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Rapid Responses: Rapid Responses published:
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Any Financial Relationships?
- c chisholm (27 February 2007)
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Mental Health is also affected by housing
- John S Watts (3 March 2007)
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Lagging Behind
- Christopher L Manning (6 March 2007)
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Communities identify investment in housing as a top health priority
- Dr. Colin S. Brown, Prof. Scott A Murray, St Columba’s Hospice Chair of Primary Palliative Care (9 March 2007)
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A Joint Approach
- Ivan Browne (9 March 2007)
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Housing changes and acute hospitalisation
- Gary P Jackson, Jude Woolston, Alan Bernacchi (13 March 2007)
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Problems with intention to treat analysis?
- Liesl M Osman, Graham Douglas (16 March 2007)
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Rights to HousingRights to Housing and Health: Critical Links for the Global Poor
- John D. Kraemer, Rajesh R. Panjabi (20 March 2007)
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How the results of the study apply to the UK - Health inequality, statistical significance, and ‘real’ significance
- Sakthidharan P Karunanithi (1 May 2007)
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c chisholm, F2 Tameside General Hospital
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Are houses in NZ without insulation owned by people of a lower socioeconomic group? Competing interests: None declared |
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John S Watts, Specialist Registrar in Child Psychiatry Orchard House Family Mental Health Centre, 17 Church Street, St. Peters, Broadstairs, Kent. CT10 2TT
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I want to congratulate Howden-Chapman et al for completing such a large study looking at the effects of insulating houses on the health of occupants.(1) It is interesting to see research confirming what often seems logical. Although one of the measures (the SF36) does collect some information on mental health, I could find no further discussion of this in the article. Being in the business of mental health, I decided to look at the issue of mental health and housing myself. I was reassured to find that the quality of housing also predicts mental health.(2) It seems that the reporting of 'dampness' can cause psychological problems,(3) as well as the location and type of dwelling.(4) Although standard methods of psychiatric history-taking include details of the home and home environment, they do not include detailed questioning of the level of insulation, presence of dampness or the type of neighbourhood. Perhaps such questioning can now be included in the new Specialist Trainiing curriculum for psychiatry. Dear PMETB .... 1. Howden-Chapman P, Matheson A et al. Effect of insulating houses on health inequality: cluster randomised study in the community. BMJ 2007;334:460 (3 March.) 2. Evans GW, Wells NM, Chan HY, Saltzman H. Housing quality and mental health. Journal of Consulting and Clinical Psychology 2000;68(3):526-30 (June.) 3. Hopton JL, Hunt SM. Housing conditions and mental health in a disadvantaged area in Scotland. Journal of Epidemiology and Community Health 1996;50:56-61 4. McCarthy P, Byrne D, Harrison S, Keithley J. Housing type, housing location and mental health. Social Psychiatry 1985;20:125-30 Competing interests: The author lives in a house that is insulated, but has some dampness |
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Christopher L Manning, CEO Primhe TW1 4JA
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Dear Sir The authors have provided a caring intervention to people whose lives are deprived of such. This aspect of the intervention applies to the inhabitants of both the 'treated' and the 'untreated' homes. However, I was surprised that the 'untreated' homes were not subject to modification with inactive insulation; this would have enabled a more blinded research protocol. In light of this study and the comments about mental health and physical health being affected, I would add that the 'mental' aspects of a physical brain and its attendant control and communications systems are all developed and delivered as physically as every other organ system in the body. Further emphasis of the importance of these connections are provided in today's review by the Royal Commission on Environmental Pollution. Despite Black, Jarman and Wanless, our Government is still ignoring many, if not most, of these issues and their impact on developing brain-minds, as detailed in the bleak overview provided by the UniCEF Report of a fortnight ago and emphasized by Dr Des Spence's Opinion piece in this same issue of the BMJ. Yours Dr Chris Manning Competing interests: None declared |
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Dr. Colin S. Brown, Research Fellow, Division of Community Health Sciences University of Edinburgh, 20 West Richmond St, Edinburgh, EH8 9DX, Prof. Scott A Murray, St Columba’s Hospice Chair of Primary Palliative Care
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The association between cold houses and poor health and wellbeing has been confirmed by Howden-Chapman et al’s study of
