Welcome! Housing improvements for health and associated socio-economic outcomes: What’s

the Evidence?

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What’s the evidence?

Thomson, H., Thomas, S., Sellstrom, E., and Petticrew, M. (2013). Housing improvements for health and associate socioeconomic outcomes (Review).Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No:CD008657.DOI:10.1002/14651858.CD008657.pub2.

http://www.healthevidence.org/view-article.aspx?a=23638

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Welcome! Housing improvements for health and associated socio-economic outcomes: What’s

the Evidence?

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A Model for Evidence-Informed Decision Making

Source: National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health. [fact sheet]. Retrieved from http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf

Stages in the process of Evidence-Informed Public Health

9

Review

Thomson, H., Thomas, S., Sellstrom, E., and Petticrew, M. (2013). Housing improvements for health and associate socioeconomic outcomes (Review).Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No:CD008657.DOI:10.1002/14651858.CD008657.pub2.

Importance of this Review

• Large volume of evidence reporting an association between poor housing and poor health

• Poor housing has significant health impacts, increasing incidence of illnesses (i.e., heart disease and stroke) and premature death

Who has heard of a PICO(S)

question before?

1. Yes

2. No

Searchable Questions Think “PICOS”

1. Population (situation)

2. Intervention (exposure)

3. Comparison (other group)

4. Outcomes

5. Setting

Review Focus: Thomson (2013) P All populations from any region of the world and from

both industrialized and non-industrialized countries I All physical house types which are static (that is not

caravans or house boats) C No intervention/no comparison

Review Focus: Thomson (2013) O Primary Outcomes: direct measure of health or mental

and physical illness, general measures of self-reported wellbeing, and quality of life measures (health service use was not included in health outcomes). Secondary Outcomes: additional social and socio-economic outcomes (i.e. fuel costs, household income, measures of social contract, social exclusion, education, employment, time off work)

Quality Rating: 10 (strong)

Senior Investigator Scientist (MRC/CSO Social and Public Health Sciences Unit), University of Glasgow, Glasgow United Kingdom

Hilary Thomson

What do we know about the health

impacts of housing improvement?

A synthesis of research evidence

Presented May 20, 2014

Hilary Thomson

MRC/CSO Social & Public Health Sciences Unit, University of Glasgow

This work is supported by the Chief Scientist Office, Scottish Government and the Medical Research

Council

Systematic review of health impacts of housing

improvement

Review question

• What are the health & socio-economic impacts of housing

improvement?

• Published as Cochrane & Campbell review (February

2013) Thomson H, Thomas S, Sellstrom E, Petticrew M. Housing improvements for health and

associated socio-economic outcomes. Cochrane Database of Systematic Reviews 2013,

Issue 2. Art. No.: CD008657. DOI: 10.1002/14651858.CD008657.pub2.

http://doi.wiley.com/10.1002/14651858.CD008657.pub2

Systematic review: housing improvements for

health

• Broad approach

– Look at all available evaluations- not just randomised trials

» Controlled studies & uncontrolled studies

– Incorporate qualitative studies

– Include all health & socio-economic outcomes

• Systematic review of housing improvement

– Searched globally (39 databases)

– Grouped according to broad intervention type

» Warmth & energy efficiency (post 1985)

» Housing-led neighbourhood renewal (post 1995)

» Basic housing in Low & Middle Income Countries

» Historical studies of rehousing from slums (pre 1960)

– Conclusions prioritised better quality evidence

What we found

59,248 records screened

336 full-text articles assessed for

eligibility

Best available evidence included in synthesis

Quantitative n=19

• Warmth & energy efficiency n=11

• Rehousing/neighbourhood renewal n=6

• Rehousing from slums n=1

• Provision of basic housing needs=1

Qualitative n=9

• Warmth & energy efficiency n=5

• Rehousing/neighbourhood renewal n=4

Randomised controlled trials of housing improvement

Assess health of residents still waiting to move BEFORE & AFTER (Control group) Intervention group

Compare BEFORE & AFTER house move (Intervention group)

1 year

1 year

• Control group move house after 1st year and enter intervention group

• Equal levels of eligibility for the intervention

1 year

Problems with controlled studies: selecting a

control group for comparison

INTERVENTION GROUP similar to CONTROL GROUP

Individual factors (age & sex) Individual factors (age & sex)

Individual deprivation (income, Individual deprivation (income,

employment, education) employment, education)

Housing type/quality Housing type/quality

Neighbourhood deprivation Neighbourhood deprivation

• Residents in control group should be similar to residents in intervention group –

EXCEPT for the house move/improvement

• Often not able to match for ELIGIBILITY for the intervention: area or individuals offered the intervention are often selected due to greater need

Controlled Before & After studies

(Prospective controlled studies, controlled cohort studies)

ALSO assess health of similar residents who do not move

BEFORE & AFTER (Control group)

