One Step at a Time Towards Better Health: Active Design in Affordable Housing

Abstract

Decreased physical activity (PA) contributes to the U.S. obesity epidemic. Leadership in Energy and Environmental Design (LEED) Design for Health PA Innovation in Design (ID) credit encourages increased stair and exercise facility use. Active design elements in South Bronx affordable housing have yet to be evaluated. Tenants of two LEED Platinum-certified affordable housing buildings, Melrose Commons V and Design for Health accredited Arbor House (AH), participated in separate semi-structured focus groups. Consensus among participants suggested active design elements positively influenced health behaviors through providing motivation, accessibility, and safety. Participants in both buildings noted ambiance and safety encouraged PA. AH participants reported gym, inviting stairwells, stair prompts, and reduced elevator speed also promoted PA. Participant recommendations included: fitness training, health education classes, and more active space for children. LEED Design for Health elements promotes PA among tenants living in affordable housing by creating welcoming, safe environments and improving access to exercise facilities.

Background

Obesity and co-morbid health conditions are epidemic in the United States, with consequences extending from economic loss to premature mortality.^1,2 A major contributor is lack of adequate physical activity (PA), influenced by elements of the built environment such as passive transportation (i.e., cars, elevators), unsafe streets, and lack of recreational space.³

Lower socioeconomic status has been correlated with higher obesity rates among women and children in urban areas.^4,5 This relationship may reflect the unequal distribution of built environment elements supporting PA; low-income and minority communities in three states were less likely to have recreational resources compared to higher-income and white neighborhoods.⁶ A national adolescent population study demonstrated that body mass index decreased as the number of recreational facilities increased.⁷ Parents' perception of the built environment, such as degree of safety, may influence children's PA.⁸

A growing body of evidence demonstrates that the built environment can increase PA. Safe, convenient access to recreational spaces as well as structural changes to non-recreational spaces is associated with increased PA.^9,10,11 Stairs are more likely to be used if visible, accessible, prominent, and visually appealing.^12,13 The U.S. Centers for Disease Control and Prevention (CDC) recommend point-of-decision stair prompts based on evidence that increased stair usage subsequently improves clinical health outcomes.^14,15

More than half of U.S. adults do not meet the CDC recommended 150 minutes weekly of moderate to vigorous PA.^16,17 Research suggests non-recreational PA opportunities influence the percentage of individuals attaining these levels—one study demonstrated an increase from 25–33% to 51% when including all active transportation.¹⁸ Non-recreational spaces may therefore represent an under-utilized opportunity for public health intervention. These findings highlight the importance of creating built environments that encourage both intentional and incidental PA, especially in low-income and minority neighborhoods.

The United States Green Building Council established the Leadership in Energy and Environmental Design (LEED) rating system in 2000 to certify the environmental sustainability of buildings (Table 1).¹⁹ Recently, as evidence emerged supporting a strong association between sustainability and health, the LEED certification has specifically distinguished design elements which promote health. LEED-certified buildings, for example, manage indoor air quality in part by banning indoor smoking and encouraging non-toxic cleaner use. The respiratory benefits of sustainable housing were previously reported by members of this research team and others.^20,21,22

Table 1.

Selected LEED Certification Credits *

Optional Credit Elements
Indoor environmental quality
Minimum indoor air quality performance
Environmental tobacco smoke control
Enhanced indoor air quality strategies
Low-emitting materials
Indoor air quality assessment
Energy and atmosphere
Fundamental commissioning and verification
Minimum energy performance
Fundamental refrigerant management
Material and resources
Storage and collection of recyclables
Building product disclosure and optimization
Construction and demolition waste management
Building life-cycle impact reduction

Adapted from: USGBC LEED Credit Library.

Those design elements credited for promoting health are further classified into elements that specifically facilitate PA. In 2009, the New York City (NYC) Department of Health and Mental Hygiene, the Mayor's Office of Management and Budget, and the Department of Design and Construction proposed that a Design for Health credit be included among the LEED Innovation in Design (ID) credits. ID credits assess benefits not addressed by current LEED systems requiring active design elements that encourage intentional and incidental PA (Table 2).

