Material and meaningful homes: mental health impacts and psychosocial benefits of rehousing to new dwellings

Considering Residents' Health and Well-Being in the Process of Social Housing Redevelopment: A Rapid Scoping Literature Review

Many aging mid-twentieth-century social housing developments worldwide are set to undergo major redevelopment, aiming to improve residents' living conditions. Nevertheless, the associated processes, particularly the challenges of relocation during the demolition and reconstruction phase, can significantly disrupt communities and social networks. Understanding the multifaceted impacts of social housing redevelopment projects is crucial to inform planning, design, and consultation for these projects. This scoping literature review explores how residents' health and well-being are considered in the process of social housing redevelopment. We identified eight studies through a search performed on EMBASE, PubMed, and Scopus databases, with an additional hand search of the bibliographies of selected studies. A thematic analysis was conducted to identify the health and well-being impacts of the different phases during redevelopment projects. The findings demonstrate that social housing redevelopment projects have varied impacts on residents' health and well-being depending on the subgroup of residents and the contextual characteristics of the original social housing estate. While improved physical infrastructure provides opportunities for better health outcomes, the disruption and lack of control during the relocation process may cause significant adverse health impacts. Moreover, the different phases during the redevelopment process expose different subgroups to varying risks. Based on these findings, we recommend that social housing redevelopment initiatives prioritize engaging and empowering residents to have better control in decision-making throughout all phases of the redevelopment.

Improvements in habitability and housing satisfaction after dwelling regeneration in social housing complexes. The RUCAS study

Housing is a pressing problem worldwide and a key determinant of health and wellbeing. The right to adequate housing, as a pillar of the right to an adequate standard of living, means more than a roof to live under. Adequate means the dwelling must fulfill material functions and psychosocial functions, thus contributing to dwellers health and wellbeing. Social housing policies aim to fulfill the right to housing, but frequently fail in fulfilling the right to it being adequate. This study capitalizes on the implementation of a national urban regeneration program in two social housing villas in central Chile (one in Santiago, in the central valley, the other in Viña del Mar, a coastal city) to run a natural experiment assessing the impact of dwelling renovation on several dimensions of perceived habitability and housing satisfaction among the -mostly female-household homemakers. We use 5 waves of survey data collected with a step-wedge design to estimate the association between a time-varying exposure status (the intervention) and 7 binary outcomes for habitability and 5 for housing dissatisfaction, including overall housing satisfaction. We use Poisson regression models with robust variance and a random intercept at the respondent level. At baseline, reports of poor habitability and dissatisfaction across all features were markedly high, the highest levels of dissatisfaction being with acoustic insulation and dwelling size in both villas, and with indoor temperature in Santiago. The intervention resulted in statistically significant and markedly large improvements in reported habitability and dissatisfaction relative to those housing components targeted by the intervention, as well as with overall dwelling satisfaction in both study cases. Implications are, first, that the policy response to quantitative housing deficits must not overlook housing quality; second, that housing renovation appears as a promising intervention for qualitative housing crises; third, that while improvements in habitability and satisfaction are specific to the interventions in place, overall housing satisfaction can improve in more limited, tailored, dwelling renovation interventions. Social housing renovation in Latin America appears as a promising intervention to improve quality of life among the urban poor dwellers and reduce inequalities in health related to housing conditions.

Structural changes in a Danish social housing area: The impact of forced permanent rehousing on contact frequency with general practitioner and use of antidepressants

There is a lack of knowledge about the health consequences of politically initiated forced permanent rehousing (FPR) of residents in social housing areas. This study investigates if FPR is associated with the contact frequency with general practitioner (GP) and the proportion of residents who use antidepressants. The study included 432 rehoused residents matched 1:2 with remaining residents and residents from a comparable neighbouring area without exposure to rehousing. For GP contact frequency, we conducted a difference-in-difference analysis while the proportion of residents who used antidepressants was investigated through descriptive statistics. We found high GP contact frequency in the three groups, but no significant differences. Further, we found a low proportion of residents who used antidepressants in all groups, but a small increase from baseline to follow-up. Our results thus suggest that FPR neither affected the rehoused residents' GP contact frequency nor the proportion who used antidepressants.

Housing as a determinant of Inuit mental health: associations between improved housing measures and decline in psychological distress after rehousing in Nunavut and Nunavik

INTERVENTION

In 2014-2015, more than 400 public housing units were constructed in Nunavut and Nunavik, two of the four Inuit regions in Canada. This provided the opportunity to assess the impact of improved housing conditions from a population health perspective in 12 Inuit communities where housing needs were the most severe. The aim of the research is to examine the associations between changes in housing conditions and changes in psychological distress pre-post rehousing.

