Assessing Occupant Reaction To Indoor Air Quality

CHAPTER 53
Co py rig hte dM ate ria l

Gary J. Raw, D.Phil.
Building Research Establishment Ltd. Garston, Watford, United Kingdom Occupant surveys are widely used to assess the reactions and responses of occupants to the air quality in their indoor environments; such surveys are a powerful tool in both research and practice in the field of indoor air quality (IAQ). This chapter describes the role of occupant surveys and how to use them most effectively; the chapter is divided into the following four main sections: 1. The role of occupant surveys. Why would someone want to carry out an occupant survey at all? How do occupant surveys fit into the wider picture of IAQ? What can they achieve and what can they not achieve? 2. Deciding to conduct an occupant survey. Given that there is a general case for conducting occupant surveys, how should someone (e.g., a building manager or a researcher) decide specifically when, where, and for what purpose to conduct a survey? 3. Instruments for the survey. This is the first part of conducting a survey: choosing the right instrument (usually a questionnaire) for the job. 4. Procedures for the survey. Having chosen the instrument, how should the survey be conducted? For each of these items, the issues are more complex than many suspect, but with a little understanding of the principles and available methods, an approach that is both manageable and effective can be created.
ASSESSING OCCUPANT REACTION TO INDOOR AIR QUALITY
53.1 THE ROLE OF OCCUPANT SURVEYS

Introduction
This section provides the theoretical underpinning for the three more practical sections that follow. It addresses the basic issues of why would someone want to carry out an occupant
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53.2
ASSESSING IAQ

The Primacy of Occupant Reactions The starting point for this discussion is to question, from a theoretical perspective, what we mean by an IAQ problem and how we can know when one exists. This chapter is concerned with the impact of indoor pollution on people, as distinct from effects on building and furnishing materials, animals, and plants. In this context, there are three main ways of defining a problem: health (either identifiable illness or the occurrence of nonspecific symptoms), comfort, and productivity. Of course, criteria for IAQ will often find expression in terms of environmental variables such as pollutant levels or ventilation rates, but the bases for the criteria are human responses. It follows that occupants have a key role in defining the quality of the air in their indoor environments. Objective measurements (e.g., contaminant concentrations) have the attraction that they are generally reproducible and that it is possible to define precisely what is being measured. However, it is not always so clear that they are directly relevant to human responses. It is possible for an investigator (whether a research scientist or IAQ practitioner) to be precisely and accurately measuring the wrong environmental parameters or measuring the right parameters at the wrong time or place. This is not to suggest that the investigator is incompetent: it is simply a fact that we have an inadequate understanding of how complex mixtures of air pollutants (together with other environmental, social, and personal factors) determine occupant responses. In summary, it is not sufficient to assume that conforming to published IAQ criteria will always prevent complaints about IAQ. Environmental measurements are only as useful as their capacity to predict human responses; therefore, if human responses can be recorded, it makes sense to use them as direct indicators of IAQ. Whatever the environmental measurements suggest, if the occupants are dissatisfied, there is a problem. The investigator must determine exactly what is wrong. Conversely, if the occupants were found to be satisfied with the indoor environment, it would seem strange to say they ought to be dissatisfied on the evidence of environmental measurements. There are exceptions to this because there are hazardous agents that the occupants would be unable to perceive, for example radon or carbon monoxide. Hence, to obtain a comprehensive assessment of IAQ, occupant reactions need to be used alongside environmental measurements and medical diagnosis of illness. Although specific illnesses such as lung cancer or Legionnaires disease would not be diagnosed by means of occupant surveys, there are many circumstances in which IAQ problems are best assessed with such surveys. The Value of Occupant Data In carrying out occupant surveys to investigate IAQ, the investigator is not limited to counting complaints. Indeed, unsolicited complaints are generally a poor guide to the nature and magnitude of IAQ problems. Instead, the investigator can make use of the remarkable capacity of people to act as measuring instruments and data loggers. The nose and mucous membranes of the eyes and airways are sensitive to airborne chemicals, some at extremely low concentrations. Consequently, people can detect, describe, and quantify a very wide range of environmental factors over a huge dynamic range. They can do this for specific
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survey at all and how such surveys fit into the wider picture of IAQ. Anyone carrying out or commissioning an IAQ survey should seek to acquire an understanding of these fundamentals. Much of the discussion in these chapters is focused on surveys of groups of 50 or more people sharing a common environment (e.g., the occupants of an office building). Although the general points will apply to other kinds of environment (e.g., individual homes), much of the specific guidance would need to be adapted.
53.3

The Key Issues Addressed in Occupant Surveys The three principal occupant reactions to be addressed using occupant IAQ surveys are acute nonspecific symptoms, environmental discomfort, and the adverse effects of poor IAQ on worker productivity. Surveys can also assess social and personal factors that can modify response to IAQ, such as underlying medical conditions, management issues, personality variables, and sensitivity to air pollutants; however such measurements are outside the scope of this chapter. Acute Nonspecific Symptoms (Sick Building Syndrome). In comparison with specific illnesses, there is less established knowledge about the causes of a range of acute nonspecific symptoms, which some people report when they are in certain buildings. The majority of surveys of occupant reaction to IAQ have been conducted in the context of seeking to explain such symptoms, even when the questions themselves have been about environmental parameters or modifying factors rather than the symptoms themselves. Hence these symptoms are discussed at greater length under Sick Building Syndrome, below. Environmental Comfort. Along with nonspecific symptoms, there are commonly complaints about aspects of the indoor environment itself (e.g., the odor level might be too high or the humidity might be too high or too low). These are complaints about the environment rather than about the persons perceptions of his or her own health. The importance of such perceptions is illustrated by their use in setting ventilation rates. In contrast to the procedures for setting pollutant limits, ventilation rates in nonindustrial workplaces have generally been set according to criteria of comfort or acceptability since the work done by Yaglou et al. (1936).
factors, locations, and times (e.g., the smell of tobacco smoke in the corridor on Monday afternoon) or for combinations of factors, averaged over time and space (e.g., the general air quality in the whole building during the past year). The information can be recorded at the time of exposure or it can be reported retrospectively, even without prior warning; this means that people are often the only source of data about how the air quality has been in the past. Some kinds of information can be acquired only by occupant surveys (e.g., symptoms of ill health related to being in a particular building). In using this rich source of data, there are two key problems: poor calibration and inefficient downloading. Calibration refers to the need to use data from different individuals, who respond and think differently from each other, to make valid judgments about indoor air quality and how to improve it. Put simply, two people in the same environment will rarely have identical reactions to that environment. This difference may reflect inherent susceptibility, the modifying effects of various environmental factors, and differences in reporting. There are two main ways to reduce this variability: (1) to train people to give similar responses and (2) to average the responses from sufficient people to reduce variation to a level that is acceptable for the purpose of decision making. Of course, sometimes individual variation is the subject of a study rather than a nuisance to be controlled, as in the case of research into the distribution of susceptibility and its determinants. Even if two people have identical reactions to a particular aspect of the environment, they may not give identical responses in a questionnaire; not only this, but slightly different questions on the same issue will elicit different answers. This is the problem of downloading data from people (obtaining information that is both valid and reliable). Peoples breadth of measuring and logging capacity can thus become a limitation of occupant surveys, particularly if the survey process is not carefully managed so that the investigator knows what the occupants are reporting and according to what criteria. Fortunately, there are procedures for addressing these problems, as discussed later in this chapter.
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ASSESSING IAQ

