Housing improvements and
health – the results of a
randomised trial
Meryl Basham
Margaret Somerville
Andy Barton
Chris Foy
George Richardson
Ken Buckingham
Beginnings
Beginnings
Concerns of a GP practice resulted in a
Health Gain Initiative funded by the Health
Authority in Barton,Watcombe and Hele
1995-98
H
Beginnings
Concerns of a GP practice resulted in a
Health Gain Initiative funded by the Health
Authority in Barton,Watcombe and Hele
1995-98
H
Community worker supported local people in
social housing in Watcombe to complete a
housing and health survey (including damp
and respiratory illness) 1997
H
Beginnings
Concerns of a GP practice resulted in a
Health Gain Initiative funded by the Health
Authority in Barton,Watcombe and Hele
1995-98
H
Community worker supported local people in
social housing in Watcombe to complete a
housing and health survey (including damp
and respiratory illness) 1997
H
Results of survey presented to Torbay
Council.Torbay Healthy Housing Group formed
1998
H
Torbay Healthy Housing
Group
Watcombe Housing Project Instigated
Torbay Healthy Housing
Group
Watcombe Housing Project Instigated
H
Torbay Council Housing Committee agreed to
use (£600,000) for house improvements in
Watcombe over two years
Torbay Healthy Housing
Group
Watcombe Housing Project Instigated
H
Torbay Council Housing Committee agreed to
use (£600,000) for house improvements in
Watcombe over two years
H NHS R & D grant to fund evaluation over a
three year period (£152,000)
Torbay Healthy Housing
Group
Watcombe Housing Project Instigated
H
Torbay Council Housing Committee agreed to
use (£600,000) for house improvements in
Watcombe over two years
H NHS R & D grant to fund evaluation over a
three year period (£152,000)
H Baseline survey £25,000 Health Gain Initiative
Watcombe Housing Project
Collaborating organisations
Watcombe Housing Project
Collaborating organisations
H
Local residents
H South & West Devon Health Authority
H
Plymouth & South Devon RDSU
H Torbay Council Housing Department
H Dept. of Environmental Sciences, University of
Plymouth
H South Devon Healthcare NHS Trust
H Primary Care Teams
H AC & T Ltd
Watcombe Housing Project
A Randomised controlled trial
Do housing improvements influence
the quality of the indoor environment,
the health and the expenditure of
residents and costs to the NHS ?
Watcombe Housing Project
Intervention
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
H Ventilation in kitchen and bathroom
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
H Ventilation in kitchen and bathroom
H Re-roofing
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
H Ventilation in kitchen and bathroom
H Re-roofing
H Insulation of roof and cavity wall
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
H Ventilation in kitchen and bathroom
H Re-roofing
H Insulation of roof and cavity wall
H Double glazed doors
Watcombe Housing Project
Intervention
H Full gas fired central heating installed in all
houses
H Ventilation in kitchen and bathroom
H Re-roofing
H Insulation of roof and cavity wall
H Double glazed doors
H Electrical upgrade
Watcombe Housing Project
Watcombe Housing Project
Population
Watcombe Housing Project
Population
Houses. 119 Council owned
houses in the Watcombe
area of Torbay
H
Watcombe Housing Project
Population
Houses. 119 Council owned
houses in the Watcombe
area of Torbay
H
H
Residents. c580 residents
of these houses
Watcombe Housing Project
OUTCOMES
Watcombe Housing Project
OUTCOMES
H
HEALTH
H
ECONOMIC
H
ENVIRONMENTAL
Watcombe Housing Project
Project design
Postal Q
Environment
& Health
Surveys
Phase I houses
upgraded (50)
Postal Q
Environment
& Health
Surveys
Phase I houses
no further work
Postal Q
Environment
& Health
Surveys
119 houses
eligible for
randomisation
1
2
Phase II houses
no work (69)
3
Phase II houses
upgraded
Watcombe Housing Project
Watcombe Housing Project
OUTCOMES HEALTH
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
H Health interviews by community nurses
measurements used :
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
H Health interviews by community nurses
measurements used :
General health questionnaires - SF36 and GHQ 12
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
H Health interviews by community nurses
measurements used :
General health questionnaires - SF36 and GHQ 12
Respiratory health - a symptom questionnaire, lung function
tests and symptom diaries for children
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
H Health interviews by community nurses
measurements used :
General health questionnaires - SF36 and GHQ 12
Respiratory health - a symptom questionnaire, lung function
tests and symptom diaries for children
Morbidity arthritis/rheumatism -AIMS/RAND
Questionnaire
Watcombe Housing Project
OUTCOMES HEALTH
Postal questionnaire included:
Health and number of occupants, smokers and pets
H Health interviews by community nurses