METHODS

A pre-post uncontrolled study was conducted in collaboration with Nunavut- and Nunavik-based organizations. Applicants at the top of public housing waitlists were recruited by local housing officers; participants completed questionnaires 1-6 months before rehousing, and 15-18 months after. Change in psychological distress was measured with the Kessler 6-item scale. Changes in three housing measures were examined: number of adults per household, number of children per household, and sense of home score. For each housing measure, a categorical variable stratified participants into three categories. The reference category included participants reporting significant change in the concerned housing measure; the two other categories included participants reporting little or no change. Associations were tested with linear multilevel regression models for change.

RESULTS

A total of 102 Inuit adults completed the study. A reduction in the number of adults per household (living with 2 adults or less after rehousing) and an increase in sense of home were associated with significant decline in psychological distress pre-post rehousing (p < 0.001).

CONCLUSION

Increased investments leading to such improvements in housing circumstances are promising ways to promote mental health in Inuit regions.

"We're Home Now": How a Rehousing Intervention Shapes the Mental Well-Being of Inuit Adults in Nunavut, Canada

This study explores the ways in which a rehousing intervention shapes the mental well-being of Inuit adults living in Nunavut, Canada, where the prevalence of core housing need is four times the national average. More specifically, it compares the housing experiences of participants who were rehoused in a newly built public housing unit, to the experiences of participants on the public housing waitlist. The study was developed in collaboration with organizations based in Nunavut and Nunavik. Semi-structured interviews were transcribed, and a deductive-inductive thematic analysis was performed based on Gidden's concept of ontological security, and Inuit-specific mental health conceptualization. Twenty-five Inuit adults participated (11 rehoused, 14 waitlist). Three themes were identified to describe how the subjective housing experiences of participants improved their mental well-being after rehousing: (1) refuge creation; (2) self-determination and increased control; (3) improved family dynamics and identity repair. Implicit to these themes are the contrasting housing experiences of participants on the waitlist. Construction initiatives that increase public housing stock and address gaps in the housing continuum across Inuit regions could promote well-being at a population level. However, larger socio-economic problems facing Inuit may hamper beneficial processes stemming from such interventions.

Urban regeneration policies and mental health in a context of economic crisis in Andalusia (Spain)

Literature suggests that urban regeneration policies might contribute towards improving mental health of residents, but to date there is a lack of empirical research on how these policies and downward social mobility can interact and influence health outcomes. The current study aims to explicitly test whether regeneration policies implemented in deprived Andalusian urban places (southern Spain) moderate the use of anxiolytics and/or antidepressants, taking into consideration families' downward social mobility during the recent period of economic crisis in Spain. We designed a post intervention survey to retrospectively compare the evolution of psychotropic drug consumption in target and comparison areas. We observe a general increase in the use of anxiolytics and/or antidepressants from 2008 to 2015, specifically for people in whose families the economic crisis had the greatest impact (odds ratio = 2.18; p value < 0.001). However, better evolution is observed among residents of the target areas compared with residents of similar urban areas where this kind of polices have been not in force (odds ratio = 0.50; p value < 0.05). Therefore, urban regeneration policies might act as moderators of the risk of mental health, particularly when people are subject to the loss of individual/family resources in urban vulnerable contexts.

Urban regeneration and mental health: Investigating the effects of an area-based intervention using a modified intention to treat analysis with alternative outcome measures

A quasi-experimental study of the mental health impacts of regeneration was carried out across fifteen communities in Glasgow, UK, grouped into five and then four types of intervention area. Regression modelling was undertaken to examine the effects of living in each type of area upon mental health (MCS-12 and SF-12 MH) and mental wellbeing (WEMWBS). Living in regeneration areas had no impacts on mental health or wellbeing, possibly due to incomplete implementation. Positive impacts from living in areas of housing improvement were not evident separately for areas of high-rise housing. Areas surrounding regeneration areas exhibited gains in mental health and wellbeing, contrary to notions of negative spillover. Moving between areas had negative effects, especially for those moving beyond the study areas. Changes in mental wellbeing appear less substantial compared with changes in mental health.

Relocating to a new or pre-existing social housing unit: significant health improvements for Inuit adults in Nunavik and Nunavut

OBJECTIVES

In 2014-2015, over 400 social housing units were constructed in selected communities in Nunavik and Nunavut, two Inuit regions in northern Canada where housing shortages and poor quality housing are endemic and undermine population health. This paper presents results from a before-and-after study examining the effects of rehousing, i.e., relocating to a newly constructed or pre-existing social housing unit, on psychosocial health and asthma-related symptoms for Inuit adults.

