Wednesday, 24 December 2014

What the shitting hell has my home got to do with public health?

Well established links between poor housing and poor health indicate that housing improvement can be an important mechanism through which investment can lead to health improvement. Interventions to upgrade the housing fabric typically involve substantial changes to housing and may affect exposure to a range of potential hazards. For example, energy efficiency measures may result in improved warmth, elimination or containment of mould or damp and improved air-quality as well as reduced fuel costs.

In addition, associated socio-economic factors may impact the potential for health improvement and housing improvement. Therefore, improved housing conditions may be regarded as an intervention which impacts on the well-established link between poverty and poor health.

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease.

Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.

Temperature & Energy efficiency

The evidence for England shows the majority of excess winter deaths occurring in those aged 75 and over, with the greatest number among women aged 85 and over. A report linked to the English House Conditions Survey found a relative risk for those aged 85 and over of 1.28 (1.13 to 1.46) compared to those aged 0-44 (Wilkinson P et al. 2001)

The main causes of excess mortality and morbidity in the winter season are cardio-respiratory disease (including CHD, cerebrovascular disease, asthma and COPD). Increases in disease rates and exacerbations of chronic conditions will inevitably put extra stress on health and social care services.

Evans et al (2000) found that people unable to “keep their house warm enough most of the time” where more likely to use outpatient departments (OR 2.1, 95% CI 1.4 – 3.3) and visit the GP four or more times (OR 1.80, 95% CI 1.2 – 2.7). Clinch & Healy (2000) compared winter related mortality in Ireland with that in Norway and found and that cardiovascular and respiratory disease is higher in Ireland (2.1 and 1.4 times that in Norway respectively). This difference they believe is related to poorer housing conditions in Ireland. Additionally there has been an observed greater improvement in self-reported health in housing improvement intervention groups compared to the control groups (proportion reporting self-reported health improved since intervention 29% versus 13%) (Braubach 2008).

Paradoxically, it has been found that that the gradient for levels of excess winter mortality is at its highest in countries with the mildest winters and lowest in the coldest countries (WHO 2005), indicating that housing in the warmer countries is poorly suited to cold weather.

There is some evidence that, below 15°C, cold is a risk factor in increasing asthma severity and COPD and may also delay recovery after discharge from hospital (Howden-Chapman 2004). Further studies, including households where at least one member had a diagnosed respiratory condition, among children (Howden-Chapman 2008) and adults (Howden-Chapman 2007), reported statistically significant lower levels of fair or poor health among the intervention group compared with the control group (OR 0.48, 95%CI 0.31 to 0.74, children; OR 0.50, 95% CI0.38 to 0.68, adults).  Furthermore, a European wide study by Analitis et al (2008) showed that a 1°C decrease in temperature was associated with the following mortality risks:

All natural deaths : 1.35% (95% CI: 1.16, 1.53)
Cardiovascular death: 1.72% (95% CI: 1.44, 2.0)
Respiratory death: 3.30% (95% CI: 2.61, 3.99)
Cerebrovascular death: 1.25% (95% CI: 0.77, 1.73)

A study by Jacobsen et al (1999) of hip fracture incidence among women aged 45 years and older found that the risk of hip fracture was increased on days with snow or freezing rain. However, among women aged 75 years and older, the effect of ice and snow were not strongly related to fracture occurrence. Similarly a study of hip fracture by Levy et al (1998) reported freezing rain as a particular risk factor and that the association of cold weather with hip fracture was stronger among younger men and women than for older persons.

It is likely then that the risks for hip fracture are greater in younger adults because of activity patterns, i.e. working age adults are more likely to go out in inclement conditions than older adults.

There is a common assumption that rural populations are more likely to be at risk of cold exposure and hence of cold-related mortality and morbidity, however, there is little evidence to support this. For example, a recent time-series analyses using national (English) data linked to small-area markers of urban-rural status have also shown no clear evidence of association between rurality and cold-related mortality or morbidity (Hajat et al 2013).

Hajat et al (2013) also found no evidence of effect modification of the cold-risk by area-level measures of deprivation. In fact they actually found that the most deprived quintile was associated with the lowest point estimate of cold-related relative risk. This is consistent with findings from similar studies into deprivation and cold related deaths. This is likely due to the conditions of housing stock varying with deprivation; people from more deprived areas will be more likely live in social housing built to good standards, whereas people in more affluent areas will typically live in older housing with poorer thermal efficiency.
It is not only the cold that can impact on a person’s health. During the heat wave in southern England in 2003 the temperature reached over 30°C for 10 days, this resulted in 1,599 deaths, 82% of which were in the over 75’s and of these 33% occurred in their own home (ONS 2006). Kaiser et al (2001) found an increased risk of heat related illness for the mentally ill and Kilbourne et al (1982) found and increased risk of heatstroke (both fatal and non-fatal) for those unable to care for themselves.

