5.

Article

Healthy-Sustainable Housing
Index: A Pilot Study to Link
Architecture and Public Health in a
Semi-Urban Community in Mexico

Pamela Zúñiga-Bello, Astrid Schilmann, Eunice Félix-Arellano , Gerardo Gama-Hernández and

Urinda Alamo-Hernández

Special Issue
Improving Safety, Health, and Wellbeing in Construction
Edited by
Prof. Dr. Albert P. C. Chan and Dr. Wen Yi

https://doi.org/10.3390/ijerph16030295
 International Journal of
Environmental Research
and Public Health

Article
Healthy-Sustainable Housing Index: A Pilot Study to
Link Architecture and Public Health in a Semi-Urban
Community in Mexico
Pamela Zúñiga-Bello 1 , Astrid Schilmann 1 , Eunice Félix-Arellano 1 ,
Gerardo Gama-Hernández 2 and Urinda Alamo-Hernández 1, *
1 Environmental Health Department, Center for Population Health Research,
National Institute of Public Health, Av. Universidad 655, Col. Santa Ma. Ahuacatitlán, Cuernavaca 62100,
Mexico; pamela.zuniga@espm.insp.mx (P.Z.-B.); aschilmann@insp.mx (A.S.);
eunice.feliz@espm.insp.mx (E.F.-A.)
2 Urbanism academy, Faculty of Architecture, Autonomous University of Morelos, Av. Universidad 1001,
Col. Chamilpa, Cuernavaca 62209, Mexico; ggama@uaem.mx
* Correspondence: ualamo@insp.mx; Tel.: +52 (777) 3293000 (ext. 3303)




Received: 7 January 2019; Accepted: 11 January 2019; Published: 22 January 2019


Abstract: The aim of this pilot study was to evaluate the link between housing and children´s
respiratory symptoms, through the construction of an index (HSHI) based on the definition of
healthy-sustainable housing criteria, in a semi-urban community from Morelos, Mexico. A general
and household questionnaire, and respiratory symptoms diary were applied in 60 households to
gather information about schoolchildren, respiratory health, housing and lifestyle characteristics.
HSHI was constructed using principal component analysis. The association between HSHI and the
presence and duration of respiratory symptoms was assessed using logistic and Poisson regression
models. HSHI had five components, which accounted for 63% of variance, and were classified into
poor and sufficient quality. It was observed that schoolchildren who inhabit a sufficient-quality
house, showed a reduction in nose irritation duration and in the allergic symptoms probability
regarding component 1 (ventilation, lighting and cloth washing) and presented three times less
duration of common cold by component 2 (construction material, painted walls inside the house and
type of bathroom) compared to poor-quality house inhabitants. Our results suggest that living in
a sufficient-quality house, as described by the HSHI, reduced the prevalence of wheezing episodes and
the probability of ear pain, providing evidence about the positive association of a healthy-sustainable
housing on the respiratory health of schoolchildren.

Keywords: healthy-sustainable housing index; respiratory symptoms; pilot study; Mexico

1. Introduction
Housing is considered as the physical structure and psychosocial environment used for
habitation [1]. A healthy housing consists of the physical and psychosocial environment that prevent
risk factors and could impact the health or welfare of their inhabitants [1]. It is also defined as the site
designed, built, renovated, and maintained in ways that support the health of residents [2]. The criteria
to define a healthy housing, according to the Pan American Health Organization (PAHO) and the
World Health Organization (WHO) include: safe location and secure tenure, adequate design and
structure, space for a healthy coexistence, basic facilities, appropriate environment, healthy habits
and protection against adverse health effects [1,3]. Engineers and architects play a major role in the
implementation of these criteria during design and construction and should be aware of their impact
on the welfare, health, and quality of life of the inhabitants [4,5].

Int. J. Environ. Res. Public Health 2019, 16, 295; doi:10.3390/ijerph16030295 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 295 2 of 16

Architecture embraces a wide range of styles in a constant evolution toward sustainability.

Sustainable architecture is within an ideal ecological, social and economic context to create and operate
a healthy built environment [5–8]. It includes the use of alternative sources of energy, environmental
management through bioclimatic design, and a development that meets the needs of the present
generation without compromising the ability of future generations to meet their own [9,10]. Moreover,
sustainable architecture argues that the quality of the indoor environment can promote healthy housing
and an improvement in the health of its inhabitants [4,5].
Despite the emergence of these architectural styles, the complex relationship between
"sustainable housing" and health is just beginning to be studied [4,11–15]. Sick building
syndrome [16–19] and housing have been associated with an increased risk of accidents and adverse
health effects [1,12,16,20–23] like respiratory diseases. Acute respiratory infections (ARIs) can be
attributed to several risk factors such as the environment, and housing characteristics fall within the
latter [21,24,25]. At the global level, studies regarding the housing-health relation are mostly focused on
respiratory diseases [11,12,16–20,25–30]. Nevertheless, ARIs imply a public health problem in México.
In Alpuyeca, Morelos, ARIs are the first leading cause of medical consultation (13.04 cases per 1000
inhabitants) [24,31,32].
Health impacts of selected housing risk factors have also been quantified applying the
environmental burden of disease approach in Europe [3]. In addition, the economic implications
of inadequate housing have been studied through a Housing health and Safety Rating System (HHSRS)
in England [3]. The HHSRS includes 29 potential hazards classified as: physiological requirements
(e.g., damp and mould, excessive cold, lead, radiation, volatile organic compounds), psychological
requirements (e.g., lighting, noise, crowding and space, entry by intruders), protection against infection
(e.g., domestic hygiene, drainage), and protection against accidents (e.g., electrical hazards, structural
collapse and falling elements) [3]. A National Healthy Housing Standard has been proposed in USA as
a tool to reconnect the housing and public health sectors, including the minimal standards for a safe
and healthy home [33]. However, many of the previously described standards are far from the Mexican
and Latin American reality.
On the other hand, various authors have proposed the construction of indexes to provide
a measure of the ‘healthiness’ and ‘safety’ of housing [26] that include housing characteristics related
to the health of its inhabitants [34–38]. In Mexico, the Mario Molina Center proposed a housing and
environmental sustainability index (Sustainability Index of Housing and its Surroundings, Índice de
Sustentabilidad de la Vivienda y su Entorno, ISV in Spanish) [39]; however, this index does not include
the variable of health of its occupants. Despite these efforts, there is a need for further research in this
emerging area [4,14,16].
In this regard and looking to build a bridge between architecture and public health, the aim of this
pilot study was to evaluate the link between housing and children´s respiratory symptoms, through
the construction of a housing index (HSHI) based on the definition of healthy-sustainable housing
criteria (Figure 1), in the semi-urban community of Alpuyeca Morelos, Mexico. This study is part of
a project called Centro Asociado en Salud Infantil y Tópicos Ambientales (CASITA) [40].