Competing interests: None declared |
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Ivan Browne, Specialist Public Health Trainee South Staffordshire PCT
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As a former EHO that previously carried out housing inspections, I read this research article with interest. The last English House Condition Survey (EHCS)(1) estimating that 29% of our housing stock remains below the ‘decent living’ standard, largely on the basis of thermal comfort. Therefore, the Howden-Chapman et al study(2)highlighted an important potential health concern. The EHCS states that many of the occupants of these substandard dwellings are already amongst the most deprived and vulnerable within the population. Howden-Chapman's study findings would suggest that some basic improvements in housing standards could have a disproportionately beneficial health effect amongst these hard to reach populations. Whilst, not suggesting that the medical profession should now consider themselves responsible for an improvement in housing standards, I do believe that an opportunity exists to develop a more coordinated approach to tackling this potential source of ill health. Last year the Housing Fitness Standard set out in the Housing Act 1985(3) was replaced by the Housing Health & Safety Rating System(4). A key change contained within the new system relates to its ability to require remedial action to be taken on the basis of the level of ‘health risk’ posed to occupants of the premises, rather then particular defects in the physical properties of the building. It is in the identification of potential ‘health risks’ that a combination of research such as Howden-Chapman et al and local medical practitioners health knowledge can play a role in the improvement of local housing standards. Addressing EHOs about the new rating system, Professor David Ormandy, one of the architects of the system, said: “Remember your PCTs are supposed to be looking at the health impacts in housing. This local information should be informing the decent home standard and programmes………Also, we should be able to demonstrate a few years down the road that this work on housing has had an effect that is beneficial to the health service”(5). Consequently, issues of blinding and the reliability of self reported responses aside, I welcome the publication of this paper in this Journal. 1)Department for Communities and Local Government, English House Condition Survey 2004 Annual Report, HMSO, London, 2006 2)Howden-Chapman P, Matheson A et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community BMJ 2007. BMJ 2007; 334: 460 3) Housing Act 1985 4) The Housing Health and Safety Rating System (England) Regulations 2005, HMSO, London 5) Spear S, New light on risk, Environmental Health Practitioner, May 2006; 24-25 Competing interests: None declared |
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Gary P Jackson, Public Health Physician Counties Manukau District Health Board, Jude Woolston, Alan Bernacchi
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The Howden-Chapman et al study (1) looking at the effects of insulating houses on health is an important milestone in the study of housing and health, and we congratulate the authors on their achievement. To this straightforward intervention we would note that multiple intervention pathways in the housing area can have further benefits. The Healthy Housing programme is a joint project between Housing New Zealand Corporation (HNZC – the provider of publicly-funded housing), and Counties Manukau, Auckland, and Northland District Health Boards (DHBs). It targets localities with high health needs, low income, and with high concentrations of HNZC properties. It aims to assist families with high rates of hospital admissions for preventable infectious diseases. HNZC staff work directly with health professionals to identify families that are living in conditions that may affect their health, and then an assessment is carried out to see what can be done. This can include a range of things – from educating families about health risks and putting them in touch with local health providers (an average of 3 referrals per household), to making the house dryer and warmer by installing insulation, or in some cases making the house physically bigger. Over 4000 homes have been assessed from the programme’s instigation in 2001. While not designed as a randomised study, evaluations have found improvements in self-rated health, self-esteem, use of primary care and reductions in the use of secondary care; all consistent with the present study. Examining acute hospital admissions, we performed a case- counterfactual study on 5357 residents of 1276 homes involved in the Healthy Housing Programme in the Counties Manukau DHB area. Almost all participants were of Pacific ethnicity, living in some of the most deprived areas of New Zealand (all NZDep01 decile 10). We used a pre- determined set of “housing-related” potentially avoidable hospitalisations (HR-PAH). HR-PAH includes acute admission for respiratory infections, tuberculosis, gastroenteritis, ear, nose and throat infections, meningococcal meningitis, asthma and COPD. A person was included as a case for each day they were living in a modified house in the period 2003- 2004. People living in houses prior to modification were the counterfactual (control group), again if they were in the 2003-2004 period. Houses that were