In a review of the literature Basu & Samet (2002) found that excessive heat (greater than 20°C) can lead to increased mortality from cardiovascular, respiratory and cerebrovascular diseases. Naughton et al (2002) examined data from a heat wave in Chicago in 1999 and found that, for heat related deaths, the strongest risk factors where living alone (OR=8.1; 95% confidence interval, 1.4 – 48.1) and not leaving home (OR=5.8; 95% CI, 1.5 – 22.0) whilst the strongest preventative factor was having working air conditioning (OR=0.2; 95% CI, 0.1 – 0.7) (Naughton et al. 2002).

Other housing impacts on health (not temperature related)

Although temperature is not significantly related to injuries, many people, especially older people, may not have sufficient physical control to negotiate stairs and so have a high risk of a fall. In a sample of 310 non-disabled older adults, more than 45% reported difficulties in climbing stairs, and about 36% reported difficulties in stair descent (Verghese et al. 2008).

Overcrowding and inadequate ventilation can increase moisture in the interior atmosphere. Damp houses provide a nurturing environment for mites, roaches, respiratory viruses, and moulds, all of which can lead to an increased likelihood of respiratory infection and, in extreme cases, encourage the transmission of tuberculosis (Krieger & Higgins 2002).

Domestic conditions are more strongly related to depression in women than any other socio-economic factor with a relative risk of malaise of 4.00, lowest compared to highest domestic conditions (Bartley et al. 1992). Crowding has been associated with psychological distress among women (Krieger & Higgins 2002) for both high (1 - 1.5 persons per room) and low (<0.5 persons per room) densities (Gabe & Williams 1986). Whilst there is little evidence to suggest overcrowding has an impact on men’s mental health, this is not the same as saying no such effect exists.

Although overcrowding has been linked to a child mental health this is thought to be a confounder in analysis regarding damp or mould housing conditions. Whilst overcrowding can lead to damp or mouldy conditions it is not the overcrowding itself that leads to poor physical/mental health in children (Platt et al. 1989).

Long-term noise exposure has been associated with an elevated risk of cardiovascular disease   (Babisch et al. 2005; Willich et al. 2006) and an inability to cope with noise can lead to additional emotional stress (WHO 2005) and prevalence ratios for hypertension between high and low noise groups range from 0 to 3.1. The relative risk for hypertension in adults has been found to be increased by continuous and strong noise annoyance by approximately 40 % in the European cities (WHO 2005).

Whilst an association with air traffic noise exposure and hypertension has been found to be statistically significant RR5 dB(A) =1.26 (95% CI 1.14 – 1.39), a positive association with road traffic and myocardial infarction and ischemic heart disease was not. Babisch et al (2005) found an odds ratio for exposure to sound levels of more than 70 dB(A) during the day was 1.3 (95% CI 0.88 – 1.8) compared with those where the sound level did not exceed 60 dB(A).

Analitis A, Katsouyanni K, Biggeri A, et al. 2008. Effects of cold weather on mortality: results from 15 European cities within the PHEWE project. Am J Epidemiol; 168(12): 1397-408.

Babisch, W. et al., 2005. Traffic Noise and Risk of Myocardial Infarction. Epidemiology, 16(1), 33 – 40

Basu, R. & Samet, J.M., 2002. Relation between Elevated Ambient Temperature and Mortality: A Review of the Epidemiologic Evidence. Epidemiologic Reviews, 24(2), 190-202.

Braubach M, Heinen D, Dame J. Preliminary results of the WHO Frankfurt housing intervention project. Copenhagen:World Health Organisation, 2008.

Clinch, J. & Healy, J., 2000. Housing standards and excess winter mortality. Journal of Epidemiology and Community Health, 54(9), 719-720

Evans, J. et al., 2000. An epidemiological study of the relative importance of damp housing in relation to adult health. Journal of Epidemiology and Community Health, 54(9), 677-686

Gabe, J. & Williams, P., 1986. Is space bad for your health? There relationship between crowding in the home and emotional distress in women. Sociology of Health and Illness, 8, 351 - 71.