2. Materials and Methods

2.1. Study Population

A cross-sectional pilot study was conducted from November 2014 to February 2015, in schoolchildren
between 7 and 12 years old, who were residents of Alpuyeca for at least three years. Participants were
selected based on a random sampling stratified by gender and school grades of elementary schools (as part
of the CASITA project). Parents of the selected children were invited to participate in the study, and those
who accepted the home visit and answered the housing questionnaire composed the final sample of 60
children. The project was approved by the Ethics, Biosecurity and Research committees of the National
Institute of Public Health in Mexico (Instituto Nacional de Salud Pública INSP in Spanish).
Int. J. Environ. Res. Public Health 2019, 16, 295 3 of 16

Figure 1. Conceptual framework considering the relationship between acute respiratory infections, sustainable housing, and healthy housing. Source: Own
creation [1,4–9,11–13,22,34–37,39].
Int. J. Environ. Res. Public Health 2019, 16, 295 4 of 16

2.2. Instruments for Collecting Information

The following instruments were applied:
(1) General Questionnaire: Applied to the mothers of participating schoolchildren by 3 trained
students of the Master of public health at the INSP. It included sociodemographic variables, housing
characteristics, lifestyle, and anthropometric measurements.
(2) Housing Questionnaire: Applied during the home visit to an adult inhabitant of the house by
an architect studying the Master of public health at the INSP (Pamela Zuñiga Bello PZB). It included
variables such as the type of boundaries, hygiene habits, and use of cleaning products, maintenance,
use of pesticides and fuels in the house, pets, and the presence of mildew and dampness. The following
measurements were conducted in the room of the schoolchildren: height and area of the room, as well
as the percentage of lighting and ventilation of the space. Ventilation and lighting were defined
according to the building code from Cuernavaca municipality in the state of Morelos. This regulation
considers the room area and the windows dimension to define an adequate ventilation (windows must
cover at least the 10% of the room surface). The natural lighting from windows should cover at least
the following percentage according to its location: north 10%, south 15%, east 12% and west 11% [41].
(3) Respiratory symptoms log: A four-week diary was designed to record the presence or absence
of the respiratory symptoms listed below. The recruitment of participants was carried out during the
period from November to December. Mothers were trained to enter the information in this diary, from
which the following respiratory profiles were defined:

• (a) Acute upper respiratory infections (URI). Presence of at least two of the following symptoms:
fever, nasal obstruction or runny nose, dry cough or coughing up mucus and sore throat [24,37,42].
• (b) Acute lower respiratory infections (LRI). Presence of rapid breathing and cough or shortness
of breath [43].
• (c) Respiratory allergy. Presence of sneezing, eye irritation or burning in the nose [44].

The number of episodes and the incidence of these respiratory profiles were calculated. A new
episode was counted as the presence of a respiratory symptom after the child has been symptom-free
for at least one day [45], while the incidence was defined as new episodes/time at risk [46].
(4) Participant Observation: Performed during the informal visit by the architect who applied
the housing questionnaire and two trained housing inspectors (construction technician students).
Qualitative notes regarding the housing characteristics and cleaning habits were taken.
(5) Informal Interviews: Intended to supplement the information gathered in the general and
housing questionnaires during their application.

2.3. Healthy-Sustainable Housing Index (HSHI)

Twenty-six variables were selected to be included as HSHI criteria (Table 1) in accordance with
national and international healthy housing criteria [1,8,47–50] of sustainable architecture (Figure 1),
and finally adapted to the local context in Alpuyeca. HSHI was constructed using principal
component analysis (PCA) [51,52] on the correlation matrix. Components were selected according
to their eigenvalue >1 and considering the variability explained by each of the components and
collectively [51,52]. To make up each component, dominant variables were identified, i.e., those that
presented an eigenvector greater than an established cut-off point in ±0.30 (Table 2). Once the
components were selected, the score for each one was generated. Components were categorized as
dichotomous variables [51] where the 50th percentile (median), for the continuous score, was set as
the cut-off point to indicate poor or sufficient housing quality for that component. The global score of
the HSHI was obtained by adding the scores of each component so that houses were classified within
a category of poor (6 points) or sufficient quality (14 points).
Int. J. Environ. Res. Public Health 2019, 16, 295 5 of 16

Table 1. Description of the characteristics of the selected houses in Alpuyeca, Morelos.

Number of Houses (55)

Characteristic N %
Area where house is located a

House located on paved street 34 61.8

House located on gully/bank of the river/channel 38 69.0
One story house a 45 81.8
Suitable height (>2.40 m) a 51 92.7
Homeownership a,b 35 66.0
Age of construction >10 years 27 49.0
a
Adequate ventilation (according to local building code) 32 58.1
a
Adequate lighting (according to local building code) 21 61.8
Period living in the house >10 years a 17 30.9
Parental presence in the household (Mom, dad and children/ Dad or mom
35 63.6
with children) a
Number of people living in the house (< 6 people) 37 63.6
Multi-family dwelling (2 to 50 houses) a 31 56.3
Possession of pets (cat, dog, birds) 46 83.6
Presence of pests (rats, mice, cockroaches) 28 53.8
Cleaning of the house less than once a week a 32 58.1
Cleaning product
Use of chlorine as cleaning product 20 36.3
Use of floor cleaners/ glass cleaner / aromatizer as cleaning product 35 63.6
Presence of dampness 29 52.7
Presence of Mold 24 43.6
The house has been waterproofed in the last 5 years a 14 25.4
The house has been remodeled in the last 6 years a 17 30.9
Floor (the house has at least a space with this type of material) a,b

Earth/ wood or other coatings 16 29.6

Concrete/or surfaced floor 38 70.3
Living room ceiling (the roof is built with any of the following materials) a,b

Bedroom ceiling (the roof is built with any of the following materials) a,b
Cardboard, palm, shingle (tejamanil) or wood, metal foil, foil of
28 52.8
asbestos, does not know.
Concrete slab, bulkhead, brick, block 25 47.1
Living room walls (the walls are built with any of the following materials) a,b

Adobe, foil of asbestos and cardboard, does not know 15 28.3

Bulkhead, brick, block 38 71.6
Kitchen walls (the walls are built with any of the following materials) a,b

Adobe, foil of asbestos and cardboard, does not know 14 26.4

Bulkhead, brick, block 39 73.5
Int. J. Environ. Res. Public Health 2019, 16, 295 6 of 16

Table 1. Cont.

