CHAPTER ONE BACKGROUND
Housing, health and regeneration
1.1 Public policy in the U.K. has recently demonstrated a strong interest in 3 areas:
- Inequalities in health, particularly spatial or area-based inequalities;
- Joined up policy which seeks to enhance the gains from particular interventions by placing them in the context of other actions and supports; and
- Measuring the impacts of policy and evaluating the evidence base for claims about the gains from current and prospective interventions.
Inequalities in health
1.2 It is widely recognised that Scotland carries an especially high burden of ill health for a developed nation, and there are persistent health inequalities between the poorest and most well-off members of society. These inequalities can be seen not only in terms of socio-economic groupings but also according to area of residence. The Report of the Measuring Inequalities in Health Working Group (2004) also noted for example urban/rural inequalities and between different ethnic groups. 1The health gap between manual or routine occupations and professional or managerial occupations in Scotland is reported to have widened over the last 2 decades. 2
1.3 Concern over the existence inequalities has been mirrored by increasing efforts to (i) understand the determinants of those inequalities, and (ii) find the means of tackling such inequalities. In looking at the determinants of poor health and health inequalities, researchers and policymakers alike have pointed to the importance of life circumstances. Thus, it is now widely accepted that poor health is not solely a result of individual behaviours and unhealthy choices (to smoke, to drink to excess, to eat unhealthily) but is strongly determined by so-called "upstream" influences on health -in particular the physical, social and legislative environment in which those choices are made. Thus, a healthy diet is influenced by ones' access to healthy, affordable food; and good mental health is influenced not just by personal stresses (including financial stresses) - though these are undoubtedly crucial - but also by health-promoting and health damaging physical environments. In such an analysis, health inequalities are seen as being the result of, or subject to, major upstream influences (such as social and health policies) rather than solely the result of downstream influences (unhealthy behaviours).
1.4 The corollary of this argument is that the means of tackling poor health and reducing health inequalities also lies upstream. Thus, improving the health of the public can be achieved through altering and improving living and working conditions; in particular through improving the quality of housing and the quality of places - the latter in terms of the upkeep/degraded nature of the local environment; the availability of services and facilities; the prevalence of health damaging or promoting behaviours; and the degree of community cohesion and support. The physical fabric of housing is also an influence on health, mediated by damp, warmth and cold 3.
1.5 Poor housing can also impact on educational and other opportunities. This has been recognised frequently in Government documents (e.g. "Poverty, poor housing, homelessness and the lack of educational and economic opportunity are the root cause of major inequalities in health in Scotland..."). 4 By extension housing and regeneration activities may provide a key opportunity for improving the health of the public, a point made frequently over the past decade, and reiterated most recently by the World Health Organisation 5. The provision of good quality, affordable housing is therefore widely seen as a "public health" intervention.
1.6 The policy response to the above has been, firstly, to extend the objectives of housing and regeneration policies in order to seek health gains from these actions: the UK Government has in the past said for example that "regeneration partnerships offer significant opportunities for health gain". Secondly, there has been an emphasis on area-based health interventions such as Health Action Zones and Healthy Living Centres, and to some extent these have been targeted upon regeneration areas where their impact might be greater.
1.7 The actual impacts of such interventions also remain a subject of interest. Much previous research into the impacts of housing upon health have been concerned with the impact of specific housing elements such as heating, insulation, and space. Yet in the case of housing associations, at the time of the SHARP study, most housing investment related to the provision of new, general needs housing, rather than rehabilitation or improvement according to the Scottish Homes Investment Programme 1999-2000. In other words, the bulk of the public housing investment in this sector involved providing a new home to someone who previously was in housing need.
1.8 There are other alterations to one's circumstances which may accompany the move to a new house. First, a change in housing provider and consequent changes in housing management practices. These practices include landlords' powers (and willingness) to deal with neighbourhood nuisance and anti-social behaviour. Second, in getting a new house, people may also acquire a better local environment in terms of its physical qualities, the provision of services and facilities and the level of community activity and support. As well as being of policy interest in terms of "healthy communities", community integration has been shown to be significantly related to health. 6 Any new research on housing and health needs to take these changes into account.
1.9 To summarise: most housing investment in the UK social rented sector results in large-scale changes in housing conditions and possibly also in neighbourhood circumstances. These changes have the potential to improve health and health inequalities, and any evaluation of housing's impacts upon health needs to assess these outcomes.
