He Kainga Oranga/ Housing and Health Research Programme University of Otago, Wellington Strategy Day July 2012

THE HOME STUDY THE TEAM: Julian Crane, Philippa Howden-Chapman, Kristin Wickens, Caroline Shorter, Phillipa Barnes, Nevil Pierse, Thorsten Stanley, Jeroen Douwes, Janice Kang, Bob Draper and Steve Scott. WHAT: To look at whether the home environment (particularly mould and leaks) is associated with the onset of wheezing in children aged 1 to 6 years. WHY: - home environment known to exacerbate asthma symptoms - want to know if home environment is associated with the onset of wheezing HOW: - based on a study done in Finland - incident case control study with 150 cases = history of wheezing requiring treatment for the first time in previous 12 months and 300 controls = no wheezing history - matched on age, gender and location - involves 2 visits from the research team and an independent building assessment

Recruitment: 54 medical centres were involved with recruitment Cases were recruited either directly by a nurse or doctor, through self referral from posters or from invitation letter from the medical centres. Controls were recruited only from invitation letter from the medical centres. What the study involves: A total of 3 visits 2 from the health research team and 1 from the building assessor. Visit 1: -Health and housing questionnaire- Skin prick test -Height and weight- Dust samples -Static dust cloths - Temp & humidity Visit 2: a brief visit which involves removing the static dust cloths and taking photos with the IR camera. Visit 3: a building assessment which looks at the home from a respiratory point of view. Looking at aspects like insulation, sun exposure and presence of mould and leaks. The assessment was developed based on the healthy housing index.

Progress 450 children visited, 4 wks final shelf pickups and BAs Results so far: Self reported leaks are more prevalent amongst our case children than control children 48% cases have at least one leak vs 33% of controls (P0.05) Appears to be more leaks per house for case children than our control children also (mean 1.51 leaks vs 1.35 leaks) Higher levels of mould are observed in case than control bedrooms Mould score (cumulative mould in childs bedroom, 4 categories) Higher mould score +vely related to case status Mould score is independently linked to colder more humid bedrooms Smell of mould more prevalent in case than control bedrooms The Home Study

Analysis Plan Immediate outcomes (3 months) i-button data, SPT atopy, health questions, home questions, mould assessments Intermediate outcomes (6 months) Building assessments, mould tape samples Longer term outcomes (12 months) Static cloth analysis, IR camera pictures, Dust Challenges & opportunities Money needed for further analysis Asthma foundation, WMRF applications Future research: intervention study to prevent wheezing, study to understand mechanism involved (irritant or allergy), follow up study do the children go on to develop asthma, and do our controls develop wheezing? The Home Study

THE HOME STUDY EXTENSION (RHINO STUDY) WHAT: An intervention study : To investigate the incidence of Rhinovirus (hRV) in NZ children (Phase 1) and examine whether heating and removal of mould in childrens bedrooms can reduce the occurrence and/or symptoms of Rhinoviruses in children (Phase 2). WHY: Growing evidence that cold, damp indoor environments may be a critical co-factor in facilitating viral transmission and infection. Viral-induced wheezing in infancy associated with an increased risk for asthma development in later childhood Rhinovirus (hRV)- most common virus to infect children - been implicated in asthma exacerbation - Non-lipid viruses, such as hRV, tend to survive longer in higher RH environments can we change the environment and reduce colds?

THE RHINO STUDY HOW: Revisit HOME study participants. Phase 1: Children will be swabbed for hRV, cold symptom diary filled in for four weeks, i-button in home for %RH & temperature. Measure nasal swabs for incidence of Rhinovirus in NZ pre intervention Phase 2: During the seasons of highest hRV carry out intervention in half of the participants homes, - raising the bedroom temperature to 18C for at least 4 weeks, - removing any visible mould that is present. - Children will again be swabbed at visit 1 and 2, and a cold symptom diary carried out. UORGPilot study - have tested Phase 1. FURTHER OPPORTUNITIES: further intervention studies (probiotics), viral transmission, environmental transmission (surfaces) DISCUSSION POINTS: Placebo or none, who is eligible eg whether to intervene in a warm home, no mould, no colds.

Peter Larsen

709 applications -> 287 Wave 1 (27 known deaths, 31 withdrawals various) -> 235 Wave 2 (20 known deaths, 37 withdrawals various +11) e.g. 52% phlegm most days of week; 42% able to walk only 100m or less before stopping for breath, 56% shivered inside at least once previous winter, median age 71 WHEZ 1 - Helen Viggers

Home heating & fuel poverty & consequences Next 3 years WHEZ 1 finished. Results analysed. Outcome of fuel voucher (health). Mechanism for outcome. Chch subanalysis. Effect of insulation on self reported temp cf objective temp. Metered out: self reported cold & coping strategies (psych & physical) WHEZ 2: resp, temp & cardiac function.

