Transcript No Slide Title

He Kainga Oranga/
Housing and Health Research
Programme
University of Otago, Wellington
Strategy Day
July 2012
THE HOME STUDY
THE TEAM: Julian Crane, Philippa Howden-Chapman, Kristin Wickens,
Caroline Shorter, Phillipa Barnes, Nevil Pierse, Thorsten Stanley,
Jeroen Douwes, Janice Kang, Bob Draper and Steve Scott.
WHAT: To look at whether the home environment (particularly mould and
leaks) is associated with the onset of wheezing in children aged 1 to
6 years.
WHY:
- home environment known to exacerbate asthma symptoms
- want to know if home environment is associated with the onset of
wheezing
HOW:
- based on a study done in Finland
- incident case control study with 150 cases = history of wheezing
requiring treatment for the first time in previous 12 months and 300
controls = no wheezing history
- matched on age, gender and location
- involves 2 visits from the research team and an independent
building assessment
Recruitment:
54 medical centres were involved with recruitment
Cases were recruited either directly by a nurse or doctor, through self referral
from posters or from invitation letter from the medical centres.
Controls were recruited only from invitation letter from the medical centres.
What the study involves:
A total of 3 visits – 2 from the health research team and 1 from the building
assessor.
Visit 1:
-Health and housing questionnaire
- Skin prick test
-Height and weight
- Dust samples
-Static dust cloths
- Temp & humidity
Visit 2: a brief visit which involves removing the static dust cloths and taking
photos with the IR camera.
Visit 3: a building assessment which looks at the home from a respiratory
point of view. Looking at aspects like insulation, sun exposure and presence
of mould and leaks. The assessment was developed based on the healthy
housing index.
The Home Study
Progress
• 450 children visited, 4 wks final shelf pickups
and BAs
• Results so far:
• Self reported leaks are more prevalent amongst
our case children than control children
 48% cases have at least one leak vs 33% of controls
(P≤0.05)
 Appears to be more leaks per house for case children
than our control children also (mean 1.51 leaks vs
1.35 leaks)
• Higher levels of mould are observed in case
than control bedrooms
 Mould score (cumulative mould in child’s bedroom, 4
categories)
 Higher mould score +vely related to case status
 Mould score is independently linked to colder
more humid bedrooms
 Smell of mould more prevalent in case than control
bedrooms
The Home Study
Analysis Plan
• Immediate outcomes (3 months)
 i-button data, SPT atopy, health
questions, home questions, mould
assessments
• Intermediate outcomes (6 months)
 Building assessments , mould tape
samples
• Longer term outcomes (12 months)
 Static cloth analysis, IR camera pictures,
Dust
• Challenges & opportunities
 Money needed for further analysis
 Asthma foundation, WMRF applications
 Future research: intervention study to
prevent wheezing, study to understand
mechanism involved (irritant or allergy),
follow up study – do the children go on to
develop asthma, and do our controls
THE HOME STUDY EXTENSION
(RHINO STUDY)
WHAT: An intervention study : To investigate the incidence of Rhinovirus
(hRV) in NZ children (Phase 1) and examine whether heating and
removal of mould in children’s bedrooms can reduce the occurrence
and/or symptoms of Rhinoviruses in children (Phase 2).
WHY:
Growing evidence that cold, damp indoor environments may be
a critical co-factor in facilitating viral transmission and infection.
Viral-induced wheezing in infancy associated with an increased
risk for asthma development in later childhood
Rhinovirus (hRV)- most common virus to infect children
- been implicated in asthma exacerbation
- Non-lipid viruses, such as hRV, tend to survive longer in
higher RH environments
can we change the environment and reduce colds?
THE RHINO STUDY
HOW:
Revisit HOME study participants.
Phase 1: Children will be swabbed for hRV, cold symptom diary
filled in for four weeks, i-button in home for %RH & temperature.
Measure nasal swabs for incidence of Rhinovirus in NZ pre
intervention
Phase 2: During the seasons of highest hRV carry out
intervention in half of the participants homes,
- raising the bedroom temperature to 18°C for at least 4 weeks,
- removing any visible mould that is present.
- Children will again be swabbed at visit 1 and 2, and a cold
symptom diary carried out.
UORG Pilot study - have tested Phase 1.
FURTHER OPPORTUNITIES: further intervention studies (probiotics), viral
transmission, environmental transmission (surfaces)
DISCUSSION POINTS: Placebo or none, who is eligible eg whether to
intervene in a warm home, no mould, no colds.