modified prior to 2003 only appear as a case, houses modified after 2004 only appear as a counterfactual. Houses modified in 2003-4 will appear in both case and counterfactual. People living in the modified houses had a 37% lower rate of HR-PAH than the counterfactual householders, 36/1000 persons/year as compared to 23. For the group of houses analysed this amounted to preventing around 120 acute admissions to hospital per year. The largest decrease was seen in respiratory conditions, particularly in children. Households that had had interventions to reduce overcrowding (eg additions of bedrooms) had a slightly larger fall (OR 0.61, 95% CI 0.43-0.86) than those that had insulation/ventilation modifications only (OR 0.68, 0.53-0.89). It is possible to work across agencies to directly impact on the living conditions of the most deprived segments of our society. Multiple interventions can have additive effects. Of particular note in this group of low-income tenants is the obvious pride they take in their renovated dwelling, as evidenced by very low turnover rates and very low damage/maintenance requirements. This improved self-esteem will impact on many aspects of the families’ lives, well beyond the effects seen in the health care sector. 1) Howden-Chapman P, Matheson A et al. Effect of insulating houses on health inequality: cluster randomised study in the community. BMJ 2007;334:460 (3 March.) Gary Jackson, Public Health Physician, CMDHB Jude Woolston, Project Manager (Intersectoral), CMDHB Alan Bernacchi: Project Manager, Healthy Housing Programme, Housing New Zealand Corporation Competing interests: None declared |
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Liesl M Osman, Senior Research Fellow Chest Clinic, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Graham Douglas
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Dear Editor Howden Chapman et al(1) report significant improvement in perceived health after insulation of homes in Otago New Zealand. What is not clear is whether this improvement was caused by objectively measured increase in indoor temperature and decrease in humidity, following insulation, or whether it reflects psychological benefits of participation in this kind of community intervention. The associated editorial by Thomson and Petticrew(2) reports that only 30% of participants in the intervention group received the full insulation package, although Howden-Chapman’s previous paper(3) makes it clear that almost all homes had at least ceiling insulation. Temperature and humidity differences between the intervention and control houses were very small, less than 1C in bedrooms (0.8C) and less than 3% difference in humidity. Self reported change in health was large but was not confirmed by data collected from GP records. Curiously, this study may demonstrate that analysis by intention to treat is not always the most rigorous method of evaluating a study’s result. It would be reassuring to see a subanalysis within the intended intervention group comparing homes which received the insulation package versus those which did not, and showing that there was a dose response effect on temperature, humidity and SF-36 change associated with actually receiving insulation. Without this we cannot be confident that the health effect reported was indeed due to the energy efficiency measures evaluated in the study, and that health effects are mediated by temperature change. We are sure that the authors can provide such a subanalysis, which would answer these questions. It would be of great interest if this could now be done. Yours sincerely Liesl M Osman Graham Douglas Reference List 1. Howden-Chapman P, Matheson A, Crane J, Viggers H, Cunningham M, Blakely T et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ 2007;334:460. 2. Thomson H,.Petticrew M. Housing and health. BMJ 2007;334:434-5. 3. Howden-Chapman P, Crane J, Matheson A, Viggers H, Cunningham M, Blakely T et al. Retrofitting houses with insulation to reduce health inequalities: aims and methods of a clustered, randomised community-based trial. Soc.Sci.Med. 2005;61:2600-10. Competing interests: None declared |
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John D. Kraemer, JD/MPH Candidate Georgetown University Law Center / Johns Hopkins Bloomberg School of Public Health, Rajesh R. Panjabi
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We applaud BMJ’s recent focus on the importance of high-quality housing to the maintenance of human health (1). Housing must be a focal point in public health research and practice. In a large, New Zealand based randomized controlled trial, Howden-Chapman et al (2) showed that insulating homes improves health. Such research and related action is of even greater importance in resource-poor countries, where much fewer randomized trials have been conducted, but where poverty’s diseases, especially those that are vector-borne, nonetheless thrive on rural dwellers of thatched-roofed, mud-walled homes in disrepair. The global poor seem to be well aware of such critical linkages, as suggests our experience working as public health workers and clinicians among a rural community in southeastern Liberia. Recent conversations there suggest a strong community-wide perception that improved housing is one step toward the avoidance of malaria. People who have been able to improve their homes, for instance, through converting materials used to construct their roofs from thatch to zinc, nearly