METHODS

Baseline data were collected 1-6 months before, and follow-up data 15-18 months after rehousing. Of the 289 participants at baseline, 186 were rehoused. Of the 169 participants eligible at follow-up, 102 completed the study. Self-reported health measures included psychological distress, perceived stress in daily life, perceived control over one's life, and asthma-related symptoms. Data are analyzed using multilevel models for longitudinal data.

RESULTS

After adjusting for age, sex, and region of residence, participants reported significantly lower levels of psychological distress and perceived stress in daily life, and improved sense of control over their lives 15 to 18 months after rehousing. Participants were also significantly less likely to report asthma-related symptoms at follow-up.

CONCLUSION

Significant positive health impacts are observed for adults who relocated to newly constructed or pre-existing social housing units. Increasing investments to redress the housing situation across Inuit Nunangat is required, not only to improve living conditions but also to improve the health and well-being of the population.

Household overcrowding and psychological distress among Nunavik Inuit adolescents: a longitudinal study

About half of Nunavik Inuit live in overcrowded households compared to very few Canadians from the general population. Living in overcrowded households is associated with greater risks of suffering from mental health problems for Canadian adolescents. The present work aims at studying prospectively the hypothesised relationship between household overcrowding at childhood and psychological distress during adolescence among Nunavik Inuit, as well as the hypothesised relationship between these phenomena when they are both measure at adolescence. Recruited as part of the Nunavik Child Development Study, 220 participants were met at 11 years old in average and then when they were 18 years old in average. Household overcrowding was assessed using the people per room ratio. Psychological distress symptoms were operationalised at adolescence using depressive symptoms and suicidal thoughts. The results did not show that childhood household crowding had a long-term effect on psychological distress. An absence of moderation by sex of the association was also found in the present study. Despite those results, household crowding could be a risk factor only when in interaction with other elements related with poverty or housing or could be experienced as a difficulty for adolescents on other aspects than depressive symptoms and suicidal thoughts.

Changes in Health Following Housing Improvement in a Vulnerable Population in Spain

The objective of this study is to compare changes in health among a sample of families living in substandard dwellings or with housing affordability problems assisted by Caritas Diocesana de Barcelona, according to the improvement of their socioeconomic and housing situation during the study period. A quasi-experimental study was performed, including 232 families assisted by Caritas who were interviewed in 2012 and one year later. Participants could have received a set of interventions, including relocation and different types of economic subsidies. Regression models were fitted to identify the association of participants' changes in self-rated general health and mental health between baseline and follow-up with improvements across three dimensions: socioeconomic situation and housing affordability, physical housing characteristics, and neighborhood. An improvement in self-reported health status was associated with having found a job and reporting fewer problems in meeting monthly housing costs. Mental health improved among participants with an increased household income, with a reduction in the perceived risk of losing their house, and with reduced housing-related material deprivations. The study shows that health gains can derive from improvements in housing conditions, especially those related to housing affordability.

The impact of life events on adult physical and mental health and well-being: longitudinal analysis using the GoWell health and well-being survey

Background

It is recognised that life events (LEs) which have been defined as incidents necessitating adjustment to habitual life either permanently or temporarily, not only have the potential to be detrimental to health and well-being, but research suggests some LEs may be beneficial. This study aimed to determine the individual and cumulative occurrence of LEs; and to establish their effect on health and well-being.

Results

Demographic factors (gender, age and highest educational attainment), LE occurrence and self-reported health data were collected as part of the longitudinal GoWell community health and wellbeing survey (2008–2011). Self-reported health was measured using the SF-12 questionnaire for physical (SF-12 PCS) and mental health (SF-12 MCS) and the Warwick–Edinburgh mental well-being scale (WEMWBS) for well-being. Statistical analysis was performed using SPSSv21 and level of significance was set at p < 0.05. Results showed that the sample was 61.6 % (n = 768) female; 20.4 % (n = 254) were aged 16–39 years, 46.1 % (n = 575) 40–64 years and 33.5 % (n = 418) were over 65 years; 68.8 % (n = 819) had no qualifications/Scottish leaving certificates, with the remaining 31.2 % (n = 372) having their highest educational qualification above Scottish leaving certificates. Health score means were 49.3 SF-12 mental health component score (SF-12 MCS); 42.1 SF-12 physical health component score (SF-12 PCS); and 49.2 WEMWBS. Participants experienced 0–7 LEs over a three year period, with the most common being: housing improvement (44.9 %), house move (36.8 %), health event (26.3 %) and bereavement (25.0 %). Overall, an increase in LEs was associated with a health score decrease. Five LEs (relationship breakdown, health event, bereavement, victimisation and house move) had negative impacts on SF-12 MCS and two (new job/promotion and parenthood) had positive impacts. For SF-12 PCS only three (health event, bereavement and housing improvement) had a negative impact. Six (health event, victimisation, bereavement, relationship breakdown housing move and improvement) had negative impacts on well-being and two (new job/promotion, marriage) had positive effects.

