Green Healthy Housing for Older Adults Jill Breysse, CIH National Center for Healthy Housing Sherry Ahrentzen , PhD Uni

1. Green Healthy Housing for Older Adults Jill Breysse, CIH National Center for Healthy Housing Sherry Ahrentzen, PhD University of Florida

2. By 2030, more than 70 million Americans – and 960 million people worldwide – will be 65 years or older

4. Seniors Susceptible to Housing Conditions • Many older adults spend 80% to 90% time indoors at home • Bronchial hyper-responsiveness, respiratory, diabetes • More likely to live in older homes • Arthritis, osteoporosis, muscular atrophy, visual impairments • With older heating/cooling systems • Thermal stress, lower activity and metabolic rate, visual impairments • Older homes can be damp, noisy, stuffy, dark • Anxiety, depression, 11.2 million seniors living alone in 2008 • Homes built prior to ADA, Fair Housing, or visitability legislation • Physical, sensory and cognitive disabilities • Majority live in auto-dependent suburbs • Limited mobility, diverse population with diverse housing needs • More likely to engage in pro-environmental behaviors, purchases • Depression-era frugality, practices, familiarity, consumption values

5. Is Green Housing Healthy Housing for Seniors? Two Retrofit Case Studies GREAT Study: Mankato MN GAP Study: Phoenix AZ • Cold Climate (Zone 6) • 7-story, circa 1970s • Public housing, primarily seniors and disabled • Retrofit to Enterprise Green Communities & LEED • Lengthy construction (~2 yrs) • Environ. monitoring, • health interviews, VA, • bldg performance • HOS-based interview • Panel study, pre- and post- • Hot, Arid Climate (Zone 2) • 3-story, circa 1970s • Project-based Section 8, • seniors only • Retrofit to ARRA Green • Retrofit Program • Short construction (~6 mos) • Environ. monitoring, health interviews, bldg performance, environ. perceptions • NHIS-, BRFSS-based interview • Panel study, pre- and post-

6. Health Outcomes Among Primarily Elderly Residents Associated with Green-Renovated Public Housing

7. Study Team Orness photo: Blumentals Architects

8. Research Goals

9. PRE-RENOVATION Source: Blumental Architects

10. GREEN RENOVATION POST-RENOVATION Source: Blumental Architects

11. Methodology • Health Interview: • Physical &Mental Health: Medicare Health Outcomes Survey (HOS) • VR-12 Health Survey Physical Component Score (PCS) & Mental Component Score (MCS) • Limitations in Activities of Daily Living (ADL) • Housing condition • Visual Assessment • Environmental Monitoring and Sampling • Building Performance Testing

12. Study and Comparison Groups Study Group: • Baseline: 53+19=72 residents in two stages • 1-Yr Post: 40 of 49 baseline participants • 2 study groups: All Ages (33-86 yrs; n=40) & Elder (65-86 yrs; n=22) Comparison Group: Medicare HOS: HOS All Ages group (n=40); HOS Elder group (n=572)

14. All Ages: Mental Health Outcomes *marginally significant and **significant at p<0.05

15. All Ages: Physical Health Outcomes *marginally significant and **significant at p<0.05

16. ELDER: Physical Health Outcomes *marginally significant and **significant at p<0.05

17. Housing Condition **significant at p<0.05

18. Environmental Monitoring and Sampling • Dewpoint: Connection between indoor and outdoor • CO2 levels significantly improved • No significant change in TVOC, formaldehyde, most allergens

19. Building Performance • Fresh Air Ventilation: 1-BR: 53 cfm (ASHRAE 20 cfm) • Bathroom Exhaust Testing: 29 cfm (ASHRAE 25 cfm) • Pressure Balance: minimal deviations from design • Energy Use: 44% reduction

20. Conclusions • Greatly improved building, esp. HVAC system • Improved mental health • Improved general physical health • Fewer falls • Substantially less indoor smoking

21. Green Apple Project [GAP] Phoenix, AZ

22. Green Apple Project Research Team

23. Sunnyslope Manor — Phoenix

24. After a green retrofit of assisted housing development for low-income older adults… • IEQ will show sustained improvement although it may be worse immediately • If IEQ improves, residents will perceive this change • Environmental and IEQ improvements will correlate with corresponding changes in resident health, behavior and attitudes • Retrofit changes may result in healthcare cost savings, for falls prevention

25. Research Methodology • Panel Study: O X O O • Data Collection Periods • P1: June-July 2010 • X: Feb – July 2011 • P2: April – Sep 2011 • P3: June – Aug 2012 • Sample Size • — P1: 77 residents in 73 units • — P1 + P2: 59 residents in 55 units • — P1 + P3: 57 residents in 53 units • Proxy + Threshold Measures

26. Major Renovations • PTAC system updated • Energy Star exhaust fans, appliances • New bedroom ceiling fan • Double-pane, low-E sliding balcony door and window • Low-flow plumbing fixtures • New roof primer, insulation • Complete kitchen remodel and bathroom remodel with low-VOC materials • Low-VOC flooring, paint, adhesives

27. Resident Characteristics • 74% women, 26% men • Average age: 73 (range 62 to 92) • Race/ethnicity: 83% White, • 5% Native American, 4% African American, • 2% Asian American, 14% Latino • 21% smoke • 88% live alone • 65% report at least 1 respiratory problem • # days in last 30 that physical health • not good (at P1): 3 (median) • Emotional distress significantly higher • than national sample (NHIS) of low-income • older adults

