Effects of improved home heating on asthma in community dwelling children: randomised controlled trial

The effects of cool roofs on health, environmental, and economic outcomes in rural Africa: study protocol for a community-based cluster randomized controlled trial

BACKGROUND

High ambient air temperatures in Africa pose significant health and behavioral challenges in populations with limited access to cooling adaptations. The built environment can exacerbate heat exposure, making passive home cooling adaptations a potential method for protecting occupants against indoor heat exposure.

METHODS

We are conducting a 2-year community-based stratified cluster randomized controlled trial (cRCT) implementing sunlight-reflecting roof coatings, known as "cool roofs," as a climate change adaptation intervention for passive indoor home cooling. Our primary research objective is to investigate the effects of cool roofs on health, indoor climate, economic, and behavioral outcomes in rural Burkina Faso. This cRCT is nested in the Nouna Health and Demographic Surveillance System (HDSS), a population-based dynamic cohort study of all people living in a geographically contiguous area covering 59 villages, 14305 households and 28610 individuals. We recruited 1200 participants, one woman and one man, each in 600 households in 25 villages in the Nouna HDSS. We stratified our sample by (i) village and (ii) two prevalent roof types in this area of Burkina Faso: mud brick and tin. We randomized the same number of people (12) and homes (6) in each stratum 1:1 to receiving vs. not receiving the cool roof. We are collecting outcome data on one primary endpoint - heart rate, (a measure of heat stress) and 22 secondary outcomes encompassing indoor climate parameters, blood pressure, body temperature, heat-related outcomes, blood glucose, sleep, cognition, mental health, health facility utilization, economic and productivity outcomes, mosquito count, life satisfaction, gender-based violence, and food consumption. We followed all participants for 2 years, conducting monthly home visits to collect objective and subjective outcomes. Approximately 12% of participants (n = 152) used smartwatches to continuously measure endpoints including heart rate, sleep and activity.

DISCUSSION

Our study demonstrates the potential of large-scale cRCTs to evaluate novel climate change adaptation interventions and provide evidence supporting investments in heat resilience in sub-Saharan Africa. By conducting this research, we will contribute to better policies and interventions to help climate-vulnerable populations ward off the detrimental effects of extreme indoor heat on health.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00023207. Registered on April 19, 2021.

The total health gains and cost savings of eradicating cold housing in Australia

BACKGROUND

Cold indoor temperature (<18 °C) is associated with hypertension-related and respiratory disease, depression, and anxiety. We estimate total health, health expenditure and income impacts of permanently lifting the temperature in living areas of the home to 18 °C in cold homes in South-eastern Australia (N = 17 million).

METHODS

A proportional multistate lifetable model was used to estimate health adjusted life years (HALYs), health expenditure and income earnings, over the remainder of the lifespan of the population alive in 2021 (3% discount rate). Multiple data were integrated including the prevalence of cold housing (5.87%; mean temperature 15 °C), the effect of temperature to hypertension-related, respiratory disease, depression and anxiety.

FINDINGS

Eradicating cold housing was predicted to lead to 89,600 (95% UI 47,700 to 177,000) lifetime HALYs gained over the population's remaining lifespan, nearly half of which occurred from 2021 to 2040. Respiratory disease (32.4%) and mental illness (60.6%) made large contributions to HALYs gained, but also had large uncertainty (95% UI 30.0%-42.9% and 45.1%-64.6%, respectively) due to uncertain estimates of their magnitude of causal association with cold housing. Health gains per capita were 6.1 times greater (95% UI 4.7 to 8.1) among the most compared to least deprived quintile. From 2021 to 2040, health expenditure decreased by AUD$0.87 billion (0.35-1.98) and income earnings increased by AUD$4.35 billion (1.89-9.81).

INTERPRETATION

Eliminating cold housing would lead to substantial health gains, reductions in health inequalities, savings in health expenditure, and productivity gains. Next steps require research to reduce uncertainty about the magnitude of causal associations of cold with mental and respiratory health.

Housing typologies and asthma: a scoping review

Asthma is related to triggers within the home. Although it is recognised that triggers likely occur due to characteristics of housing, these characteristics have not been comprehensively reviewed, and there is a paucity of housing-focused interventions to reduce asthma and asthma symptoms. Following five steps identified by Arksey and O'Malley, we conducted a scoping review of published evidence on the associations between asthma and housing characteristics. We searched three electronic databases (PubMed, Scopus, Web of Science), identifying 33 studies that met our inclusion criteria. Through an iterative approach, we identified nine housing characteristics relevant to asthma onset or exacerbation, categorised as relating to the surrounding environment (location), the house itself (dwelling), or to conditions inside the home (occupancy). We conceptualise these three levels through a housing typologies framework. This facilitates the mapping of housing characteristics, and visualises how they can cluster and overlap to exacerbate asthma or asthma symptoms. Of the three levels in our framework, associations between asthma and locational features were evidenced most clearly in the literature reviewed. Within this category, environmental pollutants (and particularly air pollutants) were identified as a potentially important risk factor for asthma. Studies concerning associations between dwelling features and occupancy features and asthma reported inconsistent results, highlighting the need for greater research in these areas. Interpreting housing-related asthma triggers through this framework paves the way for the identification and targeting of typologies of housing that might adversely affect asthma, thus addressing multiple characteristics in tandem rather than as isolated elements.

Evaluation of climate change adaptation measures for childhood asthma: A systematic review of epidemiological evidence

Global climate change (GCC) is widely accepted as the biggest threat to human health of the 21st century. Children are particularly vulnerable to GCC due to developing organ systems, psychological immaturity, nature of daily activities, and higher level of per-body-unit exposure. There is a rising trend in the disease burden of childhood asthma and allergies in many parts of the world. The associations of CC, air pollution and other environmental exposures with childhood asthma are attracting more research attention, but relatively few studies have focused on CC adaptation measures and childhood asthma. This study aimed to bridge this knowledge gap and conducted the first systematic review on CC adaptation measures and childhood asthma. We searched electronic databases including PubMed, Embase, and Web of Science using a set of MeSH terms and related synonyms, and identified 20 eligible studies included for review. We found that there were a number of adaptation measures proposed for childhood asthma in response to GCC, including vulnerability assessment, improving ventilation and heating, enhancing community education, and developing forecast models and early warning systems. Several randomized controlled trials show that improving ventilation and installing heating in the homes appear to be an effective way to relieve childhood asthma symptoms, especially in winter. However, the effectiveness of most adaptation measures, except for improving ventilation and heating, have not been explored and quantified. Given more extreme weather events (e.g., cold spells and heatwaves) may occur as climate change progresses, this finding may have important implications. Evidently, further research is urgently warranted to evaluate the impacts of CC adaptation measures on childhood asthma. These adaptation measures, if proven to be effective, should be integrated in childhood asthma control and prevention programs as GCC continues.

Implications of the COVID-19 pandemic for urban informal housing and planning interventions: Evidence from Singapore

The outbreak of the COVID-19 pandemic revealed the crucial role of social distancing and hygiene practices in reducing virus transmission and thus revealed the high risk of infection in urban informal housing. Through an empirical study of Singapore's infectious situation and antiepidemic measures, this paper shows that the number of infected migrant workers living in dormitories was three hundred times greater than the number of infected local urban residents, not only because of the migrants' 'vulnerable' position but also because their living conditions fostered widespread transmission of the virus. The dwelling conditions of migrant dormitories, such as overcrowded living spaces, widely shared sanitation facilities, and poor hygiene practices, present great challenges to standard prevention strategies and control measures. Adverse health impacts resulting from the lockdown of dormitories during the COVID-19 pandemic suggest the importance of planning intervention in the dwelling conditions of informal housing, and indicate a need for the governments' active reforms of building codes and health care systems to promote the health of disadvantaged groups and then create more inclusive and healthy cities for all the society.

