Home Truths

Philippa Howden-Chapman

Royal Society Wanaka 10 November

He Kainga Oranga/ Housing and Health

Research Programme

University of Otago, Wellington www.healthyhousing.org.nz

www.sustainablecities.org.nz

Talk outline

• Housing quality• Housing-related hospitalisations and

death• Community trials• Housing intervention programmes

• Secondary prevention Well Homes• Primary prevention NEST study,

Rental WOF

Poor housing quality

• NZ houses on average 90 years old

• Only a third even minimally insulated

• Private rental housing in poorer condition than state housing or owner-occupied houses

• Indoor environment key health exposure

• Most of our time indoors, for infants and older people ~90%

• 36% of households, 50% of population rent

• BRANZ House Conditions Survey rental houses in worse condition than owner-occupied houses (44% poor condition vs. 25% )

Declining levels of home ownership

81938 first State housing development

Low temperatures

• WHO recommends minimum indoor temperatures 18-21oC

• Children’s bedrooms average 14.5oC

• Insulation and heating each improve bedroom temperature by ~0.8oC

• Worst child’s bedroom in asthma study was -4oC while child was sleeping

10

• Cold indoor air is harder to heat

• Mould grows better in damp air

• Viruses survive for longer on cold surfaces

• Cold stresses immune system

• Blood (liquid) thickens when cold & more likely to form plaques

Physical + biological pathways

Households in 2013 Census

• 25% or 270,000 children living in households in poverty

• 50% children below the poverty live in private rental housing, 19% Housing NZ homes

• 33% of Pacific peoples lived in crowded households, 20% Māori, 18% Asian, 4% European increases risks of infectious disease.

• 9% no form of heating.12

1313

Effects of fuel poverty on children

• Growing Up in NZ parents of 9-month old babies

– 18% put up with feeling cold to save on heating

– 11% used no heating

• Parents of children under 15 admitted to hospital

– 52% lived in housing colder than they would like

– 14.2% had been unable to pay their electricity bills on time

– 7.5% had experienced disconnection due to late or non-payment of bills (4x national rate)

Housing Sensitive Diseases (MoH)Acute bronchiolitis J21

Acute rheumatic fever I00-I02

Bacterial meningitis G00,G01

Bacterial/ Unspecified pneumonia J13-J16, J18

Bronchiectasis J47

GAS sepsis A400

Meningococcal disease (includes

meningococcal meningitis)

A39

Viral / other / unspecified meningitis A87,G02,G03

Viral pneumonia J12, J100,J110

Urinary tract infection1 N10, N12,N300,N390,N136,309

0 1000 2000 3000 4000 5000

0.0

0.2

0.4

0.6

0.8

1.0

Time (days)

Pro

port

ion N

ot

Read

mitte

d

Never PAPH

Ever Anderson

Ever Baker

Ever MoH

Potentially avoidable housing-related re-hospitalisations

Hospital admission

group

Rehospitalisation

risk

Unadjusted

HR (95% CI)

Adjusted*

HR (95% CI)

Non-PAH 56.3% 1.00 (Reference) 1.00 (Reference)

PAH 78.0% 2.19 (2.17-2.21) 2.31 (2.29-3.34)

PAHHE 80.3% 2.41 (2.40-2.43) 2.49 (2.48-2.52)

Crowding 80.3% 2.47 (2.45-2.49) 2.58 (2.56-2.61)

MoH 86.2% 3.35 (3.31-3.39) 3.60 (3.55-3.66)

* Adjusted for age, sex, ethnicity and deprivation

Deaths of children previously hospitalised for PAHHE

0 1000 2000 3000 4000 5000

0.9

70

0.9

75

0.9

80

0.9

85

0.9

90

0.9

95

1.0

00

Time (days)

Pro

po

rtio

n S

urv

ivin

g

Never Admitted for PAPH

Ever Anderson

Ever Baker

Ever MoH

Hospital admission

group

Survival Unadjusted HR

(95% CI)

Adjusted HR (95%

CI)

Non-PAH 99.7% 1.00 (Reference) 1.00 (Reference)

