concerning the development; and developments offer community programs for youth and adults and, in some cases, multi-service centers. Public housing is centrally administered and financed by a housing authority responsible for building maintenance and renovation. Housing developments in Boston are located within the catchments of community health centers used by residents. Proximity to community health centers, management infrastructure, and resident leadership make public housing developments and the housing authorities good candidates for collaboration with universities, local health centers, and non-profit organizations to achieve the following Healthy Public Housing Initiative goals:

* improving residents’ health with better maintenance and repair of their housing;

* providing community health programs tailored to their lives and reality; and

* empowering residents through training, employment, and shared decision-making.

The success of the pilot studies summarized below is attributable in substantial part to the public support of tenant task forces, the involvement of residents as part of the research team, and the cooperation of the housing authority.

Pilots 1 & 2.

Surveys in West Broadway and Franklin Hill Developments

During the years 1998-1999, we conducted cross-sectional surveys of housing and health conditions in households drawn by probabilistic samples-50 in the West Broadway Development in South Boston and 53 in the Franklin Hill Development in Dorchester, two of the 64 managed by the Boston Housing Authority. Both are Veterans Era family housing constructed in the 1940s, with similar building envelope features but differing histories of renovation (Personal Communication with BHA Director of Planning, BHA, June 5, 2001). The BHA had renovated West Broadway substantially at the time of our survey, but not Franklin Hill.

Tenant task forces and residents were actively engaged in the survey process. Teams of trained residents and health center workers in the case of West Broadway, and teams of trained residents in the case of Franklin Hill, conducted the surveys with supervision. The survey had 19 categories covering health symptoms and asthma status; the commonly researched and surveyed aspects of indoor environment relating to asthma; and those housing conditions most associated with injury and illness. A set of questions on maintenance history and another on the role of the tenant task force were included to learn the tenants’ experience with each. Wherever relevant and possible, resident interviewers confirmed responses to questions about housing conditions through visual inspection, for example, cracks, holes, visible mold, and water damage.

Training Residents. We offered resident interviewers a multi-session tutorial on common physical, chemical, and biological indoor contaminants and hazards and their association with asthma and respiratory illness. We trained them in interviewing techniques and the sampling protocol. We pilot tested the survey instrument with them during the training, receiving their feedback on the clarity, relevance, and comprehensiveness of the survey questions.

Results. We have reported descriptive statistical results from the West Broadway survey previously (4). They are presented in Table 1, which summarizes the prevalent health-related housing problems, most of which were associated with the physical conditions of the building and apartments in West Broadway Development: water leaks; moisture and mold; uncontrolled heating and surfaces that burn the skin; insufficient ventilation; and sanitation in public areas. Other findings, summarized in Table 2, suggest vital areas for tenant health education and advocacy, such as child-safety programs, smoking cessation programs, and asthma education.

We incorporated in our survey a series of questions on repairs and renovations in order to learn about residents’ knowledge of the work order process for repairs and their experience with timeliness and quality of repair work and the responsiveness of inspectors. We found that virtually all West Broadway residents knew about submitting work order requests. The majority (72%) reported that BHA inspectors were responsive to their concerns. However, half of the respondents stated that multiple requests were often required for the same problem. We concluded that routine maintenance may be ineffective because maintenance personnel lack training or because they use inferior repair materials rather than that BHA maintenance staff are unresponsive.

The findings of the pilot study in the second development, Franklin Hill, were consistent with those reported in West Broadway and for some concerns, such as mold and cockroach infestation, more respondents mention them. This may be due to the relative lack of renovation in Franklin Hill compared to West Broadway and a less effective pest control program. The Franklin Hill study also found high rates of physical conditions associated with respiratory illness: moisture (42%) and mold (43%); one or more large cracks in walls, ceilings or floor (49%); overheating during the previous winter all or some of the time (73%); stuffy air (66%); pest infestations (40% mice-70% cockroach) and sewage backup in buildings or apartments (33%). Respondent smoking rates (35%) were lower than West Broadway (49%); nonetheless, they were almost twice as high as the state average for adults (17%) (35). Self-reported prevalence rates of medically diagnosed asthma in adult respondents (40%) and child asthma (56%) were extraordinarily high. The Centers for Disease Control and Prevention estimated that the prevalence rate of asthma in New England in 1998 was approximately 6.5% (36). Eleven children out of 61 included in the survey were reported to have required hospital care for an asthma attack (5).