Retrofitting home insulation reduces incidence and severity of chronic respiratory disease

To assess whether retrofitting home insulation can reduce the risk of respiratory disease incidence and exacerbation, a retrospective cohort study was undertaken using linked data from a national intervention program. The study population was made up of 1 004 795 residents from 205 001 New Zealand houses that received an insulation subsidy though a national Energy Efficiency and Conservation Authority program. A difference-in-difference model compared changes in the number of prescriptions dispensed for respiratory illness post- insulation to a control population over the same timeframe. New prescribing of chronic respiratory disease medication at follow-up was used to compare incidence risk ratios between intervention and control groups. Chronic respiratory disease incidence was significantly lower in the intervention group at follow-up: odds ratio 0.90 (95% CI: 0.86-0.94). There was also a 4% reduction in medication dispensed for treating exacerbations of chronic respiratory disease symptoms in the intervention group compared with the control group: relative rate ratio (RRR) 0.96 (95% CI: 0.96-0.97). There was no change in medication dispensed to prevent symptoms of chronic respiratory disease RRR: 1,00 (95% CI: 0.99-1.00). These findings support home insulation interventions as a means of improving respiratory health outcomes.

Retrofitting home insulation reduces incidence and severity of chronic respiratory disease

To assess whether retrofitting home insulation can reduce the risk of respiratory disease incidence and exacerbation, a retrospective cohort study was undertaken using linked data from a national intervention program. The study population was made up of 1 004 795 residents from 205 001 New Zealand houses that received an insulation subsidy though a national Energy Efficiency and Conservation Authority program. A difference-in-difference model compared changes in the number of prescriptions dispensed for respiratory illness post- insulation to a control population over the same timeframe. New prescribing of chronic respiratory disease medication at follow-up was used to compare incidence risk ratios between intervention and control groups. Chronic respiratory disease incidence was significantly lower in the intervention group at follow-up: odds ratio 0.90 (95% CI: 0.86-0.94). There was also a 4% reduction in medication dispensed for treating exacerbations of chronic respiratory disease symptoms in the intervention group compared with the control group: relative rate ratio (RRR) 0.96 (95% CI: 0.96-0.97). There was no change in medication dispensed to prevent symptoms of chronic respiratory disease RRR: 1,00 (95% CI: 0.99-1.00). These findings support home insulation interventions as a means of improving respiratory health outcomes.

Relationship between the housing coldness/warmth evaluation by CASBEE Housing Health Checklist and psychological distress based on TMM Community-Based Cohort Study: a cross-sectional analysis

OBJECTIVES

Previous studies have reported the relationship between housing environment and health, although due to cost and effort, it was difficult to conduct housing condition surveys on a large scale. The CASBEE Housing Health Checklist (the Checklist) made it possible to easily evaluate the housing condition from the resident's perspective. This study examined the relationship between housing coldness/warmth evaluation using the Checklist and psychological distress in a large-scale general Japanese population.

STUDY DESIGN

A cross-sectional study.

METHODS

We analysed data from 29,380 people aged ≥20 years who lived in Miyagi Prefecture, Japan. As an assessment of housing coldness/warmth, we used the Checklist. We classified participants' total scores on the Checklist related to coldness/warmth into quartiles. The Kessler 6 scale was used as an indicator of psychological distress. Multivariable logistic regression models were used to estimate the adjusted odds ratio (OR) and 95% confidence intervals (CIs). Adjusted OR and P-values for linear trends were calculated using the quartiles of the Checklists' score.

RESULTS

Among participants in Q1 (i.e., poorer subjective house condition), the percentage of people with psychological distress was high. Compared to the highest quartile, Q1 showed poorer evaluation of housing coldness/warmth, and higher OR for psychological distress. The OR (95% CI) of psychological distress for Q3, Q2, and Q1 compared with Q4 were 1.93 (1.74-2.14), 2.82 (2.55-3.12), and 5.78 (5.25-6.35), respectively.

CONCLUSIONS

Housing coldness/warmth evaluation was significantly related to psychological distress. This finding suggests that maintaining a comfortable thermal environment at home could be important for residents' mental health.

Childhood pneumonia in New Zealand

While deaths from pneumonia during childhood in New Zealand (NZ) are now infrequent, childhood pneumonia remains a significant cause of morbidity. In this viewpoint, we describe pneumonia epidemiology in NZ and identify modifiable risk factors. During recent decades, pneumonia hospitalisation rates decreased, attributable in part to inclusion of pneumococcal conjugate vaccine in NZ's immunisation schedule. Irrespective of these decreases, pneumonia hospitalisation rates are four times higher for Pacific and 60% higher for Māori compared with children of other ethnic groups. Consistent with other developed countries, hospitalisation rates for pneumonia with pleural empyema increased in NZ during the 2000s. Numerous factors contribute to childhood pneumonia acquisition, hospitalisation and morbidity in NZ include poor quality living environments, malnutrition during pregnancy and early childhood, incomplete and delayed vaccination during pregnancy and childhood and variable primary and secondary care management. To reduce childhood pneumonia disease burden, interventions should focus on addressing modifiable risk factors for pneumonia. These include using non-polluting forms of household heating; decreasing cigarette smoke exposure; reducing household acute respiratory infection transmission; improving dietary nutritional content and nutrition during pregnancy and early childhood; breastfeeding promotion; vaccination during pregnancy and childhood and improving the quality of and decreasing the variance in primary and secondary care management of pneumonia.

A Place-based Evaluation of a Healthy Homes Initiative

ISSUE ADDRESSED

Limited qualitative evaluations of healthy homes initiatives exist in the literature and even fewer look past physical health benefits to wider health outcomes. A qualitative evaluation of Manawa Ora, a healthy homes initiative implemented by a Māori health provider in Northland, New Zealand, was conducted to ascertain the wider health benefits a healthy homes initiative.

METHODS

Participants of Manawa Ora were recruited, their experiences were analysed through qualitative semi-structured interviews.

RESULTS

Two main themes emerged from the semi-structured interviews. "Becoming active actors" pertains to improved health, both physical and mental, following the programme. It also describes the way participants have redirected their focus from their illness to broader, more purposeful activity. "From a simple space to a place with meaning" highlights the way Manawa Ora improved the home environment by creating a 'place' that holds meaning.

CONCLUSIONS

Healthy homes initiatives can improve physical health as well as wider health outcomes. Through the provision of beds, bedding, insulation and heating Manawa Ora has created a 'therapeutic place' out of the home that promotes healing and wellbeing.

SO WHAT

Greater focus on connections to place in public health initiatives may bring about wider health gains.

Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review

OBJECTIVES

Housing is a social determinant of health that impacts the health and well-being of children and families. Screening and referral to address social determinants of health in clinical and social service settings has been proposed to support families with housing problems. This study aims to identify housing screening questions asked of families in healthcare and social services, determine validated screening tools and extract information about recommendations for action after screening for housing issues.

METHODS

The electronic databases MEDLINE, PsycINFO, EMBASE, Ovid Emcare, Scopus and CINAHL were searched from 2009 to 2021. Inclusion criteria were peer-reviewed literature that included questions about housing being asked of children or young people aged 0-18 years and their families accessing any healthcare or social service. We extracted data on the housing questions asked, source of housing questions, validity and descriptions of actions to address housing issues.

RESULTS

Forty-nine peer-reviewed papers met the inclusion criteria. The housing questions in social screening tools vary widely. There are no standard housing-related questions that clinical and social service providers ask families. Fourteen screening tools were validated. An action was embedded as part of social screening activities in 27 of 42 studies. Actions for identified housing problems included provision of a community-based or clinic-based resource guide, and social prescribing included referral to a social worker, care coordinator or care navigation service, community health worker, social service agency, referral to a housing and child welfare demonstration project or provided intensive case management and wraparound services.

CONCLUSION

This review provides a catalogue of housing questions that can be asked of families in the clinical and/or social service setting, and potential subsequent actions.

Evaluation of the Victorian Healthy Homes Program: protocol for a randomised controlled trial

INTRODUCTION

The evaluation of the Victorian Healthy Homes Program (VHHP) will generate evidence about the efficacy and cost-effectiveness of home upgrades to improve thermal comfort, reduce energy use and produce health and economic benefits to vulnerable households in Victoria, Australia.

METHODS AND ANALYSIS

The VHHP evaluation will use a staggered, parallel group clustered randomised controlled trial to test the home energy intervention in 1000 households. All households will receive the intervention either before (intervention group) or after (control group) winter (defined as 22 June to 21 September). The trial spans three winters with differing numbers of households in each cohort. The primary outcome is the mean difference in indoor average daily temperature between intervention and control households during the winter period. Secondary outcomes include household energy consumption and residential energy efficiency, self-reported respiratory symptoms, health-related quality of life, healthcare utilisation, absences from school/work and self-reported conditions within the home. Linear and logistic regression will be used to analyse the primary and secondary outcomes, controlling for clustering of households by area and the possible confounders of year and timing of intervention, to compare the treatment and control groups over the winter period. Economic evaluation will include a cost-effectiveness and cost-benefit analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from Victorian Department of Human Services Human Research Ethics Committee (reference number: 04/17), University of Technology Sydney Human Research Ethics Committee (reference number: ETH18-2273) and Australian Government Department of Veterans Affairs. Study results will be disseminated in a final report and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12618000160235.