Hajat S, Chalabi P, Jones L, Wilkinson P, Erens B, Mays N. 2013. Evaluation Of The Implementation And Health-Related Impacts Of The National Cold Weather Plan For England (interim report to the Dept. of Health). London: Department of Health.

Howden-Chapman, P., 2004. Housing standards: a glossary of housing and health. Journal of Epidemiology and Community Health, 58(3), 162 -168.

Howden-Chapman P, Matheson A, Crane J, Viggers H,Cunningham M, Blakely T, et al.2007. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ;334.

Howden-Chapman P, Pierse N, Nicholls S, Gillespie-Bennett J, Viggers H, Cunningham M, et al.2008. Effects of improved home heating on asthma in community dwelling  children: randomised controlled trial. BMJ; 337

Jacobsen SJ, Sargent DJ, Atkinson EJ, O'Fallon WM, Melton LJ. 1995. 3rd. Population-based study of the contribution of weather to hip fracture seasonality. Am J Epidemiol; 141(1): 79-83.

Kaiser, R. et al., 2001. Heat-related death and mental illness during the 1999 Cincinnati heat wave. The American Journal of Forensic Medicine and Pathology: Official Publication of the National Association of Medical Examiners, 22(3), 303-307.

Kilbourne, E.M. et al., 1982. Risk Factors for Heatstroke. JAMA: The Journal of the American Medical Association, 247(24), 3332 -3336.

Krieger, J. & Higgins, D.L., 2002. Housing and Health: Time Again for Public Health Action. Am J Public Health, 92(5), 758-768.

Levy AR, Bensimon DR, Mayo NE, Leighton HG. 1998. Inclement weather and the risk of hip fracture. Epidemiology; 9(2): 172-7.

Naughton, M.P. et al., 2002. Heat-related mortality during a 1999 heat wave in Chicago. American Journal 
of Preventive Medicine, 22(4), 221-227

ONS, 2006. Mortality in Southern England during the 2003 heat wave by place of death. Available at:

Platt, S.D. et al., 1989. Damp housing, mould growth, and symptomatic health state. BMJ: British Medical Journal, 298(6689), 1673-1678.

Verghese, J. et al., 2008. Self-reported difficulty in climbing up or down stairs in nondisabled elderly. Archives of Physical Medicine and Rehabilitation, 89(1), 100 - 104

WHO, 2005. Report on the WHO technical meeting on quantifying disease from inadequate housing.

Wilkinson P, Landon M, Armstrong B, et al. 2001. Cold comfort: the social and environmental determinants of excess winter deaths in England, 1986-96. Bristol: Policy Press

Willich, S.N. et al., 2006. Noise burden and the risk of myocardial infarction. European Heart Journal, 27(3), 276 -282

Yawn, smoking, here we go again...

Physical health: There is a wide body of evidence demonstrating a causal link between tobacco and various health issues: lung cancer and other respiratory conditions, stroke, CVD and CHD (Sim & McKee 2011).  That disease incidence/prevalence could be reduced significantly by the reduction in tobacco consumption, and that there are effective strategies to do this, puts tobacco control within the scope of public health. Additionally, that some of these diseases found in non-smokers can be attributable to passive smoking (Sim & McKee 2011) indicates that this is not just a personal choice that only affects the individual, but that it has a deleterious effect on the environment around them and consequently others.

Health inequalities: Consumption of tobacco is mechanism that prevents the reduction of health inequalities. People suffering from higher levels of deprivation both within and without the higher income countries will likely have poorer knowledge of and/or access to the health care system within their country, resulting in poorer outcomes form smoking related diseases than there more affluent counterparts. They are also likely to smoke more (ASH 2014), increasing their risk of disease, and have more co-morbidities, reducing the likelihood of a successful outcome. A higher prevalence of disease within the more deprived groups means more time away from work and a lowering of their earning potential. This implies that they and their children will have poorer access to education and therefore are less likely to escape the cycle of deprivation and health inequalities.

Cost to the health budget: Treatment and care of people with diseases, wholly or partially attributable to tobacco is very expensive. If the prevalence of tobacco attributed disease where reduced then the money freed up could be put to use elsewhere within the overall health and care economy.