Peter Larsen
Movie
WHEZ 1 - Helen Viggers
Timing
Autumn
2010
Winter
2010
Spring
2010
Summer
2011
Autumn
2011
Winter
2011
Spring
2011
Wave 1 Early
Interview
Voucher
Interview
Diary
Interview
Diary
Interview
Wave 1 Late
Interview
Interview
Diary
Interview
Voucher
Diary
Interview
Wave 2 Early
Diary
Interview
Voucher
Diary
Wave 2 Late
Diary
Interview
Diary
Summer
2012
Autumn
2012
Winter
2012
Spring
2012
Interview
Interview
Diary
Interview
Interview
Interview
Voucher
Diary
Interview
709 applications -> 287 Wave 1
(27 known deaths, 31 withdrawals
various)
-> 235 Wave 2
(20 known deaths, 37
withdrawals various +11)
e.g. 52% phlegm most days of week;
42% able to walk only 100m or less before
stopping for breath,
Home heating & fuel poverty &
consequences
Next 3 years
WHEZ 1 finished. Results analysed.
Outcome of fuel voucher (health).
Mechanism for outcome. Chch subanalysis.
Effect of insulation on self reported temp cf
objective temp.
Metered out: self reported cold & coping
strategies (psych & physical)
WHEZ 2: resp, temp & cardiac function.
In the dark: Investigating fuel poverty and
the use of prepayment meters for electricity
in NZ – Kim’s PhD thesis
What: (1) Nationwide postal survey of prepayment meter
users (vulnerable to FP) in 2010, follow-up survey in 2011
Why: to investigate prepayment metering from a consumer
perspective, explore rates of 'self-disconnection’ (cut off)
What (2) Metered Out interview study qualitative
component with HV, PLHC
Why: to get context of budgeting for electricity with ppm –
analysis underway
Outputs: 1 paper published, 1 submitted, 2 on the go
Future Directions: Thesis submission end Oct, post-doc
ideas = kids in FP in NZ, ?collaboration in Saint Louis, MO
(come visit!)
Project: HIPI (Home Injury Prevention Intervention) Study
What: Randomised controlled trial of 850 households. Half receive the
treatment at the beginning of the study, half at the end. Treatment involves
fixing slip/trip/fall hazards identified in these houses. Extended to include
Maori housing from Te Hoe Nuku Roa.
Why: Home injury is very common and costly to society. There is no
evidence internationally to indicate that fixing home hazards can reduce
home injury. This is because of a lack of well-performed trials. The results of
the HIPI study can guide injury prevention measures both in New Zealand
and internationally
Outputs: Study only just being completed, so no results yet
Opportunities: Perhaps a justification for major investment
in housing improvement
Collaborating:
Otago, BRANZ and Massey;
observing interest from ACC
Contact: Michael Keall
Project: Health Housing Index (HHI) Study
What: A measure of housing quality in relation to health outcomes and
sustainability. Developed to suit NZ conditions. Questionnaire administered
by trained inspectors.
Why: Housing has important impacts on health, safety and the environment.
NZ housing needs to be improved. Measuring housing quality provides
motivation and direction for improving housing with health, safety and
environmental benefits. Various potential uses: at individual house level; at a
neighbourhood / regional / national level
Outputs: 3 papers published in international journals; 1 under review.
Opportunities: An important research tool; building a case for major
investment in housing improvement; buy-in from agencies
interested in housing (providers, regulators, landlords, etc)
Collaborating agencies: Otago, BRANZ and Massey
Contact: Michael Keall, Julie Bennett
The Healthy Housing Index
 Draft development plan.
 Draft implementation plan.
× Implementation of the HHI into a
commercial application.
• The HHI tool and associated material.
• The Users and Stakeholders of the HHI.
• The HHI resource.
Other potential projects
× Exploring differences between
the health of occupants in social
and private rentals.
× Exploring the relationship
between paediatric hospital
admissions and housing quality.
Statistical Methodology
What: Through what specific mechanisms are our interventions
effecting health?
Why: To remove black box nature our interventions we need to
understand how much is due to each factor in the intervention?
HIPI: (Michael K) Intervention is multifaceted (rag bag) of
injury prevention measures, which bits work on which health
outcomes in which populations. Also better models and
subgroups.
WHEZ: (Helen) Hypothesis can be broken into that electricity
vouchers improve “temperature” and “temperature” effects
COPD and HRV.
RHINO: (Kristin+) Hypothesis can be broken into that the
intervention effects mould/temperature/humidity and these
effect the URTI (colds).
Others
Castle: (KC +SB) Housing and mental health study,
pathways are income, wealth, value of house, area
of home and overcrowding.
SHIVERS: (Michael B) VE time propensity of sick
people to vaccinated, test case negative design.