Associational Analysis. We calculated and have reported (5) crude prevalence odds ratios for various combinations of reported indoor environmental conditions at a particular time and health symptoms in the previous month for each housing development and adjusted odds ratios for Franklin Hill. In both cases we found statistically significant associations between a number of health symptoms and apartment conditions. Certain higher exposures in Franklin Hill, such as for cockroaches and sewage, had more significant associations with health symptoms than in West Broadway. On the other hand, we found more significant associations between symptoms and over-heating in West Broadway than in Franklin Hill.

Table 3 displays the results for associations between selected indoor environmental conditions and self-reported health symptoms, tested with 95% confidence intervals for West Broadway Development. Overall we found that 74% (26 out of 35) of the associations in West Broadway were positive, that is, increasing exposure correlated with increasing symptoms. Some of the exposure variables were associated with each other: for example, moisture was positively correlated with mold and mold was positively correlated with cockroaches.

We are aware of a number of possible biases and limitations that may have influenced our results. The health symptoms were self-reported, and not all environmental conditions, such as the presence of cockroaches, could be visually confirmed at the time of the survey. Respondents were not blinded to the purpose of the survey; and those with respiratory symptoms could have been more aware of and thus more likely to report adverse housing conditions. However, residents have been interviewed extensively over the years about housing conditions, and they conveyed to us that past experience had given them little cause to expect change or improvement in housing conditions because of our survey findings (37). Moreover, fear of reprisal is likely to result in under-reporting rather than over-reporting of adverse housing conditions by residents. In recent discussions with residents about the likelihood of under-reporting because of concern about retaliation by the housing authority, they asserted that residents are more likely to report objectively if they trust the interviewer and understand the purpose of the survey. In other words, an open environment rather than a blinded one may result in more informative and truthful response on the part of residents in public housing.

Professional interviewers unknown to the community and blinded to the purpose of the study could have been used. However, outside interviewers were not likely to gain the trust of the community as did resident interviewers. With outside interviewers we would have risked a low response rate (38), incompletely answered surveys, and inaccurate responses due to residents’ mistrust of strangers. Employing resident interviewers, we have achieved an acceptable response rate (50 of 80 in West Broadway, and 53 of 98 in Franklin Hill) and largely complete surveys.

Our sample size in each development was small, resulting in large confidence intervals. We were able to show statistical significance only for particularly robust associations and it is possible that many “real” associations were missed due to our limited power to document them. Most of our significant findings are ones that we expect to measure and document physically in the larger intervention study we are currently undertaking.

Despite the limitations of our pilot studies, the statistically significant associations (p

We drew six conclusions from these studies:

1. Housing conditions that are likely to impact respiratory health negatively were common in the public housing developments.

2. The two housing developments had extremely high self-reported rates of respiratory symptoms and asthma.

3. The associations between respiratory symptoms and housing conditions in the preceding month were frequently positive, sometimes statistically significant, and in keeping with the literature.

4. The two studies were largely consistent, with preliminary suggestions that renovated housing had slightly fewer problems.

5. Engaging community residents strengthened the research process by improving acceptance and trust of the study, thereby ensuring a higher response rate and more complete responses.

6. A larger randomized intervention study which includes environmental monitoring and objective health outcome measures could increase the likelihood of identifying housing-related interventions that decrease asthma morbidity and respiratory symptoms and increase quality of life.