Freedom of choice: The tobacco industry may claim that, in a free society, a person has a right to be unhealthy and a right to choose to smoke. However, there are several arguments against this position. One, that whilst the individual may have a right to be unhealthy they also have a duty not to cause undue harm to others. Whilst eating an entire cheese cake may be an unhealthy thing to do, it does not directly impact on the health of others around them, whereas someone who does not smoke can have their health affected by the second hand smoke from other smokers.  Second, there is the economic argument that money spent on the health care and treatment of those that suffer from tobacco attributable diseases is money taken away from the health care of those suffering from diseases not related to an avoidable risk (admittedly this is also true with eating a whole cheesecake and heart disease risk, but the risk from one cheesecake is likely small and I will fight anyone to the death who tries to ban cake). Finally, that tobacco is demonstrably addictive implies that smoking in not a truly free choice.  Also if the health consequences of smoking are not made clear the potential smoker is unable to make a truly fee and informed decision.

Jobs and national revenue: The tobacco industry claims that it is a growth industry providing employment to many people, especially in developing countries, and that sales and export taxes on tobacco crops and products provide governments with money enabling them to build roads, schools and hospitals. Whist this is undoubtedly true for some countries, Malawi receives 60% of its export earnings from tobacco, its impact on the economy is often overstated (Abdullah & Husten 2004). In developing countries the average earnings from tobacco are 0.16% of GDP (Abdullah & Husten 2004). Also following a ban on point-of-sale display bans a survey of found the cost to them to be small, around £300, (ASH 2024) so it is unlikely that, in most cases, tobacco control measure will have a significant impact on the overall economy.

Economic: Reducing global tobacco consumption will result in a reduced demand for tobacco crops. This could negatively impact those countries who are net exporters of tobacco. These countries are typically in the developing world and may not have other readily available natural resources with which to replace this cash crop. Additionally countries with significant economic power that export tobacco products to less economically powerful countries, which also rely on other imports, could come under pressure to relax tobacco import and control laws.

Education/ Social attitudes: In some countries little is known about the harmful effects of tobacco. With low general education levels, communication about the nature risk is difficult. As a result of a poor understanding of the addictive and harmful nature of tobacco, the desire for smoking cessation campaigns at individual and governmental level is likely to be low. Both of these issues will be block to any public health messages. In addition to these any message seen to come from and un-trusted government, could be easily ignored by the population. Any public health message would need to be locally driven in the community.

One further block to changing social attitudes is the prolific of smoking products. The tobacco advertising industry aims to associate smoking  with individual rights, independence and modernisation, as well as making smoking appear aspirational (Abdullah & Husten 2004) This is a powerful message for public health professional to combat, especially in an environment where little is known about the dangers of tobacco and pro-tobacco lobbyists are given plenty of money to ensure that governments are not persuaded to place curbs on advertising.

Public health resources: In developing countries with small public economies, public health programs are likely to be under resourced, and given the potential for a lack of understanding of the risks, tobacco control is likely to be a low priority.  Even if funding and political support for tobacco control where made available, with the poor infrastructure and an inadequately organised national public health system typically associated with these countries, the delivery of such interventions could be challenging.  For example if the coverage of the telephone network was far from complete establishing a quit line  would be an inefficient and ineffective use of precious resources (Abdullah & Husten 2004).

Variety of policies: Partly due to lack of public health resources, when a developing country does take action it is often in the form of economic sanctions on tobacco products,  such as higher taxes. Whilst they do have some positive effect (a 10% increase has been estimated to result in an 8% decrease in consumption, Abdullah & Husten 2004), they are crude measures and do not attempt to address the underlying social attitudes towards smoking. Additionally, by increasing the price to consumers, they can also feed into the advertising industries message that smoking is aspirational and a luxury. Also in a country with a tradition of street selling and a sufficiently organised criminal organisation, increasing tobacco prices, without changing attitudes, can lead to people buying their cigarettes on the illegal market. It has also been suggested that the tobacco industry has been complicit in tobacco smuggling  (Gilmore & Martin McKee 2002)

Abdullah, A., & Husten, C. (2004). Promotion of smoking cessation in developing countries: a framework for urgent public health interventions. Thorax, 59(7), 623–630. doi:10.1136/thx.2003.018820

ASH (2014) Smoking Statistics: Who Smokes and How Much

ASH (2012) ASH Briefing: Industry claims on point of sale display

Gilmore & Martin McKee (2002). Tobacco Control Policy: the European dimension. Clin Med JRCPL, 2, 335

Sim, F. & McKee, M. (2011). 'Issues in Public Health'. Open University Press