RESEARCH ESSAY FOR JOSHUA
ARBURY
2522603
Tutorial Time: Tuesday 12-1
Research Essay
Question:
To what
extent is housing a determinant of health?
Introduction:
Health, as defined by the World Health Organisation (W.H.O.), is a
“state of complete physical, mental and social well-being, not merely the
absence of disease or infirmity.” (Mackenbach et. al., 1994: 1273) There are
many determinants of health, including: household income, employment, working
conditions, education, diet, warm dry housing, family support and the absence
of smoking (Howden-Chapman and Cram, 1998). Historically, a strong connection
has been made between housing and health: during Victorian times efforts were
made to improve public health through the use of housing policy – in this case
slum clearance. However, as infectious diseases have declined throughout the
developed world, acknowledgement of housing as a determinant of healthcare has
decreased, while more emphasis has been placed on individual behaviour and
medical advancement. Nevertheless, continuing inequalities in health mirror
socio-economic inequalities – including housing conditions – and this has led
to a revival of studies in the past ten years in housing as a determinant of
health. In this essay I will focus on housing as a determinant of health, and
examine whether a causal link between the two can be identified. Also, I will
examine other factors related to housing that may have an impact on health and
how they interact, and whether a more integrated approach should be taken to
improve health status. This approach would accept the complex causal role of
housing, both at an individual and community level, and help not only improve
the physical condition of those with poor health, but also improve their mental
and social well-being, in accordance with the W.H.O. definition of health.
Propositions/objectives:
The objective of this research essay is to examine the link between
housing and health status. While it has been accepted that there is a link
between the two, to some extent, the lack of causal evidence has meant that
housing has often been ignored as an important determinant of health. This
essay proposes, through the use of conceptual literature, that even though
there may not be a clear causal link between housing and health, other
socio-economic factors such as income, employment status, education level and
cultural background have an influence on health that cannot be easily separated
from housing. Therefore a holistic approach should be to taken to improve
health by improving the socio-economic status of the population – including
policies related to housing.
What are the determinants of health?
Determinants of
health, defined by the W.H.O. as “the range of personal, social, economic and
environmental factors which determine the health status of individuals or
populations” (Takano and Nakamura, 2001: 263), are complex, interconnected,
multiple and interactive. They include “such factors as income and social
status, education, employment and working conditions, access to appropriate
health services, and physical environments.” (Takano and Nakamura, 2001: 263)
Advances in health status over the past 150 years in developed countries have been
quite remarkable, and are due to the improvement of much more than just medical
knowledge. “The massive improvement in the health of populations of urban
industrial societies during the past hundred years or so is far more a
consequence of collective intervention in the environment than it is of the
development, and even provision of, curative health care.” (Byrne and Keithley,
1993: 41) The importance of socio-economic and environmental factors in health
improvement was understood by Victorian Britain, where infectious diseases were
reduced very effectively through programmes designed to improve housing
standards. This was the first time housing had been officially connected with
health. Slum clearances and sanitation programmes played an extremely important
role in the decline of infectious diseases. Although social scientific
literature “suggests that the most important antecedents of human health are
not medical care inputs and health behaviours (smoking, diet, exercise, etc.),
but rather social and economic characteristics of individuals and populations”
(Dunn, 2000: 342) much of the focus upon improving health ever since the
Victorian era, but particularly since the Second World War, has been on medical
care advancements or behavioural education. This gap between the perceived
importance of socio-economic factors (which is evidently quite low) and their
actual importance (comparatively much higher) is one that needs to be addressed
in order to improve health status, while reducing health inequalities. The
correlation of poor housing with poor health still remains, as identified by
Conway (1995: 143): “despite a century of state housing intervention,
demolition of the slums, general improvements in health and near eradication of
the main killer diseases, those with the worst health still live in the worst
parts of the housing stock.”
Much of the
difficulty in determining the effect housing has upon health comes from the
definition of what in fact health and housing are. The W.H.O. definition of
health as “a state of complete physical, mental and social well-being, and not
merely the absence of disease or infirmity” (W.H.O., 1948) is incredibly
difficult to measure and potentially impossible to actually achieve. Such a
holistic concept of health, including psychological as well as physical
manifestations, is more likely to be influenced by socio-economic factors such
as housing. Poor housing, among other factors, may lead to mental illnesses
like depression or acute stress because of the standard of dwelling, or the
location of that particular dwelling. These wider effects have often been
ignored, resulting in the lack of evidence for a causal link between housing
(or wider socio-economic determinants as a whole), and health. “Doctors who
have come to expect p values and confidence intervals will be dismayed at the
lack of hard science.” (Lowry, 1989: 1262)
Is housing an important determinant of
health?
Even though there
may lack a conclusive link between housing and health, there is plenty of
evidence that the two concepts are linked very closely. Matte and Jacobs (2000:
9) explain that the “provision of safe water for drinking and personal hygiene,
proper disposal of sewage, and facilities for safe food preparation and the
absence of overcrowding are examples of how adequate housing can promote public
health.” In addition, protection from temperature extremes and natural hazards
are seen as basic requirements of housing in the developed world. While the
above provisions seem fairly limited, studies show that in 1995 1.5% of US
homes lacked some or all plumbing facilities, 2.6% had more than one person for
each room and 5% had inadequate heating (Matte and Jacobs, 2000). Moreover,
homelessness – which can be viewed as the low extreme of a continuum of access
to decent housing – denies all these basic housing provisions and therefore
leaves the homeless person in a position similar to what was faced by those
living in nineteenth century Britain, and the infectious diseases that came
with those particular housing conditions.