Number of Houses (55)

Bedroom walls (the walls are built with any of the following materials) a,b
Adobe, foil of asbestos and cardboard, does not know 10 19.2
Bulkhead, brick, block 42 80.7
Inside walls are painted a,b 36 65.45
Outside walls are painted a,b 38 69.09
Drinking water supply inside the house a,b 37 68.5
Drinking water supply once a week a,b 32 59.2
Washing work clothes together with family clothes a,b 20 37.0
Use of pesticides at home a,b 35 64.8
Separates organic and inorganic garbage a,b 27 50.0
Use of toilet connected to septic tank a,b 51 94.4
a 26 variables considered to be included in the HSHI before the PCA; b Variables with at least one missing values.

Table 2. Characteristics of the study population in Alpuyeca, Morelos.

Number of Participants (55)

Characteristic N
Gender a
Female (%) 54.5
Male (%) 45.5
Current weight (Kg), mean (S.D.) b 34.9 (±10.3)
Age (Years), mean (S.D.) b 9.8 (±1.4)
Body Mass Index c
Mild malnutrition (%) 5.5
Normal (%) 47.4
Obesity (%) 23.6
Overweight (%) 20.0
Breastfeeding (%) d 92.5
Breastfeeding period (months) (n = 49) mean (S.D) e 11.3 (±9.9)
Residence period (years) (n = 52) mean (S.D) e 8.0 (±2.4)
Education of the mother (%) b
Elementary 64.1

26.4
> Other (middle school, high school, bachelor’s degree, postgraduate studies)
Education of the father (%) b

Elementary 79.2
> Other (middle school, high school, bachelor’s degree, postgraduate
20.7
studies)
School a

General Ignacio Maya (%) 47.4

A.N. Urueta (%) 38.1
Andrés Aponte (%) 14.3
Smoking inside/outside the house (%) b 37.0
a b c
n = 55; n = 53; BMI was calculated according to the World Health Organization (WHO) recommended criteria
for population 5 to 9 years); d n = 54; e n = 52.
Int. J. Environ. Res. Public Health 2019, 16, 295 7 of 16

2.4. Statistical Analysis

The study population was described through measures of central tendency and dispersion, as
well as the prevalence and incidence of symptomatology. The association between the frequency of
respiratory symptoms and other relevant covariates, different to housing, was assessed using the
X2 test and Fisher exact test. Consequently, and through these same tests, the relationship between
components/HSHI and the presence of respiratory symptoms was assessed. To estimate the association
between the components/HSHI and the presence and duration of respiratory symptoms and/or
profiles, logistic and Poisson regression models were constructed respectively. Multivariate models
were used and adjusted by the characteristics that were significant in the bivariate analysis and by
those identified in the literature [51–54]. The STATA program version 13 (Stata Corp LP, College
Station, TX, USA) was used for the analysis.

3. Results

3.1. Characteristics of the Houses Surveyed.

Of the 60 houses surveyed, five (8.33%) were not included in the study due to the lack of
information on the monitoring of schoolchildren respiratory symptoms. More than half of the
participating houses have adequate ventilation and lighting. Around the same percentage reported
to have less than six inhabitants, the presence of pests, and cleaning the house at least once a week.
The presence of dampness and mildew was observed in approximately half of the houses (Table 1).
A similar proportion of boys and girls participated in the study, with an average age of ~10 years. Also,
most of the parents reported an elementary education level (Table 2).

3.2. Construction of the Healthy-Sustainable Housing Index (HSHI)

Table 3 shows the five selected components representing 63.38 % of the original variance. Of
the 60 houses selected, 53% were located in the category of poor housing quality and 47% in the
category of sufficient housing quality. The HSHI indicates that the houses selected are, on average, in
the medium-high category, reaching the range of 6 to 14 points (median 9.88 ± 1.88) on a scale from
0 to 14.

Table 3. Selection of dominant variables in each component for the construction of the
healthy-sustainable housing index (HSHI).

% of Variance
Component Load (Eigenvector) Dominant Variables
Explained
Ventilation
0.3899
Lighting
First component 0.3884 18.70
Washing work clothes together with family
0.3649
clothes
Construction material used in the ceiling
0.4272
of the living room
Second component 0.4268 15.92
Indoor painted walls
0.3372
Type of bathroom
Material used for the floor of the house
0.5049
Construction material used in the
Third component 0.3692 11.94
bedroom wall
0.3741
Frequency of drinking water supply
0.4050 Area where houses are located
Fourth component 0.4693 9.15 Home cleaning frequency
0.6035 Use of pesticides at home
0.4251 Drinking water supply inside the house
Fifth component 7.67
0.4950 Separating organic and inorganic garbage
Total 63.38
Int. J. Environ. Res. Public Health 2019, 16, 295 8 of 16

3.3. Respiratory Symptoms and HSHI

It was observed that schoolchildren presented at least 1 episode of a respiratory symptom
and/or profile during the follow-up period. Among the recorded symptoms, dry cough and common
cold presented the highest prevalence, while LRI and wheezing presented the lowest, although no
statistically significant differences were observed (Figure 2a). It was observed an incidence of ≥10
episodes/child-year in the symptoms of runny nose, sore throat, common cold and sneezing. On the
other hand, wheezing and LRI reported the lowest number of episodes (less than 2 episodes/child-year)
(Figure 2b).