Pilot 3

Asthma Intervention Study in Franklin Hill Housing

Attempts to show that broad, population-based interventions can reduce asthma severity are in their early stages and have met with limited success thus far. Attempts to assess effects from interventions have reported reduction in emergency room use among severe asthmatics achieved through training clinic staff (40,41) and providing asthma management plans that emphasize proper medication use and monitoring with a peak flow meter (41,42,43). The National Cooperative Inner-City Asthma Study, a randomized controlled intervention trial, found significant reduction in asthma symptoms (p=0.004) for severely asthmatic children as a result of physician and participant education, provision of pillow and mattress covers, and referral to smoking cessation programs (44). A second report from the same study was largely unsuccessful in reducing cockroach antigen through pest control (45). Health management interventions employing a case manager, such as a nurse or social worker, had positive results in reducing symptoms (42) and emergency room use (40).

Given the paucity of successful environmental interventions targeted to known risk factors for asthma exacerbation (8), the question arises why environmental interventions in inner cities have had minimal results. Are they ineffective in reducing the targeted environmental conditions; short-lived in their effectiveness; or logistically difficult to implement? We undertook a pilot study of asthma interventions to test their effectiveness in changing the environment and to learn from a small, intensively studied sample how to intervene more successfully within the family environment of public housing residents.

The pilot study, reported in more detail elsewhere (6), sought to conduct an intensive environmental intervention evaluation in the homes of nine children with physician-diagnosed asthma. Each family was provided apartment-specific interventions designed to filter air, reduce pests, and reduce dust-borne antigens. To assess baseline conditions and measure the environmental impact of the interventions over time we followed families for up to 6 months with monthly measurements of biological, physical, and chemical factors in the indoor environment. In order to study the feasibility of diary keeping, symptoms were recorded in asthma diaries. We organized a focus group discussion with the participating families toward the end of the study.

Observations

Working so intensively with families in their homes, we observed first-hand many of the realities and complexities of residents’ lives, factors we might want to take into account in the choice and design of asthma-related interventions:

1. Younger children often sleep with their parents, thus a dust mite control program should include parents’ mattresses and pillows as well as those of children. Extra mattresses were stored on top of each other, facilitating cross-contamination.

2. Low-income tenants commonly inherit or buy second-hand furniture and mattresses that probably carry a burden of biological contamination. Residents do not have the cleaning capacity needed to de-contaminate old furniture.

3. Hallways have strong chemical odors, probably a result of historical build-up from cleaning solutions. Our industrial cleaning provided only temporary relief. Entryways lack doormats to collect dirt tracked in.

4. Residents use their gas ovens for heating, particularly in transitional weather of spring and fall. Wash is often dried in apartments, which can result in standing water.

5. The structure of the walls and ceiling in the units provide limited flexibility when designing mechanical ventilation as an intervention. Un-insulated exterior walls are prone, in some cases, to condensation and mold growth.

6. Most exposed steam pipes in apartments are un-insulated and have surface temperatures between 140 and 180° Fahrenheit. Unable to manually control temperature, residents open windows in winter, which results in low relative humidity in units.

Results of Environmental Analysis and Interventions

Each family was provided with a combination of apartment-specific interventions, including bed covers, air filtration systems, integrated pest management (IPM), HEPA vacuums, industrial cleaning, and insulation. We chose the mix of interventions based on the results of allergen tests and the environmental conditions in each apartment, as assessed in an initial visual inspection of each apartment. Visual observations were made monthly for signs of pests, mold and wetness. We sampled, starting with a baseline and over a 6-month period for NO2, VOCs, PM2.5 and PM10. Dust samples were collected monthly for dust mite, cat, dog, cockroach and mouse, and mold antigen analysis. We measured temperature and relative humidity continuously in the asthmatic child’s bedroom and in the living area.

Baseline data confirmed and amplified our findings from the previous cross-sectional survey at Franklin Hill. The primary problems we encountered were overheating from exposed steam pipes, low relative humidity, fungi in some apartments, cockroach infestation, intermittent high NO2 from un-vented gas stoves and heating with gas ovens, and elevated PM 2.5 from smoking.