Occupant health in buildings: Impact of the COVID-19 pandemic on the opinions of building professionals and implications on research

The objectives of this study are to investigate building professionals' experience, awareness, and interest in occupant health in buildings, and to assess the impact of the COVID-19 pandemic on their opinions, as well as to compare the research on occupant health in buildings to professionals' opinions. To address these objectives, a mixed research methodology, including a thorough review of the literature (N_L = 190) and an online survey (N_S = 274), was utilized. In general, there is an increasing research interest in occupant health and a heightened interest in health-related projects, among professionals, following the COVID-19 pandemic. Specifically, among the nine different building attributes examined, indoor air quality was the most researched building attribute with a focus on occupant health and was also presumed to be the most important by the professionals. Professionals considered fatigue and musculoskeletal pain to be the most important physical well-being issues, and stress, anxiety, and depression to be the most important mental well-being issues that need to be the focus of design, construction, and operation of buildings to support and promote occupant health, while eye-related symptoms and loss of concentration were the most researched physical and mental well-being symptoms in the literature, respectively. Finally, professionals indicated that COVID-19 pandemic had significant effect on their perspectives regarding buildings' impact on occupant health and they believed future building design, construction and operation will focus more on occupant health because of the pandemic experience.

Energy Poverty among Tertiary Students in Aotearoa New Zealand

Energy poverty in Aotearoa New Zealand is well-documented, and tertiary students have been identified as an at-risk group. However, there has been very little research on tertiary students’ experiences of energy poverty in New Zealand. This paper used a nationwide online survey to investigate the extent and impact of energy poverty among tertiary students. Furthermore, it aimed to identify disparities between different demographic groups, understand the effects of COVID-19 and evaluate the effectiveness of the support policies available to students. Responses from 522 students were analysed; 85% were under 30 years old, 72% were female, 14% identified as Māori, and 14% reported having long-term disabilities or health concerns. The findings of this study are concerning. Tertiary students in New Zealand are largely living in dwelling conditions that do not meet recommended health standards and exacerbate energy poverty. Energy poverty has adverse effects on their physical and mental health; however, available support is limited or inaccessible. Most significantly, the impact of energy poverty is disproportionally affecting students with long-term disabilities or health concerns as well as students identifying as Māori. Moreover, the impact of COVID-19 further strained students experiencing energy poverty and again, disproportionally affected more vulnerable students.

Healthy, happy places-a more integrated approach to creating health and well-being through the built environment?

INTRODUCTION

This paper explores how the built environment impacts upon health and well-being and suggests that there are opportunities for more integrated working between professionals and citizens to create healthier, happier places.

SOURCES OF DATA

Policy and practice guidance is presented from the urban planning and design fields. Evidence and data are presented from a range of disciplines on housing, green infrastructure and mental well-being.

AREAS OF AGREEMENT

There is an overwhelming agreement around the principles and rationale of incorporating health in planning and design processes.

AREAS OF CONTROVERSY

These principles are not always implemented in practice. Challenges also exist around how different disciplines create and use evidence.

GROWING POINTS

More innovative ways of working which incorporates health, public health, planners, designers and citizens, which responds to the needs of communities, should be tested.

AREAS TIMELY FOR DEVELOPING RESEARCH

Health and public health professionals can contribute to the evidence base using objective measures to assess the impact of the built environment on mental health and well-being.

Residential energy efficiency interventions: A meta-analysis of effectiveness studies

BACKGROUND

The residential sector releases around 17% of global greenhouse gas emissions and making residential buildings more energy efficient can help mitigate climate change. Engineering models are often used to predict the effects of residential energy efficiency interventions (REEI) on energy consumption, but empirical studies find that these models often over-estimate the actual impact of REEI installation. Different empirical studies often estimate different impacts for the same REEI, possibly due to variations in implementation, climate and population. Funding for this systematic review was provided by the evaluation function at the European Investment Bank Group.

OBJECTIVES

The review aims to assess the effectiveness of installing REEIs on the following primary outcomes: energy consumption, energy affordability, CO₂ emissions and air quality indices and pollution levels.

SEARCH METHODS

We searched CAB Abst, Econlit, Greenfile, Repec, Academic Search Complete, WB e-lib, WoS (SCI and SSCI) and other 42 databases in November 2020. In addition, we searched for grey literature on websites, checked the reference lists of included studies and relevant reviews, used Google Scholar to identify studies citing included studies, and contacted the authors of studies for any ongoing and unpublished studies. We retrieved a total of 13,629 studies that we screened at title and abstract level, followed by full-text screening and data extraction.

SELECTION CRITERIA

We included randomised control trials, and quasi-experimental studies that evaluated the impact of installing REEIs anywhere in the world and with any comparison.

DATA COLLECTION AND ANALYSIS

Two independent reviewers screened studies for eligibility, extracted data and assessed risk of bias. When more than one included study examined the same installation of the same type of REEI for a similar outcome, we conducted a meta-analysis. We also performed subgroup analyses.

MAIN RESULTS

A total of 16 studies were eligible and included in the review: two studies evaluated the installation of efficient lighting, three studies the installation of attic/loft insulation, two studies the installation of efficient heat pumps, eight studies the installation of a bundle of energy efficiency measures (EEMs), and one study evaluated other EEMs. Two studies, neither appraised as having a low risk of bias, find that lighting interventions lead to a significant reduction in electricity energy consumption (Hedges' g = -0.29; 95% confidence interval [CI]: -0.48, -0.10). All the other interventions involved heating or cooling, and effects were synthesizised by warmer or colder climate and then across climates. Four studies examined the impact of attic/loft insulation on energy consumption, and two of these studies were appraised as having a low risk of bias. Three studies took place in colder climates with gas consumption as an outcome, and one study took place in a warmer climate, with the electricity consumption (air conditioning) as the outcome. The average impact across all climates was small (Hedges' g = 0.04; 95% CI: -0.09, 0.01) and statistically insignificant. However, two of the studies appear to have evaluated the effect of installing small amounts (less than 75 mm) of insulation. The other two studies, one of which was appraised as low risk of bias and the other involving air conditioning, found significant reductions in consumption. Two studies examined the impact of installing electric heat pumps. The average impact across studies was not statistically significant (Hedges' g = -0.11; 95% CI: -0.41, 0.20). However, there was substantial variation between the two studies. Replacing older pumps with more efficient versions significantly reduced electricity consumption in a colder climate (Hedges' g = -0.36; 95% CI, -0.57, -0.14) in a high risk of bias study. However, a low risk of bias study found a significant increase in electricity consumption from installing new heat pumps (Hedges' g = 0.09; 95% CI, 0.06, 0.12). Supplemental analyses in the latter study indicate that households also used the heat pumps for cooling and that the installed heat pumps most likely reduced overall energy consumption across all sources-that is, households used more electricity but less gas, wood and coal. Seven studies examined bundled REEIs where the households chose which EEMs to install (in five studies the installation occurred after an energy audit that recommended which EEMs to install). Overall, the studies estimated that installing an REEI bundle is associated with a significant reduction in energy consumption (Hedges' g = -0.36; 95% CI, -0.52, -0.19). In the two low risk of bias studies, conducted with mostly low-income households, installed bundles reduced energy consumption by a statistically significant amount (Hedges' g = -0.16; 95% CI, -0.13, -0.18).

AUTHORS' CONCLUSIONS

The 16 included studies indicate that installing REEIs can significantly reduce energy consumption. However, the same type of REEI installed in different studies caused different effects, indicating that effects are conditional on implementation and context. Exploring causes of this variation is usually not feasible because existing research often does not clearly report the features of installed interventions. Additional high quality impact evaluations should be commissioned in more diverse contexts (only one study was conducted in either Asia or Africa-both involved lighting interventions-and no studies were conducted in South America or Southern Europe).