Prevalence of respiratory symptoms

60
50
Percentaje (%)

40
30
20
10
0

HSHI poor IVSS sufficient quality

(a)

Incidence of respiratory symptoms

20
18
16
Episodes/child-year

14
12
10
8
6
4
2
0

(b)

Figure 2. Frequency of respiratory symptoms for children during the follow-up period in Alpuyeca
Morelos. November 2014–February 2015. N = 55. (a) Incidence (episodes/child-year); (b) Prevalence
regarding HSHI. * Difference of proportions between the HSHI categories statistically significant
(p < 0.05). Schoolchildren showed some symptom at least once during the month follow-up period.
Int. J. Environ. Res. Public Health 2019, 16, 295 9 of 16

In houses with poor-quality, it was observed that about half of the mothers or guardians of
schoolchildren reported that their children had at least dry cough and runny nose on one occasion,
while a quarter presented URI and a fifth part showed allergy on at least one occasion during the
follow-up period (Figure 2b). When comparing the respiratory outcomes between the houses with
a poor and sufficient quality, only significant differences (p < 0.05) were observed in the presence of
wheezing. However, there is a trend for more frequent respiratory symptoms in houses with poor-
quality (Figure 2b).
Table 4 shows the crude and adjusted odds ratio (OR) from the logistic regression models of the
prevalence and profiles of respiratory symptoms for the HSHI, and each one of the 5 components. The
presence of dry cough, runny nose, ear pain, and hoarseness, itching in the nose, URI, and allergy
were associated with the first component (ventilation, lighting and washing work and family clothing
together). This indicates that schoolchildren who live in a poor-quality house, have 5.32 times more
probability of presenting allergic symptoms compared with those who live in a sufficient-quality house
described by component 1, without adjusting for other covariates. Also, it was observed that the
schoolchildren who live in a house with a poor-quality have 5.32 times more probability of suffering
from ear pain compared with those who live in a house with a sufficient-quality HSHI, however,
this association was marginally significant in the adjusted model. Contrary to what was expected,
schoolchildren who inhabit a house of poor-quality have 11.63 times less probability of presenting
common cold, compared with those who inhabit a house of sufficient-quality described by component
2 (Table 4).
The Poisson regression models also show an association between respiratory symptoms
duration and the first component. The adjusted analysis shows that schoolchildren who inhabit
a sufficient-quality house had 4 times shorter duration of nose irritation compared to schoolchildren
who inhabit a poor-quality house regarding component 1. On the other hand, duration of sneezing
in schoolchildren who inhabit a sufficient-quality house for component 3 was 1.8 times larger
compared with those who inhabit a poor-quality house. The multivariate analysis highlights an
association between component 2 and common cold and URI, where schoolchildren living in a
sufficient-quality house described by this component, present a 2.9 and 4.3-times less duration
compared with schoolchildren in a poor-quality house. Likewise, the association between component
5 and sore throat indicates that schoolchildren who live in a sufficient-quality house, have a 2.7 times
larger duration of sore throat compared with those who live in a poor-quality house described by the
same component (Table 4).
Int. J. Environ. Res. Public Health 2019, 16, 295 10 of 16

Table 4. Selected crude and adjusted association measures between HSHI and symptoms frequency (n = 55).

Crude and Adjusted Logistic Regression Models for the Prevalence of Respiratory Crude and Adjusted Poisson Regression Models for the Duration of Respiratory
Symptoms and Profiles Symptoms and Profiles
Caption
Crude
Crude OR P IC Adjusted OR † P IC P IC Adjusted IRR † P IC
IRR
Component 1
Dry cough 1.860 0.269 (0.619, 0.588) 3.327 0.120 (0.731, 15.136) — — — — — —
Ear pain 0.606 0.484 (0.149, 2.464) 0.017 0.080 (0.000, 1.633) — — — — — —
Hoarseness 0.435 0.280 (0.336, 2.976) 0.153 0.115 (0.015, 1.581) — — — — — —
Nose irritation 0.293 0.101 (0.068, 1.268) 0.071 0.072 (0.004, 1.270) 0.250 0.013* (0.084, 0.748) 0.110 0.018 (0.018, 0.680)
URI 0.675 0.533 (0.196, 2.322) 0.259 0.143 (0.042, 1.578) 0.765 0.467 (0.371, 1.574) 0.155 0.006 * (0.041, 0.582)
Allergy 0.188 0.049* (0.035, 0.992) 0.002 0.075 (0.000, 1.857) 0.250 0.080 (0.053, 1.177) 0.043 0.069 (0.001, 1.277)
Runny nose 0.454 0.166 (0.149, 1.386) 0.254 0.118 (0.045, 1.418) 0.667 0.209 (0.339, 1.311) 0.382 0.049 * (0.146, 0.997)
Sore throat — — — — — — 0.636 0.186 (0.326, 1.244) 0.468 0.122 (0.179, 1.224)
Sneezing — — — — — — 0.636 0.105 (0.368, 1.100) 0.454 0.070 (0.193, 1.066)
Component 2
Common cold 0.388 0.098 (0.126, 1.192) 0.086 0.022* (0.010, 0.699) 0.760 0.367 (0.419, 1.380) 0.342 0.021 * (0.138, 0.848)
URI 0.675 0.533 (0.196, 2.322) 0.268 0.171 (0.041, 1.768) 1.000 1.000 (0.489, 2.046) 0.232 0.015 * (0.072, 0.749)
Allergy 0.606 0.484 (0.149, 2.464) 0.077 0.122 (0.003, 1.991) 0.667 0.530 (0.188, 2.362) 0.175 0.151 (0.016, 1.887)
Component 3
Dry cough 0.735 0.579 (0.247, 2.186) 0.311 0.120 (0.071, 1.359) 1.053 0.873 (0.562, 1.972) 0.463 0.111 (0.180, 1.192)
Runny nose — — — — — — 1.500 0.209 (0.797, 2.824) 1.932 0.125 (0.832, 4.485)
Sore throat — — — — — — 2.000 0.050* (1.000, 3.999) 1.947 0.134 (0.814, 4.656)
Nose irritation — — — — — — 2.333 0.082 (0.897, 6.072) 2.230 0.209 (0.639, 7.787)
Sneezing — — — — — — 1.842 0.032* (1.054, 3.220) 2.148 0.049 * (1.004, 4.599)
Component 4
Coughing up mucus 0.733 0.578 (0.246, 2.189) 0.228 0.073 (0.045, 1.147) — — — — — —
Nose irritation — — — — — — 3.000 0.033* (1.090, 8.254) 2.284 0.153 (0.736, 7.092)
Component 5
Common cold 1.364 0.578 (0.457, 4.071) 2.777 0.173 (0.639, 12.070) — — — — — —
Sore throat — — — — — — 1.400 0.320 (0.722, 2.716) 2.778 0.046 * (1.019, 7.572)
URI — — — — — — 3.286 0.006* (1.410, 7.657) 3.878 0.015 * (1.298, 11.588)
HSHI
Ear pain 0.188 0.049* (0.035, 0.992) 0.042 0.057 (0.002, 1.095) — — — — — —
† Model adjusted by gender, age, breastfeeding, BMI, number of people living in the house, possession of pets, presence of pests, presence of mold, education of the father and education of
the mother; * Statistically significant model (p < 0.05).
Int. J. Environ. Res. Public Health 2019, 16, 295 11 of 16