Insulating exposed steam pipes protected residents from burns and scalding; however, there was no observed effect on apartment temperature and relative humidity. For both PM 2.5 and PM 10, the mean concentration did not change after installation of the air filtering equipment. Figure 1 shows PM 2.5 levels pooled from time series data over the 6-month project period. PM 2.5 measurements were collected on pre-weighed coated filters, using Marple impacters attached to Harvard Black Box pumps. The samples were collected monthly, sorted for smoking (n=7) vs. non-smoking (n=2) apartments by visual examination, and analyzed gravimetrically at the Harvard School of Public Health Environmental Chemistry Laboratory. Our results indicate that PM 2.5 levels in non-smoking apartments are comparable to ambient concentrations at two local outdoor monitoring stations; and that PM 2.5 levels are elevated in the apartments where smoking takes place.

Cockroach antigen levels were extremely high at baseline, prior to the intervention. Our intervention consisted of removing cockroach nests, industrial strength cleaning, sealing cracks and crevices, cleaning bedding covers, and laying traps. Figure 2 shows the impact of our control measures for two enrolled apartments. The first cleaning process reduced cockroach antigen levels to half, but did not reduce them below the sensitization level of 1 U/g. A second cleaning in one of the apartments, midway through the study, reduced antigen levels to near the sensitization limit. In both apartments, however, within two months after the first cleaning, antigen levels returned to high levels.

Average levels of dust mite antigen were below levels of concern. They were further reduced in bedrooms after installing mattress and pillow covers, but no reduction was found in living rooms. Although residents reported little use of hazardous products, with the exception of air fresheners, twenty-one volatile organic compounds were detected in indoor air samples. The mean concentrations of eight compounds were above a reference dose presenting 10^sup -6^ risk of cancer (46). Analysis of dust samples from bedrooms and living areas for viable fungal spores were generally higher than those reported in the literature. Our samples contained species and varieties implicated with asthma. In summary, the environmental contamination that we found was broadly consistent with the literature.

We attribute our success in engaging and retaining nine families for the intensive six-month intervention to two reasons. We collaborated with a community partner, the Committee for Boston Public Housing, which has strong ties to residents in the development; and our field staff was Spanish-speaking, sensitive to the realities of residents’ lives, and highly respected by the residents. Nonetheless, fewer than half of the asthma diaries were successfully completed by residents.

Our industrial cleaning intervention was effective in the short term but not over time, suggesting a need to identify more permanent solutions. From our environmental measurements, we hypothesize that cockroach antigen may be of more concern than dust mites in overheated public housing developments such as Franklin Hill. Further, we strongly suspect that to achieve improved health status it will be necessary to control most, if not all, of the asthma-related indoor contaminants we identified. It is notable that the dominant environmental problems identified arise from a combination of personal factors (e.g., smoking); institutional factors (e.g., mold, exposed hot pipes, un-vented gas stoves and the heating system); and combined factors (e.g., cockroaches).

Pilot 4

Efficiency Upgrades and Public Health Concerns and Opportunities

The Boston Housing Authority, in partnership with US Department of Energy (DOE), US Department of Housing and Urban Development (HUD), local utility companies, and the state of Massachusetts, has initiated three ambitious energy and water efficiency initiatives for their housing developments. The first two initiatives include energy and water efficiency upgrades, such as new gas-fired distributed heating and direct-fired domestic hot water systems, low-volume toilets, and water conservation devices, in 2,500 apartments. The third initiative involves an intensive planning effort around energy and water conservation upgrades for the remaining 12,500 apartments. Energy-related investments of more than $40 million could yield an estimated annual savings of $4.3 million on BHA’s current annual utility bill of $25 million (Personal Communication with Kate Bennett, April 16, 2001).

Except for our cross-sectional survey in West Broadway Development, no baseline studies of the thermal comfort of residents and thermal conditions of apartments existed prior to energy retrofits to buildings. Experience has shown, however, that heating system upgrades in public housing of a similar construction to the 19405 Veteran Era housing found in the BHA portfolio can exacerbate chronic moisture problems, creating a sensation of dampness, condensation on windows, and excessive mold growth (47). To redress moisture and mold problems in Lawrence Housing Authority buildings that had undergone energy retrofits, an assessment recommended increases in temperature limits and installation of mechanical ventilation in bathrooms, basements, and crawlspaces (24).