Sick Building Syndrome The investigation and study of sick building syndrome (SBS) requires occupant surveys to obtain population-level data because it cannot be diagnosed through other means. SBS can be not only a difficult health issue but also a costly problem. What Is SBS? The concept of SBS has caused confusion since it was introduced. This section seeks to break through the confusion by offering a usable definition of SBS and showing how the definition is necessarily linked to the means of diagnosis. It is inherently difficult to characterize SBS and its causes unless there is an agreed definition that can actually be used in practice. There has so far been substantial variability among the definitions offered; in many studies, no definition at all has been given. The definition adopted in this chapter is as follows:
Sick building syndrome is a phenomenon whereby people experience a range of symptoms when in specific buildings. The symptoms are irritation of the eyes (e.g., dry/watering eyes), nose (e.g., runny/blocked nose), throat (e.g., dry/sore throat), and skin (e.g., dryness/redness), together with headache, lethargy, irritability, and lack of concentration. Although present generally in the population, these symptoms are more prevalent among the occupants of some buildings than of others and are reduced in intensity or disappear over time when the afflicted persons leave the building concerned.
Productivity. Although productivity or staff efficiency would appear to be a potential basis for standards, a principal barrier has been defining and measuring productivity. To use work performance as a criterion is feasible in some settings, for example, where people are doing repetitive routine tasks, but in other cases it is much more difficult to assess whether performance has been improved or reduced by attaining a certain level of IAQ. For some types of work it may be some years after a piece of research was performed before its usefulness can be established. In practice there is little readily usable data linking IAQ with productivity. Nevertheless, productivity is a key element in the motivation to improve IAQ in the workplace because it is generally assumed that healthy, comfortable staff are also productive staff.
Because the symptoms are associated with particular buildings, they are often called building related. The time required for recovery can vary from hours to weeks, depending on the type and severity of the symptom. Thus, to say that SBS is a real phenomenon is merely to say that there is a variation in symptom prevalence among buildings, not a clear division into sick and healthy buildings but a continuous variation. Some studies have used more extensive lists of symptoms, including for example, airway infections and coughs, wheezing, nausea, and dizziness (WHO 1982); high blood pressure (Whorton and Larson 1987); and miscarriages (Ferahrian 1984). However, although these conditions are mentioned as occurring among staff in certain sick buildings, they probably should not be included in SBS. Taste and odor anomalies are not necessarily symptoms: they are better considered as environmental perceptions and are therefore best excluded from the list of defining symptoms. SBS is thus defined, as many health problems have been in the past, in terms of symptoms and conditions of occurrence rather than cause (except at the very general level that buildings are somehow responsible). The reason is that there is no single proven causal agent, and any attempt to introduce etiology into the definition is likely to be misleading at present. This would apply equally to specific causes (e.g., tight buildings) and to common generalizations such as SBS being diagnosed only when there is no known cause or
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53.5

Diagnosis. The definition of SBS suggested in this chapter implies that the definition is inseparable from the means of diagnosis. This is because the range of symptoms reported in a given building population, and their prevalence rates, will depend on the number and nature of the questions used to elicit the information. The choice of survey instrument is thus critical for the diagnosis of SBS. Because definition is tied closely with diagnosis, if the diagnostic approach is not standardized, the definition is effectively variable across investigations. For example, if two different questionnaires are used in studying two different buildings, it may be that two different instruments are being used to measure the same phenomenon. In fact, because the questionnaire determines what is measured, two nonidentical phenomena are being measured. Diagnosis can also become inconsistent if different clusters of symptoms are statistically derived because these clusters will vary among buildings or groups of buildings (see Raw et al. 1996a, 1996b). Although this discussion may appear somewhat academic, it highlights a key issue in the current approach to diagnosing SBS. We have imperfect instruments, but we need to use them rather than to wait for agreement on the perfect diagnostic procedure. Greater standardization is critical to advancing understanding of SBS. It is important to keep in mind for this purpose that SBS is a complaint of people, not buildings, and can be diagnosed only by assessing the building occupants, not by examining the building itself. An attempt to define a working criterion for SBS diagnosis (Raw et al. 1990) specifies a level of more than two symptoms per person, recorded using the same questionnaire as in the U.K. cross-sectional survey reported by Wilson and Hedge (1987). This was the level at which respondents, on average, reported a negative effect of the indoor environment on their productivity. SBS Matters. It is generally recognized that SBS is not an isolated or occasional phenomenon. A WHO working group (Akimenko et al. 1986) estimated that, although frequency of occurrence varies from country to country, up to 30% of new or re-modelled buildings may have an unusually high rate of complaints (these complaints may extend beyond SBS). This estimate is again to some extent arbitrary and could be set considerably higher or lower by taking a different criterion for what would be considered a high rate of complaints. Apart from effects on productivity when staff are at work, SBS has been shown to affect absenteeism and quite obviously makes demands on the management and trade unions that spend time trying to resolve the problem. Other likely effects are on unofficial time off, reduced overtime, and increased staff turnover. In extreme cases buildings may be closed for a period. If building users were to associate SBS with energy-saving measures such as controlling ventilation rates, this could inhibit moves toward greater energy efficiency. Although neither life threatening nor necessarily disabling, SBS is clearly perceived to be important to those affected by it, particularly if they are affected at home (e.g., the elderly or sick in residential care) and cannot leave the affected building. The economic significance of IAQ problems is addressed further in Chapters 4 and 56.
where there are multiple causes. It is nevertheless possible to talk of preventive and remedial measures, much as many diseases were to some extent prevented (e.g., by hygiene practices) and treated by reducing specific symptoms (e.g., fever) long before the cause of them was identified. Although SBS can be defined, the definition of a case of SBS (a sick building or SBSaffected person) is to some extent arbitrary. A theoretical definition of a case could follow from the definition of SBS, but in practice the identification of specific cases would depend on what is regarded as an acceptable level of symptoms among the occupants.
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ASSESSING IAQ

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The Causes of SBS. The list of suggested causes for SBS is very long indeed, as addressed in other chapters of this book. Although this chapter does not review the evidence on the possible causes, it should be noted that, although many studies have focused on IAQ and ventilation rates, there seem to be some contributions from a wide range of other factors in the environment (particularly temperature, humidity, cleanliness of offices, and personal control over the environment). Current evidence suggests that no single factor can account for SBS: there are probably different combinations of causes in different buildings. The statement is sometimes made that we do not know the cause of SBS; this is unhelpful because we know many causes of SBS. The problem is one of identifying the cause or causes in particular buildings because this entails consideration of interactions occurring at the following four levels among etiological factors: The building. The design, construction, and location of a building and its services and furnishings may contribute to IAQ problems in a variety of ways, from the site microclimate through shell design (i.e., depth of space) to the building services and build out.
The indoor environment. The effects of the building and site will generally be mediated by characteristics of the indoor environment (e.g., temperature or allergen levels). The occupants. Households or organizations that occupy and operate buildings may contribute to IAQ complaints, for example, via the quality of building maintenance and workforce management.
The individual. Reported experience of IAQ problems varies from one person to another within buildings for a number of reasons, which would include personal control over the environment, constitutional factors, behavior, and current mental and physical health.
In addition, causes of SBS may stem from the earliest origins of a building, from the original concepts, specification, and design for a building through the construction, installation, and commissioning to the maintenance and operation of the building. Hence it is too simplistic to talk about the causes of SBS only at the level of IAQ parameters causing certain symptoms. The investigator must remember that the determinants of SBS cannot be addressed adequately using only an occupant survey.
53.2 DECIDING TO CONDUCT AN OCCUPANT SURVEY

