Housing improvement and self-reported mental distress among council estate residents

The effect of dwelling size on the mental health and quality of life of female caregivers living in informal tiny homes in Hong Kong

BACKGROUND

Although the adverse impact of substandard informal housing has been widely documented, most studies concentrated on developing societies, thereby leaving informal housing in developed regions underexplored. This study examines Hong Kong, where limited dwelling size is a distinctive feature that characterises informal housing, to explore the impact of housing informality on mental health, with a particular focus on dwelling size. It centers on subdivided units (SDUs), which are tiny compartments partitioned from a large domestic quarter, to understand how housing informality and housing size affect the mental well-being of female caregivers, who typically bear the brunt of the housework.

METHODS

In partnership with nongovernment organisations in three SDU-abundant districts, this mixed-methods study conducted a survey on 413 female caregivers aged 18-65 and qualitative research combining ethnographic observations and in-depth interviews on 36 families living in SDUs in Hong Kong between 2021 and 2023. The mental health outcomes and health-related quality of life (HRQoL) of the participants were assessed by using the Depression, Anxiety, and Stress Scale-21 and a EuroQol-5 Dimension-5 Level questionnaire.

RESULTS

Depression, anxiety and stress were prevalent across the female caregivers living in SDUs (12.4%), as well as a significantly lower HRQoL compared with that of the general population (0.882 vs. 0.919). Findings showed that a total floor area smaller than 13.0 m2 was associated with increased likelihood of experiencing anxiety and depression and reduced HRQoL. Cramped living space adversely affected the caregivers' well-being through the 1) physical, 2) relational and 3) personal aspects of home experiences. Negative experiences at home can cause housework burnout, exacerbate family conflicts and lead to feelings of repression and low self-efficacy.

CONCLUSIONS

This study contributes to the understanding of the consequences of housing informality in diverse geographical contexts and illuminates the effect of dwelling size by identifying the mechanisms through which housing size can affect the mental well-being of residents, which may vary depending on their family status. The findings yield important policy implications, including the need to establish a minimum space standard for subdivided residential dwellings and ensure equitable access to community spaces for deprived families.

An Olympic Legacy? Did the Urban Regeneration Associated With the London 2012 Olympic Games Influence Adolescent Mental Health?

Public expenditure on large events such as the London 2012 Olympic Games is often justified by the potential legacy of urban regeneration and its associated health and well-being benefits for local communities. In the Olympic Regeneration in East London Study, we examined whether there was an association between urban regeneration related to the 2012 Games and improved mental health in young people. Adolescents aged 11-12 years attending schools in the Olympic host borough of Newham in London or in 3 adjacent comparison London boroughs completed a survey before the 2012 Games and 6 and 18 months after the Games (in 2013 and 2014, respectively). Changes in depressive symptoms and well-being between baseline and each follow-up were examined. A total of 2,254 adolescents from 25 randomly selected schools participated. Adolescents from Newham were more likely to have remained depressed between baseline and the 6- and 18-month follow-up surveys (for 6-month follow-up, relative risk = 1.78, 95% confidence interval: 1.12, 2.83; for 18-month follow-up, relative risk = 1.93, 95% confidence interval: 1.01, 3.70) than adolescents from the comparison boroughs. No differences in well-being were observed. There was little evidence that urban regeneration had any positive influence on adolescent mental health and some suggestion that regeneration may have been associated with maintenance of depressive symptoms. Such programs may have limited short-term impact on the mental health of adolescents.

Can housing improvements cure or prevent the onset of health conditions over time in deprived areas?

BACKGROUND

There is a need for more evidence linking particular housing improvements to changes in specific health conditions. Research often looks at generic works over short periods.

METHODS

We use a longitudinal sample (n = 1933) with a survey interval of 2-5 years. Multivariate logistic regression is used to calculate the odds ratios of developing or recovering from six health conditions according to receipt of four types of housing improvements.

RESULTS

Receipt of fabric works was associated with higher likelihood of recovery from mental health problems and circulatory conditions. Receipt of central heating was also associated with higher likelihood of recovery form circulatory conditions. No evidence was found for the preventative effects of housing improvements.

CONCLUSIONS

Health gain from housing improvements appears most likely when targeted at those in greatest health need. The health impacts of area-wide, non-targeted housing improvements are less clear in our study.

Developing empirically supported theories of change for housing investment and health

The assumption that improving housing conditions can lead to improved health may seem a self-evident hypothesis. Yet evidence from intervention studies suggests small or unclear health improvements, indicating that further thought is required to refine this hypothesis. Articulation of a theory can help avoid a black box approach to research and practice and has been advocated as especially valuable for those evaluating complex social interventions like housing. This paper presents a preliminary theory of housing improvement and health based on a systematic review conducted by the authors. Following extraction of health outcomes, data on all socio-economic impacts were extracted by two independent reviewers from both qualitative and quantitative studies. Health and socio-economic outcome data from the better quality studies (n = 23/34) were mapped onto a one page logic models by two independent reviewers and a final model reflecting reviewer agreement was prepared. Where there was supporting evidence of links between outcomes these were indicated in the model. Two models of specific improvements (warmth & energy efficiency; and housing led renewal), and a final overall model were prepared. The models provide a visual map of the best available evidence on the health and socio-economic impacts of housing improvement. The use of a logic model design helps to elucidate the possible pathways between housing improvement and health and as such might be described as an empirically based theory. Changes in housing factors were linked to changes in socio-economic determinants of health. This points to the potential for longer term health impacts which could not be detected within the lifespan of the evaluations. The developed theories are limited by the available data and need to be tested and refined. However, in addition to providing one page summaries for evidence users, the theory may usefully inform future research on housing and health.