In this fourth pilot study, previously reported (7), we took the opportunity of the BHA energy retrofits to measure indoor environment conditions such as temperature, humidity, air changes per hour, thermal gradients, drafts, and ventilation in a small number of apartments at different housing developments. These investigations revealed several building-related air quality and thermal comfort problems. In mid- and high-rise apartment buildings, physical building conditions draw odors from trash chutes into corridors and apartments. In lower floor apartments, negative air pressure due to a thermal stack effect during the winter pulls cold draft air from around leaky exterior doors and windows. Many apartments had cold floors, substantial vertical temperature gradients, and very low (25%) relative humidity (48).

Figure 3 documents the indoor temperature and percent humidity level measured in one of the eight sample apartments at Franklin Hill Development in December 1999 (48). Figure 4 documents the temperature and humidity levels measured in one of the five sample apartments at West Broadway Development in April 2000 (48).

By the nature of their design and construction, Veterans Era public housing is very tight, measuring about one-half the air changes per hour of comparable building envelopes (47). The historic means of moisture control in overheated apartments has been for residents to leave windows open, resulting in low relative humidity. When apartment temperatures fall, residents close their windows for longer periods of time and apartment humidity levels increase.

Figure 3 documents high apartment temperatures (81° F average indoor temperature at five feet) and very low humidity levels (

Understanding the consequences of energy efficiency improvements for indoor air quality and resident health could help guide future BHA energy upgrades. Incentives for public housing managers to upgrade systems usually fail to reward improvements in indoor air quality and respiratory health achieved in selecting and installing energy savings improvements. Air quality and health have historically been deemed to be beyond the scope of energy efficiency projects and might even increase the energy consumption of the development (such as a recommendation to increase ventilation rates). Yet experience has shown that heating system upgrades, reduced rates of air exchange, and tighter windows, installed without consideration for resident health, can exacerbate chronic moisture problems in apartments and, thus, put residents at risk for poorer respiratory health (9, 47). A systematic evaluation of standard energy improvements on indoor air quality and resident health is needed.

In anticipation of adequate scientific data from our larger intervention study, we offer the following summary of indoor environment conditions as target standards for BHA to consider as part of their energy and water efficiency master plan development. In particular, BHA should specify energy and water efficiency measures that:

1. Provide consistent apartment temperature control that allows residents to maintain apartment temperatures above 65° F and below 78° F (Massachusetts State Sanitary Code 105 CMR 410.201).

2. Provide consistent apartment humidity control that allows residents to maintain all apartment room relative humidity levels between 30% and 50% relative humidity.

3. Provide exhaust ventilation in bathrooms and kitchens, if necessary.

4. Examine strategies to provide domestic hot water temperatures above 131° Fahrenheit for laundry and at 12.0° F for bathing and washing (Massachusetts State Sanitary Code 105 CMR 410.190).

5. Cover or reduce the temperature of exposed heating and domestic hot water systems’ piping in apartments.

6. Include EnergyStar rated windows that can be equipped with child window guards.

7. Insulate all potable water piping to reduce condensation.

COMMUNITY-COLLABORATIVE RESEARCH

Throughout the four pilot studies reported in this article, we have employed principles of community-based participatory research (49,50). These principles include: (1) a receptivity toward the knowledge and “local theory” of community and health center participants; and sharing of skills and knowledge; (2) just compensation to community members for work done on the project; (3) data gathering for the purposes of education, remedial action, and social change; (4) inclusion of social and environmental determinants of health as well as behavioral ones; (5) sharing results with the tenants and health center staff for joint discussion and strategizing about follow-up health programs and housing improvements; and (6) co-presenting and co-publishing the project results with resident participants and community agency partners where feasible and relevant. An examination of each of the pilot studies reveals that, while not necessarily fulfilling all of these principles, the community-collaborative research model has resulted in sounder research instruments, actionable data, and multiple community benefits.

