The Stockholm Indoor Environment Questionnaire: a sociologically based tool for the assessment of indoor environment and health in dwellings

The parameter of the Sick Building Syndrome: A systematic literature review

Sick Building Syndrome (SBS) is a collection of symptoms assumed to be related to spending time in a certain building, most typically a workplace, but no specific cause has been identified. The need to measure and assess various types of parameters of SBS is crucial and it is important to explore what parameter has been used in the previous studies of SBS. Therefore, this study aims to systematically review the parameter that has been used to monitor the SBS. This study was conducted using the PRISMA Statement and the search was conducted using two scientific databases which were Scopus and Web of Science. After a thorough and tight process, a total of 55 articles have been finalized and selected for thematic analysis. Two themes have been identified which were a) Indoor Environmental Quality (IEQ) and b) Occupant. This study also found that the spatial distribution pattern revealed that the Sick Building Syndrome research was spread over 26 nations, with the majority of articles originating from the United States and China. In terms of context, the majority of the selected publications employed the survey approach to investigate SBS parameters. Aside from that, the most researched form of building is the business building. This study has found that it would be more impactful for the SBS study if researchers could incorporate both indoor environmental quality and occupant factors into a study, resulting in more holistic conclusions.

Nocturnal temperature-controlled laminar airflow device for adults with severe allergic asthma: the LASER RCT

BACKGROUND

Severe asthma exacerbations are costly to patients and the NHS, and occur frequently in severely allergic patients.

OBJECTIVE

To ascertain whether or not nocturnal temperature-controlled laminar airflow (TLA) device usage over 12 months can reduce severe exacerbations and improve asthma control and quality of life compared with a placebo device, while being cost-effective and acceptable to adults with severe allergic asthma.

DESIGN

A pragmatic, multicentre, randomised, double-blind, placebo-controlled, parallel-group, superiority trial with qualitative interviews. The trial included an internal pilot with qualitative focus groups.

SETTING

Fourteen hospitals in the UK that manage patients with severe asthma.

PARTICIPANTS

Adults (16-75 years) with severe, poorly controlled, exacerbation-prone asthma despite high-intensity treatment, and who are sensitised to a perennial indoor aeroallergen.

INTERVENTION

Nocturnal, home-based TLA treatment using an Airsonett^® (Airsonett AB, Ängelholm, Sweden) device. The comparator was a placebo device that was identical to the active device except that it did not deliver the laminar airflow. Participants were allocated 1 : 1 to TLA therapy or placebo, minimised by site, origin of case, baseline severe exacerbation frequency, maintenance oral corticosteroid use and pre-bronchodilator forced expiratory volume in 1 second.

MAIN OUTCOME MEASURES

Primary outcome - frequency of severe asthma exacerbations occurring within the 12-month follow-up period, defined as worsening of asthma requiring systemic corticosteroids [≥ 30 mg of prednisolone or equivalent daily (or ≥ 50% increase in dose if on maintenance dose of ≥ 30 mg of prednisolone)] for ≥ 3 days. Secondary outcomes - changes in asthma control, lung function, asthma-specific and global quality of life for participants, adherence to the intervention, device acceptability, health-care resource use and cost-effectiveness.

RESULTS

Between May 2014 and January 2016, 489 patients consented to participate in the trial, of whom 249 failed screening and 240 were randomised (n = 119 in the treatment group and n = 121 in the placebo group); all were analysed. In total, 202 participants (84%) reported use of the device for 9-12 months. Qualitative analyses showed high levels of acceptability. The mean [standard deviation (SD)] rate of severe exacerbations did not differ between groups [active 1.39 (1.57), placebo 1.48 (2.03); risk ratio 0.92, 95% CI 0.66 to 1.27; p = 0.616]. There were no significant differences in secondary outcomes for lung function, except for a reduction in mean daily peak expiratory flow [mean (SD) difference 14.7 l/minute (7.35 l/minute), 95% CI 0.32 to 29.1 l/minute; p = 0.045) for those in the active device group. There were no differences in asthma control or airway inflammation and no serious harms related to the device. No significant difference between the groups in quality-adjusted life-years gained over 1 year was observed. In addition, there was no difference in generic or disease-specific health-related quality of life overall, although statistically significant higher quality of life at month 6 was observed. Increases in quality of life were not sufficient to offset the annual costs associated with use of the TLA device.