28. IEQ Data Collection • Temperature • RH • CFM50 • Particulate Matter • Formaldehyde • Acetone • Acetaldehyde

29. Health Data Collection (NHIS, BFRSS/Arizona) • Quality of Health/Life • Respiratory-related • Emotional distress • Sleep • Functional activities • Falls • also • Comfort/satisfaction of lighting, thermal, air quality, humidity • Household cleaning frequency, products

30. Panel (Fixed-Effects) Regression Analyses “Scorecard” Immediate Outcomes Sustaining Outcomes • Temperature • RH • Air Infiltration • Particulate Matter • Formaldehyde • Acetone • Acetaldehyde • Overall Quality of Health/Life • Respiratory • Emotional Distress • Sleep • Functional Limitations, Falls • IEQ Perceptions • Cleaning Behaviors19 • Temperature (min, max, extremes, var) • RH (variability) • Air Infiltration • Particulate Matter (for smokers) • Formaldehyde • Acetone (i/o only) • Acetaldehyde • Overall Quality of Health/Life • Respiratory • Emotional Distress (improve) • Sleep • Functional Limitations, Falls • IEQ Perceptions • Cleaning Behaviors + Booklet Use • Falls Risk Cost Threshold Exceeded

31. 1. Major Finding: Extreme Temperature Reductions in Units Overall across panels, a noticeable reduction in extreme indoor temperatures Count = # of times of 448 data points that Indoor temperature exceeded 81º

32. Extreme Temperature Reductions in Units (cont.) Within a resident’s apartment, significant reductions in number of instances of extreme indoor temperatures from baseline to post-retrofit panels

33. Extreme Temperature Reductions in Units (cont.) Significant correspondence between a unit’s sustained (P1P3) reduction in extreme temperature AND improvements in resident’s reported quality of health/life, emotional distress and sleep

34. 2. Major Finding: Formaldehyde Reduction Material choices (i.e. low VOC sealants and paint) had greatest impact on decreased formaldehyde. Astoundingly high levels of FA found in Panels 1 and 2; decreased in every unit in the long term. Initial elevation can be expected for installation of new carpeting or cabinetry.

35. 3. Major Finding: Reduced Emotional Distress Associated with Changes in Environmental Perceptions Following Retrofit • Physiological Changes – Quality of life/health – Functional activities • Environmental Changes – Long-term reductions in extreme temperature in unit – Short-term (and marginally long term) reductions in formaldehyde concentrations – Long-term reduction after construction • Environmental Contribution (+P2, -P3) • Resident Perceptions of Environmental Quality (P3) – Satisfaction kitchen lighting – Satisfaction kitchen temperature – Satisfaction kitchen air quality – Lighting enhances comfort – Satisfaction with visual comfort Level of significance

36. 4. Major Finding: Expected Reductions in Health Care Costs of Falls Approximate Target Renovation Costs Baseline rate of injuries over 15 years: 330 falls, of which 105 would require medical care Falls Post Renovation: • After 3 months: 52% reduction • After one year: 6% reduction • $$$ • At 6% reduction, savings in health care • costs ($266,000) approximate cost of selected renovations ($286,000) for: • Improved lighting • Improvements in floor treatments • Improvements in stairway hand rails

37. Take-Home Lessons • Both studies: Green renovation can have positive impact on mental health and fall prevention • GAP: Green renovation may reduce exposure to contaminants, and some health improvements may be tied to changes in environmental quality • GREAT: No-smoking policies may be feasible part of green renovation

38. Where to Go From Here Studies of and Programs for Older Adults need to: — Capture impact on healthcare costs — Ask appropriate questions to better assess health- and activity- related changes of older people — Oversample those with more serious chronic health problems, especially respiratory illness — Examine relevancy of conventional IEQ standards for older people — Collect biomarker data to objectively measure health changes — In conjunction with home renovations, collect data on non-structural interventions impacting health, e.g., smoking programs, home visits by health professionals

39. Teams GREAT Study: Minnesota GAP Study: Phoenix, Arizona Jill Breysse: National Center for Healthy Housing Sherry Dixon: National Center for Healthy Housing David Jacobs: National Center for Healthy Housing Jorge Lopez: Southwest Minnesota Housing Partnership Billy Weber: University of Minnesota, Center for Sustainable Building Research Co-PIs: Ernesto Fonseca, Matt Fraser, William Johnson, Mookesh Patel: Arizona State University Kimberly Shea: University of Arizona Hugo Destaillats: Lawrence Berkeley National Lab Sherry Ahrentzen: University of Florida Lead Research Assistants: Sarah Frey, John Ball, Sarah Stone, James Erickson, Angela Larson

40. Funding These projects were funded by the U.S. Department of Housing and Urban Development (HUD), Office of Healthy Homes and Lead Hazard Control. The work that provided the data for part of this presentation was supported by “Recovery Act or American Recovery and Reinvestment Act (ARRA)” funding under an award with HUD.  The substance and findings of the work are dedicated to the public.  The authors are solely responsible for the accuracy of the statements and interpretations contained in this publication. Such interpretations do not necessarily reflect the views of the Government.

41. Contact Information Jill Breysse jbreysse@nchh.org Sherry Ahrentzen ahrentzen@dcp.ufl.edu