Introduction
The process of deciding to carry out an occupant survey is important because it should identify the reason for the survey or hypotheses to be tested, which in turn will be a key factor in deciding the method to be used. The decision-making process should also bring all the interested parties together in consensus over the approach. The most common reasons for initiating a survey would be as follows:
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There is a suspected problem with the indoor environment, based on spontaneous complaints, illness reports, sickness absence, or environmental monitoring. There is a desire to be proactive in monitoring the quality of the indoor environment. It fits the needs of a research project.
53.7
Each of these is addressed in turn.
Response to Suspected Problems If an IAQ problem is suspected, there is rarely a good reason for not conducting an occupant survey. Neither the act of conducting a survey nor the results found define liability for the IAQ problem. Rather, the survey is a first step toward finding a solution. In many cases, the occupants may consider that they have already made a diagnosis, that remedial action should be taken, and that any further survey is likely to be uninformative. Although such feelings are understandable, an unsystematic and anecdotal collection of complaints is a poor guide to what action should be taken. On the other hand, some managers would prefer to believe that there is no problem and that surveys will only cause further complaints. Unless spontaneous complaints are investigated in a more rigorous manner, such conflicts in views cannot be resolved. Either the occupants will continue to be affected by SBS, with implications for their health and the success of the company occupying the building, or effort may be wasted addressing a problem that never existed. A good occupant survey should not just confirm (or otherwise) the level of complaints in the building but should also provide information about where and when there are problems and what types of complaints are being made. It may also give an indication of the cause of the problems, but this must always be backed up with further investigations involving other measurements and/or interventions. A survey will also provide a basis for evaluating the effectiveness of any remedial measures that might subsequently be undertaken. This application could include piloting remedial measures in one part of a building and assessing the outcome before extending the measures to other parts of the building. This type of application has many of the characteristics of a research project, with all the methodological rigour entailed.

Proactive Monitoring It is sometimes claimed that faulty management is responsible for IAQ problems. At one stereotyped extreme, problems in the workplace can always be attributed to bad management. At the other extreme, blame is placed purely on the environment. A proper balance between these views can be struck by establishing in specific terms what management could have done to have avoided the problems. Broadly speaking, management can be seen as contributing to IAQ problems if it does not act effectively to create a good indoor environment or if it does not establish a good organizational environment for reducing stressors that foster complaints about IAQ and for dealing with complaints should they arise. Carrying out an occupant survey only in response to complaints might be called bad management, although it is more conciliatory to call it good management, albeit too late. By analogy, consider a company that did not routinely check the safety of its vehicle fleet but chose instead to wait until a truck reached the point of swerving off the road before checking the whole fleet. If we can be proactive with machines, why not with people? Occupant surveys indicate whether the final clients (i.e., the people who occupy the building) are satisfied with the architect and building services engineers final product (i.e., the indoor environment and the control of that environment). The data provided by such surveys have two essential purposes:
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To tell the facilities manager and other parties whether a building is performing to an acceptable standard
53.8
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ASSESSING IAQ
To tell those who contribute to future buildings about how to create better environments (whether their contribution is in design, building, installation, commissioning, operation, maintenance, or management)

Research, Including Following Up Mitigation Attempts Survey research on SBS can be seen to have passed through three phases, representing a transition from exploratory to confirmatory studies. The approaches represented by each of the three phases have validity for specific purposes, but each needs to be done well if meaningful results are to be achieved. The first phase of research was concerned with the existence of the problem. It effectively commenced in the late 1970s, although there were earlier warnings of the emerging problem of SBS (Black & Milroy 1966). By the early 1980s, it had demonstrated to the satisfaction of most researchers that there was a phenomenon that we now call SBS. Second, notably in the 1980s, there were many investigations that relied on comparisons of occupants symptom prevalences between buildings. These studies provided evidence on what can be termed risk factors (e.g., open plan offices and low perceived control over the indoor environment). These factors cannot necessarily be regarded as direct causes because of the many confounding factors and confusion over causal pathways. For example, air-conditioning was identified as a risk factor, but the causal factors could include various building characteristics that are commonly associated with air-conditioned buildings, such as deep building plans, reliance on artificial lighting, and lack of personal control of the indoor environment. Now, in the third phase of SBS research, the risk factors constitute important clues as to the causes, clues that are being followed up by making experimental changes to buildings. The basic plan of such intervention studies is first to apply theoretical knowledge and an examination of a building to generate hypotheses about causes of SBS in the particular building being studied. Modifications are then made to the building and/or the indoor
In other words, the purpose of carrying out surveys is to improve the product, whether that product is the environment in a current building or in a future building. In a busy facilities management situation, it can be tempting to believe that occupant surveys are not necessary (because occupants will complain if there is a problem) or actually counterproductive (because they create or exaggerate problems or create an awareness of problems). A forward-looking company will set aside these concerns in favor of the goal of achieving greater client satisfaction. Occupants do complain, but their complaints are often an unreliable indication of the scale and nature of any problems because complaints are also motivated (positively or negatively) by a range of factors unrelated to the subject of the complaint. Besides, what kind of service provider can really afford to wait until the situation becomes bad enough to provoke complaints? It is good practice in any industry to identify and deal with complaints before they break out and are labeled as a problem. Thus, the second objection (i.e., that occupant surveys create problems) is unsound. Surveys will identify whether a problem exists and thereby offer an opportunity to solve the problem. By using a standard questionnaire, the results of the survey can be compared with a wider database to show how the building is performing in relation to comparable stock (see Section 53.3). Alternatively, repetition of the survey will show whether there are changes over time in the performance of a building, which would give an even clearer indication of impending problems. An interval of 2 years between surveys is a reasonable norm, but the interval could be shorter or longer depending on the pace of change in the building or workforce.
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53.3 INSTRUMENTS FOR THE SURVEY
Choosing an Approach Occupant data can be collected by a number of means, including structured or unstructured interviews (medical examinations generally include an interview with the patient, and this interview may be more or less structured), discussion groups, diaries, and self-completion questionnaires. Medical examinations are outside the scope of this chapter, but they do have a role to play, especially where complaints have become sufficiently serious for rapid action to be required or where the nature of the symptoms is unusual. Although the presence of symptoms of SBS is normally assessed by self-completion questionnaire, this is for convenience, and most of the symptoms can be assessed by other means and shown to be correlated with questionnaire responses (see the later discussion of reliability and validity). Demonstrations that symptoms can be reduced markedly in blind trials of remedial measures (Raw et al. 1993) also support the validity of the questionnaires used. The remainder of this section assumes the use of self-completion questionnaires. Most of the information provided would apply equally to structured interviews or diaries. Selecting or Designing a Questionnaire Introduction. For most surveys, the use of an existing questionnaire is preferred, whether the purpose is proactive monitoring, response to complaints, or a screening survey carried out in a research project. Designing a new questionnaire is time consuming and difficult, if done properly. By using a standard questionnaire, the results of the survey can be compared with a wider database. In some cases, there will be a need to modify an existing questionnaire. In such cases, or where questions are borrowed from existing questionnaires to create a new one, pretesting is important because the meaning of questions can be affected by even small wording changes and by the context provided by neighboring questions in the questionnaire (Rathouse and Raw 2000). Various general guidelines on questionnaire design have been produced (e.g., Sudman and Bradburn 1982, Converse and Presser 1986). The following sections can be used to gain an understanding of questionnaires for the purpose of selecting, adapting, or designing. Readers should be aware that no single SBS questionnaire has been selected as a gold standard. For example, the phrasing of questions can be used to bring about large variations in measured symptom prevalence; such data therefore have little value unless norms are available for a particular standard questionnaire. In every study, some key common questions should be used that have proven validity relative to other similar surveys.
environment, and measurements are made to determine whether the modifications have been successful in reducing the symptoms experienced. This approach allows for control of potential confounders and thus provides stronger evidence on the causes of SBS. Identifying the type of research that is to be carried out is the key to choosing the right research design and the right survey instruments. Research that seeks only to identify sick buildings requires a relatively simple screening questionnaire. A search for risk factors requires the collection of additional data on potential determinants and modifying factors. Intervention studies require yet another layer of sophistication: Their design has recently been discussed at length (Berglund et al. 1996) and is summarized later in this chapter.
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ASSESSING IAQ