Housing and asthma disparities

The burden of asthma disproportionately affects minority and low-income communities, resulting in racial and socioeconomic disparities in asthma prevalence, asthma exacerbations, and asthma-related death. Social determinants of health are increasingly implicated as root causes of disparities, and healthy housing is perhaps the most critical social determinant in asthma health disparities. In many minority communities, poor housing conditions and value are a legacy of historical policies and practices imbued with structural racism, including redlining, displacement, and exclusionary zoning. As a result, poor-quality, substandard housing is a characteristic feature of many underrepresented minority communities. Consequently, structurally deficient housing stock cultivates home environments rife with indoor asthma triggers. In this review we consider the historical context of urban housing policies and practices and how these policies and practices have contributed to the substandard housing conditions for many minoritized children in the present day. We describe the impact of poor housing quality on asthma and interventions that have attempted to mitigate its influence on asthma symptoms and health care utilization. We discuss the need to promote asthma health equity by reinvesting in these neighborhoods and communities to provide healthy housing.

Home environmental interventions for prevention of respiratory tract infections: a systematic review and meta-analysis

OBJECTIVES

Poor housing conditions have been associated with increased risks of respiratory infections. This review aims to determine whether modifying the physical environment of the home has benefits in reducing respiratory infections.

CONTENT

We performed a systematic review and meta-analysis of the effectiveness of home environmental interventions for preventing respiratory tract infections. Ten electronic databases were searched to identify randomized controlled trials published from inception to July 31, 2020. Random-effects meta-analyses were used to assess the study outcomes. Our search identified 14 eligible studies across 12 countries, which comprised 87,428 households in total. The type of interventions on home environment included kitchen appliance and design, water supply and sanitation, house insulation, and home heating. Meta-analysis indicated a potential benefit of home environmental interventions in preventing overall respiratory tract infections (Absolute RR=0.89, 95% CI=0.78-1.01, p=0.07; Pooled adjusted RR=0.72, 95% CI=0.63-0.84, p<0.0001). Subgroup analyses depicted that home environmental interventions had no significant impact on lower respiratory tract infections, pneumonia, and severe pneumonia. A protective effect against respiratory infections was observed in high income country setting (RR=0.82, 95% CI=0.78-0.87, p<0.00001).

SUMMARY AND OUTLOOK

Home environmental interventions have the potential to reduce morbidity of respiratory tract infections. The lack of significant impact from stand-alone housing interventions suggests that multicomponent interventions should be implemented in tandem with high-quality health systems.

Commentary on Housing, Health, and Well-Being in Aotearoa/New Zealand

Housing is poorly constructed for the New Zealand climate and is a major cause of poor health and premature mortality. Private rental housing is older and in poorer condition than public housing and owner-occupied housing. This special issue describes four different approaches to improving housing, which have implications for international housing, health, and well-being policies. The first approach looks at generating the evidence base for improving the quality of the rental sector; the second, the aftereffects of the Christchurch earthquake and the unprecedented role taken by the central government to override local government and community involvement in rebuilding housing and regenerating the city; the third, measuring the effectiveness of the remediation of public housing; and finally, community-based partnerships between community workers and academics to improve the housing of children who have been hospitalized for housing-sensitive hospitalizations.

Home modifications to prevent home fall injuries in houses with Māori occupants (MHIPI): a randomised controlled trial

BACKGROUND

As with many Indigenous populations internationally, Māori in New Zealand suffer health inequity. We aimed to assess the rate of fall injuries at home with and without home modifications in houses with Māori occupants.

METHODS

We did a single-blind randomised controlled trial in the Wellington and Taranaki regions of New Zealand and enrolled owner-occupied households with at least one Māori occupant. Only households who stated they intended to live at that address for the subsequent 3 years were eligible for participation. We randomly assigned (1:1) households to either the intervention group, who received home modifications (handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, repairs to window catches, high-visibility and slip-resistant edging for outside steps, fixing of lifted edges of carpets and mats, non-slip bath mats, and slip-resistant surfacing for outside areas such as decks) immediately, or the control group, who received the modifications 3 years later. Data on home injuries were obtained from the Accident Compensation Corporation and coded by study team members, who were masked to study group allocation. The primary outcome was the rate of medically treated fall injuries at home per household per year, analysed according to intention to treat. This Māori Home Injury Prevention Intervention (MHIPI) trial is now completed, and is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000148774.

FINDINGS

Between Sept 3, 2013, and Oct 1, 2014, 824 households were assessed for eligibility and 254 were enrolled, of which 126 (50%) were assigned to the intervention group and 128 (50%) were assigned to the control group. After adjustment for previous falls and geographical region, there was an estimated 31% reduction in the rate of fall injuries at home per year exposed to the intervention compared with households in the control group (adjusted relative rate 0·69 [95% CI 0·47-1·00]).

INTERPRETATION

Low-cost home modifications and repairs can be an effective means to reduce injury disparities. The high prevalence of modifiable safety issues in Māori homes merits considerable policy and community effort.

FUNDING

Health Research Council of New Zealand.

Air pollution and indoor settings

Indoor environments contribute significantly to total human exposure to air pollutants, as people spend most of their time indoors. Household air pollution (HAP) resulting from cooking with polluting ("dirty") fuels, which include coal, kerosene, and biomass (wood, charcoal, crop residues, and animal manure) is a global environmental health problem. Indoor pollutants are gases, particulates, toxins, and microorganisms among others, that can have an impact especially on the health of children and adults through a combination of different mechanisms on oxidative stress and gene activation, epigenetic, cellular, and immunological systems. Air pollution is a major risk factor and contributor to morbidity and mortality from major chronic diseases. Children are significantly affected by the impact of the environment due to biological immaturity, prenatal and postnatal lung development. Poor air quality has been related to an increased prevalence of clinical manifestations of allergic asthma and rhinitis. Health professionals should increase their role in managing the exposure of children and adults to air pollution with better methods of care, prevention, and collective action. Interventions to reduce household pollutants may promote health and can be achieved with education, community, and health professional involvement.

Sekuwe (My House): building health equity through Dene First Nations housing designs

The Truth and Reconciliation Commission of Canada determined that the Dene people, among other Indigenous groups, experienced cultural genocide through policies that separated them from their lands and resources, and from their families, languages, cultures, and by forcibly sending children to Indian Residential Schools. The resultant social inequity is manifested in conditions of social injustice including inadequate housing. The Dene healthy housing research was a continuing partnership between the two Dene First Nation communities, the university and a provincial First Nation non-government organisation. This project engaged the creative energies of university students and Dene senior-high students to create and articulate Dene healthy housing so that concepts/plans/designs are ready for future funding interventions. We co-developed methods and networks to reframe housing as a social determinant of health and an important factor in social justice. This project reflects the fundamental requirement for a respectful understanding of Dene perspectives on housing and health and the need for Dene control over their built environment.

Air Pollution and Asthma: Critical Targets for Effective Action

Evidence to advocate for cleaner air for people with asthma is not in short supply. We know that air pollution is associated with the development and worsening of the condition and that mitigating interventions can improve respiratory outcomes. We have clear targets, particularly traffic emissions, especially in urban areas, and plenty of potentially effective actions. Road traffic must be reduced, and what remains should be cleaner and greener. Urban green spaces, safe cycle networks and wider pavements will promote active travel and leisure time exercise. Healthcare professionals must ensure people are aware of their air quality, its impact on asthma and the appropriate behaviour to safeguard health. What remains are realistic policies and effective measures, based on the correct scientific evidence, to be taken forth with political courage and investment so that air pollution no longer contributes to the development or worsening of respiratory ill health.

Health Benefits of Air Pollution Reduction

Air pollution is a grave risk to human health that affects nearly everyone in the world and nearly every organ in the body. Fortunately, it is largely a preventable risk. Reducing pollution at its source can have a rapid and substantial impact on health. Within a few weeks, respiratory and irritation symptoms, such as shortness of breath, cough, phlegm, and sore throat, disappear; school absenteeism, clinic visits, hospitalizations, premature births, cardiovascular illness and death, and all-cause mortality decrease significantly. The interventions are cost-effective. Reducing factors causing air pollution and climate change have strong cobenefits. Although regions with high air pollution have the greatest potential for health benefits, health improvements continue to be associated with pollution decreases even below international standards. The large response to and short time needed for benefits of these interventions emphasize the urgency of improving global air quality and the importance of increasing efforts to reduce pollution at local levels.

