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.
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P, Matheson A, Crane J, Viggers H,Cunningham M, Blakely T, et al.2007. Effect
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J. & Higgins, D.L., 2002. Housing and Health: Time Again for Public Health
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