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Health effects of housing improvement: systematic review of intervention studies

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7306.187 (Published 28 July 2001) Cite this as: BMJ 2001;323:187

Data supplement

  • Table 1

    Table 2
     
     

    Table 1 Controlled and uncontrolled intervention studies of the health impacts of housing
     

    Study, location

    		Study methods, length of follow up, No of participants

    (intervention/control)

    		InterventionHealth and social outcomesSample selection*Adjustment for potential confounding factors Blinded assessment of outcomes†Main results

    (Response rate/follow up rate at end point)

    		Strength of evidence
    Medical Priority Rehousing (MPR)
    Elton & Packer (1987) 7, 8 SalfordProspective controlled observational study (within a randomised controlled trial). Interview and questionnaire before, 6-8 and 52 weeks after

    (n=28/28)

    		Prioritised rehousing by council on mental health groundsMental health, by Foulds and Bedford Personal Disturbance Inventory and Scales (DSSI/SAD) and Present State Examination (PSE)YesNoneNo6-8 weeks after initial interview 23/28 of the intervention group and 6/28 of the control group had been rehoused. B
    Health outcomes: Greater reduction in anxiety and depression in those rehoused, based on comparison of 11 matched rehoused/non-rehoused pairs (anxiety –6.5 v –0.6, P=0.0003, depression –6.0 v –1.5, P=0.005)
    (100% at 1 year)
    Smith et al. (1997) 9 North, Midlands, and south of EnglandRetrospective cross-sectional study. Interviews at 3 sites 1-12 months after application for rehousing

    (n=349/189)

    		Rehousing by council on mental health groundsSelf-reported general health status by Nottingham Health Profile (NHP); health service useYesNoneNoHealth outcomes: Movers show improved NHP scores compared to those awarded priority but not yet moved (NHP energy: 44.8 v 63.4; pain 30.6 v 44.4; emotion 26.2 v 44.5; 39.2 v 52.2; 21.1 v 31.1, all P<0.05). Of those with mental health problems 56% reported an improvement in their mental health since the moveC
    Health service use: Movers reported GP use was increased for 21% and decreased for 22%; Similar patterns for contact with consultants (14%, 24%), outpatient departments (14%, 22%), and time in hospital (14%, 30%). Improvements in general health were reported by 61% of MPR movers (no control data available). 
    (76% at 1-12 months)
    Cole & Farries (1986) 10 Bolton Retrospective cross sectional study. Questionnaire survey of households 2-3 years after rehousing

    (n=271 households)

    		Rehousing by council on mental health groundsSelf-reported health improvementNANoneNoHealth outcomes: 57 (37.7%) reported improvements to health since rehousing. The most common reason (56.5%) given by rehoused residents for health gain due to rehousing was ‘lack of stairs’(one third of those rehoused had moved due to osteoarthritis). C
    (59% at 2-3 years)
    Rehousing/refurbishment plus relocation from slum area or community regeneration
    Wilner et al. (1958, 1960) 11, 12 Baltimore Prospective controlled study. Interviews before and 18 months after

    (n=400/600)

    		Rehousing from slum areaSelf-reported social adjustment, morbidity and mental healthYesControls matched for; quality of housing, family size, income, welfare, education, employment, ageNoHealth outcomes: Greater increase in illness episodes in intervention group at 9 months compared to controls (+301.2 v +261.4 episodes per 1000 persons) but greater reduction at 18 months (-129.9 v -100.9). Social adjustment and mental health improved more among the intervention group (sit and talk 11.1% v 1.9%; positive mood: 13.6% v 10.6; satisfaction with status quo: 23.3% v 19.5%). 56% of the control group moved during follow up; further analyses showed association between extent of housing improvement and amount of psychological improvement. B
    (unclear follow up rate at 9-18 months)
    Carp (1975, 1977) 13, 14 USAProspective controlled study. Interviews with residents before and 8 years after

    (n=127/62)

    		Rehousing from socially isolated, substandard housingSelf-reported health (diaries), physician contact, mortality rate, morale and life satisfaction (interview)YesNoneNoHealth outcomes: Ratings of "good" or "excellent" health fell more in the control group (-13% v -28%, P=0.02). Increase in those reporting low life satisfaction at 8 years was greater in controls (intervention group: 17% v 18%; controls: 10% v 38%).C
    Health service use: Rates of physician contact in previous year and mortality were higher in control group (64% v 79%, P=0.03; 26% v 41%; P=0.045).
    (84% at 8 years)
    McGonigle & Kirby (1936) 15 Stockton-on-Tees Prospective controlled study. Analysis of routine data for individuals 5 years before and 5 years after

    (n=710/1298)

