Measuring hygiene and health perfomance of buildings: a multidimensional approach

Abstract

This paper proposes an innovative and transparent methodology to support the "ASL Milano" (Local Health Agency) in the hygiene and health evaluation of construction projects, in order to highlight their positive and negative performance beyond the requirements imposed by the current laws and regulations regarding buildings' hygiene performance, which are too old and therefore unsuitable to ascertain the real quality of indoor environments. The compliance with laws or regulations, mostly out of date, and the assessment of performance involving only a part of the current emerging needs and problems, in fact, should be considered as a necessary, although not a sufficient step, to ensure high quality indoors. Consequently, it is necessary to identify and test an assessment tool which could provide an effective and flexible support for the development of hygiene and health statements regarding projects at building scale (new construction, conversion of the existing, rehabilitation, extension, change of use, etc). The assessment tool suggested by this paper is tailored for the metropolitan area of the city of Milan, but its evaluation framework could be developed and applied to other contexts.

Full text

1
Measuring Hygiene and Health performance of buildings
* Department BEST, Politecnico di Milano, Italy
Ann Ig 2013; 25: 1
Measuring hygiene and health perfomance of buildings:
a multidimensional approach
S. Capolongo*, M. Buffoli*, A. Oppio*, S. Rizzitiello*
Key words: Hygiene, public health, buildings, evaluation, sustainability
Parole chiave: Igiene, sanità pubblica, edifici, valutazione, sostenibilità
Abstract
This paper proposes an innovative and transparent methodology to support the “ASL Milano” (Local Health
Agency) in the hygiene and health evaluation of construction projects, in order to highlight their positive
and negative performance beyond the requirements imposed by the current laws and regulations regarding
buildings’ hygiene performance, which are too old and therefore unsuitable to ascertain the real quality of
indoor environments.
The compliance with laws or regulations, mostly out of date, and the assessment of performance involving
only a part of the current emerging needs and problems, in fact, should be considered as a necessary, al-
though not a sufficient step, to ensure high quality indoors.
Consequently, it is necessary to identify and test an assessment tool which could provide an effective and
flexible support for the development of hygiene and health statements regarding projects at building scale
(new construction, conversion of the existing, rehabilitation, extension, change of use, etc). The assessment
tool suggested by this paper is tailored for the metropolitan area of the city of Milan, but its evaluation
framework could be developed and applied to other contexts.
Introduction
Sustainable development requires that
buildings respect environmental measures
and, in addition, that they comply with
long-term maintenance for the well being
of the users.
As people spend about 90% of their
time indoors, one of the main purposes
of buildings is to provide healthy and
comfortable environments for working,
living, learning, curing, etc.
Indoor air quality is therefore of parti-
cular importance in order to achieve and to
maintain an optimal health state, defined
by WHO as “a state of complete physical,
mental and social wellbeing and not mere-
ly the absence of disease or infirmity” (1).
When indoor climate is good, the number
of illnesses decreases and wellbeing and
productivity of residents increase.
In the light of the complex relationship
man-environment-object, it is clear that
the quality of indoor environment does
not depend exclusively on the fulfillment
of regulatory requirements, but it requires
a design sensitive to those technical and
functional aspects, that ensure healthy
buildings and directly or indirectly affect
the perception of well-being (2, 3).