Conclusions

Findings from the current study confirm LEs have both detrimental and beneficial impacts on health and well-being. Further research is required to disentangle the complexity of LEs and the ways they affect health and well-being.

Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

BACKGROUND

NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned.

OBJECTIVES

The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives.

DESIGN

The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use.

SETTING

The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services.

PARTICIPANTS

There were 202,804 cases included in secondary analysis and 3075 in the prospective study.

INTERVENTIONS

A combination of behavioural support and stop smoking medication delivered by SSS practitioners.

MAIN OUTCOME MEASURES

Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test.

RESULTS

Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected.

CONCLUSIONS

Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.

Mental health and houses in multiple occupation

Purpose

– Previous research has established that there is a relationship between housing and mental health, however, understanding about how and why housing affects mental health is still limited. The purpose of this paper is to address this deficit by focusing on the experiences of residents of houses in multiple occupation (HMOs).

Design/methodology/approach

– Semi-structured interviews were carried out with 20 HMO residents who were asked about their housing career and experience of living in a HMO. Participants were recruited with assistance from community organisations and landlords.

Findings

– The physical properties and social environment of the property, as well as personal circumstances experienced prior to the move into the property, all influenced how mental health was affected. The authors identify and discuss in detail three key meditating factors: safety, control and identity which may affect how living in the property impacts the mental health of tenants.

Practical implications

– Good property management can lessen the potential harmful effects of living in a HMO. However, poorly run properties which house numerous vulnerable people may increase the risk of poor mental health due to attendant high levels of stress and possible risk of abuse.

Originality/value

– Based on the reports of HMO residents, the authors outline the key mediating processes through which living in HMOs may affect mental wellbeing, as well as illuminating the potential risks and benefits of HMOs, an overlooked tenure in housing research.

Towards explaining the health impacts of residential energy efficiency interventions - A realist review. Part 1: Pathways

This paper is Part 1 of a realist review that tries to explain the impacts of residential energy efficiency interventions (REEIs) on householder health. According to recent systematic reviews residential energy efficiency interventions may benefit health. It is argued that home energy improvement are complex interventions and that a better understanding of the latent mechanisms and contextual issues that may shape the outcome of interventions is needed for effective intervention design. This realist review synthesises the results of 28 energy efficiency improvement programmes. This first part provides a review of the explanatory factors of the three key pathways, namely warmth in the home, affordability of fuel and psycho-social factors, and the pitfall of inadequate indoor air quality. The review revealed that REEIs improved winter warmth and lowered relative humidity with benefits for cardiovascular and respiratory health. In addition, residential energy efficiency improvements consolidated the meaning of the home as a safe haven, strengthened the householder's perceived autonomy and enhanced social status. Although satisfaction with the home proved to be an important explanation for positive mental health outcomes, financial considerations seemed to have played a secondary role. Evidence for negative impacts was rare but the risk should not be dismissed. Comprehensive refurbishments were not necessarily more effective than thermal retrofits or upgrades. A common protocol for the quantitative and qualitative evaluation of interventions would facilitate the synthesis of future studies. Householder and contextual influences are addressed in Part 2.

Is changing status through housing tenure associated with changes in mental health? Results from the British Household Panel Survey

Background

Actual or perceived status, such as housing tenure, may impact on health through stress-inducing social comparisons. Studies of how status change impacts mental health change are rare but important because they are less prone to confounding.

Methods

We used data from the British Household Panel Survey to compare psychological distress in local authority renters who opted to buy their home under the UK's Right to Buy (RTB) policy versus those who continued to rent the same (social non-mover (SNM)) or a different (social mover (SM)) local authority property or who bought privately (owner mover (OM)). General Health Questionnaire (GHQ-12) scores before and after any change in tenure and/or address were compared across groups using a difference-in-difference approach.