LIMITATIONS

Missing outcome data could have resulted in an underestimation of exacerbations and rendered the study inconclusive.

CONCLUSIONS

Within the limits of the data, no consistent benefits of the active device were demonstrated, and the differences observed were not sufficient to make the device cost-effective. The types of patients who may benefit from the TLA device, and the reasons for large reductions in exacerbation frequency in severe asthma trials, which also incorporate other methods of recording exacerbations, need to be explored.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46346208.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 29. See the NIHR Journals Library website for further project information.

Analyzing symptom data in indoor air questionnaires for primary schools

Questionnaires on symptoms and perceived quality of indoor environment are used to assess indoor environment problems, but mainly among adults. The aim of this article was to explore best ways to analyze and report such symptom data, as part of a project to develop a parent-administered indoor air questionnaire for primary school pupils. Indoor air questionnaire with 25 questions on child's symptoms in the last 4 weeks was sent to parents in five primary schools with indoor air problems and in five control schools. About 83% of parents (N=1470) in case schools and 82% (N=805) in control schools returned the questionnaire. In two schools, 351 (52%) parents answered the questionnaire twice with a 2-week interval. Based on prevalence of symptoms, their test-retest repeatability (ICC), and on principal component analysis (PCA), the number of symptoms was reduced to 17 and six symptoms scores were developed. Six variants of these six symptom scores were then formed and their ability to rank schools compared. Four symptom scores (respiratory, lower respiratory, eye, and general symptoms) analyzed dichotomized maintained sufficiently well the diversity of symptom data and captured the between-school differences in symptom prevalence, when compared to more complex and numerous scores.

Asthma, allergy and eczema among adults in multifamily houses in Stockholm (3-HE study)--associations with building characteristics, home environment and energy use for heating

Risk factors for asthma, allergy and eczema were studied in a stratified random sample of adults in Stockholm. In 2005, 472 multifamily buildings (10,506 dwellings) were invited (one subject/dwelling) and 7,554 participated (73%). Associations were analyzed by multiple logistic regression, adjusting for gender, age, smoking, country of birth, income and years in the dwelling. In total, 11% had doctor's diagnosed asthma, 22% doctor's diagnosed allergy, 23% pollen allergy and 23% eczema. Doctor's diagnosed asthma was more common in dwellings with humid air (OR = 1.74) and mould odour (OR = 1.79). Doctor's diagnosed allergy was more common in buildings with supply exhaust air ventilation as compared to exhaust air only (OR = 1.45) and was associated with redecoration (OR = 1.48) and mould odour (OR = 2.35). Pollen allergy was less common in buildings using more energy for heating (OR = 0.75) and was associated with humid air (OR = 1.76) and mould odour (OR = 2.36). Eczema was more common in larger buildings (OR 1.07) and less common in buildings using more energy for heating (OR = 0.85) and was associated with water damage (OR = 1.47), humid air (OR = 1.73) and mould odour (OR = 2.01). Doctor's diagnosed allergy was less common in buildings with management accessibility both in the neighbourhood and in larger administrative divisions, as compared to management in the neighbourhood only (OR = 0.49; 95% CI 0.29-0.82). Pollen allergy was less common if the building maintenance was outsourced (OR = 0.67; 95% CI 0.51-0.88). Eczema was more common when management accessibility was only at the division level (OR = 1.49; 95% CI 1.06-2.11). In conclusions, asthma, allergy or eczema were more common in buildings using less energy for heating, in larger buildings and in dwellings with redecorations, mould odour, dampness and humid air. There is a need to reduce indoor chemical emissions and to control dampness. Energy saving may have consequences for allergy and eczema. More epidemiological studies are needed on building management organization.

Social determinants of the sick building syndrome: exploring the interrelated effects of social position and psychosocial situation

This paper examines the importance of various social factors for the prevalence of "sick building syndrome" (SBS) in residential buildings. A survey has been conducted in Malmö, Sweden, resulting in 1131 randomly selected residents participating in the study (response rate 57 %). Two clusters of social factors were examined: the socio-structural position of the individual and psychosocial aspects of the housing situation. The results show that country of birth, in particular, and also education and employment status are important predictors of "domestic SBS". "Housing satisfaction" turns out to be an important psychosocial predictor of SBS, explaining, for example, why immigrants report more symptoms than natives.