measurements used :
General health questionnaires - SF36 and GHQ 12
Respiratory health - a symptom questionnaire, lung function
tests and symptom diaries for children
Morbidity arthritis/rheumatism -AIMS/RAND
Questionnaire
Ischaemic Heart Disease - the Rose Angina Questionnaire
Watcombe Housing Project
Outcome : Environmental
H
humidity
H
temperature
H
damp
H
house dust mite
Watcombe Housing Project
Outcome : Environmental
H
humidity
H
mould spores
H
temperature
H
particulates
H
damp
H
carbon monoxide/
H
house dust mite
dioxide
Watcombe Housing Project
Outcome Economic
Watcombe Housing Project
Outcome Economic
To residents
H heating costs
H time lost from school/work
H over the counter medicines
H trips to GP/hospital
Watcombe Housing Project
Outcome Economic
To residents
To NHS
H heating costs
H prescriptions
H time lost from school/work
H contacts
H over the counter medicines
H trips to GP/hospital
Watcombe Housing Project
Response rates by Year and Instrument
Intention to
treat 119
households
Year 1
Year 2
Year 3
Prevalence
Survey
N=118 99%
N=115 97%
N=108 91%
Environmental
Tests
N=115 97%
N=114 96%
N=105 88%
Health
Interviews
N=102 86%
N=101 86%
N=78 66%
By the end of the third year 15 households had left the area
Watcombe Housing Project
Comparison between Phase 1 and Phase II households (119
houses randomised) by age group and gender.
60
% population
50
40
Phase I
30
Phase II
20
10
0
0-4
5-17
18-44
45-64
Age group
65+
Male
Female
Gender
Watcombe Housing Project
Comparison between the two phases of the self
reported incidence of illness and symptoms
45
40
% of population with condition
35
30
25
Phase I
Phase II
20
15
10
5
0
asthma
arthritis or
rheumatism
respiratory
illnesses
Diseases
headache
tired
Watcombe Housing Project
Percentage of children exposed to
animals and ETS by phase at start of the
study
90
80
70
% children
60
50
Phase I
Phase II
40
30
20
10
0
Exposed to ETS
Exposed to Pets
Exposure
Watcombe Housing Project
Results Environmental
O
Temperature, Living room ( C)
20
19
oC
Phase I
Phase II
18
17
1999
2000
2001
Year
Between phase difference 1999–2000: p=0.14
Between phase difference 1999–2001: p=0.67
Watcombe Housing Project Results
Environmental
Bedroom temperature ( oC)
20
19
Phase I
Phase II
o 18
C
17
16
1999
2000
2001
Year
Between phase difference 1999 – 2000: p=0.002
Between phase difference 1999 – 2001: p=0.89
Watcombe Housing Project Results
Environmental
Bedroom relative humidity (%)
60
55
Phase I
%
Phase II
50
45
1999
2000
2001
Year
Between phase difference 1999 – 2000: p=0.28
Between phase difference 1999 – 2001: p=0.03
Watcombe Housing Project
Results Environmental
Wall surface dampness (WME%)
6
WME
Phase I
4
%2
Phase II
0
1999
2000
2001
Year
Between phase difference 1999 – 2000: p=0.001
Between phase difference 1999 – 2001: p=0.51
Watcombe Housing Project
ResultsEnvironmental
Mould Count (Number of colonies)
14
.
No colonies
12
10
Phase I
8
6
Phase II
4
2
0
1999
2000
2001
Year
Between phase difference 1999 – 2000: p=0.60
Between phase difference 1999 –2001: p=0.35
Watcombe Housing Project
Results Environmental
Fine particles. These are caused by such
things as smoking and discharge from cooking.
There is no detectable difference in the
number of fine particles in the living room or
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Fine particles. These are caused by such
things as smoking and discharge from cooking.
There is no detectable difference in the
number of fine particles in the living room or
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Fine particles. These are caused by such
things as smoking and discharge from cooking.
There is no detectable difference in the
number of fine particles in the living room or
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Between phase difference 1999 -2001:p=0.11
Fine particles. These are caused by such
things as smoking and discharge from cooking.
There is no detectable difference in the
number of fine particles in the living room or
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Between phase difference 1999 -2001:p=0.11
Fine particles. These are caused by such
thingsParticles
as smoking–and
discharge
cooking.
Fine
caused
e.g. from
smoking,
cooking
There is no detectable difference in the
number of fine particles in the living room or
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Between phase difference 1999 -2001:p=0.11
Fine particles. These are caused by such
thingsParticles
as smoking–and
discharge
cooking.
Fine
caused
e.g. from
smoking,
cooking
There
is nois
detectable
differencedifference
in the
There
no detectable
in the living
roomofor
bedroom
house
number
fine
particles infollowing
the living room
or improvements
bedroom following house improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Between phase difference 1999 -2001:p=0.11
Fine particles. These are caused by such
thingsParticles
as smoking–and
discharge
cooking.