Mapping the co-benefits of climate change action to issues of public concern in the UK: a narrative review

To avoid a 1·5°C rise in global temperatures above preindustrial levels, the next phase of reductions in greenhouse gas emissions will need to be comparatively rapid. Linking the co-benefits of climate action to wider issues that the public are concerned about can help decision makers to prioritise decarbonisation options that increase the chance of public support for such changes, while ensuring that a just transition is delivered. We identified key issues of concern to the UK public by use of Ipsos MORI public opinion data from 2007 to 2020 and used these data to guide a narrative review of academic and grey literature on the co-benefits of climate change action for the UK. Correspondence with civil servants, third sector organisations, and relevant academics allowed us to identify omissions and to ensure policy relevance of the recommendations. This evidence-based Review of the various co-benefits of climate change action for the UK identifies four main areas: health and the National Health Service; security; economy and unemployment; and poverty, housing, and inequality. Associated trade-offs are also discussed. City-level and regional-level governments are particularly well placed to incorporate co-benefits into their decision making because it is at this scale that co-benefits most clearly manifest, and where interventions can have the most immediate effects.

Impact of Air Pollution on Asthma Outcomes

Asthma is a chronic respiratory disease characterized by variable airflow obstruction, bronchial hyperresponsiveness, and airway inflammation. Evidence suggests that air pollution has a negative impact on asthma outcomes in both adult and pediatric populations. The aim of this review is to summarize the current knowledge on the effect of various outdoor and indoor pollutants on asthma outcomes, their burden on its management, as well as to highlight the measures that could result in improved asthma outcomes. Traffic-related air pollution, nitrogen dioxide and second-hand smoking (SHS) exposures represent significant risk factors for asthma development in children. Nevertheless, a causal relation between air pollution and development of adult asthma is not clearly established. Exposure to outdoor pollutants can induce asthma symptoms, exacerbations and decreases in lung function. Active tobacco smoking is associated with poorer asthma control, while exposure to SHS increases the risk of asthma exacerbations, respiratory symptoms and healthcare utilization. Other indoor pollutants such as heating sources and molds can also negatively impact the course of asthma. Global measures, that aim to reduce exposure to air pollutants, are highly needed in order to improve the outcomes and management of adult and pediatric asthma in addition to the existing guidelines.

The relationship between buildings and health: a systematic review

Background

The built environment exerts one of the strongest directly measurable effects on physical and mental health, yet the evidence base underpinning the design of healthy urban planning is not fully developed.

Method

This study provides a systematic review of quantitative studies assessing the impact of buildings on health. In total, 7127 studies were identified from a structured search of eight databases combined with manual searching for grey literature. Only quantitative studies conducted between January 2000 and November 2016 were eligible for inclusion. Studies were assessed using the quality assessment tool for quantitative studies.

Results

In total, 39 studies were included in this review. Findings showed consistently that housing refurbishment and modifications, provision of adequate heating, improvements to ventilation and water supply were associated with improved respiratory outcomes, quality of life and mental health. Prioritization of housing for vulnerable groups led to improved wellbeing. However, the quality of the underpinning evidence and lack of methodological rigour in most of the studies makes it difficult to draw causal links.

Conclusion

This review identified evidence to demonstrate the strong association between certain features of housing and wellbeing such as adequate heating and ventilation. Our findings highlight the need for strengthening of the evidence base in order for meaningful conclusions to be drawn.

Healthy buildings for a healthy city: Is the public health evidence base informing current building policies?

Research has demonstrated that housing quality is a key urban intervention in reducing health risks and improving climate resilience, addressing a key ambition of the United Nations Sustainable Development Goals. Yet housing quality remains a problem even in high income countries such as England. In particular, hazards such as excess cold, excess heat and lack of ventilation leading to damp and mould have been identified as a major issue in homes. Research shows that these hazards can lead to a range of health conditions, such as respiratory and cardiovascular disease, infections and mental health problems. This article explores the use of public health research and evidence in policy to regulate new buildings in England to deliver improved public health, climate resilience and a reduced carbon footprint, in particular exploring the policy drivers and awareness of the public health evidence. Findings show that public health evidence is hardly referenced in policy and that the focus on other evidence bases such as on climate mitigation in building regulations results in both positive and negative impacts on health. This reflects a lack of a systems approach around urban interventions leading to weaknesses in standards regulating the private development sector. In conclusion, this paper recommends: 1. the consideration of health impact in future building regulations; 2. the integration and coordination of key policies covering various scales and phases of the development processes and 3. the better education of residents to understand advances in new energy performance technologies.

Prospective community programme versus parent-driven care to prevent respiratory morbidity in children following hospitalisation with severe bronchiolitis or pneumonia

BACKGROUND

Hospitalisation with severe lower respiratory tract infection (LRTI) in early childhood is associated with ongoing respiratory symptoms and possible later development of bronchiectasis. We aimed to reduce this intermediate respiratory morbidity with a community intervention programme at time of discharge.

METHODS

This randomised, controlled, single-blind trial enrolled children aged <2 years hospitalised for severe LRTI to 'intervention' or 'control'. Intervention was three monthly community clinics treating wet cough with prolonged antibiotics referring non-responders. All other health issues were addressed, and health resilience behaviours were encouraged, with referrals for housing or smoking concerns. Controls followed the usual pathway of parent-initiated healthcare access. After 24 months, all children were assessed by a paediatrician blinded to randomisation for primary outcomes of wet cough, abnormal examination (crackles or clubbing) or chest X-ray Brasfield score ≤22.

FINDINGS

400 children (203 intervention, 197 control) were enrolled in 2011-2012; mean age 6.9 months, 230 boys, 87% Maori/Pasifika ethnicity and 83% from the most deprived quintile. Final assessment of 321/400 (80.3%) showed no differences in presence of wet cough (33.9% intervention, 36.5% controls, relative risk (RR) 0.93, 95% CI 0.69 to 1.25), abnormal examination (21.7% intervention, 23.9% controls, RR 0.92, 95% CI 0.61 to 1.38) or Brasfield score ≤22 (32.4% intervention, 37.9% control, RR 0.85, 95% CI 0.63 to 1.17). Twelve (all intervention) were diagnosed with bronchiectasis within this timeframe.

INTERPRETATION

We have identified children at high risk of ongoing respiratory disease following hospital admission with severe LRTI in whom this intervention programme did not change outcomes over 2 years.

TRIAL REGISTRATION NUMBER

ACTRN12610001095055.

The Role of Environmental Controls in Managing Asthma in Lower-Income Urban Communities

Children living in lower-income urban communities are at much greater risk of developing asthma, going to the emergency department for an asthma attack and being hospitalized for asthma than children living in upper- and middle-income communities. For many asthmatic children living in urban communities, especially those with greater morbidity, the allergic pathway is important in the etiology of the disease. The stages of developing allergic disease can be divided into the onset of allergic sensitization, development of allergic disease and subsequent exacerbations, and it is useful to consider the relevance of interventions at each of these stages. Indoor allergens and environmental exposures are a major contributor to allergic disease, particularly among lower socioeconomic status, urban, minority communities. These exposures include allergens, environmental tobacco smoke, combustion by-products, and mold, all of which can play an important role in asthma progression as well as morbidity. These exposures are often not found in isolation and thus these concomitant exposures need to be considered when conducting environmental interventions. There have been numerous studies looking at both primary and tertiary prevention strategies and the impact on allergic sensitization and asthma with varied results. While the outcomes of these studies have been mixed, what has emerged is the need for tertiary interventions to be targeted to the individual and to reduce all relevant exposures to which an asthmatic child is exposed and sensitized. In addition, effective intervention strategies must also consider other social determinants of asthma morbidity impacting low socioeconomic, urban communities.