PAH 99.3% 2.23 (2.01-2.47) 3.07 (2.74-3.43)

PAHHE 99.2% 2.45 (2.20-2.72) 3.31 (2.94-3.71)

Crowding 99.1% 2.66 (2.39-2.96) 4.00 (3.55-4.50)

MoH 97.6% 7.03 (6.27-7.87) 10.44 (9.18-

11.86)

* Adjusted for age, sex, ethnicity and deprivation

Survival rates of children previously hospitalised for preventable housing-related admissions

20

Robust research evidence• Housing, Insulation & Health Study

• Housing, Heating & Health Study

• Housing, Injury Prevention Intervention

• Warm Homes for Elderly New Zealanders

• Social Housing Outcomes Worth Study

• NEST primary prevention newborn babies

• Well homes secondary prevention for children

• Housing First with wrap around services

Housing, Insulation & Health Study

•

Study DVD www.healthyhousing.org.nz

Insulation

• Housing, Insulation and Health Study

• 1400 households in 8 areas where one member had chronic respiratory symptoms

• Occupants of insulated houses exposed to significantly warmer and less damp houses

• Key energy result: Occupants in insulated houses used 23% less energy

Howden-Chapman, P., J. Crane, et al. Retrofitting houses with insulation to reduce health inequalities: aims and

methods of a clustered, randomised trial in community settings." Social Science and Medicine, 2005, 61: 2600-2610.

Howden-Chapman P et al. Retrofitting houses with insulation to reduce health inequalities: results of a clustered,

randomised trial in a community setting. British Medical Journal 2007;334:460-464.

Big gains: actions below the line save money

Source: McKinsey (2009)

Housing, Heating & Health

• Even insulated houses colder than ideal 18oC

• NZ has Scottish pattern of spot heating one room

• Third of NZ households use unfluedgas heaters (1 kg LPG = 1.6 kg H20)

• 30 NZ cities exceed air quality standards

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Previous:

X electric heaters (2kW)

X unflued gas heaters (4kW)

Replaced with:

√ 320 heat pumps (4-7kW)

√ 55 wood pellet burners (10kW)

√ 11 flued gas heaters

Intervention in 409 households

• 409 households in community trial

• Does non-polluting, more effective, home heating reduced children’s asthma symptoms over winter?

• Households had choice of sustainable heaters

Heating

Howden-Chapman P, Pierse N, Nicholls S, Gillespie-Bennett J, Viggers H, Cunningham M, et al.

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

study. British Medical Journal 2008;337(a1411doi:10.1136.a1411).

Heating

Average living rooms 1.1°C warmer

People felt warmer

Condensation reduced

Less mould and mouldy smells reported

Levels of nitrogen dioxide halved

Levels of wheezing & coughing halved

Effects more marked in low-income families

Two more days at school during winterFree, S., P. Howden-Chapman, et al. (2009). "Does More Effective Home Heating Reduce School Absences for Children

with Asthma?" Journal of Epidemiology and Community, doi:10.1136/jech.2008.086520.

Gillespie-Bennett, J., N. Pierse, et al. (2008). "Sources of nitrogen dioxide (NO2) in New Zealand homes: Findings from

a community randomised controlled trial of heater substitution." Indoor Air 18(6): 521-528.

Housing Outcome Mould Study

(HOME)

• Third of NZ houses have mould

• Leaky buildings major problem (~80,000 houses); estimated health costs $474m

• Case-control study linking public health and mycology

• Replicating Finnish study, first & only study to show wheezing caused by mould

•Howden-Chapman P, Saville-Smith K, Crane J, Wilson N. Risk factors for mould. Indoor Air 2005;15:469-476.

•Howden-Chapman P, Bennett J, Siebers R, editors. Do Damp and Mould Matter? Health impacts of leaky homes.

Wellington: Steele Roberts Publishers, 2010.