4. Discussion
The main findings of this pilot study suggest that living in a house with a sufficient-quality,
expressed by the HSHI, lowered the frequency of some of the respiratory symptoms, which is evidenced
by the reduction of the prevalence of wheezing episodes and of the probability of suffering from ear
pain. In addition, the housing quality assessed by the component 1 reduced the presence and duration
of symptoms such as allergy, nose irritation, runny nose, and URI, while component 2 was associated
with a lower probability of suffering common cold and URI; components 3 and 5 were also identified
as risk factors for sneezing, sore throat, and URI. These findings were statistically significant.
To the best of our knowledge, this is the first pilot study that evaluates the respiratory health and
the quality of the housing through a "healthy-sustainable housing index" in Mexico. Our results for
component 1 are consistent with those reported by Fisk et al; 1997 who noted that a high-performance
ventilation system reduces respiratory diseases by 9–20% [55]; while Norhidayah et al; 2013 suggest
that ventilation is one of the significant predictors of diseases related to buildings [19]. In turn,
Hesselmar et al; 2005 reported that inadequate ventilation is associated with the presence of wheezing
(OR = 3.13, IC 1.05–9.29) and asthma (OR = 1.1, IC 0.48–2.48) [54]. On the other hand, the construction
of component 2 included variables such as construction material (living room ceiling), indoor painted
walls and type of bathroom, features that were deemed fundamental for establishing a housing-health
relationship [53–57]. In component 3, characterized by the construction material of the house’s floor,
it was noted that 29.63% of houses with floors made of earth/wood or other coatings, showed better
hygiene habits that those with concrete or surfaced floor (results not displayed in tables). Regarding
component 5, which considers the drinking water supply inside the house, it was noted that, despite
the fact that most of the population (68.52%) had this service, it is only available once a week in 59.26%
of households, which could influence the presence of moisture (52.73%) and mold (43.64%) given
the storage practices. The foregoing is consistent with Cuijpers et al; 1995 and Hagmolen et al; 2007
whose results indicate that moisture has been associated with respiratory symptoms such as wheezing
(ORBOYS = 1.86, IC 0.22–1.44, or ORGIRLS = 1.48 IC 0.62–3.54), while the mold and moisture located in
the living room or children rooms, are associated with respiratory diseases such as asthma (OR = 3.95,
IC 1.82–8.57) [53,54].
In addition, the presence of respiratory symptoms reported in this pilot study may have
been influenced by the geographical and sociocultural context [21,57]. Since it was conducted in
a semi-urban area, the quality of the indoor/house environment might not be a priority because of the
urgency to address other economic and social problems [21,57,58]. In turn, according to other studies,
there is widespread ignorance about the relationship between housing and respiratory health [4,12],
which is consistent with the information gathered in the informal interviews. It is possible that the
increase in the frequency of some episodes in schoolchildren living in a sufficient-quality house, could
be influenced by a higher socio-economic status since they have greater possibilities to visit a physician
to detect the symptoms.
When interpreting our results, the methodological strengths and limitations shall be considered.
The sample size (n = 55) limited the associations found between the HSHI and the respiratory
symptoms, even with the results found when performing the PCA. Regarding the measurement
of the symptoms, the present pilot study does not have a clinical diagnosis of symptoms/respiratory
profiles, so that the construction of the tracking log was based on other studies [13,25,28,30]; therefore,
we cannot rule out a measurement error. During the study period, mothers were reminded on the
follow-up of the symptomatology. However, it cannot be ruled out that there is a memory bias.
To reduce the bias of information regarding the data of the housing, the visits were carried out by
technicians trained in construction who were unaware of the hypothesis of the pilot study.
Certain characteristics deemed important in previous studies could not be included in our analysis
due to the little-attributed variability, such is the case of living in multifamily dwelling [37,58], the age
and remodeling of the construction, homeownership [29], as well as having a comfortable temperature
in the interior of the house, and the type of construction material used in the roof of the schoolchildren’s
Int. J. Environ. Res. Public Health 2019, 16, 295 12 of 16

bedroom [36]. Likewise, relevant data regarding exposure were not considered which, according to the
literature, would have made it possible to establish associations with greater certainty, such as relative
humidity, indoor and outdoor ambient temperature, indoor samples of mold and dust, the number of
hours that mothers keep the windows open or the number of hours that schoolchildren spend inside
the house [26,27,30,36,37,59–61]. Moreover, it was not possible to determine whether schoolchildren
had a deficiency of vitamin A, a characteristic that has been associated with the presence of URI [42,62].
Also, the high incidence of symptoms such as dry cough, runny nose, sore throat, and sneezing, could
be related to the follow-up period (November 2014–February 2015). However, there is no seasonality
adjustment, since climate change is one of the major factors increasing the incidence of respiratory
diseases [29,56].
While it is true that housing in Alpuyeca was placed within a medium-high quality, it should be
noted that the construction of the HSHI is based on the current characteristics of the housing of this
community and not on the ideal healthy [1,4] and sustainable criteria [1–8,47–50].

5. Conclusions
The results evidence the relationship of the healthy-sustainable housing and the respiratory health
of its inhabitants through the proposed HSHI. In Mexico, the promotion of sustainable housing is scarce
in spite of having a national criterion. While the efforts to promote healthy housing have been greater,
there are no specific criteria for the country, which draws on the recommendations suggested by the
Pan American Health Organization/World Health Organization (PAHO/WHO). At our discretion and
according to other studies, the transdisciplinary work between the community, specialists in public
health, environmental health, architects, engineers and other stakeholders, is necessary to encourage
the efforts to promote a healthy-sustainable housing and benefit the respiratory health and quality of
life of the Mexican population. These efforts should start with the inclusion of this knowledge in the
professional education of all key elements.
This pilot study constitutes a platform for raising new research on this topic. Future projects
should consider higher sample sizes, longer follow-up periods, different seasons of the year,
comparison groups regarding the type of housing, other public health problems in addition to
respiratory health, and a qualitative-quantitative methodology.