Evaluating natural experiments to measure the co-benefits of urban policy interventions to reduce carbon emissions in New Zealand

Finding effective policy interventions for addressing the Sustainable Development Goals, such as reducing carbon emissions (SDG 13), which can also enhance good health and wellbeing (SDG 3), is urgent. Many promising interactions occur between sustainable cities and communities (SDG 11), clean water and sanitation (SDG 6) and affordable and clean energy (SDG 7), which sit at the centre of integrated urban planning and regeneration. In this paper, we consider the framing and findings of four policies we have evaluated as natural experiments, all of which have important co-benefits, which were not always the focus of the initial policies. These policies are: the installation of cycleways and walkways in existing suburbs; a central government measure to recentralise employment after the 2011 Christchurch earthquakes; the streamlining of housing developments by reducing land-use regulation; and ongoing changes of policy about public housing investment. We show that having a clear understanding of the benefits of increased physical activity for health, for example, could accelerate the reduction of carbon emissions. Also, decisions about infrastructure, housing and job locations can generate health and environmental gains if supported by broader public transport investments. Cycling and walking are also more likely to substitute for short habitual car trips. Similarly, measuring the co-benefits of differential residential models, relating to land-use and renewable energy, provides a framework that can facilitate learning from policy interventions, enabling wider and potentially more rapid generalisation of policies, including those for climate change mitigation.

Interactions between dietary habits and home environmental exposures on respiratory symptoms in Romanian school children: an analysis of data from the SINPHONIE project

In this study, we investigated the interactions between household pollutants and dietary habits on children's respiratory health. Our cross-sectional study collected self-reported information including health symptoms (allergy-like, asthma-like, and flu-like symptoms), home characteristics, dietary habits, and demographic information from questionnaires administered to parents of 280 school children in Romania. Unconditional logistic regression and stratified analyses were used to assess the interactions between dietary factors and environmental exposures on health symptoms among children, controlling for sociodemographic characteristics and co-exposures. We found that frequency of fruit consumption had significant interaction with residing near heavy traffic on allergy-like symptoms among children (p = 0.036). However, no association was observed by frequency of fruit consumption. Although no significant interaction was observed, we found that students with infrequent fruit consumption and residing near heavy traffic roads had elevated odds of asthma-like (POR 6.37; 95% CI 1.22, 33.29) and flu-like symptoms (POR 3.75; 95% CI 1.12, 11.86) than those who frequently consumed fruits. Likewise, low vegetable consumption was associated with increased asthma-like symptoms (POR 2.93; 95% CI 1.04, 8.24). Increased odds of asthma-like symptoms were observed among school children that resided near heavy traffic roads and frequently consumed milk (POR 2.80; 95% CI 1.24, 6.31) and yoghurt (POR 2.86; 95% CI 1.05, 7.75) compared to those that infrequently consumed dairy. Our findings suggest that frequent fruit and vegetable consumption may mitigate the negative effects of exposure to heavy traffic near dwelling on respiratory symptoms in Romanian children.

Housing and Healthy Child Development: Known and Potential Impacts of Interventions

Housing is often described as an important determinant of health, but less commonly of child health. Despite acknowledgment of the importance of housing to health, however, there are relatively few studies of the effects of housing interventions on health, and again even fewer on child health. This article argues that a broad focus on healthy child development-as opposed to just physical health-coupled with a conceptual framework outlining specific attributes of housing with the potential to influence child health, should be adopted to guide a comprehensive approach to public health policy for healthy child development. Most housing interventions address direct pathways linking in-home hazard exposures to child health outcomes, with promising but mixed results. But few housing interventions address the broader aspects of healthy child development. This review addresses potential housing interventions that could impact the broader determinants of healthy child development and accompanying methodological challenges.

Household energy efficiency and health: Area-level analysis of hospital admissions in England

INTRODUCTION

Fuel poverty affects up to 35% of European homes, which represents a significant burden on society and healthcare systems. Draught proofing homes to prevent heat loss, improved glazing, insulation and heating (energy efficiency measures) can make more homes more affordable to heat. This has prompted significant investment in energy efficiency upgrades for around 40% of UK households to reduce the impact of fuel poverty. Despite some inconsistent evidence, household energy efficiency interventions can improve cardiovascular and respiratory health outcomes. However, the health benefits of these interventions have not been fully explored; this is the focus of this study.

METHODS

In this cross sectional ecological study, we conducted two sets of analyses at different spatial resolution to explore population data on housing energy efficiency measures and hospital admissions at the area-level (counts grouped over a 3-year period). Housing data were obtained from three data sets covering housing across England (Household Energy Efficiency Database), Energy Performance Certificate (EPC) and, in the South West of England, the Devon Home Analytics Portal. These databases provided data aggregated to Lower Area Super Output Area and postcode level (Home Analytics Portal only). These datasets provided measures of both state (e.g. EPC ratings) and intervention (e.g. number of boiler replacements), aggregated spatially and temporally to enable cross-sectional analyses with health outcome data. Hospital admissions for adult (over 18 years) asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) were obtained from the Hospital Episode Statistics database for the national (1st April 2011 to 31st March 2014) and Devon, South West of England (1st April 2014 to 31st March 2017) analyses. Descriptive statistics and regression models were used to describe the associations between small area household energy efficiency measures and hospital admissions. Three main analyses were undertaken to investigate the relationships between; 1) household energy efficiency improvements (i.e. improved glazing, insulation and boiler upgrades); 2) higher levels of energy efficiency ratings (measured by Energy Performance Certificate ratings); 3) energy efficiency improvements and ratings (i.e. physical improvements and rating assessed by the Standard Assessment Procedure) and hospital admissions.

RESULTS

In the national analyses, household energy performance certificate ratings ranged from 37 to 83 (mean 61.98; Standard Deviation 5.24). There were a total of 312,837 emergency admissions for asthma, 587,770 for COPD and 839,416 for CVD. While analyses for individual energy efficiency metrics (i.e. boiler upgrades, draught proofing, glazing, loft and wall insulation) were mixed; a unit increase in mean energy performance rating was associated with increases of around 0.5% in asthma and CVD admissions, and 1% higher COPD admission rates. Admission rates were also influenced by the type of dwelling, tenure status (e.g. home owner versus renting), living in a rural area, and minimum winter temperature.

DISCUSSION

Despite a range of limitations and some mixed and contrasting findings across the national and local analyses, there was some evidence that areas with more energy efficiency improvements resulted in higher admission rates for respiratory and cardiovascular diseases. This builds on existing evidence highlighting the complex relationships between health and housing. While energy efficiency measures can improve health outcomes (especially when targeting those with chronic respiratory illness), reduced household ventilation rates can impact indoor air quality for example and increase the risk of diseases such as asthma. Alternatively, these findings could be due to the ecological study design, reverse causality, or the non-detection of more vulnerable subpopulations, as well as the targeting of areas with poor housing stock, low income households, and the lack of "whole house approaches" when retrofitting the existing housing stock.

CONCLUSION

To be sustainable, household energy efficiency policies and resulting interventions must account for whole house approaches (i.e. consideration of the whole house and occupant lifestyles). These must consider more alternative 'greener' and more sustainable measures, which are capable of accounting for variable lifestyles, as well as the need for adequate heating and ventilation. Larger natural experiments and more complex modelling are needed to further investigate the impact of ongoing dramatic changes in the housing stock and health.

STUDY IMPLICATIONS

This study supports the need for more holistic approaches to delivering healthier indoor environments, which must consider a dynamic and complex system with multiple interactions between a range of interrelated factors. These need to consider the drivers and pressures (e.g. quality of the built environment and resident behaviours) resulting in environmental exposures and adverse health outcomes.

Service usage by a New Zealand Housing First cohort prior to being housed

Background

The Ending Homelessness in New Zealand: Housing First research programme is evaluating outcomes for people housed in a Housing First programme run by The People's Project in Hamilton, New Zealand. This baseline results paper uses administrative data to look at the scope and duration of their interactions with government services.

Methods

We linked our de-identified cohort to the Integrated Data Infrastructure (IDI). This database contains administrative data on most services provided by the New Zealand Government to citizens. Linkage rates in all datasets were above 90%. This paper reports on the use of government services by the cohort before being housed. We focus on the domains of health, justice and income support.

Results

The cohort of 390 people had over 200,000 recorded interactions across a range of services in their lifetime. The most common services were health, justice and welfare. The homeless cohort had used the services at rates far in excess of the general population. Unfortunately these did not prevent them from becoming homeless.

Conclusion

These preliminary findings show the homeless population have important service delivery needs and a very high level of interaction with government services. This highlights the importance of analysing the contributing factors towards homelessness; for evaluation of interventions such as Housing First, and for understanding the need for integrated systems of government policy and practice to prevent homelessness. This paper also provides the baseline for post-Housing First evaluations.