Parameters contributing to occupants’ satisfaction

Purpose

– The aims of this paper is to investigate the overall satisfaction of occupants of green and conventional residential buildings and their perception of indoor environment quality (IEQ) and to study factors that may cause occupants’ dissatisfaction.

Design/methodology/approach

– Data were collected through a survey sent to occupants of comparable green and conventional multi-family buildings. The difference in responses between occupants of green and conventional buildings was analysed using Mann–Whitney (rank sum) test. The ordered logistic models were applied to the data to test whether the overall satisfaction changes depending on the level of acceptance of indoor environment quality and whether the building environmental profile and the apartment tenure affect occupant satisfaction.

Findings

– The results show that both categories of occupants are very satisfied with their apartments and that there is no statistically significant difference between the stated overall satisfaction of occupants living in green and conventional buildings, although a difference was found in the acceptance level for thermal and sound quality. The research highlights the importance of occupant feedback, user-friendly technical installations and the ability to control indoor environment. This knowledge is important for designers, engineers and developers alike in enabling them to improve dwelling quality and minimize post-occupancy problems.

Research limitations/implications

– It was not possible to include physical measurements of IEQ parameters; the analysis is based only on occupants’ responses, which may carry a certain subjectivity.

Originality/value

– The paper contributes to the understanding of IEQ from occupant perspective and to knowledge on green building performance.

Indoor air is a significant source of tri-decabrominated diphenyl ethers to outdoor air via ventilation systems

Ventilation of indoor air has been hypothesized to be a source of PBDEs to outdoors. To study this, tri-decabrominated diphenyl ethers were analyzed in outgoing air samples collected inside ventilation systems just before exiting 33 buildings and compared to indoor air samples from microenvironments in each building collected simultaneously. Median ∑(10)PBDE (BDE- 28, -47, -99, -153, -183, -197, -206, -207, -208, -209) concentrations in air from apartment, office and day care center buildings were 93, 3700, and 660 pg/m(3) for outgoing air, and 92, 4700, and 1200 pg/m(3) for indoor air, respectively. BDE-209 was the major congener found. No statistically significant differences were seen for individual PBDE concentrations in matched indoor and outgoing air samples, indicating that outgoing air PBDE concentrations are equivalent to indoor air concentrations. PBDE concentrations in indoor and outgoing air were higher than published outdoor air values suggesting ventilation as a conduit of PBDEs, including BDE-209, from indoors to outdoors. BDE-209 and sum of BDE-28, -47, -99, and -153 emissions from indoor air to outdoors were roughly estimated to represent close to 90% of total emissions to outdoor air for Sweden, indicating that contaminated indoor air is an important source of PBDE contamination to outdoor air.

Qualitative environmental health research: an analysis of the literature, 1991-2008

Qualitative research uses nonnumeric data to understand people's opinions, motives, understanding, and beliefs about events or phenomena. In this analysis, I report the use of qualitative methods and data in the study of the relationship between environmental exposures and human health. A primary search for peer-reviewed journal articles dated from 1991 through 2008 included the following three terms: qualitative, environ*, and health. Searches resulted in 3,155 records. Data were extracted and findings of articles analyzed to determine where and by whom qualitative environmental health research is conducted and published, the types of methods and analyses used in qualitative studies of environmental health, and the types of information qualitative data contribute to environmental health. The results highlight a diversity of disciplines and techniques among researchers who used qualitative methods to study environmental health. Nearly all of the studies identified increased scientific understanding of lay perceptions of environmental health exposures. This analysis demonstrates the potential of qualitative data to improve understanding of complex exposure pathways, including the influence of social factors on environmental health, and health outcomes.