In the dark: Investigating fuel poverty and the use of prepayment meters for electricity in NZ Kims PhD thesis What: (1) Nationwide postal survey of prepayment meter users (vulnerable to FP) in 2010, follow-up survey in 2011 Why: to investigate prepayment metering from a consumer perspective, explore rates of 'self-disconnection (cut off) What (2) Metered Out interview study qualitative component with HV, PLHC Why: to get context of budgeting for electricity with ppm analysis underway Outputs: 1 paper published, 1 submitted, 2 on the go Future Directions: Thesis submission end Oct, post-doc ideas = kids in FP in NZ, ?collaboration in Saint Louis, MO (come visit!)

Project: HIPI (Home Injury Prevention Intervention) Study What: Randomised controlled trial of 850 households. Half receive the treatment at the beginning of the study, half at the end. Treatment involves fixing slip/trip/fall hazards identified in these houses. Extended to include Maori housing from Te Hoe Nuku Roa. Why: Home injury is very common and costly to society. There is no evidence internationally to indicate that fixing home hazards can reduce home injury. This is because of a lack of well-performed trials. The results of the HIPI study can guide injury prevention measures both in New Zealand and internationally Outputs: Study only just being completed, so no results yet Opportunities: Perhaps a justification for major investment in housing improvement Collaborating: Otago, BRANZ and Massey; observing interest from ACC Contact : Michael Keall

Project: Health Housing Index (HHI) Study What: A measure of housing quality in relation to health outcomes and sustainability. Developed to suit NZ conditions. Questionnaire administered by trained inspectors. Why: Housing has important impacts on health, safety and the environment. NZ housing needs to be improved. Measuring housing quality provides motivation and direction for improving housing with health, safety and environmental benefits. Various potential uses: at individual house level; at a neighbourhood / regional / national level Outputs: 3 papers published in international journals; 1 under review. Opportunities: An important research tool; building a case for major investment in housing improvement; buy-in from agencies interested in housing (providers, regulators, landlords, etc) Collaborating agencies: Otago, BRANZ and Massey Contact : Michael Keall, Julie Bennett

The Healthy Housing Index Draft development plan. Draft implementation plan. Implementation of the HHI into a commercial application. The HHI tool and associated material. The Users and Stakeholders of the HHI. The HHI resource.

Other potential projects Exploring differences between the health of occupants in social and private rentals. Exploring the relationship between paediatric hospital admissions and housing quality.

What: Through what specific mechanisms are our interventions effecting health? Why: To remove black box nature our interventions we need to understand how much is due to each factor in the intervention? HIPI: (Michael K) Intervention is multifaceted (rag bag) of injury prevention measures, which bits work on which health outcomes in which populations. Also better models and subgroups. WHEZ: (Helen) Hypothesis can be broken into that electricity vouchers improve temperature and temperature effects COPD and HRV. RHINO: (Kristin+) Hypothesis can be broken into that the intervention effects mould/temperature/humidity and these effect the URTI (colds). Statistical Methodology

Others Castle: (KC +SB) Housing and mental health study, pathways are income, wealth, value of house, area of home and overcrowding. SHIVERS: (Michael B) VE time propensity of sick people to vaccinated, test case negative design. ARF: (JO + MB) What factors effect surveillance systems? Placebo Effect: From PHD to allow some adjustment for placebo effects in our RCTs. Goal: Write more papers

Evaluation of the WUNZ:HS programme $340 million 4 year programme [2009-2013] part-funding insulation and heating retrofits. MED commissioned evaluation completed Oct 2011. [Collaboration with Motu and Victoria] Positive outcomes included reduction in hospitalisation costs and mortality rates MED funded extension: Intention is to extend health dataset to further explore previous findings Also basis of Nick Preval PhD.

WILUTE What: Wellington Integrated Land Use, Transport & Environment model; It is to evaluate land use, transport & housing development policies and future scenarios in terms of transport-related environmental and social effects. Why: (1) How does the development of the transport and land use system affect pollutants emissions from transport in the region? (2) To what extent transport system and traffic volume in different suburbs are vulnerable to sea-level rise caused by tsunami and storm surge? Opportunities: Apply to other cities and regions. Contact: Pengjun Zhao, Ralph Chapman, Philippa Howden- Chapman, Ed Randal, Angus Hulme-Moir

21 Transport system and traffic volume vulnerable to sea-level rise

Housing, Crowding & Infectious Diseases

Child Hospitalization in relation to housing Child (

What: Potentially modifiable risk factors for acute child hospital admissions in the Wellington Region compared with San Antonio area children Why: Children are vulnerable; poor housing conditions in New Zealand Outputs: Screening tool; international comparison; identify prevalence of PAH; measure prevalence of risk factors (i.e. crowding, heat source, hazards) in child hospitalization; MPH thesis>DrPH dissertation Child Hospitalization in relation to housing

What: Impact of housing factors (household crowding, damp/mould, heating/insulation, etc.) on ped. hospitalisations Why: Many potentially preventable pediatric hosps in NZ; housing conditions are an important factor in health outcomes; interventions that work are available Outputs: (1) screening tool for clinical use; (2) integration into a larger network of care/intervention. Opportunities: Connection to other work investigating links between housing conditions and health. Good support from clinicians and frontline workers. Collaborating/funding agencies: ? (possibly extending to Boston/USA, Sweden); Lotteries Health, HRC feasibility study Contacts: Jens Richter Short Clinical Screening Tool for Adverse Housing Factors Contributing to Pediatric Hospitalisations