•

A homeless cohort in New Zealand had a high rate of service usage leading up to engagement with Housing First services.

•

The cohort appeared in government linked data at higher rates than the general population.

•

The cohort had over 200,000 interactions with government services within the five years prior to being housed by Housing First services.

•

This paper shows the need for a systems-wide strategy to prevent homelessness.

Evidence base for a housing warrant of fitness

Substandard housing is a major public health issue in New Zealand. Approximately, two-thirds of the housing stock is uninsulated and many homes are inadequately heated, with an average indoor temperature of 14.5°C. Cold, damp, and mouldy housing results in poor health; each year, respiratory hospital admissions are 74% higher during winter, and excess winter mortality is 20% higher than other seasons. The relationship between injury and housing conditions is also well established. Each year, 500,000 New Zealanders suffer falls requiring medical treatment in their homes. As a step towards improving the quality of existing housing, an evidence-based warrant of fitness has been developed. This article outlines the evidence base to each criterion in the warrant of fitness. We conclude that introducing and properly enforcing a housing warrant of fitness will ensure that basic minimum standards are met, which could mitigate the disease burdens and injuries associated with, or caused, by poorer quality housing. In addition, there are potential fiscal and economic advantages of the scheme, including reduced hospitalisations and increased productivity.

Impact of non-drug therapies on asthma control: A systematic review of the literature

BACKGROUND

Despite growing access to effective therapies, asthma control still needs improvement. Many non-drug factors, such as allergens, air pollutants and stress also affect asthma control and patient quality of life, but an overview of the effectiveness of non-drug interventions on asthma control was lacking.

OBJECTIVES

To identify non-drug interventions likely to improve asthma control.

METHODS

A systematic review of the available literature in Medline and the Cochrane Library was conducted in March 2017, without any time limit. Initial searching identified 884 potentially relevant clinical trial reports, literature reviews and meta-analyses, which were screened for inclusion using criteria of quality, relevance, and reporting outcomes based on asthma control.

RESULTS

Eighty-two publications met the inclusion criteria. In general, the quality of the studies was low. Patient education programmes (22 studies) significantly improved asthma control. Multifaceted interventions (10 studies), which combined patient education programmes with decreasing exposure to indoor allergens and pollutants, significantly improved asthma control based on clinically relevant outcomes. Renovating homes to reduce exposure to allergens and indoor pollutants improved control (two studies). Air filtration systems (five studies) were effective, especially in children exposed to second-hand smoke. Most measures attempting to reduce exposure to dust mites were ineffective (five studies). Dietary interventions (eight studies) were ineffective. Promoting physical activity (five studies) tended to yield positive results, but the results did not attain significance.

CONCLUSION

Twenty-six interventions were effective in asthma control. Simultaneously combining several action plans, each focusing on different aspects of asthma management, seems most likely to be effective.

The effect of the Winter Fuel Payment on household temperature and health: a regression discontinuity design study

Background

The Winter Fuel Payment (WFP) is a non-NHS population-level policy intervention that aims to reduce cold exposure and enhance the health and well-being of older adults. Labelling this cash transfer as ‘winter fuel’ has been shown to lead to increased household energy expenditure, but it is not known if this expenditure produces warmer homes or health benefits.

Objectives

First, the association between indoor temperature and health was established to identify the outcome measures most likely to be affected by the WFP. Then, whether or not receiving the WFP is associated with raised household temperature levels and/or improved health was assessed.

Design

Random and fixed effects regression models were used to estimate the link between ambient indoor temperature and health. A regression discontinuity (RD) design analysis exploiting the sharp eligibility criteria for the WFP was employed to estimate the potential impact of the payment.

Setting

The sample was drawn from the English Longitudinal Study of Ageing (ELSA), an observational study of community-dwelling individuals aged ≥ 50 years in England.

Participants

Analyses examining the association between household temperature and health had a maximum sample of 12,210 adults aged 50–90 years. The RD analyses drew on a maximum of 5902 observations.

Intervention

The WFP provides households with a member who is aged > 60 years (up to 2010, from which point the minimum age increased) in the qualifying week with a lump sum annual payment, typically in November or December.

Main outcome measures

Differences in indoor temperature were examined, and, following an extensive literature review of relevant participant-reported health indicators and objectively recorded biomarkers likely to be affected by indoor temperature, a series of key measures were selected: blood pressure, inflammation, lung function, the presence of chest infections, subjective health and depressive symptom ratings.

Data sources

The first six waves of the ELSA were drawn from, accessible through the UK Data Service (SN:5050 English Longitudinal Study of Ageing: Waves 0–7, 1998–2015).

Results

Results from both random and fixed-effects multilevel regression models showed that low levels of indoor temperature were associated with raised systolic and diastolic blood pressure levels and raised fibrinogen levels. However, across the RD models, no evidence was found that the WFP was consistently associated with differences in either household temperature or the health of qualifying (vs. non-qualifying) households.

Limitations

The presence of small effects cannot be ruled out, not detectable because of the sample size in the current study.

Conclusions

This study capitalised on the sharp assignment rules regarding WFP eligibility to estimate the potential effect of the WFP on household temperature and health in a national sample of English adults. The RD design employed did not identify evidence linking the WFP to warmer homes or potential health and well-being effects.

Future work

Further research should utilise larger samples of participants close to the WFP eligibility cut-off point examined during particularly cold weather in order to identify whether or not the WFP is linked to health benefits not detected in the current study, which may have implications for population health and the evaluation of the effectiveness of the WFP.

Funding

The National Institute for Health Research Public Health Research programme.

Epidemiology of Asthma in Children and Adults

Asthma is a globally significant non-communicable disease with major public health consequences for both children and adults, including high morbidity, and mortality in severe cases. We have summarized the evidence on asthma trends, environmental determinants, and long-term impacts while comparing these epidemiological features across childhood asthma and adult asthma. While asthma incidence and prevalence are higher in children, morbidity, and mortality are higher in adults. Childhood asthma is more common in boys while adult asthma is more common in women, and the reversal of this sex difference in prevalence occurs around puberty suggesting sex hormones may play a role in the etiology of asthma. The global epidemic of asthma that has been observed in both children and adults is still continuing, especially in low to middle income countries, although it has subsided in some developed countries. As a heterogeneous disease, distinct asthma phenotypes, and endotypes need to be adequately characterized to develop more accurate and meaningful definitions for use in research and clinical settings. This may be facilitated by new clustering techniques such as latent class analysis, and computational phenotyping methods are being developed to retrieve information from electronic health records using natural language processing (NLP) algorithms to assist in the early diagnosis of asthma. While some important environmental determinants that trigger asthma are well-established, more work is needed to define the role of environmental exposures in the development of asthma in both children and adults. There is increasing evidence that investigation into possible gene-by-environment and environment-by-environment interactions may help to better uncover the determinants of asthma. Therefore, there is an urgent need to further investigate the interrelationship between environmental and genetic determinants to identify high risk groups and key modifiable exposures. For children, asthma may impair airway development and reduce maximally attained lung function, and these lung function deficits may persist into adulthood without additional progressive loss. Adult asthma may accelerate lung function decline and increase the risk of fixed airflow obstruction, with the effect of early onset asthma being greater than late onset asthma. Therefore, in managing asthma, our focus going forward should be firmly on improving not only short-term symptoms, but also the long-term respiratory and other health outcomes.

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

Emergency hospital admissions associated with a non-randomised housing intervention meeting national housing quality standards: a longitudinal data linkage study

BACKGROUND

We investigated tenant healthcare utilisation associated with upgrading 8558 council houses to a national quality standard. Homes received multiple internal and external improvements and were analysed using repeated measures of healthcare utilisation.

METHODS

The primary outcome was emergency hospital admissions for cardiorespiratory conditions and injuries for residents aged 60 years and over. Secondary outcomes included each of the separate conditions, for tenants aged 60 and over, and for all ages. Council home address and intervention records for eight housing cointerventions were anonymously linked to demographic data, hospital admissions and deaths for individuals in a dynamic cohort. Counts of health events were analysed using multilevel regression models to investigate associations between receipt of each housing improvement, adjusting for potential confounding factors and regional trends.

RESULTS

Residents aged 60 years and over living in homes when improvements were made were associated with up to 39% fewer admissions compared with those living in homes that were not upgraded (incidence rate ratio=0.61, 95% CI 0.53 to 0.72). Reduced admissions were associated with electrical systems, windows and doors, wall insulation, and garden paths. There were small non-significant reductions for the primary outcome associated with upgrading heating, adequate loft insulation, new kitchens and new bathrooms.