    		Rehousing from slum areaCrude and standardised quinquennial mortality ratesNoAge and sex controlled for in analysisYesHealth outcomes: Age-standardised mortality rates increased in the rehoused population (22.91 v 26.10 per 1000) but fell in the slum area (26.1 v 22.78). Death rates increased across all age groups, apart from infants, where infant mortality rates fell in both groups but more in those rehoused (-54.8 v -39.2).C
    Other outcomes: Rent in improved area doubled, and impacted on households’ ability to buy food. Quantities of different food groups (first class proteins, total protein) fell short of the BMA Scale of Minimum Diets. These deficiencies were most extreme in the intervention group, especially among the unemployed (90% of households in intervention group). 
    (routine data set for 5 years)
    Blackman et al (2001) 16 Newcastle Prospective uncontrolled study. Structured interviews with 488/791 households before and 5 years after. At 5 years 98 of original households were re-interviewed. Cross-sectional data at 5 years also reported for 230 households

    (n=166 residents)

    		Major refurbishment, neighbourhood renewal, security and safety improvements to areaSelf-reported health status, respiratory conditions, mental health, smoking health service use, view of area, safety, draughts in houseNA.Preintervention group data compared with age matched controls post-intervention (children only)NoHealth outcomes: Adults ratings of good general health status decreased (53% v 51%, P<0.01), chronic respiratory conditions increased (adults 32% v 44%, p<0.05, children 23% v 26%, P>0.05). % with a self-reported mental health problem decreased (adults 52% v 41%, P<0.05, children 21% v 2%, P<0.05), trouble with nerves (20% v 10%, P<0.05). % of smokers decreased (72% v 28%, P<0.001). C
    Health service use: No changes in self-reported use. % prescribed medication for a month or more increased (36% v 47%, P<0.05)
    Other outcomes: View of area as very/quite nice increased (49% v 62%, P<0.05), area seen as very/quite safe (25% v 50%, P<0.001). % reporting seriously draughty house reduced (35% v 20%, P<0.05)

    (20% of original households at 5 years)

    Ambrose (2000) 17 London Prospective uncontrolled study. Interviews with residents before and 1-4 years after intervention

    (n=70)

    		Rehousing or housing improvement and area regenerationSelf-reported illness episodes (standardised for days recorded), illness days, use of health services, prescriptions and self-treatmentNANoneNoHealth outcomes: Illness episodes increased by 56%, (from 0.0036 to 0.0056/person/day) partly due to flu epidemic. Increase in coughs and colds (42% v 67%, P<0.0001); no change in dietary and digestive disorders (12% v 15%, P=0.3). Reduction in aches and pains (23% v 12%, P=0.0004), asthmatic and bronchial symptoms (17% v 6%, P=0.0001), stress and depression (6% v 1%, P=0.002).C
    Health service use: Reduction in use of general practitioner (74.6% v 59.4%, P<0.0001), prescription use (65.4% v 51.0%, P=0.0002), and use of casualty or outpatients (20% v 5%, P<0.0001); and illness days (per person, per day) decreased (0.37 v 0.05). No difference in purchase of proprietary medicines (25% v 26%, P=0.8).
    Other outcomes: Increases in feeling of safety (46.7% v 72.0%, P<0.0001); also significant improvements in sense of belonging to community and social networks, and significant reductions in concerns about criminal activity and behaviour of young people. Residents also reported significantly decreased access to health and hospital services.
    (71% at 4 years)
    Wells (2000) 18 Michigan Prospective uncontrolled study. Interviews before, 5 months, and 2 and 3 years after (women only)

    (n=23)

    		RehousingPsychological wellbeing (using Psychiatric Epidemiological Research Instrument, PERI), neighbourhood atmosphereNANoneNoHealth outcomes: Reduction in psychological distress at first follow up (mean PERI score 31 v 22.6, t=4.00, P<0.001). Changes in housing quality contributed 12% of the variance in distress. At 3 years mean PERI score was 23.22, not significantly different to the post-move average of 22.26 but significantly different to the pre-move mean of 31, t(22)=4.19, P<0.001.C
    (74%at 3 years)
    Halpern (1995) 19 UKMixture of cross-sectional and prospective data presented. Structured interview before, & 1 year after

    (n=55)