2S. Capolongo et al.
Although from the health viewpoint
the importance of the quality of indoor
air has been recently highlighted as one
of the most important goals of design and
construction, building regulations regar-
ding hygiene and health issues have not
been updated everywhere.
Currently, the ASL Milano has been
called upon to assess the consistency of
construction projects to buildings’ spe-
cific health and hygiene regulations at
national and local level.
The compliance with laws or regula-
tions, most of them out of date, and the
assessment of performance related only
to some of the current emerging needs
and problems could be considered as
necessary, but not a sufficient condition,
however, for ensuring high indoor air
quality (4-6). Needs and instances have
been evolving over time and the Envi-
ronmental and Buil ding Hygiene has
always tried to improve the performances
provided by the buildings and the level of
health depending on them (7). However,
since hygiene and health regulations for
buildings have not been updated after
the ‘70s and the ‘80s, they shouldn’t be
considered adequate for verifying the real
quality of indoors.
Therefore it is necessary to develop a
tool in order to support the examination
of projects, with the aim of highlighting
the positive and negative health perfor-
mance of each project being evaluated
and to overcome the prescriptive logic of
the regulations and laws, which are not
able, acting mostly by prohibitions, to
effectively address the projects towards
the protection of individual and public
health, which is one of the fundamental
principles of the concept of sustainability
at the building level.
This assessment tool has been defined
by the BEST (Built Environment Science
& Techonology) Department of Polytech-
nic of Milan in collaboration with the
ASL Milano with the aim of providing an
effective and flexible support for the for-
mulation of opinions concerning projects
of new or existing building (upgrading,
extension, change of use, etc) in the city
of Milan and its suburban area.
The identification of hygiene and he-
alth evaluation criteria at building level
assumes that the evaluation of the context
has already been carried out in a previous
research project entitled: “A multicrite-
ria system for the evaluation of hygiene
and health aspects of local government
plans”(8), always carried out in synergy
with the ASL Milano.
Materials and methods
Given the experimental nature of the
tool and the need to support the evalua-
tion of the projects, submitted to the
ASL Milano, by a clear indication of the
requirements that they should fulfill, it
was decided to take a qualitative approach
to research.
More specifically, the definition of the
assessment tool was preceded by a preli-
minary phase focused on the comparative
analysis of the main sustainability asses-
sment tools currently used at national and
international level (Itaca, CasaClima, Eco-
label, LEED, BREEAM, HQE, SBTool,
Nabers, CASBEE) and on the collection
of best practices, in order to select a set
of agreed criteria for the evaluation of the
effects of the quality of construction on
the individual health (9, 10).
Although the tools analyzed foc us
on the energy and other environmental
sustainability topics, the issue of health
and well-being is widely recognized as
one of the key factors for the sustainabi-
lity of interventions, consistent with the
holistic approach suggested by the Health
Strategy adopted by the European Union
in 2007 (11).

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Measuring Hygiene and Health performance of buildings
For this reason, the analysis of those
assessment tools has been carried out
with the aim of highlighting the aspects
closely related to occupants’ health and
indoor comfort.
A key role in this step was played by
the experts in charge of analyzing the
projects, who have been involved in a se-
ries of thematic focus groups designed to
open a dialogue with the technical staff of
the ASL Milano about the most important
issues emerging from the current hygiene
evaluation of projects.
Results
According to the instance of promoting
health, starting from the quality of the
built environment, a multicriteria evalua-
tion system has been designed with the
aim of supporting the hygiene and health
statements that all ASL are asked to draw
on buildings and, at the same time, of
enhancing the improvement of the quality
of life in our cities.
The rating system has been defined
with reference to the most popular as-
sessment tools of buildings’ sustaina-
bility because of the performance, and
not prescriptive, approach that they have
adopted and of the easy communication
of the results, which has led to a rapid
and widespread diffusion well beyond
their countries of origin. To evaluate
under a performance approach it means
to anchor the quality of a building, or its
behavior (performance), to a set of needs
(requirements) expressed implicitly or
explicitly by the users and systematized
by the technical standard.
More specifically, the methodology of
hygiene and health evaluation assumed is
based on the principles that have inspired
the SBMethod: hierarchical decomposi-
tion of the problem in evaluation issues
and criteria; adoption of a multicriteria
evaluation system; adherence to technical
standards and current legislation; transpa-
rency, objectivity and flexibility of the
assessment process (12, 13).
As regards the first principle, the issue
of environmental quality has been deve-
loped in different assessment areas or
thematic issues, divided into criteria. As
the quality of indoor climate is affected
by heating, natural/artificial ventilation,
construction works, building materials,
operation and maintenance, the areas of
evaluation cover all these topics, while the
criteria examine a particular aspect of the
building in relation to a specific theme.
The sy stem consists therefore of
15 evaluation criteria grouped into the
following five assessment areas: Indo-
or Environmental Quality - Health (1.
Hygrothermal Comfort, 2. Indoor Air
Quality, 3. Natural/Artificial Lighting
and Views, 4. Noise and Acoustics, 5.
Ionizing radiations); Outdoor Quality (6.
Parking, 7. Green, 8. Quality and efficien-
cy of the open spaces), Project Quality
(9. Functional mix, 10. Solid Waste, 13.
Liquid Waste - Water 14. Building Mate-
rials/Finishings), Quality of Service (15.
Building Management).
Each evaluation criterion is described
by a specific assessment card with the
following framework:
1. Description of the criterion;
2. Effects on health;
3. Goal and comparison with regula-
tions;
4. Evaluation according to different
uses;
5. Best practices
6. Regulations/Technical standard.
In short, the paragraph 1 (description
of the criterion), as well as providing a
synthetic definition of each criterion, spe-
cifies those aspects that have important
effects on the environmental quality of the
building. In order to highlight the impact
on health conditions, the second paragra-