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Theories of health impacts of complex interventions are valuable but poorly developed.

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Including socio-economic data may explain why health impacts are observed or not.

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A theory of healthy housing improvement was prepared using systematic review data.

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Quantitative and qualitative data on health and socio-economic impacts were used.

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Warmth, affordability & suitable space provision may mediate health impacts of housing.

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.

Economic analysis of the health impacts of housing improvement studies: a systematic review

BACKGROUND

Economic evaluation of public policies has been advocated but rarely performed. Studies from a systematic review of the health impacts of housing improvement included data on costs and some economic analysis. Examination of these data provides an opportunity to explore the difficulties and the potential for economic evaluation of housing.

METHODS

Data were extracted from all studies included in the systematic review of housing improvement which had reported costs and economic analysis (n=29/45). The reported data were assessed for their suitability to economic evaluation. Where an economic analysis was reported the analysis was described according to pre-set definitions of various types of economic analysis used in the field of health economics.

RESULTS

25 studies reported cost data on the intervention and/or benefits to the recipients. Of these, 11 studies reported data which was considered amenable to economic evaluation. A further four studies reported conducting an economic evaluation. Three of these studies presented a hybrid 'balance sheet' approach and indicated a net economic benefit associated with the intervention. One cost-effectiveness evaluation was identified but the data were unclearly reported; the cost-effectiveness plane suggested that the intervention was more costly and less effective than the status quo.

CONCLUSIONS

Future studies planning an economic evaluation need to (i) make best use of available data and (ii) ensure that all relevant data are collected. To facilitate this, economic evaluations should be planned alongside the intervention with input from health economists from the outset of the study. When undertaken appropriately, economic evaluation provides the potential to make significant contributions to housing policy.

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.

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

OBJECTIVE

To establish whether rehousing people to new dwellings had impacts upon residents' mental health and psychosocial benefits derived from the home.

METHODS

A prospective controlled study across Scotland involving 723 householders (334 intervention; 389 control). Interviews were carried out just prior to the move, and 2 years thereafter.

RESULTS

Changes in self-reported psychosocial benefits were greater than changes in mental health. Respondents in family households appeared to have gained the most and those in older person households the least. For those in families, the most consistent effects flowed from improvements in space, privacy and change of location; for those in adult-only households, improvements in crime and safety mattered most. Gains in psychosocial benefits were associated with improved mental health (SF-36) scores.

CONCLUSIONS

Rehousing has substantial impacts on residential conditions and on psychosocial benefits, and lesser (possibly indirect) impacts upon mental health. Housing is a complex intervention applied to a heterogeneous group for a range of reasons. Hence its impacts result from different aspects of residential change for particular types of household.

The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007

OBJECTIVES

We conducted a systematic review of the health impacts of housing improvement.

METHODS

Forty-two bibliographic databases were searched for housing intervention studies from 1887 to 2007. Studies were appraised independently by H. T. and S. T. or E. S. for sources of bias. The data were tabulated and synthesized narratively, taking into account study quality.

RESULTS

Forty-five relevant studies were identified. Improvements in general, respiratory, and mental health were reported following warmth improvement measures, but these health improvements varied across studies. Varied health impacts were reported following housing-led neighborhood renewal. Studies from the developing world suggest that provision of basic housing amenities may lead to reduced illness. There were few reports of adverse health impacts following housing improvement. Some studies reported that the housing improvement was associated with positive impacts on socioeconomic determinants of health.

CONCLUSIONS

Housing improvements, especially warmth improvements, can generate health improvements; there is little evidence of detrimental health impacts. The potential for health benefits may depend on baseline housing conditions and careful targeting of the intervention. Investigation of socioeconomic impacts associated with housing improvement is needed to investigate the potential for longer-term health impacts.

Individual and contextual determinants of self-reported poor psychological health: a population-based multilevel analysis in southern Sweden

OBJECTIVE

To investigate the influence of contextual and individual factors on self-reported psychological health.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

The 2000 public health survey in Scania is a cross-sectional postal questionnaire study with a 59% participation rate. A total of 13,715 persons aged 18-80 answered the questionnaire. A multilevel logistic regression model, with individuals at the first level and municipalities/city quarters at the second, was performed. The effect (intra-class correlation, cross-level modification, and odds ratios) of individual and municipality/city quarter factors on self-reported psychological health was analysed.

RESULTS

The crude variance between municipalities/city quarters was small but significant. It was particularly affected and lowered by individual civil status, country of origin, economic stress, and social participation. The inclusion of all individual factors age, sex, civil status, country of origin, education, economic stress, and social participation lowered the between municipality variance to not-significant levels, which is the reason why no contextual variables were included in the calculations.

CONCLUSIONS

The results of this study suggest that poor self-reported psychological health is affected mainly by individual characteristics of the population and not by contextual factors at the municipality/city quarter level.