Warm Homes for Elder

New Zealanders (WHEZ)

• 522 people over 55 with COPD

• Intervention $500 electricity voucher

• Heat as medicine

• Whanganui, Palmerston North, Wellington & Christchurch

• Community partnerships with asthma societies, outpatient respiratory clinics

• Half participants’ homes colder than they would like and they have shivered inside

Warm Up NZ: Heat Smart Programme

• 100,000 houses in first 2 years of programme

• $320 million, not targeted to low income

• Quasi-experimental study, detailed anonymised matching of first 46,655 houses

• Small but significant drop in metered energy

• Significant health outcomes in pharmaceutical usage, length of hospitalisation, avoidable mortality for over 65s

• Benefit/cost ratio for adults 3.9:1 children 6:1

http://www.motu.org.nz/news-

media/detail/reports_on_warm_up_new_zealand_heat_smart_now_available.

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• Low-cost modifications & repairs can reduce injury in general population

3434

Housing, Injury, Prevention Intervention

(HIPI) study

Healthy Housing Programme (HHP)

• Social Housing Outcomes Worth cohort

(SHOW) links 220,000 tenants to

hospitalisations, 2004-2008

• After HHP, acute and arranged

hospitalisations fell (27%) year after

• Fall in hospitalisations (61%) for most

intensive intervention

Baker et al reports on www.healthyhousing.org.nz

2014

Homelessness and housing

Housing First

The Rental Warrant of Fitness

• Tenants can’t fix their houses• Landlords (mostly) don’t fix

their houseswww.rwof.org.nz

The intervention

• Developed with Green Building Council

• 29-point evidence based checklist covering basic insulation, ventilation/dryness, fixed heating, amenities, state of repair and safety hazards

• Field tested 2014

• App available from Google Play or the App Store!

1. Is there a functional, safe stove-top and oven? 2. Is there adequate space for food preparation and storage? 3. Is there an adequate supply of hot and cold potable water? 4. Is the hot-water at the tap 55°C (±5°C?) 5. Is there a functional toilet, which does not have a cracked or broken seat, cistern or bowl? 6. Is there a suitably located bath or shower in good working order? 7. Are there secure or high level cupboards or shelves for storing hazardous or toxic substances out of children's reach? 8. Is there a fixed form of safe and effective space heating? 9. Do the bathroom, kitchen and all bedrooms have some form of ventilation to outside? 10. Is the house reasonably free of visible mould, i.e. the total area of mould is less than an A4 sheet of paper? 11. Are the power outlets and light switches safe and in good working order? 12. Is there adequate indoor lighting? 13. Does the house have adequate working smoke alarms? 14. Have the windows got effective latches?

15. Do high level windows have security stays to prevent falls? 16. Are there curtains or blinds in the bedrooms and living area? 17. Do glass doors have safety visibility strips? 18. Does the house have ceiling insulation to WOF standards? 19. Does the house have underfloor insulation to WOF standards? 20. Is a ground vapour barrier installed under the ground floor?21. Is the house weathertight with no evident leaks, or moisture stains on the walls or ceiling? 22. Is the house in a reasonable state of repair? 23. Is the storm and waste water drainage being adequately discharged? 24. Is there any water ponding under the house? 25. Is there adequate outdoor lighting near entrance ways? 26. Does the house appear to be structurally sound? 27. Are there handrails for all internal stairs and all outdoor steps that access the house, and do balconies/decks have balustrades to the current Building Code? 28. Is the address clearly labelled and identifiable? 29. Are there securely locking doors?

HRC-funded Rental WoF study

• Does introducing a Rental WoF improve health without reducing rental affordability or availability?

• Intervention cities Wellington and Dunedin

– Control cities Porirua and Invercargill

• Health outcomes: ACC claims, hospitalisations, mortality

• Economic outcomes: Trademe rental listing prices and numbers (by bedroom size)

Quasi-experimental study design

Policy influences

Bierre & Howden-Chapman, Telling stories: the role of narratives in

rental housing policy in New Zealand, Housing Studies, 2017, p.9.

Conclusion

• Systematic problems with NZ housing

• Old, cold, damp, mouldy and unsafe

• HR conditions increase risk of

(re)hospitalisations & death in children & older

people

• Home ownership dramatically declining

• Private rental housing in worse condition than

state housing and owner-occupied housing

• Strong evidence base from community trials

• Resulting major policy changes emphasise

primary prevention