Health Evidence hosted a 90 minute webinar that focused on changes in any health and associate socioeconomic outcomes following housing improvements. Key messages and implications for practice were presented on Tuesday May 20, 2013 at 11:30 am EDT. This webinar focused on interpreting the evidence in the following review: Thomson, H., Thomas, S., Sellstrom, E., and Petticrew, M (2013). Housing improvements for health and associate socioeconomic outcomes (Review). Cochrane Database of Systematic Reviews, 2013(2): Art. No:CD008657 Hilary Thomson, the review author, lead the webinar.

1. Welcome!
Housing improvements for
health and associated socio-
economic outcomes: What’s
the Evidence?
You will be placed on hold until the webinar begins.
The webinar will begin shortly, please remain on the line.

2. What’s the evidence?
Thomson, H., Thomas, S., Sellstrom, E., and
Petticrew, M. (2013). Housing improvements
for health and associate socioeconomic
outcomes (Review).Cochrane Database of
Systematic Reviews 2013, Issue 2. Art.
No:CD008657.DOI:10.1002/14651858.CD00865
7.pub2.
http://www.healthevidence.org/view-
article.aspx?a=23638

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4. Welcome!
Housing improvements for
health and associated socio-
economic outcomes: What’s
the Evidence?
You will be placed on hold until the webinar begins.
The webinar will begin shortly, please remain on the line.

5. The Health Evidence Team
Maureen Dobbins
Scientific Director
Tel: 905 525-9140 ext 22481
E-mail: dobbinsm@mcmaster.ca
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Robyn Traynor
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Heather Husson
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Project Coordinator
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Research Assistant

6. What is www.healthevidence.org?
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inform

7. Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
3. Transparent process
4. Supports for EIDM available
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8. A Model for Evidence-Informed
Decision Making
Source: National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-
Making in Public Health. [fact sheet]. Retrieved from http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf

9. Stages in the process of
Evidence-Informed Public Health
9

10. Review
Thomson, H., Thomas, S., Sellstrom, E., and Petticrew,
M. (2013). Housing improvements for health and
associate socioeconomic outcomes (Review).Cochrane
Database of Systematic Reviews 2013, Issue 2. Art.
No:CD008657.DOI:10.1002/14651858.CD008657.pub2.

11. Importance of this Review
• Large volume of evidence reporting an association
between poor housing and poor health
• Poor housing has significant health impacts,
increasing incidence of illnesses (i.e., heart disease
and stroke) and premature death

12. Who has heard of a PICO(S)
question before?
1. Yes
2. No

13. Searchable Questions Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting

14. Review Focus: Thomson (2013)
P All populations from any region of the world and from
both industrialized and non-industrialized countries
I All physical house types which are static (that is not
caravans or house boats)
C No intervention/no comparison

15. Review Focus: Thomson (2013)
O Primary Outcomes: direct measure of health or mental
and physical illness, general measures of self-reported
wellbeing, and quality of life measures (health service
use was not included in health outcomes). Secondary
Outcomes: additional social and socio-economic
outcomes (i.e. fuel costs, household income, measures
of social contract, social exclusion, education,
employment, time off work)
Quality Rating: 10 (strong)

16. Senior Investigator Scientist (MRC/CSO Social and Public Health
Sciences Unit), University of Glasgow, Glasgow United Kingdom
Hilary Thomson

17. What do we know about the health
impacts of housing improvement?
A synthesis of research evidence
Presented May 20, 2014
Hilary Thomson
MRC/CSO Social & Public Health Sciences Unit, University of Glasgow
This work is supported by the Chief Scientist Office, Scottish Government and the Medical Research
Council

18. Systematic review of health impacts of housing
improvement
Review question
• What are the health & socio-economic impacts of housing
improvement?
• Published as Cochrane & Campbell review (February
2013)
Thomson H, Thomas S, Sellstrom E, Petticrew M. Housing improvements for health and
associated socio-economic outcomes. Cochrane Database of Systematic Reviews 2013,
Issue 2. Art. No.: CD008657. DOI: 10.1002/14651858.CD008657.pub2.
http://doi.wiley.com/10.1002/14651858.CD008657.pub2

19. Systematic review: housing improvements for
health
• Broad approach
– Look at all available evaluations- not just randomised trials
» Controlled studies & uncontrolled studies
– Incorporate qualitative studies
– Include all health & socio-economic outcomes
• Systematic review of housing improvement
– Searched globally (39 databases)
– Grouped according to broad intervention type
» Warmth & energy efficiency (post 1985)
» Housing-led neighbourhood renewal (post 1995)
» Basic housing in Low & Middle Income Countries
» Historical studies of rehousing from slums (pre 1960)
– Conclusions prioritised better quality evidence

20. What we found
59,248 records screened
336 full-text articles assessed for
eligibility
Best available evidence included in synthesis
Quantitative n=19
• Warmth & energy efficiency n=11
• Rehousing/neighbourhood renewal n=6
• Rehousing from slums n=1
• Provision of basic housing needs=1
Qualitative n=9
• Warmth & energy efficiency n=5
• Rehousing/neighbourhood renewal n=4

21. Randomised controlled trials of housing improvement
Assess health of residents still waiting to move
BEFORE & AFTER (Control group) Intervention group
Compare BEFORE & AFTER house move (Intervention group)
1 year
1 year
• Control group move house after 1st year and enter intervention group
• Equal levels of eligibility for the intervention
1 year