Author Contributions: Conceptualization, P.Z.-B., G.G.-H. and U.Á.-H.; Data curation, P.Z.-B. and U.Á.-H.;
Formal analysis, P.Z.-B. and A.S.; Investigation, P.Z.-B. and U.Á.-H.; Methodology, P.Z.-B., A.S. and U.Á.-H.;
Supervision, P.Z.-B. and U.Á.-H.; Writing – original draft, P.Z.-B.; Writing – review & editing, A.S., E.F.-A., G.G.-H.
and U.Á.-H.
Funding: The authors are thankful to the community of Alpuyeca, Morelos, and to the project “Assessment
and continuity actions for an integral strategy of a community intervention in environmental health in
Alpuyeca, Morelos”, project number 201277, Sectoral Fund for Research in Health and Social Security (FOSISS)
SSA/IMSS/ISSSTE-CONACyT. Finally, we thank to the National Institute of Public Health in Mexico (INSP), and
to the National Council of Science and Technology (CONACyT) for their support in the form of the scholarship
#557021
Conflicts of Interest: The authors declare no conflict of interest.

References
1. OPS/OMS. Vivienda Saludable: Reto del Milenio en los Asentamientos Precarios del América Latina
y el Caribe. Organización Panamericana de la Salud (OPS)/Organización Mundial de la Salud (OMS).
Venezuela. Available online: http://www.minsa.gob.pe/servicios/serums/2009/dgps_para_serums_
2009ii/pfvs/vivienda_saludable.pdf (accessed on 15 August 2014).
2. Office of the Surgeon General (US). The Surgeon General’s Call to Action to Promote Healthy Homes.
Rockville (MD): Office of the Surgeon General (US). Available online: https://www.ncbi.nlm.nih.gov/
books/NBK44192/ (accessed on 7 January 2019).
3. World Health Organization. Environmental Burden of Disease Associated with Inadequate Housing.
Methods for Quantifying Health Impacts of Selected Housing Risks in the WHO European Region. Summary
Int. J. Environ. Res. Public Health 2019, 16, 295 13 of 16

Report (World Health Organization (WHO)) Denmark. 2011. Available online: http://www.euro.who.int/
__data/assets/pdf_file/0003/142077/e95004.pdf. (accessed on 5 May 2018).
4. Loftness, V.; Hakkinen, B.; Adan, O.; Nevalainen, A. Elements that contribute to healthy building design.
Environ. Health Perspect. 2007, 115, 965–970. [CrossRef] [PubMed]
5. Weschler, C. Changes in indoor pollutants since the 1950s. Atmos. Environ. 2009, 43, 153–169. [CrossRef]
6. Neufert, E. Arte de Proyectar La Arquitectura, 16th ed.; Editorial Gustavo Gili: Barcelona, Spain, 2013.
7. Environmental Protection Agency (EPA). Green Building. EPA’S Web Archive. Available online: https:
//archive.epa.gov/greenbuilding/web/html/ (accessed on 12 March 2014).
8. CONAVI. Comisión Nacional de Vivienda. In Criterios E Indicadores Para Desarrollos Habitacionales Sustentables;
Primera, Ed.; Editorial Comisión Nacional de Vivienda: Ciudad de Mexico, Mexico, 2008.
9. Goldstein, G.; Novick, R.; Schaefer, M. Health and well-being. Housing, health, and well-being:
An international perspective. J. Sociol. Soc. Welf. 1990, 17, 10.
10. United Nations. Report of the World Commission on Environment and Development: Our Common Future. 1987.
Available online: http://www.un-documents.net/our-common-future.pdf (accessed on 22 September 2014).
11. Jacobs, D.E.; Breysse, J.; Dixon, S.L.; Aceti, S.; Kawecki, C.; James, M.; Wilson, J. Health and housing
outcomes from green renovation of low-income housing in Washington, DC. Environ. Health 2014, 76, 8–16.
Available online: http://www.nchh.org/Portals/0/Contents/Journal_of_Environmental_Health_2014.03_
Jacobs.pdf (accessed on 28 November 2014).
12. Mitchell, C.S.; Zhang, J.J.; Sigsgaard, T.; Jantunen, M.; Lioy, P.J.; Samson, R.; Karol, M.H. Current state of
the science: Health effects and indoor environmental quality. Environ. Health Perspect. 2007, 115, 958–964.
[CrossRef]
13. Garland, E.; Steenburgh, E.T.; Sanchez, S.H.; Geevarughese, A.; Bluestone, L.; Rothenberg, L. Impact of
LEED-certified affordable housing on asthma in the South Bronx. Prog. Community Health Partnersh. 2013,
7, 29–37. [CrossRef] [PubMed]
14. Yang, Y.; Zeng, N.; Shen, M.; Sun, Z. Development of green hospitals home and abroad. J. Cent. South Univ.
Med. Sci. 2013, 38, 949–953. [CrossRef]
15. Breysse, J.; Jacobs, D.E.; Weber, W.; Dixon, S.; Kawecki, C.; Aceti, S.; Lopez, J. Health outcomes and green
renovation of affordable housing. Public Health Rep. 2011, 126 (Suppl. 1), 64–75. [CrossRef]
16. Environmental Protection Agency (EPA). Indoor Air Facts No. 4. Sick Building Syndrome.
Available online: https://www.epa.gov/sites/production/files/2014-08/documents/sick_building_
factsheet.pdf (accessed on 23 February 2014).
17. Junta de Andalucía. Síndrome del Edificio Enfermo. Available online: https://www.juntadeandalucia.
es/empleo/webiaprl/ladep/sites/es.empleo.webiaprl.ladep/files/recursos/documentacion_normativa/
SindromedeledificioEnfermo.ConsejeriadeEducacion--JuntadeAndalucia.pdf (accessed on 15 April 2014).
18. National Aeronautics and Space Administration. Technical Reports Server (NTRS). Originating
Technology/NASA Contribution. Public Safety. Plants Clean Air and Water for Indoor Environments. 2007.
Available online: https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/20080003913.pdf (accessed on 13
January 2019).
19. Norhidayah, A.; Chia-Kuang, L.; Azhar, M.K.; Nurulwahida, S. Indoor Air Quality and Sick Building
Syndrome in Three Selected Buildings. Procedia Eng. 2013, 53, 93–98. [CrossRef]
20. Sevilla, R.; Almanzar, A.; Valadez, L. La vivienda y su impacto en la salud. In Revista de La Academia Mexicana
de Ciencias; Revista Ciencia: Ciudad de Mexico, Mexico, 2014; Volume 65, pp. 80–86.
21. Prüss-Ustün, A. Ambientes Saludables y Prevención de Enfermedades. Ginebra. Organización Mundial
de la Salud (OMS). 2006. Available online: http://www.who.int/quantifying_ehimpacts/publications/
prevdisexecsumsp.pdf?ua=1 (accessed on 27 April 2014).
22. Thomson, H.; Thomas, S.; Sellstrom, E.; Petticrew, M. Housing improvements for health and associated
socio-economic outcomes (Review). Cochrane Database Syst. Rev. 2013, 28, CD008657.
23. Keall, M.; Baker, M.; Howden-Chapman, P.; Cunningham, M.; Cunningham, C. Healthy Housing
Index Pilot Study—HeKaingaOranga; University of Otago: Wellington, New Zealand, 2007; Available
online: http://www.healthyhousing.org.nz/wp-content/uploads/2010/01/Healthy-Housing-Index-Pilot-
Study-Final-Report-2007.pdf (accessed on 9 December 2013).
24. Chelala, C. Impacto Del Ambiente Sobre Salud Infantil. In Organización Panamericana de La Salud (OPS);
Estados Unidos: Washington, DC, USA, 1999.
Int. J. Environ. Res. Public Health 2019, 16, 295 14 of 16