Recall of the Past. Valid descriptive data are obtained from questionnaires that focus on the current, the specific, and the real (Turner and Martin 1984). Questions on the past in general appear to be more difficult than questions on the present, especially if (1) a decision was made almost without thought in the first place, (2) an event was so trivial that people have hardly given it a second thought, (3) questions refer to events that happened long ago, and (4) recall is required of many separate events. Even important events can fade with time or require specific cues to bring them into focus. The following five techniques have been recommended to improve the validity of reporting on past events (Converse and Presser 1986):
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Reliability and Validity. One problem in IAQ research is that questionnaires have been accepted without sufficient evidence of validity or reliability. It is important to characterize these properties of any instrument, including questionnaires. The reliability of a measurement refers to how precisely it measures. The reliability is usually expressed as a reliability coefficient, which is the proportion of obtained variance that is due to true variance in the variable being measured. Repeatability is one indicator of reliability because if an instrument is imprecise, there will be a low correlation between repeated measurements; this is how reliability was established for the U.K. Office Environment Survey (OES). The validity of a measurement refers to how well it measures what it intends to measure. One type of validity is empirical validity, the degree of association between the measurement and some other observable measurement. For example, the OES was validated in comparison with medical interviews (Burge et al. 1990), whereas others have used objective measures such as tear film breakup (Franck & Skov 1991). An alternative type of validity is construct validity, which means that the measurement should correlate with all other tests with which theory suggests it should correlate and should not correlate appreciably with other tests with which theory suggests it should not correlate. The OES symptom prevalences correlate with environmental discomfort and productivity but much less with control over the job. Symptoms are, by their nature, subjectively reported. Hence, symptom reports have an implicit validity because what the respondent says is important in its own right. This is helpful only up to a point because if the report has no relation to physiological states, the investigator could be misled about the nature of the problem. The important point is that good practice should be used in recording symptom reports.
Bounded recall addresses overreporting due to forward telescoping outside the requested time range (it may be controlled by establishing the baseline in an initial survey). Narrowing the reference period for survey reporting is a good corrective means. Averaging refers to questions about typical conditions, which provide more representative data than single day focused questions. Landmark events may be referred to instead of specific dates to anchor the timing of other events. The question could ask about a symptom experienced since Christmas, instead of during the last month. Cueing means that cues are provided to help memorizing. The purpose of cues is to stimulate recall by presenting a variety of associations.
Simplicity Is the Rule, Complexity the Exception. There is a need for simplicity, intelligibility, and clarity. It is imperative that common language should be used, questions should be short, and confusions should be avoided (Sheatsley 1983). If the respondents are faced with a task they cannot manage or they believe they cannot manage, the responses
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Questionnaire Construction. A number of basic issues have to be decided in constructing a new questionnaire, including the following:
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have low information value. It is generally easier to answer questions bearing on ones own experience and behavior (facts) than questions on opinions and attitudes (evaluations). The latter are assumed to be more open to the respondents own definition than the former. Ranking scales have a long history in survey research. Alwin and Krosnick (1985) showed that rankings (rank order is given) do not show the same relationship to predictor variables as ratings (category scale value is given) even though the same factors were investigated. Magnitude estimation scales are a third, more complex, technique of responding. Magnitude scaling of attitudes has been calibrated against numerical estimation and physical line-length estimation of physical stimuli such as light, sound, and odors (Berglund et al. 1975, Berglund and Lindvall 1979, Lodge 1981). Although these more complex techniques have considerable interest and potential usefulness, they have been little used in survey research into IAQ (Garriga-Trillo and Bluyssen 1999). Questionnaires with closed questions are easiest to standardize. A widespread criticism of closed questions is that they force people to choose among offered alternatives instead of answering in their own words. Nevertheless, because closed questions give the same response options, they are more specific than open questions and therefore more apt to communicate the same frame of reference to all respondents. The typical survey question incorporates assumptions not only about the nature of what is to be measured but also about its very existence.
Type of response format (e.g., ranks, ratings, magnitude estimation scales). Open or closed questions (closed questions are easiest to standardize but they are sometimes criticized for limiting the respondents options). The effect of the context of other questions, especially neighboring questions, in the questionnaire. The overall length and difficulty of the questionnaire (consider the amount of information collected per respondent, how useful the information is, and how many sampled people will respond at all).
In some cases, other issues will need to be considered; for example, the questionnaire might need to be completed by children or by adults who have restricted literacy. If the questionnaire is to be translated into other languages, it should be checked to ensure that adequate translation is possible and that the questions are likely to be culturally acceptable wherever they are asked. Investigators should characterize the instruments to be used by the following: Piloting or otherwise validating the instrument Knowing the meaning of each measure, score or index Assessing and correcting for any predictable source of error such as habituation, practice, response sets, and false responses
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This would require reading the literature on an instrument (including questionnaires) and being trained in its use. Sometime researchers may rely on developing an understanding of the instrument in the course of the study, but this carries obvious risks. The following should be considered in the pilot: variation in responses, meaning, task difficulty, respondent interest and attention, flow and naturalness of the sections, the order of questions, skip patterns, timing, respondent interest and attention overall, and respondent well being (Converse and Presser 1986).
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The Example of the ROES Questionnaire Introduction. In the United Kingdom, an expert group set up by the Royal Society of Health has agreed on a standard questionnaire, the Revised Office Environment Survey questionnaire (ROES) together with instructions for its use and normative data (Raw 1995). ROES is intended to be used for screening surveys to determine the prevalence of SBS in a particular building. An account follows of the issues that need to be covered when designing or selecting a questionnaire for indoor environment surveys, with examples taken from the development of ROES (see Appendix A for sample of the ROES). More detail on ROES itself can be found in Raw (1995). Two other major questionnaires, used extensively in the United States by the Environmental Protection Agency (EPA) and National Institute of Safety and Health (NIOSH) are discussed at greater length in Chapter 3. Another questionnaire that has been widely used is the Swedish MM Questionnaire (Andersson et al. 1988). The Symptoms to Be Included. The starting point for the selection of symptoms to be included was the list of symptoms in the largest U.K. study of SBS, the Office Environment Survey, or OES (Burge et al. 1987, Wilson and Hedge 1987). The same list has been used in many subsequent and previous U.K. studies. Using the same list of symptoms provided immediate reference to an established database. These symptoms were as follows:
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Dry eyes Itching or watering eyes Blocked or stuffy nose Runny nose Dry throat Headache Tiredness or lethargy Flulike symptoms Difficulty breathing Chest tightness The last three of these are probably not correctly regarded as typical SBS symptoms. Runny nose is also problematic as a defining symptom because it appears to indicate primarily respiratory infections. Itching or watering eyes may also be nonessential because itching partly duplicates dry eyes, and watering may reflect specific allergic reactions. An analysis carried out in the course of the development of the questionnaire (Burge et al. 1993) showed that a building symptom index (BSIthe mean number of symptoms reported per person in a building) based on the remaining five symptoms is almost perfectly correlated with an index based on all 10 symptoms. The following five symptomsdry eyes, blocked/stuffy nose, dry throat, headache, and tiredness/lethargywould therefore be enough to provide an index of SBS. Consideration was given to including only these five symptoms on the questionnaire, but this approach was rejected for two reasons. First, the above analysis was based on removing the symptoms at the analysis stage; removing them from the questionnaire might have a very different effect; some evidence for this is provided by Raw et al. (1996a). Second, a shorter list of specified symptoms would place a greater load on the final item concerning other symptoms. The first point represents a lesser problem regarding flulike symptoms, difficulty breathing, and chest tightness because these appeared at the end of the list in previous
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Recall Period. The response of any one individual to IAQ will vary over time. This variation might occur over minutes (e.g., because of adaptation to odor or changes in the interpretation of perceptions), hours (e.g., delayed reactions of sensory irritation), or years (e.g., as awareness and understanding of IAQ issues develops). Some psychological variables will be continuously varying over time, whereas other variables will be present or absent or will be discrete events. The selected time period of a study will censor the data by design: If the study period is made longer, for example, there is a greater possibility of symptom occurrence. The reference period for reporting symptoms in the ROES questionnaire is 12 months, as in most U.K. questionnaires, based on two or more occurrences over the period. Seasonal variation of the symptoms can be addressed separately if it is suspected that this was likely to occur in a particular building. Recall over a 12-month period is unlikely to be reliable in absolute terms: it is likely to represent mainly the previous few weeks, possibly moderated by recall of particularly severe symptoms prior to this or any marked seasonal variation. It is necessary to emphasize here that the questionnaires main function is to make comparisons among buildings or over time for a particular building. Thus it is not appropriate to attempt to assign absolute meanings to the questionnaire responses. The use of relative ratings largely circumvents the problem of recall because it is the same for each building and each occasion. The test-retest reliability of the symptom questions is good (Wilson and Hedge 1987), but they should not be repeated within too short a period because this tends to create a decline in the number of symptoms reported (Raw et al. 1993). The critical interval for this is not known, but an interval of a year is probably adequate to prevent it (there would normally be no reason to conduct screening surveys at shorter intervals). If the requirement is to assess a building in relation to the whole year, not just the time of the survey, the only alternative to using 12-month recall would be to repeat the questionnaire during the course of a year, perhaps four times with 3-month recall on each occasion. A requirement to carry out a survey more frequently would increase costs and would discourage use of the questionnaire. Frequent repetition would also affect interpretation of the symptom scores, as noted above. It would therefore be necessary to collect data from repeat surveys in a sample of buildings to generate a new database for comparison. Questionnaires are available to cover shorter recall periods, where this is required. The Swedish MM questionnaire (Andersson et al. 1988) has been translated into English and a number of other languages. It uses a 3-month recall period. The U.S. EPA (BASE)
surveys and are unlikely to be misreported as earlier symptoms on the list. It was therefore agreed to delete these symptoms. A number of questionnaires, particularly in Scandinavia (Andersson et al. 1988, Skov et al. 1989), have included skin symptoms on the list (e.g., dry skin, skin rash, redness of the skin). For the sake of greater international compatibility it was thought advisable to introduce a question about skin symptoms at the end of the list. If particular investigators or researchers added symptoms to the end of the list, it could still be possible to compare with a database unless the symptoms added were similar to those on the main list. However, it would be advisable to test this assumption. If questions were subtracted, or if the symptom descriptions were changed, comparison with the database would be invalidated. The layout of the symptom questions was changed from that used in the OES (Burge et al. 1987, Wilson and Hedge 1987) because the opening question (in the past 12 months have you had more than two episodes of any of the following symptoms) was considered ambiguous and, with the questions now covering more than one page, likely to be forgotten by the respondent. The question is therefore now asked separately for each symptom. This creates some monotony but at least the question is clear.
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ASSESSING IAQ
questionnaire uses a 4-week period, as does the related NIOSH questionnaire. The ROES was adapted for 1-month recall and for reporting current conditions, as part of the European IAQ audit project (Groes et al. 1995). These questionnaires would generally be suitable for intervention studies in which changes over a period of much less than a year normally need to be detected. Building Relatedness. The ROES questionnaire seeks to establish whether symptoms are related to being in the target building by asking the question Was this better on days away from the office? From the point of view of comparison with the OES data, it is preferable to maintain this approach. However, the question is not specific about the comparison to be made and demands interpretation on the part of the respondent. For example, does it mean on whole days away from the office, away from the office at home or away from the office in other buildings or outdoors or on holiday. For building-level comparison, it should be valid, assuming that people will, on average, adopt the same kind of interpretation. It also appears, in fact, that the phrasing of the building-relatedness question has little effect on symptom reports (Raw et al. 1996a). Frequency of Occurrence. For screening purposes, it is not necessary to include ratings of the frequency of the symptoms, although such scales can be useful. A frequency scale has been included, placed after the assessment of building relatedness to maintain compatibility with the U.K. database. The scale meets the dual requirements of (1) covering the complete scale of frequency without (2) having overlap between categories. Including such a scale gives the potential for greater sensitivity in comparing symptom prevalence between buildings or over time. Layout. The layout of the questions (i.e., whether it is question by question or with the responses given in a grid) may be significant. Where responses are given in a grid, Raw et al. (1996a) report that respondents have a greater tendency simply to pick the symptoms that particularly apply but not give a response to the others at all (i.e., there are more missing responses). They also found that there is less variance in response within respondents, as though there is a tendency to stay within or close to a particular column (frequency category) of the grid. Therefore, although a grid would require less space (probably one page rather than two), separate questions are preferred.