22. Problems with controlled studies: selecting a
control group for comparison
INTERVENTION GROUP similar to CONTROL GROUP
Individual factors (age & sex) Individual factors (age & sex)
Individual deprivation (income, Individual deprivation (income,
employment, education) employment, education)
Housing type/quality Housing type/quality
Neighbourhood deprivation Neighbourhood deprivation
• Residents in control group should be similar to residents in intervention group –
EXCEPT for the house move/improvement
• Often not able to match for ELIGIBILITY for the intervention: area or individuals
offered the intervention are often selected due to greater need

23. Controlled Before & After studies
(Prospective controlled studies, controlled cohort studies)
ALSO assess health of similar residents who do not move
BEFORE & AFTER (Control group)
1 year
Assess health BEFORE & AFTER house move
(Intervention group)
1 year

24. Before & After studies
(Prospective uncontrolled studies, uncontrolled study)
Assess health BEFORE AND AFTER house move
• Assess change in (impact on) health outcome 1 year after
house move
» at same time of year as before measures
1 year

25. Problems of Before & After studies
• Not able to control for other important changes
which might influence health- do not know if health
would have changed anyway
• Health may change due to
» changes neighbourhood
» changes to income & state benefits
» changes in local services, amenities, transport, opportunities
» changes to individual circumstances (employment, family
changes, other ill health)

26. What we found:
Warmth & energy efficiency improvements
• Best available evidence (11 studies)
– 5 randomised controlled trials (RCTs)
– 5 controlled before/after studies
– 1 uncontrolled before/after studies
• Included
– loft/cavity wall insulation, double glazing,
central heating, lagging, flued heaters,
energy advice…

27. Warmth & energy efficiency improvements
• Mixed reports across studies
– Some improvements in mental health, respiratory
health, and general health
– Greatest improvement in RCTs in New Zealand
» Among those with respiratory illness
– Least improvement in UK studies
» General population
• Warmth improvements can lead to health
improvements
– especially when targeted at individuals with
inadequate warmth & chronic respiratory disease

28. Warmth & energy efficiency improvements: other
impacts
• Reduced time off work/school due to illness
• Increased usable space at home
– Improved household relationships
– Increased entertaining at home
• Increased control over home environment
• Reduced fuel costs (sometimes)
• Increased rent costs- protected by welfare
• Mechanisms for later health impacts?

29. Housing led neighbourhood renewal
• Best available UK evidence (n=6)
─ 6 controlled before/after studies
• Unclear impacts across different health
measures
─ Little indication of improved health
No changes statistically significant
─ Impacts reported in qualitative data
similar to those in warmth studies
»...but didn’t lead to health impacts-
WHY?

30. Comparing warmth only with programmes
of housing-led regeneration
• Studies of warmth improvements more likely to be targeted
according to individual need
– Studies which targeted those with poor health and living in poor housing
reported greatest health impact
» Comparing New Zealand & UK studies
– Greater potential to benefit across whole sample
• Housing led regeneration- area based need
– Wider range of intervention type
– Additional neighbourhood change/relocation
– More potential for disruption related to improvement
– Not targeted according to individual need
» Less consistent potential to benefit across whole sample
» Those who benefit most are hidden by the mean improvement in health

31. Why the small impact on health?
• Evaluations only assess short term impacts
– Health impacts may be seen years after event
• Delivery of tangible improvements in housing conditions was rarely
confirmed in studies
– Was new heating system used by residents?
– Were baseline conditions affecting health?
• Complex interaction of influences on housing & health
– Historical study of rehousing from slums: increased mortality following
rehousing explained by increased rents and inability to buy food
• Housing improvements only one factor in link between poverty & poor
health
– Link between housing & health perhaps not as strong as assumed
– Is addressing one factor likely to lead to break link between poverty & health?

32. What about impacts on proxy
measures of health?
?
Examine immediate impacts on socio-economic
determinants of health to shed light on pathways to longer
term health impacts

33. Pathways from housing improvement to
health improvement
• Examine impacts on socio-economic determinants of
health
– Proxies for health impacts:
» may be detectable in the short timescale of evaluation
» point to potential for future health impacts
– Mediating factors:
» explain absence of or small health impacts observed
» Identify ways of maximising potential for health benefits in future

34. Logic model mapping reported qualitative and quantitative
impacts/pathways following warmth and energy efficiency
improvements, and rehousing/retrofitting

35. Summary of short term impacts of housing
improvement
• Housing improvement is likely to affect:
– Domestic space & design appropriate to needs
– Thermal comfort
– Housing costs
– Attitudes to home- satisfaction & control over living environment
• These may act as mechanisms through which housing improvement
might lead (or may not) to longer term improvements in health or
wellbeing

36. Conclusions of systematic review:
health impacts
• Improvements in warmth can lead to health improvements, but
cannot be assumed
– Improvements seen in New Zealand RCTs
– But less conclusive in UK studies
– No evidence of harmful effects
• Greatest potential for health improvement is where improvements
targeted at those with inadequate warmth and with chronic
respiratory disease
• Unclear health impacts reported in studies of housing led-
neighbourhood renewal
– No evidence of harmful effects

37. Conclusion
• Housing improvement is likely to affect:
– Domestic space & design appropriate to needs
– Thermal comfort
– Housing costs
– Attitudes to home- satisfaction & control over living environment
• These changes have the potential to lead to longer term health
impacts
• Health housing investment should aim to provide
affordable thermal comfort in housing of appropriate size
& design to meet household needs

38. A Model for Evidence-Informed
Decision Making
Source: National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-
Making in Public Health. [fact sheet]. Retrieved from http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf

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