25. Polyzois, D.; Polyzoi, E.; Wells, J. Housing Conditions and Children’s Respiratory Health. National Institute
of Building Sciences. Available online: https://c.ymcdn.com/sites/www.nibs.org/resource/resmgr/BEST/
BEST1_010.pdf (accessed on 21 October 2014).
26. Tox Town. Environmental Health Concerns and Toxic Chemicals Where You Live, Work and Play.
Construcción. Por qué es la Construcción Motivo de Preocupación? U.S. National Library of Medicine.
Available online: https://toxtown.nlm.nih.gov/text_version/descriptions.php?id=77&type=1 (accessed on
30 September 2013).
27. Blanc, P.D.; Quinlan, P.J.; Katz, P.P.; Balmes, J.R.; Trupin, L.; Cisternas, M.G.; Wymer, L.; Vesper, S.J. Higher
environmental relative moldiness index values measured in homes of adults with asthma, rhinitis, or both
conditions. Environ. Res. 2013, 122, 98–101. [CrossRef] [PubMed]
28. Spengler, J.D.; Jaakkola, J.J.; Parise, H.; Katsnelson, B.; Privalova, L.; Kosheleva, A. Housing Characteristics
and Children’s Respiratory Health in the Russian Federation. Am. J. Public Health 2004, 94, 657–662.
[CrossRef] [PubMed]
29. Hagmolen, W.; Van den Berg, N.; Van der Palenz, J.; Aalderen, V.; Bindels, P. Residential Exposure to Mould
and Dampness Is Associated with Adverse Respiratory Health. Clin. Exp. Allergy 2007, 37. [CrossRef]
[PubMed]
30. Clausen, G.; Høst, A.; Toftum, J.; Bekö, G.; Weschler, C.; Callesen, M.; Buhl, S.; Ladegaard, M.B.; Langer, S.;
Andersen, B.; et al. Children’s health and its association with indoor environments in Danish homes and
daycare centers—Methods. Indoor Air 2012, 22, 467–475. [CrossRef] [PubMed]
31. Alejaldre, H. Diagnóstico de Salud, Alpuyeca Morelos. Promoción Febrero 2013-Enero 2014. In Centro de
Salud Rural Disperso Alpuyeca; Servicio de Salud de Morelos: Alpuyeca, Morelos, 2013; pp. 1–56.
32. Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease (GBD) Data Visualizations.
Available online: http://www.healthdata.org/ (accessed on 24 August 2013).
33. American Public Health Association. National Healthy Housing Standard. Available online: https://nchh.
org/resource-library/national-healthy-housing-standard.pdf. (accessed on 7 January 2019).
34. Ansarin, K.; Sahebi, L.; Sabur, S. Obstructive sleep apnea syndrome: complaints and housing characteristics
in a population in the United States. Sao Paulo Med. J. 2013, 131, 220–227. [CrossRef] [PubMed]
35. Quandt, S.A.; Wiggins, M.F.; Chen, H.; Bischoff, W.E.; Arcury, T.A. Heat index in migrant farmworker
housing: implications for rest and recovery from work-related heat stress. Am. J. Public Health 2013,
103, e24–e26. [CrossRef] [PubMed]
36. Liu, J.X.; Bousema, T.; Zelman, B.; Gesase, S.; Hashim, R.; Maxwell, C.; Chandramohan, D.; Gosling, R.
Is housing quality associated with malaria incidence among young children and mosquito vector numbers?
Evidence from Korogwe, Tanzania. PLoS ONE 2014, 9, e87358. [CrossRef] [PubMed]
37. Keall, M.; Crane, J.; Baker, M.; Wickens, K.; Howden-Chapman, P.; Cunningham, M. A measure for
quantifying the impact of housing quality on respiratory health: A cross-sectional study. Environ. Health
2012, 11, 33. [CrossRef]
38. Bueno, M. Vivir En Casa Sana. Las Radiaciones Cosmotelúricas y su Influencia en los Seres Vivos.
In Introducción a la Geobiología; Martínez Roca, S.A., Ed.; Editorial Martínez Roca: Barcelona, Spain, 1988.
39. Centro Mario Molina. Evaluación de La Sustentabilidad de la vivienda en México. Asociación de Vivienda
Y Entorno Sustentable A.C. México. 2012. Available online: http://centromariomolina.org/wp-content/
uploads/2012/09/14.-Evaluaci%C3%B3nSustetabilidadViviendaM%C3%A9xico_fin.pdf (accessed on 7
January 2019).
40. Farías, P.; Álamo-Hernández, U.; Mancilla-Sánchez, L.; Texcalac-Sangrador, J.L.; Carrizales-Yáñez, L.;
Riojas-Rodríguez, H. Lead in school children from Morelos, Mexico: levels, sources and feasible interventions.
Int. J. Environ. Res. Public Health 2014, 11, 12668–12682. [CrossRef]
41. Que el H.; Ayuntamiento de Cuernavaca; Gobierno del Estado de Morelos. Reglamento de Construcción del
municipio de Cuernavaca, Morelos. Cuernavaca, Morelos, Mexico. Última reforma 19 de Diciembre de 2012.
Available online: http://www.cuernavaca.gob.mx/wp-content/uploads/2013/07/REGLAMENTO-DE-
CONSTRUCCI%C3%93N-DEL-MUNICIPIO-DE-CUERNAVACA-MORELOS..pdf (accessed on 11 January
2014).
42. Instituto Mexicano del Seguro Social (IMSS). Diagnóstico y Manejo de la Infección aguda de vías Aéreas
Superiores en Pacientes Mayores de 3 Meses Hasta 18 años de Edad; Instituto Mexicano del Seguro Social
(IMSS): Ciudad de Mexico, Mexico, 2016.
Int. J. Environ. Res. Public Health 2019, 16, 295 15 of 16