Table 2.

LEED Design for Health PA Innovation in Design Suggested Credit Requirements *

Minimum 20 of 29 Required
Stair door operation
Locking operation
Transparency from corridor (material)
Transparency from corridor (operation)
Stair location
Visibility
Location with respect to elevators - priority
Location with respect to elevators - visibility
Location—principal path of travel
Proximity of occupants to stairs
Circulation signage
Prompts at stairs
Prompts at elevators
Stair design and aesthetics
Electrical lighting
Natural lighting
Music
Artwork
Finishes
Ventilation
Security
Size
Elevator Functionality and Location
Door speed
Location
Operation
Adults
Exercise room or gym in building
Designated exercise class space
Walking trails and open space
Dedicated community garden space
Children
Outdoor active public facilities
Onsite playground or children's play space—indoor
Onsite playground or children's play space- outdoor
Within walking distance of a public school

Adapted from: Sample Submittal, LEED Innovation in Design Credit: Design For Health Through Physical Activity for Via Verde/The Green Way.

The impact of active design elements on PA has yet to be evaluated in affordable residential neighborhoods. To contribute to the evidence supporting the health impact of these elements, this qualitative study evaluated tenant experiences in two South Bronx LEED-certified affordable housing developments. Through tenant-reported perceptions and behaviors, we evaluated the effects of five design elements on PA.

Methods

Melrose Commons V (MCV) and Arbor House (AH) are LEED-platinum certified affordable residential buildings in the South Bronx. Constructed in 2009, MCV is a five-story building with 63 units, while AH is an eight-story building with 124 units built in 2012. Applicants to both buildings must demonstrate a household income less than 60% of area median.

Both buildings feature sustainability elements with potential to improve health outcomes. Beyond these, AH also earned the LEED Design for Health credit by including features like delayed speed and non-prominent location of elevators, point-of-decision stair prompts (Table 3), central stairwell placements, wide and well-lit stairwells with music and artwork, an indoor gym, and an outdoor exercise circuit.

Table 3.

AH and MCV sample stair prompts

AH	MCV
“A person's health can be judged by which they take two of at a time pills or stairs”	“Burn Calories, Not Electricity”
“I have to exercise in the morning before my brain figures out what I'm doing”	“Take the stairs”
“If your dog is fat you're not getting enough exercise”
“The victory is not always to the swift but to those who keep moving”
“Physical activity will add years to your life and life to your years”
“Going down? Gravity assist provided free of charge”
“I'm in shape. Round is a shape, isn't it?”
“No waiting, one door over.”
“There are 1440 minutes in every day…schedule 30 of them for physical activity.”
“If it wasn't for the fact that the TV set and refrigerator are so far apart, some of us wouldn't get any exercise at.”

Recruitment was conducted via telephone and e-mail to English-speaking tenants (age >18 years) who were previously enrolled in an on-going quantitative study of the two buildings. Participants received $30 for their time.

Two one-hour focus groups assessed tenants' experiences of design elements in AH and MCV. Semi-structured questions were developed from Design for Health guidelines and the literature (Table 4).²³ Research assistants piloted and revised questions. The moderator conducted focus groups on-site at AH and MCH on the same day (September 2013). Each focus group was audio-recorded; field notes captured non-verbal cues and group interactions. Data were de-identified and research team members transcribed recordings and checked for accuracy. All participants provided informed consent and the Institutional Review Board approved the study.

Table 4.

Focus Group Sample Questions

Sample Questions
There has been a big movement to get people more active—do you think this building is trying to do that?
—What features of the building do you think are trying to achieve this?
In what way has living in this building impacted the way you think about your health? Or not?
Other than in this building, have you noticed any changes in your physical activity level/habits since moving here (e.g.: at work, shopping, visiting friends).

We used a team-based analytic approach to evaluate session transcripts and field notes. Three independent researchers developed and implemented codes. Discrepancies were resolved through consensus using an iterative process.