Pedestrians' perception of environmental stimuli through field surveys: focus on particulate pollution

The between perception of individual exposure to different environmental stimuli; microclimate, noise and especially particulate matter (PM) was examined. Microclimate, noise and PM were monitored during field surveys with 260 questionnaire-guided interviews at a road construction site and a traffic site on the UC San Diego campus. The overall comfort was determined primarily by the thermal environment. The air quality was considered to be poor by 42% of the interviewees at the construction site, which was burdened with higher PM counts and sound levels. Overall, higher PM concentrations were correlated with perception of poor air quality. Similarity between the overall air quality and how dusty it feels suggests that visual clues of PM, such as dust, affect the perception of air quality and pollution. The effect of medical or smoking history on the perceived air quality was also examined. People with a medical history of hay fever voted more frequently for poor air quality conditions than those without, whereas current smokers were the least sensitive to ambient air quality conditions. Through the exposure-response relationships between the various perception votes and PM, it was possible to predict perceived air cleanliness using the PM count. Understanding the human assessment of environmental stimuli could inform the design and development of urban spaces, in relation to the allocation of uses and activities, along with air quality management schemes.

Qualitative environmental health research: an analysis of the literature, 1991-2008

BACKGROUND

Recent articles have advocated for the use of qualitative methods in environmental health research. Qualitative research uses nonnumeric data to understand people's opinions, motives, understanding, and beliefs about events or phenomena.

OBJECTIVE

In this analysis of the literature, I report the use of qualitative methods and data in the study of the relationship between environmental exposures and human health.

DATA SOURCES

A primary search on ISI Web of Knowledge/Web of Science for peer-reviewed journal articles dated from 1991 through 2008 included the following three terms: qualitative, environ*, and health. Inclusion and exclusion criteria are described.

DATA EXTRACTION

Searches resulted in 3,155 records. Data were extracted and findings of articles analyzed to determine where and by whom qualitative environmental health research is conducted and published, the types of methods and analyses used in qualitative studies of environmental health, and the types of information qualitative data contribute to environmental health.

DATA SYNTHESIS

Ninety-one articles met inclusion criteria. These articles were published in 58 different journals, with a maximum of eight for a single journal. The results highlight a diversity of disciplines and techniques among researchers who used qualitative methods to study environmental health, with most studies relying on one-on-one interviews. Details of the analyses were absent from a large number of studies. Nearly all of the studies identified increased scientific understanding of lay perceptions of environmental health exposures.

DISCUSSION AND CONCLUSIONS

Qualitative data are published in traditionally quantitative environmental health studies to a limited extent. However, this analysis demonstrates the potential of qualitative data to improve understanding of complex exposure pathways, including the influence of social factors on environmental health, and health outcomes.

A new multiple regression model to identify multi-family houses with a high prevalence of sick building symptoms "SBS", within the healthy sustainable house study in Stockholm (3H)

PURPOSES

The aim was to develop a new model to identify residential buildings with higher frequencies of "SBS" than expected, "risk buildings".

METHODS

In 2005, 481 multi-family buildings with 10,506 dwellings in Stockholm were studied by a new stratified random sampling. A standardised self-administered questionnaire was used to assess "SBS", atopy and personal factors. The response rate was 73%. Statistical analysis was performed by multiple logistic regressions.

RESULTS

Dwellers owning their building reported less "SBS" than those renting. There was a strong relationship between socio-economic factors and ownership. The regression model, ended up with high explanatory values for age, gender, atopy and ownership. Applying our model, 9% of all residential buildings in Stockholm were classified as "risk buildings" with the highest proportion in houses built 1961-1975 (26%) and lowest in houses built 1985-1990 (4%).

CONCLUSION

To identify "risk buildings", it is necessary to adjust for ownership and population characteristics.

Ill-lighting syndrome: prevalence in shift-work personnel in the anaesthesiology and intensive care department of three Italian hospitals

Background

Light is one of the most important factors in our interaction with the environment; it is indispensable to visual function and neuroendocrine regulation, and is essential to our emotional perception and evaluation of the environment. Previous studies have focussed on the effects of prolonged anomalous exposure to artificial light and, in the field of work-related illness. Studies have been carried out on shift-work personnel, who are obliged to experience alterations in the physiological alternation of day and night, with anomalous exposure to light stimuli in hours normally reserved for sleep. In order to identify any signs and symptoms of the so-called ill-lighting syndrome, we carried out a study on a sample of anaesthesiologists and nurses employed in the operating theatres and Intensive Care Departments of three Italian hospitals. We measured the subjective emotional discomfort (stress) experienced by these subjects, and its correlation with environmental discomfort factors, in particular the level of lighting, in their workplace.

