Development of a multidimensional housing and environmental quality index (HEQI): application to the American Housing Survey

Background: Substandard housing conditions and hazardous indoor environmental exposures contribute to significant morbidity and mortality worldwide. Housing indices that capture the multiple dimensions of healthy housing are important for tracking conditions and identifying vulnerable households. However, most indices focus on physical deficiencies and repair costs and omit indoor environmental exposures, as few national data sources routinely collect this information. Methods: We developed a multidimensional Housing and Environmental Quality Index (HEQI) based on the World Health Organization’s Housing and Health Guidelines and applied it to the 2019 American Housing Survey (AHS). The HEQI consisted of ten domains associated with poor health: household fuel combustion, dampness and mold, pests and allergens, lead paint risk, high indoor temperatures, low indoor temperatures, household crowding, injury hazards, inadequate water and sanitation, and ventilation. We evaluated the validity and performance of the HEQI against three housing characteristics (i.e., year built, monthly rent costs, unit satisfaction rating) and two established indices (i.e., Adequacy Index, Poor Quality Index). Results: Approximately 79% (92 million) of U.S. households reported at least one HEQI domain associated with poor health (mean per household: 1.3; range: 0,8). Prevalent domains included household fuel combustion (61.4%), dampness and mold (15.9%), inadequate water and sanitation (14.3%), and injury hazards (11.9%). Pests and allergens, low indoor temperatures, and injury hazards were consistently associated with older homes, lower rent costs, and lower unit satisfaction. Compared to established housing indices, the HEQI captured four new environmental domains which enabled the identification of 57.7 million (63%) more households with environmental risk factors like mold, cockroaches, crowding, household fuel combustion, and higher building leakage. Conclusions: Indoor environmental exposures are prevalent in U.S. households and not well-captured by existing housing indices. The HEQI is a multidimensional tool that can be used to monitor indoor environmental exposures and housing quality trends in the U.S. Some domains, including radon, pesticides, asbestos, noise, and housing accessibility could not be assessed due to the lack of available data in the AHS. The mounting evidence linking residential environmental exposures with adverse health outcomes underscore the need for this data in the AHS and other national surveys.