ARF: (JO + MB) What factors effect surveillance
systems?
Placebo Effect: From PHD to allow some
adjustment for placebo effects in our RCTs.
Goal: Write more papers 
Evaluation of the WUNZ:HS
programme
• $340 million 4 year programme [2009-2013]
part-funding insulation and heating retrofits.
• MED commissioned evaluation completed
Oct 2011. [Collaboration with Motu and
Victoria]
• Positive outcomes included reduction in
hospitalisation costs and mortality rates
• MED funded extension: Intention is to extend
health dataset to further explore previous
findings
• Also basis of Nick Preval PhD.
WILUTE
What: Wellington Integrated Land Use, Transport &
Environment model; It is to evaluate land use, transport &
housing development policies and future scenarios in terms of
transport-related environmental and social effects.
Why: (1) How does the development of the transport and land
use system affect pollutants emissions from transport in the
region? (2) To what extent transport system and traffic volume
in different suburbs are vulnerable to sea-level rise caused by
tsunami and storm surge?
Opportunities: Apply to other cities and regions.
Contact: Pengjun Zhao, Ralph Chapman, Philippa HowdenChapman, Ed Randal, Angus Hulme-Moir
Transport system and traffic volume
vulnerable to sea-level rise
21
Housing,
Crowding &
Infectious
Diseases
Prevalence of exposure to household crowding (2+
bedroom deficit) by selected ethnic group and census
year, for children <15 years, 1991-2006
Percent
25
20
15
10
5
0
European/other
Maori
Pacific
Selected ethnic group
1991
1996
2001
2006
Total
Child Hospitalization in relation to housing
Child (<15 years) admissions by year 2000-2010
2000
12000
2001
10000
2002
8000
6000
0
Total Admissions
3000
2500
2004
2000
2005
1500
2007
2000
3500
2003
2006
4000
Average child admissions by month 2008-10
1000
2008
500
2009
0
2010
Average annual admissions by ICD-10 chapter 2008-10
4000
Infections/parasitic diseases
Neoplams
Blood/immune disorders
3500
Endocrine/nurtitional/metabolic diseases
Mental/behavioral diseases
3000
Nervous systems diseases
Eye/adnexa diseases
2500
Ear/mastoid diseaes
Circulatory diseases
2000
Respiratory diseases
Digestive system diseases
1500
Skin/subcutaneous diseases
Muscloskeletal/connective tissue diseases
1000
Genitourinary diseases
Perinatal conditions
500
0
Total admissions
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Congenital malformations
Other
Total admisions
Injury/poisioning
*excludes data for new born babies and pregnancies
Child Hospitalization in relation to housing
What: Potentially modifiable risk factors for acute child
hospital admissions in the Wellington Region compared
with San Antonio area children
Why: Children are vulnerable; poor housing conditions in
New Zealand
Outputs: Screening tool; international comparison; identify
prevalence of PAH; measure prevalence of risk factors
(i.e. crowding, heat source, hazards) in child
hospitalization; MPH thesis>DrPH dissertation
Short Clinical Screening Tool for Adverse
Housing Factors Contributing to Pediatric
Hospitalisations
What: Impact of housing factors (household crowding,
damp/mould, heating/insulation, etc.) on ped. hospitalisations
Why: Many potentially preventable pediatric hosps in NZ;
housing conditions are an important factor in health outcomes;
interventions that work are available
Outputs: (1) screening tool for clinical use; (2) integration into
a larger network of care/intervention.
Opportunities: Connection to other work investigating links
between housing conditions and health. Good support from
clinicians and frontline workers.
Collaborating/funding agencies: ? (possibly extending to
Boston/USA, Sweden); Lotteries Health, HRC feasibility study
Contacts: Jens Richter
Housing Issues - Disabled and Elderly People
• Accessible housing (in the rental market)
• Aging population means more impairments and
competition for accessible housing – where do
people go? Close to social networks?
• Cost and tenure/permission to modify houses
• Low income populations
• ‘Housebound’
• Location of housing in relation to transport,
community facilities and social networks
Research Interests
• Accessing housing
• ‘Housebound’ – cultural, environmental
• The way disabled/elderly people negotiate social and
relationship/family private spaces, when they can’t
access public spaces.
• Housing location and accessing the community
• Social networks and community and their disruption
and reformation due to housing crises
Housing Standards in the rental sector: Hope and a prayer
What: How are housing standards enforced in the tenancy
tribunal?
Enforcement:
“the landlord would be foolish not to carry out repairs at
the end of the tenancy”
“Generally an older house will be colder than a newer
house because of the lack of insulation. A tenant who
chooses to rent an older house cannot complain about
that”
Conclusions: Tribunal enforces subjective and unstandardised
measure. No power to compel repair – rather, the tenancy is
terminated and the house goes back on the market.