43. Schilmann, A.; Riojas-Rodríguez, H.; Ramírez-Sedeño, K.; Berrueta, V.M.; Pérez-Padilla, R.; Romieu, I.
Children’s Respiratory Health After an Efficient Biomass Stove (Patsari) Intervention. Ecohealth 2014.
[CrossRef]
44. Mayo Clinic. Dust Mite Allergy. Diseases and Conditions. Symptoms. Available online: http:
//www.mayoclinic.org/diseases-conditions/dust-mites/basics/symptoms/con-20028330 (accessed on
12 August 2014).
45. Escamilla-Nuñez, M.C.; Barraza-Villarreal, A.; Hernandez-Cadena, L.; Moreno-Macias, H.;
Ramirez-Aguilar, M.; Sienra-Monge, J.J.; Cortez-Lugo, M.; Texcalac, J.L.; del Rio-Navarro, B.; Romieu, I.
Traffic-related air pollution and respiratory symptoms among asthmatic children, resident in Mexico City:
the EVA cohort study. Respiratory Res. 2008, 9, 74. [CrossRef] [PubMed]
46. Koch, A.; Mølbak, K.; Homøe, P.; Sørensen, P.; Hjuler, T.; Olesen, M.E.; Pejl, J.; Pedersen, F.K.; Olsen, O.R.;
Melbye, M. Risk factors for acute respiratory tract infections in young Greenlandic children. Am. J. Epidemiol.
2003, 158, 374–384. [CrossRef] [PubMed]
47. SEDEMA. Secretaria del Medio Ambiente. Gaceta Oficial del Distrito Federal. Programa de certificación
de Edificaciones Sustentables. Secretaria del Medio Ambiente. Gaceta Oficial del Distrito Federal.
Available online: http://www.sedema.cdmx.gob.mx/storage/app/media/tramites-servicios/auditoria-
autoregulacion-ambiental/edificaciones-sustentables/programa-certificacion-edificaciones-sustentables.
pdf (accessed on 3 November 2014).
48. Secretaria de Economía. Norma de Edificación Sustentable NMX-AA-164-SCFI-2013-Edificación Sustentable,
Criterios y Requerimientos Ambientales Mínimos. 2013. Available online: http://biblioteca.semarnat.gob.
mx/janium/Documentos/Ciga/agenda/DOFsr/DO3156.pdf (accessed on 3 November 2014).
49. Leadership in Energy & Environmental Design. LEED v4 para EL DISEÑO Y LA CONSTRUCCIÓN DE
EDIFICIOS (LEED v4 for BUILDING DESIGN AND CONSTRUCTION). US Green Build Counc USGBC.
2014:168. Available online: https://www.usgbc.org/sites/default/files/LEEDv4BDC_100114_ES_3.25.17.
pdf (accessed on 30 May 2014).
50. Building Research Establishment. Building Research Establishment Environmental Assessment Method.
BREEAM. Available online: http://www.breeam.com/index.jsp (accessed on 12 October 2014).
51. Chuc, S.; Hurtado-Díaz, M.; Schilmann, A.; Riojas-Rodríguez, H.; Rangel, H.; González-Fernández, M.I.
Condiciones locales de vulnerabilidad asociadas con dengue en dos comunidades de Morelos.
Salud Pública Mex. 2013, 55, 170–178. [CrossRef] [PubMed]
52. Burstyn, I. Principal component analysis is a powerful instrument in occupational hygiene inquiries.
Ann. Occup. Hyg. 2004, 48, 655–661. [CrossRef] [PubMed]
53. Cuijpers, C.; Swaen, G.; Wesselin, G.; Sturmans, F.; Wouters, E. Adverse effects of the indoor environment on
respiratory health in primary school children. Environ. Res. 1995, 68, 11–23. [CrossRef]
54. Hesselmar, B.; Aberg, B.; Eriksson, B.; Björkstén, B.; Aberg, N. Building characteristics affect the risk of
allergy development. Pediatr. Allergy Immunol. 2005, 16, 126–131. [CrossRef] [PubMed]
55. Fisk, W.J.; Rosenfeld, A.H. Estimates of Improved Productivity and Health from Better Indoor Environments.
Indoor Air 1997, 7, 158–172. [CrossRef]
56. Verdier, T.; Coutand, M.; Bertron, A.; Roques, C. A review of indoor microbial growth across building
materials and sampling and analysis methods. Build. Environ. 2014, 80, 136–149. [CrossRef]
57. Lanata, C.F.; Rudan, I.; Boschi-Pinto, C.; Tomaskovic, L.; Cherian, T.; Weber, M.; Campbell, H. Methodological
and quality issues in epidemiological studies of acute lower respiratory infections in children in developing
countries. Int. J. Epidemiol. 2004, 33, 1362–1372. [CrossRef]
58. Organización Panamericana De La Salud. Hacía una Vivienda Saludable. Organización Panamericana
De La Salud. Available online: http://www.paho.org/col/index.php?option=com_docman&view=
download&category_slug=publicaciones-ops-oms-colombia&alias=1260-hacia-una-vivienda-saludable-
cartilla-educativa-para-la-familia&Itemid=688 (accessed on 17 July 2015).
59. Consejo Nacional de Evaluación de la Política de Desarrollo Social (CONEVAL)/Secretaria de Desarrollo
Social (SEDESOL). Informe Anual Sobre la Situación de Pobreza y Rezago Social. Xochitepec,
Morelos. Available online: https://www.gob.mx/cms/uploads/attachment/file/45741/Morelos_028.pdf
(accessed on 17 December 2013).
Int. J. Environ. Res. Public Health 2019, 16, 295 16 of 16

60. Instituto Nacional de Estadística y Geografía. Censo de Población y Vivienda (2010). Panorama
sociodemográfico de Morelos. Available online: http://www.inegi.org.mx/est/contenidos/proyectos/
ccpv/cpv2010/iter_2010.aspx (accessed on 23 October 2013).
61. Ebisu, K.; Holford, T.R.; Belanger, K.D.; Leaderer, B.P.; Bell, M.L. Urban land-use and respiratory symptoms
in infants. Environ. Res. 2011, 111, 677–684. [CrossRef]
62. Secretaria de Salud. Infecciones Respiratorias Agudas (IRAS). Distrito Federal. Mexico. Available online:
https://www.gob.mx/salud/articulos/infecciones-respiratorias-agudas-iras.Published2009 (accessed on
28 August 2014).

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