Results

Individuals who moved house (bought or rented) were younger while those who bought (the same or different house) were better off, more likely to be employed, and had higher educational qualifications. Individuals who bought their home (under RTB or privately) had lower distress scores from the outset. Individuals who moved house (bought or rented) experienced a rise in distress prior to moving that was no longer evident 1 year after the move. There was no evidence that changing tenure reduced psychological distress comparing (difference (95% CI)) average GHQ score 2 years preaddress and 1 year postaddress/tenure change in RTB vs SNM, SM, OM: −0.08 (−0.68 to 0.51), 0.16 (−0.70 to 1.01) and −0.17 (−1.28 to 0.94), respectively).

Conclusions

Changing tenure under RTB did not, on average, impact psychological distress, suggesting that this status change did not change mental health.

Physical and mental health outcomes following housing improvements: evidence from the GoWell study

BACKGROUND

Existing research points towards physical and mental health gains from housing improvements, but findings are inconsistent and often not statistically significant. The detailed characteristics and variability of housing improvement works are problematic and studies are often small, not experimental, with short follow-up times.

METHODS

A quasi-experimental design was used to assess the impact on physical health and mental health (using SF-12v2 Physical and Mental health component summary scales) of four types of housing improvement works-central heating, 'Secured By Design' front doors, fabric works, kitchens and bathrooms-both singly and in pairwise combinations. A longitudinal sample of 1933 residents from 15 deprived communities in Glasgow, UK was constructed from surveys carried out in 2006, 2008 and 2011. Sociodemographic characteristics and changes in employment status were taken into account.

RESULTS

Fabric works had positive associations with physical health (+2.09, 95% CI 0.13 to 4.04) and mental health (+1.84, 95% CI 0.04 to 3.65) in 1-2 years. Kitchens and bathrooms had a positive association with mental health in 1-2 years (+2.58, 95% CI 0.79 to 4.36). Central heating had a negative association with physical health (-2.21, 95% CI -3.74 to -0.68). New front doors had a positive association with mental health in <1 year (+5.89, 95% CI 0.65 to 11.14) and when provided alongside kitchens and bathrooms (+4.25, 95% CI 1.71 to 6.80). Gaining employment had strong associations with physical health (+7.14, 95% CI 4.72 to 9.55) as well as mental health (+5.50, 95% CI 3.27 to 7.73).

CONCLUSIONS

Fabric works may provide insulation benefits and visual amenity benefits to residents. Front doors may provide important security benefits in deprived communities. Economic regeneration is important alongside property-led regeneration.

Household crowding and psychosocial health among Inuit in Greenland

OBJECTIVES

Poor housing conditions experienced by many Indigenous peoples threaten their health and well-being. This study examines whether household crowding is associated with poorer psychosocial health among Greenlanders, and the mediating role of social support. It also assesses whether Inuit men and women are differently influenced by their housing conditions.

METHODS

Data on more than 3,000 Inuit aged 18 years and older are from the Inuit health in transition Greenland survey. Associations between household crowding and composition, and mental well-being and binge drinking were examined using logistic regression models, adjusting for individuals' characteristics.

RESULTS

Household crowding was associated with poorer mental well-being. Binge drinking was more common among people living in households without children. These effects were more important for women than for men. The association between household crowding and mental well-being was significantly mediated by social support. This suggests that having a strong social network may buffer the deleterious impacts of household crowding.

CONCLUSIONS

Targeting housing conditions and fostering social support as part of population health interventions might contribute to improving psychosocial health and well-being in Greenland.

Investing in health: is social housing value for money? A cost-utility analysis

BACKGROUND

There is a healthy public policy agenda investigating the health impacts of improving living conditions. However, there are few economic evaluations, to date, assessing value for money. We conducted the first cost-effectiveness analysis of a nationwide intervention transferring social and private tenants to new-build social housing, in Scotland.

METHODS

A quasi-experimental prospective study was undertaken involving 205 intervention households and 246 comparison households, over 2 years. A cost-utility analysis assessed the average cost per change in health utility (a single score summarising overall health-related quality of life), generated via the SF-6D algorithm. Construction costs for new builds were included. Analysis was conducted for all households, and by family, adult and elderly households; with estimates adjusted for baseline confounders. Outcomes were annuitised and discounted at 3.5%.

RESULTS

The average discounted cost was £18, 708 per household, at a national programme cost of £ 28.4 million. The average change in health utility scores in the intervention group attributable to the intervention were +0.001 for all households, +0.001 for family households, -0.04 for adult households and -0.03 for elderly households. All estimates were statistically insignificant.

CONCLUSIONS

At face value, the interventions were not value for money in health terms. However, because the policy rationale was the amenity provision of housing for disadvantaged groups, impacts extend beyond health and may be fully realised over the long term. Before making general value-for-money inferences, economic evaluation should attempt to estimate the full social value of interventions, model long-term impacts and explicitly incorporate equity considerations.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.