In effect, often no enforcement of housing standards.
OUTPUT: paper, disseminate to Tribunal Adjudicators and Local
Council re referral of uninhabitable housing to Local Council?
Housing quality in the rental sector
Negotiating housing conditions:
How do tenants respond to problematic housing conditions?
Why: Only 5 % of complaints to TT concern housing quality.
Little recourse for tenants living in poor quality housing. High
mobility. Split incentives for repair, especially in lower cost
housing.
Data:
•Further review of tenancy data held at DBH and MoJ
•Interviews with tenants?
•Survey of tenants? – Similar to 2004 survey of landlords?
Opportunities: Collaboration on data set? Interviews and/or
survey used for multiple RQ?
Outputs: Write & publish papers. Increased collaboration with
local council and TT/DBH?
A Comparison of the Regulation of
private rental housing in NZ with
eight other countries
• What: regulation of private rental housing
in NZ compared with chosen countries
• Why: over quarter of NZ population lives in
private rental housing, neglected policy
area, poor quality, disparities exist
• Outputs: (1)Master’s dissertation (2)
papers & posters
• Opportunities: contribute to other housing
research on effective regulation and how to
implement it
Private rental housing quality standards employed in USA (left) & Scotland (right)
The renters’ voice: initial thoughts
Civil society
• Good democracy and good policy
require a vibrant civil society.
• Advocacy and activism role of civil
society limited in NZ (small society;
funding arrangements).
• Private and state renters have
organised differently (advocacy vs
direct action).
• Renters are not an organised group in
NZ, esp. compared to other places, eg
Victoria (supported by state)
• The absence or presence of the
renters’ voice affects housing policy.
Renters
• Policy is biased towards homeownership and against renters.
• Number of private renters increasing
(house prices; HNZ policy changes).
• Renters more likely to experience poor
health outcomes due to tenure
insecurity and poor quality housing.
State tenancies increasingly insecure.
• Landlords are an organised group.
• Difficulties inherent in organising
renters.
• Renters have a weak political voice to
challenge policy.
Like in other countries, a renters organisation that
campaigned and lobbied on issues affecting renters in
New Zealand could improve health outcomes.
Sustainable Social Housing
What: A policy paper on social housing reform using
sustainability as a framework.
Why: Improve social housing policy, planning, action and
measurement.
Outputs: Report to Fulbright NZ and Department of Building
and Housing. Partnerships for Social Housing workshop. Te
Papa talk, IPANZ presentation
Opportunities: Applies to the entire housing sector.
Partnerships between central and local government, iwi, the
private sector and third sector
Collaborating agencies: Department of Building and Housing
(Ministry of Business, Innovation and Employment)
Contact: Philippa Howden-Chapman, Christian Stearns
Discussion points
1. Think – Sustainability as a framework for social
housing policy
2. Plan – Social housing as part of the sustainable
community infrastructure
3. Act – Sustainable community partnerships
4. Measure – Sustainable Return on Investment
(SROI)
The Advantages and Disadvantages of Boarding Houses
Clare Aspinall MPH Student
Qualitative, Grounded Theory, semi-structured interviews, nine participants, 3 health
workers, 2 boarders, 4 Landlords or managers
Definition of boarding house =
“(a) containing 1 or more boarding rooms along with facilities for communal use by the
tenants of the boarding house; and
“(b) occupied, or intended by the landlord to be occupied, by at least 6 tenants at any one
time.”
• The drivers for living in boarding house
• Provide insight into the experiences of living in these dwellings
• Explore options to improve boarding houses, particularly for those with
poor health and disability
Results
Drivers
•
Affordability, lack of available
alternatives for those on low
incomes, particularly those with
poor health and disability, Debt.
• Location, convenience,
• Those leaving institutions (prison,
hospital, CYF), new migrant
workers, relationship breakdown.
Experiences
• Physical and social environments
varied from “boutique” to
“squalid”(this at times varied within
the boarding house).
• Strict entry criteria for the midrange places excluding people on
benefits.
•
Better linkages between health and
social services and landlords in
places housing vulnerable
boarders.
What could be done?
•
•
•
•
•
Increase the tenancy rights of
boarders’ to those equal to others
under the RTAA (2010).
Proactive inspection of all boarding
houses, regular inspection of those
housing vulnerable people.
Improve release and discharge
from institution practices to reduce
dependency on poorest places.
Better linkages between health and
social services and landlords in
places housing vulnerable
boarders.
Check landlord and managers
credentials