CONCLUSION

Results suggest that hospital admissions can be avoided through improving whole home quality standards. This is the first large-scale longitudinal evaluation of a whole home intervention that has evaluated multiple improvement elements using individual-level objective routine health data.

A time for everything and everything in its time - exploring the mechanisms underlying seasonality of COPD exacerbations

Across Europe, COPD affects 23 million people leading to annual health care costs of ~€25.1 billion. This burden is particularly severe during winter months in association with the peak incidence of exacerbation events. Seasonal variation in the health status of patients with COPD places additional and often critical pressure on already strained health care resources. COPD exacerbations are characterized by worsening day-to-day symptoms of an individual and often triggered by respiratory infections, but the process by which this occurs in a seasonal fashion is likely to be multifactorial. In this review, we discuss recent population studies that highlight the impact of seasonality in COPD and review the proposed biological mechanisms underlying this. An appraisal of the role of the host susceptibility and response, environmental triggers and the biology of respiratory pathogens is detailed. The impact of each aspect is considered, and an integrated model of the context for the whole individual and society in general is explored.

Health impact, and economic value, of meeting housing quality standards: a retrospective longitudinal data linkage study

Background

Poor-quality housing adversely affects residents’ health but there is a paucity of high-quality evidence to support this.

Objective

This research investigated the health impact of bringing housing to a national quality standard.

Design

A natural experiment of improvements to housing quality analysed using repeated measures of health-care utilisation and economic outcomes at an individual person level.

Setting

Carmarthenshire, UK.

Participants

A total of 32,009 residents registered for a minimum of 60 days at 8558 social homes that received housing improvements between January 2005 and March 2015.

Interventions

Multiple internal and external housing improvements, including wall and loft insulation, windows and doors, heating system upgrades, new kitchens and bathrooms, garden path safety improvements and electrical system upgrades (adding power sockets, and extractor fans in kitchens and bathrooms).

Main outcome measures

Emergency hospital admissions for cardiorespiratory conditions and injuries. Primary health-care utilisation for respiratory and common mental health disorders, emergency department injury attendances and health-care utilisation costs.

Data sources

Carmarthenshire County Council home address and intervention records were anonymously linked within the Secure Anonymous Information Linkage databank to demographic information from the Welsh Demographic Service data set; hospital admission data from the Patient Episode Dataset for Wales; primary care contacts and prescribed medications from general practice data; emergency department attendances from the Emergency Department Data Set; and deaths from the Office for National Statistics mortality register.

Methods

The study used a longitudinal panel design to examine changes in standard of eight housing cointervention from intervention records, and linked to individuals registered at intervention homes. Health outcomes were obtained retrospectively for each individual in a dynamic cohort and were captured for up to 123 consecutive months. An additional local authority region could not be utilised as a comparator owing to different reporting pressures resulting in the recording of a different intervention. The exposure group for each cointervention was compared with an internal reference group of people living in homes that did not receive the cointervention during their tenancy. A multilevel modelling approach was used to account for repeated observations for individuals living in intervention homes. Counts of health outcomes were analysed using negative binomial regression models to determine the effect of each cointervention that reached housing quality standards during an individual’s period of tenancy, compared with those living in properties that did not. We adjusted for potential confounding factors and for background trends in the regional general population. A cost–consequences analysis was conducted as part of the health economic evaluation.

Results

Residents aged ≥ 60 years living in homes in which electrical systems were upgraded were associated with 39% fewer admissions than those living in homes in which they were not [incidence rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.53 to 0.72;p < 0.01]. Reduced admissions were also associated with windows and doors (IRR 0.71, 95% CI 0.63 to 0.81;p < 0.01), wall insulation (IRR 0.75, 95% CI 0.67 to 0.84;p < 0.01) and gardens and estates (IRR 0.73, 95% CI 0.64 to 0.83;p < 0.01) for those living in homes in which these cointervention were upgraded. There were no associations of change in emergency admissions with upgrading heating (IRR 0.91, 95% CI 0.82 to 1.01;p = 0.072), loft insulation (IRR 0.98, 95% CI 0.86 to 1.11;p = 0.695), kitchens (IRR 0.98, 95% CI 0.83 to 1.17;p = 0.843) or bathrooms (IRR 0.93, 95% CI 0.81 to 1.06;p = 0.287).

Limitations

There was no randomisation, there were incomplete data on the scale of the intervention for individual households and there were no estimates for the impact of the whole programme.

Conclusions

This complex interdisciplinary study found that hospital admissions could be avoided through improving housing quality standards.

Future work

At their initiation, future non-health projects should have a built-in evaluation to allow intervention exposures to be randomly allocated to residents, with the simultaneous analysis of multiple health outcomes in one statistical model.

Funding

The National Institute for Health Research Public Health Research programme.

High burden of atopy in immigrant families in substandard apartments in Sweden - on the contribution of bad housing to poor health in vulnerable populations

Background

Atopic disorders are a global concern. Studies in migrant populations can illuminate the interplay of genetic and environmental factors. Exposures related to bad housing (indoor dampness, mould growth, crowding etc.) are likely to play a role in how socioeconomic inequalities can turn into health disparities for disadvantaged populations. The sizable immigrant population living in very poor-quality housing in Malmö, Sweden, became the focus of a cross-sectional study.

Objective

To describe atopic disorders and sensitizations in a population living in substandard housing in Malmö, Sweden, with an emphasis on their relation to harmful exposures from the built environment.

Methods

Families were recruited via identification of any children with symptomatic airway afflictions from health care records, and also asymptomatic children from school lists. Interviewer-led health questionnaire data and data from self-reports about living conditions were obtained together with data from home inspections carried out by health communicators. Families underwent skin prick tests (SPT) against common aeroallergens.

Results

As could be expected from background demographic information, it turned out that we effectively studied an immigrant population inhabiting very precarious housing outside the center of Malmö. A total of 359 children from 130 families (total 650 participants) were included. Overall the prevalence of potentially harmful environmental exposures was high (signs of moisture or mould in more than 50% of apartments, indoor smoking in 37% of households). Atopic disorders were common among both adults and children. SPTs showed a spectrum of sensitizations consistent with unselected populations in Sweden. Paternal sensitization in the SPT was associated with higher risk of sensitization for offspring than maternal sensitization. Few statistically significant associations of atopic sensitization with studied environmental exposures were detected (for example objective signs of dampness /mould in bathrooms). There were marked discrepancies between asthma diagnoses obtained from the health records and parental reports of such diagnoses and treatment for their children.

Conclusions

The atopic burden in this selected immigrant population was high, and results point to unmet medical needs. Health care systems caring for such populations need to be aware of their specific health needs; comprehensive asthma and allergy care should include consideration of harmful environmental exposures, adhering to the precautionary principle.

Evidence from SINPHONIE project: Impact of home environmental exposures on respiratory health among school-age children in Romania

BACKGROUND

Exposure to indoor air pollutants at home was found to be associated with respiratory diseases. As lifestyle changes with rapid economic growth in Romania, the aim of our study is to describe the characteristics of Romanian homes and their impact on children's respiratory health.

METHODS

Self-reported information on respiratory symptoms was collected from 280 Romanian elementary school students in 2011, and the symptoms were categorized into allergy, asthma-like, and flu-like symptoms. Home characteristics and demographic information were collected from questionnaires answered by parents. The association between home characteristics and respiratory health was assessed through multivariate logistic regression controlling for school indoor exposure.

RESULTS

As compared to U.S. households, Romanian homes have a higher percentage of smokers, limited use of indoor climate control, and higher use of iron stoves. Exposure to environmental tobacco smoke was associated with both asthma and allergy symptoms. Additional risk factors identified for allergy symptoms include living in apartments, near pesticide sprayed areas, and the use of incense sticks. The significantly higher risk of flu-like symptoms was associated with mold and dampness issues, the use of air conditioner, gas heater/iron stove in children's bedroom.

CONCLUSION

Our findings suggest that an increase in respiratory symptoms among Romanian school-age children can be partly related to their environmental exposure at home. Since most of the identified risk factors are preventable, our results provide critical information and evidence for policymakers, to develop target intervention and education strategies.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.