Questions about the Environment. Ratings of the environment can assist in the identification of causes but cannot be always taken at face value; their primary purpose should be to indicate what aspects of the environment give rise to most concern and therefore which aspects offer the best chance for improvement. A very large number of ratings could be included in a questionnaire, depending on the level of detail with which environmental factors need to be specified. For a screening survey, only the main likely problem areas should be evaluated, normally with separate ratings for summer and winter. The key ratings would generally be temperature, humidity, air movement, and air quality. Lighting, noise, and vibration are probably less important in most cases of SBS, and therefore ROES has only a single question on each of them for each season. More detailed questions, or a follow-up questionnaire, could be added in specific surveys if the investigator wished to do so. As with symptoms, the impact of doing this should be assessed before comparing with the database. A rating of office cleanliness has also been added. Some studies have used a rating of office cleaning, but it was felt that this could be ambiguous, including for example the extent to which cleaners interrupt work or feelings about the use of chemicals that may damage the indoor or global environment. The previous OES question on personal control over heating, ventilation, and lighting has been rephrased to remove any ambiguity concerning which part of the office the control refers to. The question about exposure to tobacco smoke has also been made less ambiguous.
53.15
If the environment questions are not required in a particular survey, they can be omitted by taking out the central pages of the questionnaire. This has subtle effects on symptom reporting, depending on the gender of the respondent and the overall quality of the indoor environment, but it does not affect the overall symptom prevalence (Rathouse and Raw 2000). Questions on Confounding Factors. Two kinds of confounding factors can be included in an SBS questionnaire: variables that permit adjustment of the building symptom score and variables that may provide insight into the causes of problems in the building (and modifying factors and confounders). The building symptom index (BSI) can be corrected for gender, job type, and visual display unit use (the latter is a relatively minor modifying factor). If some staff are part time or spend time in different parts of the building, this also may need to be taken into account. In a screening questionnaire, there is only a limited role for seeking to identify the cause of SBS: The existence of the problem should be determined before its causes. However, a limited number of questions were included about the office environment as discussed above, plus questions on speed and effectiveness of the management in dealing with indoor environment problems, privacy, office layout, and decor. Ratings of overall working conditions, productivity, personal medical history, alcohol consumption, and work breaks are not included because they are not likely to add significantly to data at the building level. Questions about the job and quality of management are also not included because these are not primary issues in screening (they may be relevant in certain research studies) and may inhibit some managers from agreeing to the survey and some staff from returning the questionnaire. Consideration was given to including some kind of check for honest and consistent reporting, to improve the validity of responses. This could significantly increase the length of the questionnaire, and the usefulness of a lie scale is likely to reduce over time as people become aware of its existence. The required comparisons are in any case probably valid without this kind of check because the database used for comparison would have any tendency to misreport built into it. The presence of unusual patterns of response to the questionnaire could in principle be used as a form of lie scale, but this idea has not been developed. Adding Questions. It is always tempting to collect too much information, much of which will never be subjected to any useful analysis. The ROES questionnaire is designed with this in mind: It is a basic screening questionnaire to determine whether there are problems with occupant health and comfort, not a method of showing what is causing the problems. If there is any intention, in a particular survey, to add to this questionnaire, it can be useful to ask the following questions: Is it possible or necessary to carry out a statistical analysis of the information to be gathered? How much, approximately, should the study cost, how long should it take to complete, and what uncertainty can be tolerated in the results? What are the motives and purposes of the study and for gathering particular items of information, and would they be credible to the respondents?