Results/Findings

Focus group participants living in MCV (n=5) and AH (n=6) were predominately young Hispanic or African American women; only one male tenant from MCV participated. Both groups commented on the impact of building design on PA and other health markers. This article focuses on the emergent recurrent themes of the active design elements: motivation, accessibility, safety, family features, and education.

Active design element 1: Delayed speed and non-prominent location of elevators

An AH participant remarked, “I believe that they slowed the elevators down so that we can walk up the steps more often.” All participants noted this feature, which prompted many to take the stairs. One participant who now uses only stairs explained “I just used [the elevator] a few times and I was like ‘Forget it.’” By contrast, the MCV elevator prompted one participant to take the stairs far less often than in his previous residence.

Active design element 2: Prominent, well-lit stairwell with music and artwork

The combined impact of delayed elevators and active design stairwells prompted four of the six AH participants to use stairs frequently. One woman commented: “[Y]ou could think about just walking up the steps instead of always taking the elevator.” Participants reported that these factors encouraged children's stair use, too. “They go straight to the staircase and [don't] take the elevator,” a mother explained. Music in the stairwells also reportedly attracted participants, particularly children. “They love the music, they just love it,” the mother continued, adding that her children also motivated her to take the stairs by saying “Mom, walk! Walk! The music is beautiful!”

Perceived safety was a major predictor of stair use. Brightly lit, wide stairwells with good sight lines to succeeding flights and hallways provided a sense of comfort. One woman, who now uses the AH stairs regularly, said of the building where she previously lived, “I don't take the steps there [because] it's dark…Our exits are big and bright.” Furthermore, she reported that strangers often linger in those stairwells and explained that, “To be safe, I will take the elevator.” Similarly, several AH participants who are now more apt to use stairs even when off-site indicated that this habit does not extend to buildings that they perceive unsafe.

Most MCV participants did not report increased stair usage. Although one woman reported regularly climbing stairs, four other participants reported using stairs only when the elevator was out of service. Participants commented on stairwell darkness and poor ventilation, and noted that squatters have resided on landings in MCV, posing a particular safety concern, especially for parents.

Active design element 3: Point-of-decision stair prompts

Stair prompts were noticed by all AH participants. Participants believed the prompts were meant to encourage and highlight the benefits of stair use, and “make you think: ‘Maybe I should do a little something more.’” While slogans were easily recited, some tenants habituated to the signage saying, “It just becomes a part of the background.”

MCV's single, subtler stair prompt was hardly noticed. It inspired one participant. “I'm always up and down…I think that's what got me motivated.” The male participant remarked that on one occasion, an amused guest took a photo of the prompt. But when asked if she took the stairs, he laughed and replied, “She still took the elevator, but she thought [the sign] was catchy.”

Active design element 4: On-site, indoor gym

All AH participants considered a free gym in the building beneficial. Four of the five participants reported gym use intermittently to three times per week, while the remaining participant indicated that asthma prevented her gym use. One regular user stated, “[T]his building has an impact on my health…because we have access to a gym for most of the day.” The on-site gym prompted another woman—who had previously held a gym membership but only gone twice—to increase her PA. “Now I really don't have an excuse because I can just come downstairs. It's open from 6 a.m. to 9 p.m.…I was active already before, but even more so now because the access is easier.” A mother stated that her son's enthusiasm encouraged her to take him to the gym and use it herself.

Despite these benefits, some usage barriers were highlighted. Two women reported progressively decreased gym use as a result of habituation and “taking it for granted.” Additionally, one woman who used the gym less frequently noted time constraints: “I started going back to school. I work and I have kids.” Participants collectively agreed later hours would give them more options.

Further recommendations to encourage increased use of indoor gym and outdoor exercise facilities included on-site fitness classes and education regarding use of gym equipment. One participant pointed out: “A lot of people like me don't know really how to use most of those machines in there. I won't go in there and kill myself. I'll walk on the treadmill and get on the bike, and that's about it.” Several participants also requested “more motivational” music replace the current “smooth jazz.”