    		Refurbishment and community regenerationMental health (Hospital Anxiety & Depression Scale - HADS), self esteem (Rosenberg Scale), neighbourhood involvementYes- from neighbouring localityAge, length of residence, children under 14, employment, income controlled for in analysisNoHealth outcomes: Reduction in anxiety and depression at 1 year (8.2 v 5.8, P<0.05; 5.4 v 3.6, P<0.05). Self-esteem rose non-significantly (53.1 v 57.5, P<0.1). Mean total HADS score fell (11.5 v 8.7).C
    Other outcomes: Following intervention residents more likely to attend Residents Association meeting (3% v 19%) more likely to recognise neighbours (55% v 74%) Social support score increased over time (4.7 v 5.6, P<0.05).
    (60-70% at 3 years, only 49% of original sample followed up at 3 years)
    Walker & Bradshaw (1999) 20 Gwent Retrospective controlled study. Comparison of 2 GP practices to matched control area data, 2-7 years afterRehousing and area regenerationRoutine prescribing data over 5 years. Health service providers views on local area and health changes. Interviews with service providersYes- control practices from neighbouring localityControl practices matched for practice population, Townsend score & social class (from census data)YesHealth outcomes: Hypnotic prescribing was reduced in the practices covering the regeneration area (-10.85 v +1.9). Anxiolytic prescribing fell in one intervention practice compared to reference area (Area A:-0.45, Area B:-25.56 v reference area: +16.22). Mixed results for antidepressants (A:+29.88, B:+53.59 v +55.57). No beneficial effect of housing renewal on respiratory prescribing (A: +4.75, B: +18.11 v 4.4). Factors other than area regeneration may account for these changes.C
    (routine data at 2 and 7 years)
    Wamben & Piland (1973) 21 California Retrospective controlled study. 

    Routine data 18 months before and 12 months after 

    (n=81/86)

    		Rehousing from slum areaHospital out-patient visitsNoNoneYesHealth service use: Among children (0-9 years) greater reduction in outpatient visits in those rehoused (all causes, -1.667 v –0.130, P=0.03; housing related visits,--0.963 v 0.020, P=0.05), no significant differences among other age groups. Significantly greater reduction in housing related visits among rehoused women (-0.538 v 0.120, P=0.02) (though the groups differed significantly at baseline) but not men.C
    (% age follow up not reported at 1 year)
    Baba et al. (1996) 22 Tokyo Retrospective uncontrolled study Survey 6-24 months after housing improvement

    (n=375)

    		Improvement to housing conditions (ranging from new bed to major renovation)Change in daily activities, need for home care and hospital based care, by questionnaireNANoneNoHealth outcomes: 34% of users became more active after house improvement (42% no change, 7% worse). Workload for carer declined in 39% of cases (36% no change, 3% increased). 33.8% of respondents reported an increase in activity levels.C
    Health service use: Decreased need for home care reported by 39%, reduced likelihood of hospitalisation by 40.3% (no details on reported increased need for care). Changes in entrances and approaches to the residence were most closely associated with improvement in daily activities.
    (83% at 6-24 months)
    Woodin et al. (1996) 23 London Retrospective cross sectional study. Survey of households 6-12 months after rehousing

    (n=160)

    		Rehousing and area regenerationSelf-reported health service use, experiences of crime and violence, by questionnaireNANoneNoHealth service use: Decreased visits to GP after rehousing (before v after: 86% v 69%, P=0.003), frequent users (>6 GP visits per year) reduced (38% v 22%, P=0.01).C
    Other outcomes: These include: large reductions reported in sense of isolation (19% v 6%), fear of crime (60% v 16%), and problems with traffic (39% v 22%). Increased involvement in community affairs (14% v 21%).
    (70% at 6-12 months)
    Energy Efficiency Measures
    Somerville et al. (1999) 24, 25 Cornwall Prospective uncontrolled study. Survey of school age children before and 3 months after

    (n=72)

    		Central heating installationAsthma symptoms, time off school. An economic analysis compared health service use, and prescribing is being carriedNANoneNoHealth outcomes: Respiratory symptoms reduced (eg, median frequency of nocturnal cough reduced from "most days" to "1 or several days" in previous month; P<0.001). School age children lost less time from school from asthma (9.3 days per 100 school days before, vs 2.1 days after, P<0.01), but not for other reasons (1.4 days per 100 school days before and 3.2 after, P>0.05).C
    (68% at 3 months)
    Hopton & Hunt (1996) 26 Glasgow Prospective controlled study. Survey of children under 16 years-before, 6 and 12 months after

    (n=254 households)

    		Installation of ‘Heat with Rent’ systemSelf-reported symptomsYesSmoking, unemployment, changes in other housing conditions, perceived financial situation controlled for in analysisNoHealth outcomes: No group differences in overall mean number of symptoms reported, or in each of 14/15 symptoms reported; significant increase in reporting of aches and pains in intervention group after installation (9.1 v 25.5, P<0.05) but not in control group (9.1 v 18.2, P=0.1). Change in reported level of dampness was the only significant predictor of change in reporting of runny nose (t=2.41; P<0.01). 

    (30% at 1 year. Not clear of response rate in control group. At follow up control group differences in smoking and employment disappeared.)