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53.4 PROCEDURES FOR THE SURVEY

Introduction
A questionnaire is not in itself a method; it is an instrument, which will produce valid results if used in accordance with the manufacturers instructions. There is very little
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ASSESSING IAQ

Planning the Survey The survey should be carried out by an organization that can guarantee (to the satisfaction of the staff) that the survey is confidential and that information on individuals will not reach management or other staff in the building without the consent of the individuals concerned. Eligible organizations could be, for example, a body that is independent of the building management or, if one exists, the occupational health department of the organization occupying the building. It is of value to plan with all parties concerned with the study and to do the following:
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value in using a standard questionnaire without following the data collection method recommended for that questionnaire. A questionnaire study is an important part of monitoring the health of people in the workplace, and it is worth a little effort to organize it well. Much effort can be wasted through simple oversights, but a few basic principles will make the task more manageable. The following guidance is based on that given with the ROES questionnaire. If available, the guidance provided with whichever questionnaire is used should be followed.
Hold preliminary discussion between the organization that will carry out the survey, management, unions, and other representatives of the building occupants, safety officer, maintenance staff, and so forth (the survey should nonetheless be seen by staff to be independent of management and unions). Ensure that staff know the survey is approved by management and other parties as appropriate and can therefore be regarded as part of their work. Establish agreements about confidentiality and lines of communication between all parties. Agree to inform building management immediately about any health risks that are discovered.
Confidentiality is particularly important, not only from the point of view of motivating the respondents but also for evaluation of the results. If the survey is being conducted as part of a research project, an early stage of the work will often be to select a building. This selection will depend on the purpose of the project and cannot be covered in detail here. However, in the case of an intervention study, the following should be considered when selecting a building: A single large building (with many rooms and people) allows better specification of experimental/control conditions than several small buildings, unless the small buildings are all very similar in design, operation, occupancy, and managementin either case the objective is to reduce confounders by making the experimental and control groups as similar as possible. The initial level of SBS symptoms should be high in the building, to be able to demonstrate an improvementone way of identifying such a building is by examining the level of spontaneous complaints from building users, but the actual level of symptoms should be confirmed by a structured survey. There needs to be a high level of cooperation from all parties concerned with the building, especially in relation to carrying out the intervention. The management of the study will probably be simplified if the organization that occupies the building is also responsible for its maintenance.
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Survey Sampling The survey sample design should be developed as an integral part of the overall study design. Survey sampling is a highly specialized and developed component of the survey process. Therefore the wisest decision for a researcher with limited sampling knowledge is to consult an experienced survey statistician, particularly in relation to the size of the sample to be used. Some general guidance is given here. The total number of people who could, in principle, complete the questionnaire may be referred to as the target population. This might be, for example, all the staff in a particular building or in certain parts of the building. The advantage of defining the target population is that the exclusion of any subgroups is explicit and the restrictions of the survey will be known. When practical constraints are considered (for example, the target population may be very large), the target population is often replaced by a survey population, or sample. About 100 workers need to be included in a sample to produce reasonably reliable results (Raw et al. 1996b). If the target population is larger than this, a sample can be used of approximately 100 workers. The sample size should be increased if different areas of the same building are to be compared (e.g., 100 from an area where complaints have been made and 100 from a comparison area). If fewer than 100 workers are available, a survey can still be conducted, but as the number of workers is reduced there is a progressive decrease in the reliability of the results and an increase in risk of bias due to variation in individual sensitivity among occupants. Unless the target population is very large, it is often easier (logistically and politically) to include every person present during the survey than to go through the process of selecting a sample and then finding the selected persons. The most basic sampling procedure is simple random sampling, which requires that each person or workstation has an equal probability of being included in the sample. Strictly, this means that a list of people or a plan of workstations should be available. For example, people might be chosen randomly from a staff list. In this way, selection biases are avoided. A reasonable approximation to random sampling can generally be achieved by selecting from a plan of workstations. However, if sampling is based on workstations rather than persons, rigorous care is needed to follow a plan and not to select only the workers who are present at the time of the first visit to the workstation. With any sampling strategy, a complete sample will only be obtained if those who are unavailable through absence or for other reasons are contacted at a later date. Several common practical sampling designs are modifications of simple random sampling (Kalton 1983, Lee et al. 1989), as follows: 1. With systematic sampling, each nth element is selected after a random start in a list or a chosen route around the building.
There is of course the additional question of when the researcher should embark on a major study: Should obvious problems with the building be put right first and should the first questionnaire survey be carried out before any such remedial measures? The answer will depend largely on the researchers resources and research objectives. It may be of interest to assess whether any obvious problems in a building are actually responsible for occupant complaints. In such cases it will be necessary to carry out a first stage of monitoring before carrying out any remedial measures. If, however the requirement is to identify the causes of problems once the building appears to be operating within normally accepted conditions, the first stage of the monitoring could be delayed. If it is delayed, it should be well after the first remedial measures have been completedat least as long as the recall period of the questionnaire.
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In general, samples should be balanced for workers near windows and near the center and on different faces and floors of the building. The above approaches are all examples of probability sampling. Nonprobability sampling covers a variety of procedures, including the use of volunteers and other bases for choice of elements for the sample with the purpose that they are representative of the population (Kalton 1983). Of course, the weakness of all nonprobability sampling is its subjectivity. A sample of volunteers or a representative sample chosen by an expert can be assessed only by subjective evaluation, not by assumption free statistical methods. Motivating the Respondents Questionnaire studies can be perceived by busy respondents as wasting time, and they do not always understand the purpose of the survey. The loss of respondents from the sample is therefore a risk if proper care has not been taken, and this can have two consequences. First, there may be insufficient responses for satisfactory statistical analysis (particularly if there is a small sample to start with). Second, there may be biased sampling. In particular, people with more complaints may become overrepresented in the sample. To achieve a reasonably representative sample, response rates of over 80 percent are needed from either whole building populations or from occupants randomly selected from a population. In practice it should be possible to achieve over 90 percent for a single survey (this can be difficult to maintain if repeated surveys are conducted of the same population at short intervals). The following paragraphs provide recommendations for recruiting and retaining a sample. First, consider the demands to be made on the respondent, for example the length and complexity of the questionnaire, and the number of occasions on which it is to be completed. If the number of respondents is sufficiently small, a meeting could be held in advance of the survey; otherwise hold a meeting with representatives (possibly trade unions) and/or send a letter to the respondents in advance of the survey and/or in a letter accompanying the questionnaire when it is distributed. This exercise should seek to do the following: Convey the value of the study (this ought to be straightforward if the study may lead to remedial measures to improve the indoor environment). Explain the need to have the participation of everyone who has been selected. Make clear who is carrying out the study (e.g., independent researcher who is neutral to any conflicts within the building is likely to have an advantage). Make the information collected completely confidential and inform the respondent of this.
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2. Stratified random sampling classifies population elements (e.g., people) into strata (e.g., departments, job grades), and random sampling is then carried out separately from each stratum. This can be complex but may be useful to ensure an adequate statistical sample of any small population subgroups. Any mean values calculated for the building as a whole would then have to be corrected to take account of the overrepresentation of particular groups. 3. Multistage cluster sampling can be used when the population is very large, for example, an estate of many buildings. Clusters of elements are selected randomly in one or more stages (e.g., 5 out of 20 buildings, then half the floors on each selected building), and then at the final stage individuals are randomly sampled. 4. Probability proportional to size sampling would select, for example, a sample of rooms weighted by number of individuals in each room (i.e., the more people in the room, the more likely it is to be selected).

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Give a contact point for queries. Fix dates for feedback to respondents, especially the end of the study.

Analysis Definition of Outcome. Usually, ratings of environmental conditions are considered as independent scales. Symptoms of SBS are also sometimes treated as independent but often as all relating to a common phenomenon, which can be represented by an index or score based on all the symptoms. An intermediate approach is to use several indexes, based on hypothesized mechanisms or anatomic location of the symptoms. For example, Jaakkola (1986) calculated a score consisting of six components: skin, eye, nasal, pharyngeal symptoms, headache, and lethargy. A presence of one or more symptoms of each component during the past 7 days added 1 to that score (range 06). The intensity or severity of the symptoms has rarely been considered in detail; however, see Jaakkola et al. (1991), Reinikainen et al. (1991), Berglund et al. (1990a, 1990b), and Lundin (1991) for studies of the frequency of symptoms over a longer time period. Index or Score to Describe the Total Phenomenon. The principal measure to be obtained from the ROES questionnaire will normally be the sum of the building-related symptoms reported by each person, giving the person symptom index (PSI). The mean PSI of a random sample of building occupants is the BSI. The BSI can be used in one of two ways: for comparison with the OES database or for comparing over time using repeated surveys of the same building. Eight symptoms are listed on the questionnaire; seven are listed in Table 53.1, and a final symptom (dry, itching, or irritated skin) has been added to the questionnaire since the OES, and comparison data are therefore not available. As the use of the questionnaire progresses, comparison data will be published. Of the remaining symptoms, two (itchy or watery eyes and runny nose) have been included to maintain comparability with the OES data and to avoid too many symptoms being entered under other. They are probably less relevant to SBS than the remaining five symptoms. If the results from different buildings are being compared with each other or with the OES figures, it is recommended to use a BSI based on five core symptoms: dry eyes, blocked or stuffy nose, dry throat, headache, and lethargy or tiredness (Burge et al. 1993). Each symptom that a respondent experienced on at least two occasions in 12 months, and that was better on days away from the office, scores 1. Where a respondent has not marked either yes or no to the question about whether a symptom has been experienced, but has
Direct social interaction can also be valuable by showing appreciation, understanding that they are tired and busy, and showing a presence. A few minutes dealing with a simple misunderstanding or objection can prevent nonresponse. Of course it is critical that the investigators do not actively influence the answers that respondents give in questionnaires: Social interaction should be kept at a moderate and professional level. This interaction should be achieved by delivering the questionnaire personally to each selected person and collecting the questionnaire a short time later. The questionnaire should be collected the same day if possible in case the respondent is absent the following day. On collection, the questionnaire should be briefly checked for any obvious errors and for completeness. Errors can then be corrected at this time, or the respondent can be encouraged to complete the whole questionnaire. It can be helpful to monitor nonresponses and, where possible, to understand the reasons for them. This may make it possible to reinstate a respondent or to avoid the nonresponse of others. Analysis of nonresponse is not necessary if the target of 80 percent is achieved.
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TABLE 53.1 Percentage of Respondents Reporting the Occurrence of Each Symptom Symptom Lethargy Blocked or stuffy nose Dry throat Headache Itchy or watery eyes Dry eyes Runny nose % Reporting 57 47 46 43 28 27 23

