Housing Improvements for Health and Associated Socio‐Economic Outcomes: A Systematic Review

Poor housing is associated with poor health. This suggests that improving housing conditions might lead to improved health for residents. This review searched widely for studies from anywhere in the world which had investigated whether or not investment to improve housing conditions is linked with improvement in health. A huge amount of research on housing and health has been published but very few studies have investigated if improved housing conditions impact on residents' health. Neighbourhood renewal programmes often include housing improvements but a key aim of these programmes is to improve the area by attracting new residents, often those who are better off. In these programmes, improvements in health statistics may simply reflect a change in the population living in an area and the original population may not have benefited from the improved living conditions. This review only looked at studies where changes in health for the original population were being investigated rather than changes for the area. We identified 39 studies which assessed changes in health following housing improvement. The studies covered a wide range of housing improvements. The housing improvements in high income countries, and conducted in the past 30 years, included refurbishment, rehousing, relocation, installation of central heating and insulation. Studies from the developing world included provision of latrines. Older studies (pre‐1965) examined changes in health following rehousing from slums. Overall, it would appear that improvements to housing conditions can lead to improvements in health. Improved health is most likely when the housing improvements are targeted at those with poor health and inadequate housing conditions, in particular inadequate warmth. Area based housing improvement programmes, for example programmes of housing‐led neighbourhood renewal, which improve housing regardless of individual need may not lead to clear improvements in housing conditions for all the houses in a neighbourhood. This may explain why health improvements following these programmes are not always obvious. Improvements in warmth and affordable warmth may be an important reason for improved health. Improved health may also lead to reduced absences from school or work. Improvements in energy efficiency and provision of affordable warmth may allow householders to heat more rooms in the house and increase the amount of usable space in the home. Greater usable living space may lead to more use of the home, allow increased levels of privacy, and help with relationships within the home. An overview of the best available research evidence suggests that housing which promotes good health needs to be an appropriate size to meet household needs, and be affordable to maintain a comfortable indoor temperature. Abstract Background The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow‐up periods. Impacts on socio‐economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts. Objectives To assess the health and social impacts on residents following improvements to the physical fabric of housing. Search methods Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH‐DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In‐Process & Other Non‐Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status. Selection criteria Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross‐sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio‐economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language. Data collection and analysis Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non‐experimental and uncontrolled studies. Health and socio‐economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta‐analysis was not appropriate the data were tabulated and synthesized narratively following a cross‐study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model. Results Thirty‐nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty‐three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non‐experimental studies of warmth improvements, 12 non‐experimental studies of rehousing or retrofitting, three non‐experimental studies of provision of basic improvements in low or middle Income countries (LMIC), and three non‐experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review. Very little quantitative synthesis was possible as the data were not amenable to meta‐analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively. Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing‐led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre‐1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio‐economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced. Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis. Authors' conclusions 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. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. 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. While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities. Plain language summary Housing improvement as an investment to improve health Poor housing is associated with poor health. This suggests that improving housing conditions might lead to improved health for residents. This review searched widely for studies from anywhere in the world which had investigated whether or not investment to improve housing conditions is linked with improvement in health. A huge amount of research on housing and health has been published but very few studies have investigated if improved housing conditions impact on residents' health. Neighbourhood renewal programmes often include housing improvements but a key aim of these programmes is to improve the area by attracting new residents, often those who are better off. In these programmes, improvements in health statistics may simply reflect a change in the population living in an area and the original population may not have benefited from the improved living conditions. This review only looked at studies where changes in health for the original population were being investigated rather than changes for the area. We identified 39 studies which assessed changes in health following housing improvement. The studies covered a wide range of housing improvements. The housing improvements in high income countries, and conducted in the past 30 years, included refurbishment, rehousing, relocation, installation of central heating and insulation. Studies from the developing world included provision of latrines. Older studies (pre‐1965) examined changes in health following rehousing from slums. Overall, it would appear that improvements to housing conditions can lead to improvements in health. Improved health is most likely when the housing improvements are targeted at those with poor health and inadequate housing conditions, in particular inadequate warmth. Area based housing improvement programmes, for example programmes of housing‐led neighbourhood renewal, which improve housing regardless of individual need may not lead to clear improvements in housing conditions for all the houses in a neighbourhood. This may explain why health improvements following these programmes are not always obvious. Improvements in warmth and affordable warmth may be an important reason for improved health. Improved health may also lead to reduced absences from school or work. Improvements in energy efficiency and provision of affordable warmth may allow householders to heat more rooms in the house and increase the amount of usable space in the home. Greater usable living space may lead to more use of the home, allow increased levels of privacy, and help with relationships within the home. An overview of the best available research evidence suggests that housing which promotes good health needs to be an appropriate size to meet household needs, and be affordable to maintain a comfortable indoor temperature.