Fine
caused
e.g. from
smoking,
cooking
There
is nois
detectable
differencedifference
in the
There
no detectable
in the living
roomofor
bedroom
house
number
fine
particles infollowing
the living room
or improvements
Between
phase
difference
1999 –2000:p=0.43
bedroom
following
house
improvements.
Watcombe Housing Project
Results Environmental
Coarse Particles – due to human or animal activities .
There is no discernable pattern commensurate with
house improvements in the living room or bedroom
Between phase difference 1999 –2000:p=0.19
Between phase difference 1999 -2001:p=0.11
Fine particles. These are caused by such
thingsParticles
as smoking–and
discharge
cooking.
Fine
caused
e.g. from
smoking,
cooking
There
is nois
detectable
differencedifference
in the
There
no detectable
in the living
roomofor
bedroom
house
number
fine
particles infollowing
the living room
or improvements
Between
phase
difference
1999 –2000:p=0.43
bedroom
following
house
improvements.
Between phase difference 1999 -2001:p=0.40
Watcombe Housing Project Results
Health
GHQ-12 score
Mean by phase and year
Adults
Mean GHQ-12 score
12
10
8
6
Phase
4
First
2
Second
0
1999
2000
Year
2001
Watcombe Housing Project
Results Health
Severity of arthritic pain
Mean by phase and year
All subjects
4
Mean score
3
2
Phase
1
First
Second
0
1999
2000
Year
2001
Watcombe Housing Project
Results Health Respiratory
All respondents: Symptom score 6+ (with or without BTS)
Total (%)
Phase I (%)
Phase II (%)
1999
125/479 (26.1%)
26.3%
25.9%
2000
92/453 (20.8%)
23.1%
19.0%
2001
84/430 (19.6%)
16.6%
21.8%
χ 2 for trend = 5.82, p = 0.016
All respondents: BTS 1+ (with or without symptoms)
1999
2000
2001
Total (%)
Phase I (%)
Phase II (%)
83/479 (26.1%)
53/453 (20.8%)
39/430 (19.6%)
16.7%
11.3%
7.0%
17.8%
12.0%
9.1%
χ2 for trend = 14, p = <0.001
Watcombe Housing Project
ECONOMIC EVALUATION
Indications are that overall
there is a reduction in some
health service costs but not in
association with either study
phase in particular
Watcombe Housing Project Results
Environmental
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
H
Cost of providing both domestic hot water and heating
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
H
Cost of providing both domestic hot water and heating
annual saving of £250 across all property types.
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
H
Cost of providing both domestic hot water and heating
annual saving of £250 across all property types.
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
H
Cost of providing both domestic hot water and heating
annual saving of £250 across all property types.
CO2 emissions
Watcombe Housing Project Results
Environmental
SAP (Standard Assessment Procedure) changes
H
Increase of average SAP of 41 to a revised average of
74 = an increase of 33 SAP points
H
Cost of providing both domestic hot water and heating
annual saving of £250 across all property types.
H
CO2 emissions
Reduced by over 2 tonnes per property per year.
Watcombe Housing Project
Watcombe Housing Project
Conclusions
Watcombe Housing Project
Conclusions
H This study is the first randomised trial of house
improvements and has demonstrated the feasibility
of conducting sound scientific research on
community wide interventions
Watcombe Housing Project
Conclusions
H This study is the first randomised trial of house
improvements and has demonstrated the feasibility
of conducting sound scientific research on
community wide interventions
H It is gaining national recognition for the
outstanding response rate and involvement of
study participants
Watcombe Housing Project
Conclusions
H This study is the first randomised trial of house
improvements and has demonstrated the feasibility
of conducting sound scientific research on
community wide interventions
H It is gaining national recognition for the
outstanding response rate and involvement of
study participants
H It is a positive example of partnership working in
housing and health
Watcombe Housing Project
Watcombe Housing Project
H The analysis demonstrates an improvement in
some of the indoor environmental variables
Watcombe Housing Project
H The analysis demonstrates an improvement in
some of the indoor environmental variables
H To date we have been unable to link this
improvement to the health of residents but
analysis is continuing
Watcombe Housing Project
H The analysis demonstrates an improvement in
some of the indoor environmental variables
H To date we have been unable to link this
improvement to the health of residents but
analysis is continuing
H Qualitative feedback from residents has been
positive
Watcombe Housing Project
H The analysis demonstrates an improvement in
some of the indoor environmental variables
H To date we have been unable to link this
improvement to the health of residents but
analysis is continuing
H Qualitative feedback from residents has been
positive
H Five further studies on the relationship between
housing and health care in progress