indicated that the symptom is better when away from the office, this can be counted as a building-related symptom and scored 1. All other responses score 0. The PSI5 and BSI5 will therefore range from a minimum of 0 to a maximum of 5. Of the 46 buildings in the OES, the best 8 (all naturally ventilated) had a BSI5 of less than 1.5 symptoms. This level can be regarded as indicative of minimal problems with SBS. The worst 13 buildings had a BSI5 of over 2.5 (maximum 3.4), and of these, 11 were airconditioned. This can be regarded as an action level, above which steps should be taken to reduce the BSI. Between 1.5 and 2.5 there is a case for taking action, but the levels are more open to interpretation, depending on the frequency of the symptoms, other health and safety problems in the workplace, and the degree of commitment to health in the workplace. The percentage of respondents reporting each symptom is shown in Table 53.1. A case can be made for correcting the BSI5 for gender and job category; this produces a basis for comparing buildings while reducing any bias that might be due to the particular people who happen to be occupying the building at the time of the survey. This is most easily done by applying weightings to the individual scores. Dividing a PSI5 by the appropriate weighting will standardize the score to that which would be expected of a male manager. Care should be taken in interpreting corrected scores because part of the variance attributed to gender and job type may in fact be a result of nonrandom allocation of staff to working locations. For example, people in lower-paid, more routine jobs might have lowerquality accommodation and less power to get conditions changed. Uncorrected scores represent the building as it is, with its current occupants. Its meaning is therefore transparent, and it will normally be sufficient for most purposes. However, the same building could give a different score if occupied by a different population. The BSI can be based on all eight symptoms on the questionnaire if comparisons within a particular building are being made. This may arise for example if the questionnaire is repeated at intervals as a monitoring procedure to determine whether good environmental conditions are being maintained. A different sample of respondents can, in such cases, be used on different occasions so long as the sampling procedure is the same. In such cases there is little advantage to be gained from adjusting scores for gender and job type. The results should be stable over time unless the environment has changed, given an interval of a year or more. Short intervals between surveys will reduce the BSI if the same respondents are used in each survey. Interpretation of Environmental Ratings. There is no absolute interpretation of the ratings of environmental comfort. Each individual rating should be taken as what it is claimed to be: a subjective rating. This means that there are three major limitations on the interpretation of the ratings. A poor rating means that something is wrong with the environment, but

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The obvious interpretation is not necessarily the correct one (e.g., ratings of dry air can mean that the air is dusty or polluted with organic vapors, ratings of stuffiness can mean that it is too warm, and reports of offices that are too warm can be due to low air movement rather than air temperatures in excess of recommended levels). The suggested failing in the environment may well be present, but it is not necessarily related to SBS in the building. Symptoms could cause adverse perceptions of the indoor environment, rather than vice versa.
As a guide, some figures from the OES are given in Table 53.2. The mean is not necessarily the optimum, but it does give an indication of what can reasonably be expected. Most of the scales are unipolar: One extreme is good and the other bad. In these cases, any score higher than the mean should be investigated further, and any figure more than one standard deviation above the mean should be a cause for concern. Three scales (temperature, air movement, humidity) are bipolar: Neither end of the scale is ideal, and a deviation above or below the mean of more than one standard deviation represents a cause for concern. In all cases, interpretation of the environmental ratings should be complemented by local knowledge of the conditions in the building and/or by objective monitoring of the indoor environment.
Ethical Considerations
Environmental change intended as treatment of subjects who have SBS may cause ethical problems for the researcher. In the laboratory experiment, the researcher may avoid the
TABLE 53.2 Means and Ranges of Environmental Ratings from the OES Rating Mean S.D.
Winter 3.43 3.65 3.24 3.10 2.76 3.97
Comfort Temperature Ventilation Air quality Humidity Satisfaction
1.79 1.58 1.73 1.44 1.36 1.89
Summer 3.28 2.68 2.60 2.72 2.62 3.60
Comfort Temperature Ventilation Air quality Humidity Satisfaction
2.08 1.65 1.66 1.63 1.66 2.16
Control of 2.05 2.35 3.31
Temperature Ventilation Lighting
1.77 2.01 2.39
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Intervention Studies The power of intervention studies has recently become more widely realized, but many attempts at this kind of research have been subject to methodological problems. The design of intervention studies has been discussed at length in a recent report (Berglund et al. 1996), which makes recommendations on minimum requirements for the study design, measurement procedures, assessment of outcomes and determinants, and data analysis.
ethical problems by exposing only voluntary subjects to known concentrations of specific pollutants for controlled periods. In field settings, the building occupants have to be fully informed about their participation in an experiment and about the possible consequences of the environmental change. Because the occupants best interests have to be met by the scientific manipulation, what the researcher may accomplish will be restricted in field research. For ethical reasons the researcher should be able to reasonably well assure that the occupants are provided the best treatment by the planned environmental change. Rothman (1986) lists a number of constraints that have to be considered for ethical reasons. One obvious constraint is that exposures assigned to occupants should be limited to potential preventives of disease or disease consequences, thus including SBS. Another constraint is that the exposure alternatives should be equally acceptable under present knowledge. A third constraint is that by being admitted to the study, occupants should not be deprived of some preferable form of treatment or preventive measure that is not included in the study. For example, it is unethical to include a placebo therapy measure (e.g., an unconnected ventilation inlet) in circumstances for which there is an accepted remedy or preventive measure.
53.5 CONCLUSION
Making sense of IAQ problems depends not on any single research finding but on putting together the right conceptual framework and using it in research that has been well designed and implemented. The following are necessary interrelationships among three important issues regarding SBS:
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The definition of SBS Diagnosis of SBS in specific buildings Establishing and comparing the prevalence of SBS in different buildings and contexts
This chapter has set out a definition that makes diagnosis possible and a diagnostic method that produces consistent and useful results. The method comprises both a questionnaire and a procedure for using the questionnaire; both are essential. The method is not unique, and an indeterminate number of other approaches might be taken. It is better to choose a single approach even if it is for no other reasons than that this particular approach has been tried and has produced a database of comparison figures. Against this conceptual framework, the benefits and methods of intervention studies have been described. Future research and problem solving will need to be directed in an integrated and multidisciplinary manner to all stages in the life of the building and will need to cover the building itself (and its location), the indoor environment, the organizations that occupy buildings, and the needs of individual workers. There are many possible causes of complaints about IAQ, and they are interrelated and interactive, creating multifactorial problems that demand a multidisciplinary approach: a comprehensive view and systematic checking of possible problems, not a standard solution applied to all buildings.
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APPENDIX: REVISED OFFICE ENVIRONMENT SURVEY 1

1 This questionnaire remains the copyright of Building Research Establishment Ltd of Garston, Watford, Hertfordshire, WD2 7JR, United Kingdom, and is reproduced by permission. The right to use the questionnaire can be acquired by purchasing the questionnaire and guidance for its use, as provided in the following publication: Raw GJ ed. 1995. A questionnaire for studies of sick building syndrome. BRE Report Construction Research Communications, London. Data collected using this questionnaire can be compared with the benchmark values provided in the publication only if the prescribed method of use is followed.
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53.29
REFERENCES
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CHAPTER 53

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