Tenants’ knowledge and experience living in West Broadway and Franklin Hill Developments influenced the housing and health assessment survey conducted in Pilots 1 and 2. Discussions with the residents during our training and a preliminary walkthrough of their apartments resulted in our adding questions in several categories, including heating, appliances, building maintenance, and sewage backups. A recommendation from one health worker resulted in our including the section of questions on child safety. We shared skills and knowledge with tenants to demystify indoor environment principles and enable them to conduct the surveys in as professional a manner as possible. They, in turn, gave feedback during the trainings about survey questions that were ambiguous or awkwardly constructed and in focus groups once the surveys were completed. Our survey instrument is clearer and more user-friendly, particularly for community-researchers, as a consequence. In funded projects, we reimbursed residents with a fair market wage for their participation in training and interviewing other residents (in keeping with the principle of just compensation for their work on the project). Finally, two resident researchers participated as co-authors in two of the publications cited in this paper and a third resident researcher spoke on panels sponsored by the university partners.

Because of its inclusive and participatory nature, Pilot 3 provided many insights into the reality of residents’ lives that, if ignored and unobserved, could constrain and limit the design and outcomes of a future intervention project. In particular, the pilot intervention results, such as the short term effect of the IPM intervention and the failure of asthma diaries for health data collection, were valuable lessons brought to the next full-scale phase of our research collaboration-a year-long IPM intervention in the homes of asthmatic children studying longitudinally the change in environment and asthma symptoms, lung function, and medical outcomes (51). Pilot 4 provided early empirical results suggesting the impact that buildingrelated energy conservation can have on indoor air, particularly by increasing indoor humidity. It also helped heighten institutional awareness within Boston Housing Authority of the potential links between conservation measures and respiratory health. The results affected actions, a goal of community-based research. In its recent 5-year energy-related master-plan, BHA has made a public commitment to create more healthful living conditions with the energy efficiency capital improvements, a commitment influenced by the pilot findings of this project.

In concluding, the words of Lilly Berry, a resident of West Broadway Development who participated as an interviewer in the housing and health survey, speaks to the goal of empowerment within community-based research:

I think the Healthy Public Housing project empowered a lot of residents and gave them a better sense of themselves, better self-esteem because they could share their knowledge with their families and neighbors. When residents see we did something very simple like letting BHA know that these conditions are affecting our health and we want a change and that there are people willing to work with us, it’s very empowering.

Acknowledgments: The authors would like to acknowledge the residents of West Broadway and Franklin Hill Developments, the Boston Housing Authority, the staff of the Public Health Initiative of the South Boston Community Health Center, the Boston Public Health Commission, and the Committee for Boston Public Housing for their contribution to this project. Pilot studies 1 and 3 were funded by the U.S. Environmental Protection Agency. They received IRB approval from the Boston University School of Medicine and Tufts School of Medicine, respectively.

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ABSTRACT

The self-reported prevalence of asthma increased by 75% from 1980 to 1994, a trend found to be significant and evident in every region of the country. The increase has been most marked in children 0-14 years of age, and there is evidence that, as with lead poisoning, inner-city and urban populations are most at risk. Attention has turned to the role of indoor environment risk factors, especially in homes and schools. Such factors include moisture and mold growth, pest infestation, dust mites, the building envelope, heating systems, inadequate ventilation, NO2, and environmental tobacco smoke. The Healthy Public Housing Initiative (HPHI) is a Boston-based community-centered research and intervention project designed to engage Boston Housing Authority residents in a collaborative process to improve respiratory health, quality of life, building conditions, and building maintenance in public housing. This article summarizes the significant research findings from four pilot studies in housing developments that lay the foundation for the larger HPHI asthma-related environmental intervention study. The research design for the pilot projects is informed by principles of community-collaborative research. The strengths of this model of research to our work are also discussed.

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