1 year

Assess health BEFORE & AFTER house move

(Intervention group)

1 year

Before & After studies (Prospective uncontrolled studies, uncontrolled study)

Assess health BEFORE AND AFTER house move

• Assess change in (impact on) health outcome 1 year after

house move

» at same time of year as before measures

1 year

Problems of Before & After studies

• Not able to control for other important changes

which might influence health- do not know if health

would have changed anyway

• Health may change due to » changes neighbourhood

» changes to income & state benefits

» changes in local services, amenities, transport, opportunities

» changes to individual circumstances (employment, family

changes, other ill health)

What we found:

Warmth & energy efficiency improvements

• Best available evidence (11 studies)

– 5 randomised controlled trials (RCTs)

– 5 controlled before/after studies

– 1 uncontrolled before/after studies

• Included

– loft/cavity wall insulation, double glazing,

central heating, lagging, flued heaters,

energy advice…

Warmth & energy efficiency improvements

• Mixed reports across studies

– Some improvements in mental health, respiratory

health, and general health

– Greatest improvement in RCTs in New Zealand

» Among those with respiratory illness

– Least improvement in UK studies

» General population

• Warmth improvements can lead to health

improvements

– especially when targeted at individuals with

inadequate warmth & chronic respiratory disease

Warmth & energy efficiency improvements: other

impacts

• Reduced time off work/school due to illness

• Increased usable space at home

– Improved household relationships

– Increased entertaining at home

• Increased control over home environment

• Reduced fuel costs (sometimes)

• Increased rent costs- protected by welfare

• Mechanisms for later health impacts?

Housing led neighbourhood renewal

• Best available UK evidence (n=6) ─ 6 controlled before/after studies

• Unclear impacts across different health

measures

─ Little indication of improved health

No changes statistically significant

─ Impacts reported in qualitative data

similar to those in warmth studies

»...but didn’t lead to health impacts-

WHY?

Comparing warmth only with programmes

of housing-led regeneration

• Studies of warmth improvements more likely to be targeted

according to individual need

– Studies which targeted those with poor health and living in poor housing

reported greatest health impact

» Comparing New Zealand & UK studies

– Greater potential to benefit across whole sample

• Housing led regeneration- area based need

– Wider range of intervention type

– Additional neighbourhood change/relocation

– More potential for disruption related to improvement

– Not targeted according to individual need

» Less consistent potential to benefit across whole sample

» Those who benefit most are hidden by the mean improvement in health

Why the small impact on health?

• Evaluations only assess short term impacts

– Health impacts may be seen years after event

• Delivery of tangible improvements in housing conditions was rarely

confirmed in studies

– Was new heating system used by residents?

– Were baseline conditions affecting health?

• Complex interaction of influences on housing & health

– Historical study of rehousing from slums: increased mortality following

rehousing explained by increased rents and inability to buy food

• Housing improvements only one factor in link between poverty & poor

health

– Link between housing & health perhaps not as strong as assumed

– Is addressing one factor likely to lead to break link between poverty & health?

What about impacts on proxy

measures of health?

? Examine immediate impacts on socio-economic

determinants of health to shed light on pathways to longer

term health impacts

Pathways from housing improvement to

health improvement

• Examine impacts on socio-economic determinants of

health

– Proxies for health impacts:

» may be detectable in the short timescale of evaluation

» point to potential for future health impacts

– Mediating factors:

» explain absence of or small health impacts observed

» Identify ways of maximising potential for health benefits in future

Logic model mapping reported qualitative and quantitative

impacts/pathways following warmth and energy efficiency

improvements, and rehousing/retrofitting

Summary of short term impacts of housing

improvement

• Housing improvement is likely to affect:

– Domestic space & design appropriate to needs

– Thermal comfort

– Housing costs

– Attitudes to home- satisfaction & control over living environment

• These may act as mechanisms through which housing improvement

might lead (or may not) to longer term improvements in health or

wellbeing

Conclusions of systematic review:

health impacts

• Improvements in warmth can lead to health improvements, but

cannot be assumed

– Improvements seen in New Zealand RCTs

– But less conclusive in UK studies

– No evidence of harmful effects

• Greatest potential for health improvement is where improvements

targeted at those with inadequate warmth and with chronic

respiratory disease

• Unclear health impacts reported in studies of housing led-

neighbourhood renewal

– No evidence of harmful effects

Conclusion

• Housing improvement is likely to affect:

– Domestic space & design appropriate to needs

– Thermal comfort

– Housing costs

– Attitudes to home- satisfaction & control over living environment

• These changes have the potential to lead to longer term health

impacts

• Health housing investment should aim to provide

affordable thermal comfort in housing of appropriate size

& design to meet household needs

A Model for Evidence-Informed Decision Making

Source: National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health. [fact sheet]. Retrieved from http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf

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