By Public Health Expert 17/07/2019 1


Elinor Chisholm, Nevil Pierse, Cheryl Davies, Philippa Howden-Chapman

We know that poor housing conditions result in ill health for many New Zealanders, and we know which interventions are required to ensure good quality housing that supports health. Healthy Housing Initiatives intervene to improve the homes of kids who are hospitalised for illnesses that could be related to poor housing conditions.

In this blog post, we draw on recently published research to gain insights about housing and health, and explore views about the effectiveness of these Ministry of Health-funded programmes.

There is overwhelming evidence that living in poor quality housing is devastating to health and that improving housing conditions can promote good health.  New Zealand research has shown how low indoor temperatures and mould impair children’s lung function (1,2), that almost 28,000 hospitalisations per year are for diseases potentially attributable to inadequate housing (3), that exposure to poor housing conditions is associated with increased risk of rheumatic fever (4), and that hazards and lack of safety features in the home increase the risk of injury (5). However, the good news is that there are effective interventions to reduce the harm caused by poor housing. These include: reducing draughts, installing insulation, and providing better heating and the money to pay for it. This increases indoor temperatures (6–8), which in turn improves respiratory symptoms. (1,7,8) Fixing up homes reduces the risk of injury (9) and providing better quality (public) housing reduces hospitalisations (10).

That’s why Healthy Housing Initiatives (HHIs) –  services aimed at improving the homes of kids who are hospitalised for illnesses that could be related to poor housing conditions –  make a lot of sense. Since  2013, HHIs have been rolled out in eight regions. In Wellington, for example, through Well Homes, low-income families are offered a visit from a health and housing assessor. The assessor will check out the home, offer tailored advice on heating and ventilation, and provide items such as beds, bedding, curtains, heaters, draught-stoppers, and mould-cleaning kits that can help make the home warmer or drier. If relevant they may offer to talk to the landlord to ask them to make repairs or improvements to the home. They can also refer on to other services, including public housing, insulation provision, budget advice, and an assessment by Work and Income to check households are receiving their full benefit entitlements. While the HHI services are funded by the Ministry of Health, the interventions offered, such as heaters, are funded by charities, so what’s offered depends on what different HHIs are able to fund.

Last year, we interviewed 21 staff members involved in delivering the Well Homes programme to learn about their experiences and to explore the advantages and challenges of this approach to health promotion. Participants reported really dire conditions in some cases – entering people’s homes, they could see grass through cracks in the floor, smell mould, and feel wet carpet through their socks. Staff reported that providing items such as heaters, blankets and draught stoppers was useful because it enabled families to see an immediate improvement to their homes. As one participant explained, a heater is just a basic need to be warm, so it is going to impact them straight away”.  To another participant, the provision of such items was the “ethical” and “fair” approach to working with families:  “You don’t want to go talk to whānau about anything that we don’t have a solution for”. Other ways Well Homes workers were able to support clients were through sharing information on how to effectively ventilate and heat homes, in some cases tailoring their advice to fit in with the reality of people’s homes and budgets. As one participant explained, “we… advise around heating the most vulnerable person’s room if that’s the only place you can afford to heat.”

Other ways Well Homes helps is by advocating on behalf of clients – for example,, helping clients to access their Work and Income entitlements, or advocating to landlords to make improvements, sometimes through the Tenancy Tribunal processes. In the case of private landlords, it can be difficult. Participants reported that some landlords  “just often don’t see the point [of making improvements]”. Participants blamed this on the lack of standards in the Residential Tenancies Act (RTA): “You can make suggestions but they don’t really have to do anything about it.”  In many cases, clients preferred that Well Homes workers did not contact landlords. As one participant explained, “there is a sense that if they try and rock the boat too much they will jeopardise their tenancy”.  Clients were particularly wary of asking for improvements if the tenancy relationship was under stress: “they won’t want to address it with the landlord especially if they are in rent arrears or they have asked for things before and they haven’t been done and they are worried about rent.” Participants noted that some people would be better served by public housing, yet long waiting lists meant that moving to public housing was not always a possibility. Participants also reported that some homeowners struggled to afford repairs that their homes urgently needed – while funding was available for insulation, for example, this was of no use if the roof leaked.

This study’s findings demonstrate that a programme that combines advocacy, practical interventions, and education for healthy housing, can make a real contribution to enhancing housing conditions. The literature suggests that the interventions provided by Well Homes, if implemented effectively, will contribute to improved health. However, our findings suggest that the lack of availability of social housing and wider systematic problems in the private rental housing market, as well as a lack of funding and regulatory support for housing improvements constrain the ability of HHI workers to do their jobs and effectively implement all the interventions that the housing requires. This limits the capability of this joint government and charitable programme to fulfil its potential. The recent changes to rental housing standards and new funding for housing improvements for homeowners may enhance the ability of HHI staff to improve the housing of Well Homes clients. It will be important to see whether they do.