Methods

We used a questionnaire developed by the Scandinavian teams who investigated Sick-Building Syndrome, that was self-administered on one day in the environments where the degree of illumination was measured according to UNIEN12464-1 regulations.

Results

Upon comparison of the types of exposure with the horizontal luminance values (lux) measured (< 700 lux, between 1000–1500 lux, > 1500 lux) and the degree of stress reported, (Intensive Care: mean stress = 55.8%, high stress = 34.6%; Operating Theatres: mean stress = 51.5%, high stress = 33.8%), it can be observed that the percentage of high stress was reduced as the exposure to luminance was increased, although this finding was not statistically significant.

Conclusion

We cannot share other authors' enthusiasm regarding the effects on workers well-being correlated to the use of fluorescent lighting. The stress level of our workers was found to be more heavily influenced by their familial and working conditions, irrespective of the ambient light stimulus.

Classification of Patients Complaining of Sick House Syndrome and/or Multiple Chemical Sensitivity

Sick house syndrome (SHS) is a Japanese concept derived from sick building syndrome (SBS), however SHS includes a broader scope of sickness than does SBS. Symptoms of SHS/SBS disappear after leaving the sick house/building, while symptoms of multiple chemical sensitivity (MCS) are elicited by the chance of chemical exposure after leaving the sick house/building. To establish the concept of SHS, we propose to introduce a new classification for SHS. A total of 214 patients complaining of SHS and/or MCS were independently classified using a new classification by clinical ecologists who are experienced physicians with expert knowledge of clinical ecology and general physicians according to disease pathogenesis from clinical records. The classification is as follows: type 1 (symptoms of chemical intoxication), type 2 (symptoms developed possibly due to chemical exposure), type 3 (symptoms developed not because of chemical exposure but rather because of psychological or mental factors), and type 4 (symptoms developed due to allergies or other diseases). The agreements on the classification made by clinical ecologists and general physicians reached 77.1% (Cohen's kappa=0.631), suggesting that this new classification was both apt and accurate. Relations between SHS and allergy/MCS were also studied. The cases classified as SHS type 4 more frequently had allergic past histories than did other types. The proportion of possible MCS cases was higher in the chemical induced SHS group (types 1 and 2) than in other types among male patients. For the universal use in clinical practice, it is necessary to prepare helpful diagnostic criteria of this SHS classification based on pathogenesis and carry our study forward all over the country.

Baseline prevalence of symptoms related to indoor environment

AIMS

Health problems associated with indoor environments have been reported and discussed extensively during the past few decades, not least in Sweden. There is, however, great uncertainty concerning the background prevalence of the symptoms in question. The main objective of the present study was to investigate the prevalence of general, mucosal, and skin symptoms in the Swedish population.

METHODS

A survey comprising 3,000 randomly selected Swedes, age 18-64, was carried out. The survey addressed 25 symptoms, principally general, mucosal, and skin symptoms. A number of other areas were covered and individual data registered at Statistics Sweden were added. The response rate was 70% (2,154 cases).

RESULTS

The prevalence of symptoms in the Swedish population was found to accord with results in studies based on different kinds of samples. Women reported significantly more single symptoms, as well as sets of symptoms, than men. There was no clear connection between age and symptoms. The prevalence of symptoms was slightly lower among employees compared with non-workers. Office workers did not report symptoms related to "sick building syndrome" (SBS) more frequently than employees not working in offices. SBS symptoms, skin symptoms, and symptoms similar to those reported by individuals with "electric hypersensitivity" were significantly more prevalent among employees with extensive VDU usage.

CONCLUSIONS

The prevalence of reported health complaints accords with that which has been found in previous studies. The background prevalence reported here can serve as a reference for further studies. The high prevalence of symptoms among individuals with extensive VDU usage gives cause for further studies.

Knowledge of the effects of indoor air quality on health among women in Jordan

OBJECTIVE

To assess the extent of knowledge about symptoms relating to respiratory illnesses and home environments among a random sample of 200 urban Jordanian women.