4S. Capolongo et al.
ph describes the relationship between the
main alterations in individual well-being
and the quality of buildings. The third
section summarizes the goal that the ful-
fillment of each criterion aims to achieve
in the light of the indications emerging
from regulations and laws. It has been
also considered important to differentiate
the performance targets and, consequen-
tly, the judgements in relation to different
building uses because of their specificity.
According to different functions, the rea-
sons are therefore argued that have led to
differentiate the judgement into the three
levels: good, critical, insufficient, in order
to minimize the degree of subjectivity in
the evaluation of the degree of fulfillment
of the requirements. Specifically, sub-
criteria has also been identified, whose
achievement contributes to get to the
final score, according to a logic aimed at
raising the level of current design prac-
tice beyond the legislative requirements,
assuming that - should they not be obser-
ved - the project would not be considered
entirely adequate.
Finally the last sections of the as-
sessment card are intended to guide the
designer through best practices and a
comprehensive legal framework.
Furthermore each criterion has been
weighted in order to highlight its impact
on health (low=1; medium=2; high=3)
and the number of components of health
involved in the evaluation (physical well-
being, social well-being, psychological
well-being). The weight of each criterion,
which must be understood as the rele-
vance of the same in contributing to the
individual health, is given by multiplying
the scores thus obtained, subsequently
normalized with respect to the sum of
the weights.
In order to ensure a good flexibility in
the application of the evaluation system,
it is possible to exclude those criteria that
cannot be considered applicable. In the
case of absence of one or more criteria,
the weights are automatically recalculated
by the system itself.
The analysis and the communication
of the performance levels achieved is ena-
bled by the use of a score: 3 for the good
level; 1 for the critical and 0 for insuffi-
cient. The score of each area of evaluation
is given by the weighted average of the
scores obtained by each criterion, while
the total score of the project is obtained
from the weighted average of the scores
obtained by each assessment area.
According to the minimum and maxi-
mum scores, 3 intervals of the evaluation
scale have been identified which corre-
spond to three different performance ra-
tings: insufficient if the score is between 0
and 1; critical if between 1 and 2; good if
between 2 and 3. The code “NV”, finally,
refers to criteria not evaluable for lack
of relevance to the type of project under
consideration.
In order to enhance the communication
between the parties directly and indirectly
involved in the projects, the outputs are
provided by the use of different charts,
which reflect the hierarchical structure
of the evaluation system and allow a deep
view of the level of sustainability achie-
ved: a radar diagram (figure 1) that shows
the score obtained by each assessment
area in the range between 0 and 3, a histo-
gram showing the total score, a histogram
showing the distribution of scores for
each area of assessment (figure 2).
Currently, the evaluation tool is being
tested on a sample of 25 case studies
located in the city of Milan, selected
from an initial sample of 100 projects
submitted to the mandatory hygiene and
health judgement, with the aim, firstly,
to check the consistency of the results
with the inspiring principles of the tool,
and, secondly, to test the limits of current
legislation often overcame by the contents
of the evaluation system.

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Measuring Hygiene and Health performance of buildings
In order to get to a feedback on the
results obtained for different uses, the
inclusion of the projects into the sample
was carried out taking into account the
following types of buildings: hospitals,
nursing homes and similar uses; schools;
housing; recreational and sport activities.
In particular, 6 health facilities, 6 schools,
6 residential buildings, 2 sport facilities,
2 hotels, 2 public services, 1 building
with historic and architectural constraints
were included.
The results of this first phase have
shown that for most of cases analyzed
(84%) the overall judgement is insuf-
ficient, few cases (12%) have a critical
score and only 4% got a good judgement.
Specifically regarding these last cases, it
is possible to observe relevant improve-
ments over the legal standard and regu-
Figure 1 - Radar diagram the score obtained by each assessment area in the range between 0 and 3.
Figure 2 - Histogram showing the distribution of scores for each area of assessment