The perspectives of Well Homes workers shared in our article, some of which are summarised in this blog post, are likely to be useful in interpreting the results of our ongoing study, a quantitative analysis on the effects of the programme on children’s readmissions to hospital for housing-related health needs.

More information: Chisholm E, Pierse N, Davies C, Howden‐Chapman P. Promoting health through housing improvements, education and advocacy: Lessons from staff involved in Wellington’s Healthy Housing Initiative. Heal Promot J Aust [Internet]. 2019;00:1–9. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1002/hpja.247

References

  1. Pierse N, Arnold R, Keall M, Howden-Chapman P, Crane J, Cunningham M, et al. Modelling the effects of low indoor temperatures on the lung function of children with asthma. J Epidemiol Community Health. 2013;67(11):918–25.
  2. Shorter C, Crane J, Pierse N, Barnes P, Kang J, Wickens K, et al. Indoor visible mold and mold odour are associated with new-onset childhood wheeze in a dose dependent manner. Indoor Air. 2017;28(1):6–15.
  3. Oliver J, Foster T, Kvalsvig A, Williamson DA, Baker MG, Pierse N. Risk of rehospitalisation and death for vulnerable New Zealand children. Arch Dis Child. 2018;103:327–34.
  4. Oliver JR, Pierse N, Stefanogiannis N, Jackson C, Baker MG. Acute rheumatic fever and exposure to poor housing conditions in New Zealand: A descriptive study. J Paediatr Child Health. 2017;53(4):358–64.
  5. Keall M, Baker M, Howden-Chapman P, Cunningham M. Association between the number of home injury hazards and home injury. Accid Anal Prev. 2008;40(3):887–93.
  6. Rangiwhetu L, Pierse N, Howden-Chapman P. Effects of minor household interventions to block draughts on social housing temperatures: a before and after study. Kotuitui. 2017;12(2):235–45.
  7. Howden-Chapman P, Pierse N, Nicholls S, Gillespie-Bennett J, Viggers H, Cunningham M, et al. Effects of improved home heating on asthma in community dwelling children: Randomised community study. Br Med J. 2008;337(1411):852–5.
  8. Howden-Chapman P, Matheson A, Crane J, Viggers H, Cunningham M, Blakely T, et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. Br Med J. 2007;334(7591):460–4.
  9. Keall M, Pierse N, Howden-Chapman P, Cunningham C, Cunningham M, Guria J, et al. Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: A cluster-randomised controlled trial. Lancet. 2015;385(9964):231–8.
  10. Baker M, Zhang J, Howden-Chapman P. Health Impacts of Social Housing: Hospitalisations in Housing New Zealand Applicants and Tenants, 2003-2008 [Internet]. Wellington; 2010. Available from: http://www.healthyhousing.org.nz/wp-content/uploads/2010/07/Microsoft-Word-Health-Impacts-of-Social-Housing-June-2010-FINAL1.pdf

One Response to “What can we learn from Healthy Housing Initiatives? New evidence from the Wellington Well Homes scheme”

  • I am genuinely curious about, and bewildered by, the constant emphasis upon relatively poor housing as the major factor, if not seemingly the only factor, as the above article seems to suggest, in the relatively poor health of a certain segment of the population of NZ. Could it not be the case that bad diet, lack of exercise, smoking tobacco (including secondarily), excessive alcohol and other drug intake, too much stress, atmospheric pollution, etc, are equally significant, if not more so? (Possibly even genetic propensity?)
    Regarding all the papers which point to poor housing as being so significant, has anyone done any critical appraisal of how well the authors of these studies have accounted for these confounding variables? Perhaps to do so would be so un-PC that nobody wants to do this. That would be ‘blaming the victims’. So of course policy advisors and our politicians will tend to avoid addressing these alternatives.
    I am also curious about just how much tax-payers’and/or rate-payers’ money the above authors think the NZ/local governments should put into improving the housing of those who live in relatively poor conditions. Might it be the case that the same amount might deliver better health outcomes for the poor-housing-dwellers if this sum, or at least some of it, were to be directed towards trying to ameliorate some of the other contributory adverse influences?
    Anecdotally, as a child I was raised in a draughty old house, with no insulation, just an open fire for heating, where on winter mornings we often had frost on the windows, sleeping three in a room. On winter evenings we played barefooted outside, often in the mud, wearing shorts. We had a diet of mostly un-processed food. Now, three score and ten years later, I have remained in excellent health.