    Iversen et al. (1986) 27 Copehagen, Aalberg, Esberg, Herning and Vejle, DenmarkProspective controlled study. Survey of residents in private housing before and up to 3-9 months after

    (n=106/535)

    		Replacement of windowsSelf reported symptom listYesAge, smoking & colds controlled for in analysis- no reported dataNoHealth outcomes: Some symptoms significantly reduced in the intervention group; joint pains (OR=0.28), headache (OR=0.72), neck or back pain (OR=0.18) (all P<0.01). Odds Ratio normalised for month when baseline measures were taken. Also adjusted for age, smoking and colds; no data reported. No confidence intervals given or calculable.B
    (31% at 3-9 months- but owing to changes in refurbishment plans only 641 (19%) used in analysis.)
    Green & Gilbertson (1999) 28, 29 Sheffield Retrospective controlled study. Survey of residents after housing renewal

    (n=135/140)

    		Energy efficiency improvements to tower blocksHealth status (SF36)Yes—but intervention group more likely to be employed (28.2% v 15.7%)Control group matched for income, housing and areaNoHealth outcomes: Residents of improved housing had higher SF36 scores on 2 of the 8 dimensions; ‘physical role’ (mean 87.7 v 73.9, P=0.003), ‘energy and vitality’ (mean 59.9 v 51.9, P=0.014). No significant differences on physical function, emotional role, social function, mental health, pain, or general health perception.C
    (response rate not clear)

    * Were intervention and control groups from the same population?

    †Were those assessing health outcomes blind to housing status of interviewees?
     
     
     

    Table 2 Ongoing studies of health impacts of housing
     

    Author and/or study location

    		MethodInterventionOutcomesExpected completion date
    Eastleigh HA, HampshireInvestigate local authority practice and health gains from rehousing for health reasons Rehousing from medical priority rehousing listHealth gains, local authority practice and procedures, collaborative working with health providers 2002
    Gwent & CaerphillyProspective controlled study before 3 & 9 months after (n=40/40) Mould eradicationRespiratory health2003
    Fife Kingdom HARetrospective questionnaire/interview of households relocated to sustainable homes (n=15) Sustainable and energy efficient homesEnergy measures, housing survey, indoor environmental measures, health measures, health service use, economic analyses 2001
    Sandwell HAZ, BirminghamProspective questionnaire to households before and 12 months after Prescribing central heating and an insulation package to the elderly and children with asthma SF12, asthma symptom diary, quality of life, health service use, prescriptions, days lost from school 2002
    Torbay Healthy Housing Project, Torbay30Randomised stepped wedge of rehousing for residents from 142 local authority houses (n=580) Housing refurbishmentRespiratory, health diaries, health service use, environmental measures 2002
    "Warm Homes" study, GlasgowProspective controlled questionnaire and housing survey of households (n=300/200) Major housing refurbishmentFuel costs, indoor temperature, physical and environmental living conditions, health service use. Also economic analysis 2001
    Liverpool Housing Action Trust, LiverpoolProspective controlled study following residents for 2 years following move (n=225/225) Moving from hi-rise to low rise flats. Control group matched for age, type and duration of residence, socio-economic status Health service use, health status (SF36), energy efficiency, quality of life, income, service use 2001
    Cordale HA, West DunbartonshireProspective matched control, structured interview before and 1 year after (n=50/100) RehousingSF36, self-reported .symptom list & health service use 2002
    Riverside Project, CardiffProspective study. Questionnaire and routine data from households, 4 months before and 6 months after rehousing (n=150) Housing renovation and community regenerationIndoor housing conditions, SF36, quality of life, self-reported respiratory symptom diaries 2001
    Willow Park HA, ManchesterProspective controlled questionnaire and interview survey Rehousing and regenerationMental health (GHQ-12), quality of life, self-reported consulting rates 2001
    Shepherd’s Bush HA

    London

    		Prospective controlled questionnaire survey (n=600/300) House refurbishment, new housing and general area reinvestment Health and health service use, housing measures2002
    Rhymmney Valley, Mid GlamorganProspective questionnaire survey (n=4000)Area and housing renewalSF362010
    Scotswood, Newcastle-upon-TyneProspective structured interview survey (n=600)Medical Priority rehousing applicationSF36, self-reported health, neighbourhood and housing changes 2002
    Lambeth Housing, LondonProspective controlled structured interview survey of elderly tenants (n=400/400) Central heating, insulation, benefit adviceSF36, self-reported health, health service use, hospital admission data 2003

    HA=housing association, HAZ=health action zone, SF12=short form 12- health survey questionnaire, SF36=short form 36, GHQ-12=general health questionnaire—12 item.
     

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