6S. Capolongo et al.
lation of the following thematic issues:
Indoor air quality, Waste and resources
and Quality of service.
In view of the emerging prevalence of
the judgement “insufficient”, it should
be noted that it doesn’t depend on a
performance that really doesn’t meet the
standards, but rather on the impossibility
to carry out the evaluation because of the
gaps in the construction drawings and
technical documents. For the 28% of ca-
ses, in fact, the overall insufficient judge-
ment depends on the presence of criteria
that cannot be assessed (10%) and on the
inability to assign a judgement (90%). At
this level, it is significant to note that for
slightly more than half of the case studies
analyzed (52%) the number of indicators
for which it is not possible to verify the
compliance with the standards is greater
than 10 (> 67%).
Conclusions
These preliminary research findings
have highlighted the need for a hygiene
and health assessment tool of projects in
order to get to a judgement based on the
analysis of a wider set of criteria than the
ones traditionally required by building
hygiene regulations and, at the same time,
to address the design process toward those
requirements that ensure individual and
public wellbeing and health. The use of
this tool for supporting the development
of hygiene and health opinions should
also strengthen the role of local health
authorities as proactive institutions in
health promotion at the local level.
In this sense, the evaluation system
was designed to be adapted to different
contexts, while retaining its evaluation
framework.
In order to make the proposed metho-
dology a useful tool for designers in the
light of the significant gaps in the tech-
nical documents submitted for obtaining
a positive hygiene and health judgement
as emerged from these first outputs, the
attention should be paid not only to the
final score, but also to the level of ful-
fillment of the requirements defined for
each criterion according to the perfor-
mance rating scale.
Under this perspective the commu-
nication of the evaluation outputs is en-
couraged for different stakeholders since,
in addition to providing a report about
building performance at different levels,
it gives a clear and synthetic analysis of
the strengths and weaknesses, enhancing
the development of better design actions
(short-term strategies) and targeting in-
terventions towards the achievement of
higher levels of sustainability (long-term
strategies).
Riassunto
Un approccio multidimensionale alla valutazione
igienico-sanitaria degli edifici
Il presente contributo propone una metodologia inno-
vativa e trasparente di supporto all’esame dei progetti
edilizi, al fine di evidenziare le prestazioni igienico-
sanitarie positive e negative di ogni singolo progetto
oggetto di valutazione e di superare la mera verifica
dei requisiti imposti dall’attuale normativa, perlopiù
non aggiornata e quindi non adatta ad accertare la reale
qualità degli spazi indoor.
Il rispetto di prescrizioni che riguardano solo una parte
delle attuali esigenze, peraltro in continua evoluzione,
può essere considerato infatti una condizione necessa-
ria, ma tuttavia non sufficiente per la realizzazione di
ambienti indoor di qualità.
Da qui risulta evidente la necessità di definire e
sperimentare uno strumento di valutazione in grado di
fornire un efficace supporto alla formulazione dei pareri
igienico-sanitari che le Aziende Sanitarie Locali (ASL)
sono chiamate a esprimere in merito ai progetti edilizi di
nuova realizzazione o trasformazione (riqualificazione,
ampliamento, trasformazione d’uso, ecc.), con l’obiettivo
di superare la logica prescrittiva dell’attuale normativa,
che mediante la sola imposizione di divieti non è in grado
di orientare efficacemente il progetto verso la tutela della
salute individuale e collettiva.

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Measuring Hygiene and Health performance of buildings
Tale strumento di valutazione è stato definito nell’am-
bito di una ricerca svolta dal Dipartimento BEST
(Politecnico di Milano) in collaborazione con l’ASL
Milano e applicato a un insieme di progetti nell’area
metropolitana milanese.
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Corresponding Author: Arch. Maddalena Buffoli, Department BEST, Politecnico di Milano, Via Bonardi 3, 20129
Milano
e-mail: maddalena.buffoli@polimi.it

8S. Capolongo et al.
Corresponding author: Dott. Alberto Firenze, Sciences for Health Promotion and Mother and Children Health Depart-
ment, University of Palermo, Via del Vespro 133, Palermo 90127, Italy
e-mail: alberto.firenze@unipa.it