universally perceived fewer cases of malaria after the improvements than before. The viewpoints of rural Liberians are well supported by a growing body of evidence, which is well reviewed by Lindsay et al (3). Some improvements are intuitive, such as window and door screens and the modification of eves to prevent mosquitoes’ access to homes. Others are less intuitive but just as effective. Research in Burkina Faso found that children under five years of age had a greater than double the odds of malaria infection if they lived under a mud roof than under a metal roof (4). In Sri Lanka, improved housing was found to be a cost-effective intervention that would pay for itself in health savings over a relatively short period of time (5). Additionally, housing improvements have been shown to be protective against other vector-borne diseases of the developing world, including Chagas disease(6) and filariasis (7). Policy makers should view housing improvements as a means to improve the human condition, not only as it pertains to health, but also in terms of the inherent right to live in safe and edifying conditions that promote the flourishing of the human spirit (8,9). There is a synergy between health, housing, and human dignity that must be taken as seriously by policy makers and researchers as it already is by the world’s destitute sick. Sincerely, John D. Kraemer JD/MPH Candidate Georgetown University Law Center / Johns Hopkins Bloomberg School of Public Health jkraemer@jhsph.edu Rajesh R. Panjabi, MPH University of North Carolina School of Medicine panjabi@med.unc.edu References 1. Thomson H, Petticrew, M. Housing and health. BMJ. 2007; 334: 434 -435. 2. Howden-Chapman P., Matheson A, Crane J, Viggers H, Cunningham M, Blakely T, Cunningham C, Woodward A, Saville-Smith K, O’Dea D, Kennedy M, Baker M, Waipara N, Chapman R, Davie G. Effect of insulating houses on health inequality: cluster randomized study in the community. BMJ. 2007; 334: 460. 3. Lindsay SW, Emerson PM, Charlwood, JD. Reducing malaria by mosquito-proofing houses. Trends Parasitol. 2003; 18: 510-514. 4. Ye Y, Hoshen M, Louis V, Seraphin S, Traore T, Sauerborn R. Hosing conditions and Plasmodium falciparum infection: protective effect of iron-sheet roofed houses. Malar J. 2006; 5: 8-14. 5. Gunawardena DM, Wickremasinghe AR, Muthuwatta L, Weersingha S, Rajakaruna J, Senanayaka T, Kotta PK, Attanayake N, Carter R, Mendis KN. Malaria risk factors in an endemic region of Sri Lanka, and the impact and cost implications of risk factor-based interventions. Am J Trop Med Hyg. 1998; 58: 533-542. 6. Rojas de Arias A, Ferro EA, Ferreira ME, Simancas LC. Chagas disease vector control through different intervention modalities in endemic localities of Paraguay. Bull World Health Organ. 1999; 77: 331- 339. 7. Baruah K, Rai RN. The impact of housing structures on filarial infection. Jpn J Infect Dis. 2000; 53: 107-110. 8. United Nations. Universal declaration of human rights, Article 25. Geneva: UN, 1948. 9. United Nations. International Covenant on Economic Social and Cultural Rights. Geneva: UN, 1976 Competing interests: None declared |
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Sakthidharan P Karunanithi, Specialist Registrar in Public Health Blackpool Primary Care Trust, Blackpool, FY1 6JX
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Dear Editor, Randomised control trials, which are higher up in the hierarchy of evidence, are more difficult to do in a community setting and the authors’ efforts are commendable. The title of the study clearly attracts the attention of anyone passionate of reducing health inequalities by tackling the wider determinants such as housing. Though there is clearly an improvement in self reported health outcomes in the intervention group, the difference is not statistically significant in terms of objectively measured health outcomes like use of primary care and hospital admissions which denotes a possibility of responder bias. Also, it is unclear whether insulating existing houses had any effect on health inequality in terms of reduction in the health gap between different socio economic areas. The study clearly indicates that insulating houses can increase the mean bedroom temperature from 13.6oC to 14.2oC, i.e. a 0.6oC rise due to insulation, which is statistically significant (P=0.04) due to a large sample size1. The energy usage in insulated households were only 81% of the control households (P=0.0006). According to the UK fuel poverty strategy, the recommended minimum temperature levels that maintain health in the living and other used rooms are 18oC and 16oC respectively2. Therefore, though there is a statistically significant evidence that insulating houses can increase the indoor temperature by 0.6oC, it alone cannot achieve a desired level of temperature rise of 4-5oC to maintain health. Perhaps we need to consider both heating our homes as well as insulating them and not just insulate them to reduce the winter related morbidity and mortality. 1. Howden-Chapman P et al. Effect of insulating houses on health inequality: cluster randomised study in the community. BMJ 2007; 334:460 2. Department of Trade and Industry and Department for Environment, Food and Rural Affairs. 2001. The UK Fuel Poverty Strategy. London:Department of Trade and Industry and Department for Environment, Food and Rural Affairs. Competing interests: None declared |
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