Housing Issues - Disabled and Elderly People Accessible housing (in the rental market) Aging population means more impairments and competition for accessible housing where do people go? Close to social networks? Cost and tenure/permission to modify houses Low income populations Housebound Location of housing in relation to transport, community facilities and social networks

Research Interests Accessing housing Housebound cultural, environmental The way disabled/elderly people negotiate social and relationship/family private spaces, when they cant access public spaces. Housing location and accessing the community Social networks and community and their disruption and reformation due to housing crises

What: How are housing standards enforced in the tenancy tribunal? Enforcement: the landlord would be foolish not to carry out repairs at the end of the tenancy Generally an older house will be colder than a newer house because of the lack of insulation. A tenant who chooses to rent an older house cannot complain about that Conclusions: Tribunal enforces subjective and unstandardised measure. No power to compel repair rather, the tenancy is terminated and the house goes back on the market. In effect, often no enforcement of housing standards. OUTPUT: paper, disseminate to Tribunal Adjudicators and Local Council re referral of uninhabitable housing to Local Council? Housing Standards in the rental sector: Hope and a prayer

Housing quality in the rental sector Negotiating housing conditions: How do tenants respond to problematic housing conditions? Why: Only 5 % of complaints to TT concern housing quality. Little recourse for tenants living in poor quality housing. High mobility. Split incentives for repair, especially in lower cost housing. Data: Further review of tenancy data held at DBH and MoJ Interviews with tenants? Survey of tenants? Similar to 2004 survey of landlords? Opportunities: Collaboration on data set? Interviews and/or survey used for multiple RQ? Outputs: Write & publish papers. Increased collaboration with local council and TT/DBH?

A Comparison of the Regulation of private rental housing in NZ with eight other countries What: regulation of private rental housing in NZ compared with chosen countries Why: over quarter of NZ population lives in private rental housing, neglected policy area, poor quality, disparities exist Outputs: (1)Masters dissertation (2) papers & posters Opportunities: contribute to other housing research on effective regulation and how to implement it

Private rental housing quality standards employed in USA (left) & Scotland (right)

The renters voice: initial thoughts Civil society Good democracy and good policy require a vibrant civil society. Advocacy and activism role of civil society limited in NZ (small society; funding arrangements). Private and state renters have organised differently (advocacy vs direct action). Renters are not an organised group in NZ, esp. compared to other places, eg Victoria (supported by state) The absence or presence of the renters voice affects housing policy. Renters Policy is biased towards home- ownership and against renters. Number of private renters increasing (house prices; HNZ policy changes). Renters more likely to experience poor health outcomes due to tenure insecurity and poor quality housing. State tenancies increasingly insecure. Landlords are an organised group. Difficulties inherent in organising renters. Renters have a weak political voice to challenge policy. Like in other countries, a renters organisation that campaigned and lobbied on issues affecting renters in New Zealand could improve health outcomes.

What: A policy paper on social housing reform using sustainability as a framework. Why: Improve social housing policy, planning, action and measurement. Outputs: Report to Fulbright NZ and Department of Building and Housing. Partnerships for Social Housing workshop. Te Papa talk, IPANZ presentation Opportunities: Applies to the entire housing sector. Partnerships between central and local government, iwi, the private sector and third sector Collaborating agencies: Department of Building and Housing (Ministry of Business, Innovation and Employment) Contact: Philippa Howden-Chapman, Christian Stearns Sustainable Social Housing

Discussion points 1.Think Sustainability as a framework for social housing policy 2.Plan Social housing as part of the sustainable community infrastructure 3.Act Sustainable community partnerships 4.Measure Sustainable Return on Investment (SROI)

The Advantages and Disadvantages of Boarding Houses Clare Aspinall MPH Student Qualitative, Grounded Theory, semi-structured interviews, nine participants, 3 health workers, 2 boarders, 4 Landlords or managers Definition of boarding house = (a) containing 1 or more boarding rooms along with facilities for communal use by the tenants of the boarding house; and (b) occupied, or intended by the landlord to be occupied, by at least 6 tenants at any one time. The drivers for living in boarding house Provide insight into the experiences of living in these dwellings Explore options to improve boarding houses, particularly for those with poor health and disability

Results Drivers Affordability, lack of available alternatives for those on low incomes, particularly those with poor health and disability, Debt. Location, convenience, Those leaving institutions (prison, hospital, CYF), new migrant workers, relationship breakdown. Experiences Physical and social environments varied from boutique to squalid(this at times varied within the boarding house). Strict entry criteria for the mid- range places excluding people on benefits. Better linkages between health and social services and landlords in places housing vulnerable boarders. What could be done? Increase the tenancy rights of boarders to those equal to others under the RTAA (2010). Proactive inspection of all boarding houses, regular inspection of those housing vulnerable people. Improve release and discharge from institution practices to reduce dependency on poorest places. Better linkages between health and social services and landlords in places housing vulnerable boarders. Check landlord and managers credentials

Documents

He Kainga Oranga/ Housing and Health Research Programme University of Otago, Wellington Strategy Day July 2012