MCV participants were aware of the AH gym and stated a desire for free access or their own similar facility. All believed fitness equipment would encourage PA. Those with gym memberships reported using them rarely due to inconvenient locations.

Active design element 5: Secure outdoor exercise circuit

The AH outdoor fitness circuit was reported to offer PA benefits to parents and children as a safe recreational space. As one mother explained, “[My son] runs free, and I let him…I don't have to worry so much because it's a closed area. Usually at the park I'm [saying], ‘Where are you? Where are you?’ Here it's, ‘Okay, go ahead and play.’” PA was further promoted by allowing children to play on-site, reducing parental time constraints.

Despite these benefits, a desire for more child-oriented active space and on-site recreational programming was voiced by parents. AH participants believed the outdoor exercise circuit currently perceived as geared towards adults held the most potential and requested design elements that foster youth PA.

At MCV, children's outdoor play was restricted due to tenant noise complaints. Parents perceived local public parks and playgrounds to be unsafe due to crime. One woman said her daughter would be safer and could spend more time being active if she could play on-site at MCV.

Discussion/Conclusions

Focus group results indicate positive impact of active design on healthy behaviors. The fitness centers and stairwell design at AH were seen as assets. AH participants internalized the message that PA is important, and found design elements motivational and thought provoking.

Active design elements impacted behaviors of the majority of AH participants who reported more PA from using the on-site facilities than they routinely engaged in before living there. Some participants habituated to stair prompts and convenient gym access, however, and most were only occasional users. Participants expressed desire to make greater use of the gym, but not all positive attitudes translated to behavioral change.

In opposition to the experience at MCV, stairwell ambiance and clear sight lines at AH enhanced participants' and children's stair usage experience and fostered a sense of safety. Some AH participants were inspired to extend increased stair use off-site. All participants agreed that perceived lack of safety is a major deterrent. Children were the primary stair users in both buildings, but AH children's enthusiasm also reportedly motivated parents' stair use.

Children were the primary beneficiaries of the AH outdoor facility. Children reportedly enjoyed the space, and parents were grateful for the safe, enclosed area; parents at MCV were eager for a similar space. As with stair use, children's outdoor PA also encouraged the PA of parents. Participants reported limited child-oriented play spaces or activities in both buildings and requested a greater focus on children. MCV did not have play space for children, and crime in local parks was a deterrent to children's PA.

Participants in both buildings were eager for on-site programming for all ages, such as health education, fitness classes, and training in proper use of gym equipment.

Focus group results were consistent with previous studies that demonstrate the built environment's impact on PA. In NYC, point-of-decision stair prompts increased PA and stair usage at affordable residential and academic buildings and a health clinic, which was maintained at nine month follow-up.²⁴ Workplace studies have correlated likelihood of stair use with stairwell visibility, natural lighting, and stair prompts²⁵ as well as artwork.²⁶ Our focus groups reinforce that active design elements are powerful tools for enhancing PA and subsequently improving health.

This study was not without limitations. While the study highlighted attitudes and behaviors of people living in two NYC LEED-certified affordable apartment buildings, it does not represent all such tenants. The sample was small and predominately female. Since all AH participants were women, the focus group did not capture men's experiences. The focus groups were held during traditional workday hours and were voluntary, thus subject to selection bias.

LEED housing with active design designation is one positively received means by which to address the U.S. obesity epidemic and its attendant co-morbidities. Highlighting opportunities for increased PA through use of active design elements is successful in prompting greater PA. Reported benefits from active design interventions included increased awareness and likelihood of engaging in PA. Training in the use of active design elements emerged as one opportunity to optimize these benefits. Families would be better served by a greater focus on children's PA since children most eagerly adopt changes and aid in changing parents' behaviors. These focus group results should encourage public health experts and architects to make greater use of active design elements.

Footnotes

Author Disclosure Statement

The authors have no conflicts of interest or financial ties to disclose. This project was funded in part by the Mount Sinai Children's Environmental Health Center.