METHOD

This customized, validated, cross-sectional questionnaire evaluated the knowledge of these women about the association between the indoor environment and health, the presence or absence of indoor discomforts, symptoms of respiratory illnesses, and behaviors related to the home environment such as cleaning practices.

RESULTS

Results showed an alarming rate of smoking in the homes; the extent of knowledge was moderate but higher among those exhibiting symptoms and those with children. Cleaning practices associated with healthy home environments were reported at a high rate but seemed to be based on cultural influences.

CONCLUSIONS

This type of information is crucial to the formation of health education programs and policy recommendations for pollutant source and exposure reductions in homes in the Middle East and other developing countries.

Indoor air pollution in old people's homes related to some health problems: a survey study

The present research reports on a survey of 96 subjects between the ages of 60 and 95 years, living close to Paris in a social collective habitat. The aim was to show, using goodness-of-fit statistical tests (P < 0.1), how old people lifestyles can subject them to generated chemical or bacteriological indoor pollutants. Risk factors due to lifestyles were analyzed in relation to complaints and to health condition. There are many ways that old people are exposed to pollutants: difficulty in maintaining the residence, preference for staying in the kitchens, substantial use of cleaning chemicals. However, the principal risk for health problems is arguably inadequate ventilation (unclean screens, blocked air vents, etc.), which increases the concentration of indoor pollutants. These risks are amplified by ignorance about the hazards of inadequate ventilation.

PRACTICAL IMPLICATIONS

The present investigation suggests that the lifestyle and the behavior of old people could be the cause of an interior air pollution of their housing. Measures realized in representative dwellings selected in relation to results must confirm that these risks would require the installation of an automatic monitoring system of the indoor air near these people.

Sick building syndrome and perceived indoor environment in relation to energy saving by reduced ventilation flow during heating season: a 1 year intervention study in dwellings

Ventilation in Scandinavian buildings is commonly performed by means of a constant flow ventilation fan. By using a regulated fan, it is possible to make a seasonal adjustment of outdoor ventilation flow. Energy saving can be achieved by reducing the mechanical ventilation flow during the heating season, when natural ventilation driven by temperature differences between outdoor and indoor is relatively high. This ventilation principle has been called 'seasonally adapted ventilation (SAV)'. The aim was to study if a 25-30% reduction of outdoor ventilation flow during heating season influenced sick building syndrome (SBS) and the perception of the indoor environment. This was done in a 1-year cross-over intervention study in 44 subjects in a multi-family building. During the first heating season (November to April), one part of the building (A) got a reduced flow during the heating season [0.4-0.5 air exchanges per hour (ACH)] while the other part (B) had constant flow (0.5-0.8 ACH). The next heating season, part A got constant flow, while part B got reduced ventilation flow. Reduced ventilation increased the relative air humidity by 1-3% in the living room (mean 30-37% RH), 1-5% in the bathroom (mean 48-58% RH) during heating season. The room temperature increased 0.1-0.3 degrees C (mean 20.7-21.6 degrees C), mean carbon dioxide (CO2) concentration in the bedroom increased from 920 to 980 p.p.m. at reduced flow. The indoor air quality was perceived as poorer at reduced outdoor airflow, both in the bedroom and in the apartment as a whole. There was a significant increase of stuffy odor (P = 0.05) at reduced outdoor airflow and the indoor air quality was perceived as poorer, both in the bedroom (P = 0.03) and in the apartment as a whole (P = 0.04). No significant influence on SBS symptoms or specific perceptions such as odors, draught, temperature, air dryness or stuffy air could be detected. In conclusion, reducing the ventilation flow in dwellings to a level below the current Swedish ventilation standard (0.5 ACH) may cause a perception of impaired air quality. Technical measurements could only demonstrate a minor increase of indoor temperature, relative air humidity, and bedroom CO2 concentration. This illustrates that it is important to combine technical measurements with a longitudinal evaluation of occupant reactions, when evaluating energy-saving measures.

PRACTICAL IMPLICATIONS

It is important to combine technical measurements with a longitudinal evaluation of occupant reactions, when evaluating energy-saving measures. Reduction of outdoor airflow in dwellings below the current ventilation standard of 0.5 ACH may lead to a perception of impaired air quality, despite only a minor increase of bedroom CO2-concentration.