Previous research on housing and health
1.10 There is a "housing evidence base" which goes back many decades, and includes many hundreds of surveys demonstrating the relationship between poor quality housing and poor health 7. It may seem surprising therefore that there is a need for yet more evidence. However, much of the existing evidence is concerned with demonstrating cross-sectional associations; there have been far fewer studies which have demonstrated the health and other outcomes which follow from investing in social housing - that is, evaluative rather than descriptive studies. The earliest evaluation studies probably date from around the 1930's, and were conducted in Glasgow. In more recent years there have been several controlled trials, and, most recently several, randomised controlled trials. 8
1.11 A systematic review of intervention studies (carried out in 2001) found that housing improvement may lead to small improvements in self-reported physical and mental health and reductions in some symptoms, but noted that adverse effects on health are also possible. 9 However, the evidence is patchy and controlled study designs are rare. Of the 18 studies identified in the review, 6 were prospective controlled studies and only one was a randomised controlled trial. The most recent study in this field (published in 2007), a large randomised controlled trial from New Zealand, assessed whether insulating older houses increases indoor temperatures and improves occupants' health and well-being. Its findings suggested that improving the indoor environment may lead to improved self-rated health and reduced health service use. Previous studies have also indicated that warmer and less humid living conditions may improve health, but they also suggest that the health benefits disappear if housing costs increase. The authors of the New Zealand study also highlighted the almost complete lack of an evidence base for the effectiveness and cost-effectiveness of public health and social interventions, and pointed to the need to collect better evidence of the effects of interventions in the housing sector.
1.12 Housing professionals also recognise that there is a lack of evidence to back up claims that housing investment produces health gains. One of The Chartered Institute of Housing's Policy Officers commented in 1997 that " There is obviously still much work to be done to produce convincing arguments for increasing expenditure on housing in order to directly benefit the health of people and communities". 10 Little has changed in the subsequent years to alter this situation, and yet as policy initiatives multiply to respond to health inequalities, the call for "better evidence" increases.
Regeneration and health
1.13 While research on components of housing improvement (such as insulation installation) is important, new evaluative research on housing has to take into account the fact that housing investment increasingly occurs within a wider context of regeneration programmes. In the case of Scotland, we know that nearly 40% of the housing output from Scottish Homes urban investment in the year 1999/2000 - when initial plans for the SHARP study were made - were in the Priority Partnership Areas (the main urban regeneration initiative prior to Social Inclusion Partnerships). But this also meant that 60% of housing output was to occur either in urban areas not subject to the main regeneration programmes, or in rural areas. This offered the SHARP research team the opportunity to investigate whether housing investment in the wider regeneration context produces health gains over and above housing investment in itself; in effect a "natural" experiment.
1.14 By mounting a study of the social housing investment programme as a whole, we were also able to overcome one of the limitations of past research on the effects of wholesale housing change, namely that they have been focused on a single site or development; this introduces contextual biases that limit the generalisation of the findings. Rather, we wanted to conduct a multi-site study that would avoid this limitation.
The need for an experimental study
1.15 When circumstances permit, any intervention should be evaluated in the form of an experiment, in which individuals (or households) are randomly allocated to the Intervention Group - which receive the new housing, or new intervention, or to a Control Group - which may receive the intervention at a later point in time. When this is not possible, for example when the researchers do not control the roll-out of the intervention (e.g., a new housing building programme, or other new investment in housing), then a controlled study is essential, to ensure that any change in health or well-being can be identified over and above any changes in health which happen naturally over time. This is sometimes referred to as an observational design, or a quasi-experimental design.
1.16 The SHARP study used this design in that it followed, over a period of years, the effects on health and well-being of people who moved into general-needs, new-build accommodation provided by housing associations during 2002-2003. However, as researchers it was not possible or practical for the SHARP team to control the allocation of families to the new homes. Instead we identified a matched comparison group whose health and other outcomes were followed up over time, in parallel with the Intervention Group. The study design is described in more detail in Chapters 3 and 4.
Summary
- There is ongoing policy interest in the social determinants of health and health inequalities, and in the potential for housing and regeneration policies to improve health and well-being.
- Though there is a long history of research on housing and health, there are still relatively few studies which explore the health impacts of large-scale changes in housing conditions and in neighbourhood circumstances.
- Previous studies suggest possible effects on physical and to a greater extent mental health, although controlled studies are scarce.