Poor housing, as well as homelessness,
can exacerbate existing health problems or cause new ones. Studies, such as the
one conducted by Hopton and Hunt (1996) show that the presence of dampness and
mould in housing leads to certain symptoms of ill health, indicating that
housing indeed does play a causal role in health status. However, other factors
may influence health, such as financial difficulties, are probably deeply
intertwined with poor housing making it difficult to single out housing as
having a causal role. Their research shows that damp housing conditions leads
to the flourishing of viruses, bacteria, dust mites and mould. Mould, although
appearing harmless compared with the other ‘well-known’ causes of ill health,
can be a cause of respiratory allergens and lead to infection of the lungs –
some fungi can even become toxic at certain stages of their life cycle.
“Significant links [have been] found between aches and pains, diarrhoea,
headaches and respiratory complaints in children, and the presence of visible
mould in the house.” (Hopton and Hunt, 1996: 272) Matte and Jacobs (2000) have
also discovered a link between housing and the occurrence of asthma among New
York City hospitalisation records. The high rates of asthma experienced by
low-income, inner-city children can be explained by their exposure to indoor
allergens from dust mites, domestic pets and cockroaches, which is increased in
a number of ways through poor housing. Structural defects can allow entry by
cockroaches and rodents while high relative humidity (those living in poor
housing are probably unable to afford a dehumidifier, while poor ventilation
can also lead to the build-up of moisture) can lead to the proliferation of
dust mites (Matte and Jacobs, 2000). Moreover, potentially helpful mattresses
and pillow covers may be unavailable due to socio-economic factors, further
increasing the severity and occurrence of asthma among low-income areas with
poor housing.
Further studies show
that housing also has wider impacts on health than just certain illnesses
related to dampness, mould and coldness. Welfare benefit cuts in New Zealand in
1991 led to many families having to move in with relatives or friends to
economise on rent. This led to intense overcrowding, especially among Maori and
Pacific Islanders, and many health problems. Overcrowding leads to “higher
rates of infectious diseases such as meningococcal meningitis, tuberculosis,
rheumatic fever, measles and mental health problems.” (Howden-Chapman and Cram,
1998: 21) Mental health problems are especially important, as they are often
overlooked (especially if not considered particularly severe) but are an
integral part of the W.H.O. definition of health. Surveys have estimated that
in New Zealand, 20-35% of those with chronic psychiatric illness who were
living in the community occupied inappropriate or substandard housing
(Howden-Chapman and Cram, 1998), while other studies have found a direct
correlation of mental well-being with quality of housing (Kearns et. al. 1993).
Depression is commonly associated with poor housing, and housing was identified
as being a significant factor in 28% of reported cases of chronic depression in
a study conducted by Brown and Harris (1982). Howden-Chapman et. al. (1996:
175) explain these findings through the decreased ability to cope with mental
and physical problems if the living environment is crowded, noisy, dilapidated
and cold. Although severe life events and major difficulties were far more
likely to be identified by the individual rather than housing problems, Brown
and Harris felt that sudden events could be seen as ‘provoking agents’ which
exacerbated the problems caused by poor housing and ‘pushed things over the
edge’. (Brown and Harris, 1982) Poor social support networks also play a major
role in the causes of depression, and this emphasises the fact that not only
must the standard of individual dwellings be considered as a determinant of
health, but the location of the dwellings within the residential environment.
Therefore, a focus
on community and individual health must be taken into account. There is
a need to ask questions about what influences the health of whole populations,
and what influence housing and health policies have on the determinants of
health status. It is clear that housing refers not only to the type and quality
of a particular dwelling, but also its location. Howden-Chapman et. al. (1996:
179) contend that “the consistent differences in self-assessed housing areas
could be explained more by the location of a dwelling than by dwelling type or
the presence of structural defects.” Residential location affects access to
healthcare, while quality of care usually varies across different
neighbourhoods, often least provided where it is most needed. Environmental
hazards such a noise and air pollution, as well as radon and lead poisoning are
spatially variable factors that can have an impact upon the health of an entire
neighbourhood. As with many impacts of poor housing, other socio-economic
factors such as income, ethnicity and employment status influence both the
ability to enjoy good quality housing as well as the availability of healthcare
facilities. Poorer neighbourhoods may be unable to fund an effective lobby
group to stop polluting facilities locating in the area, and also may be unable
to move away once the facility is located.
Clearly, both
individually and communally, housing has some impact upon health.
However, it has been very difficult to identify an exact scientific causal role
for housing as a determinant of health – which has led some to believe that the
role has actually been overestimated. Kasl (1990) contends that residential
environment has a surprisingly weak and limited effect on physical and mental
health, and only really shows up as a strong determinant of ‘well being’ and
‘satisfaction’ while having a relatively weak impact on symptom checklists.
This, perhaps surprising, result is explained by Kasl, as “the residential
environment as an independent variable and health as the dependent variable are
both embedded in a rich matrix of other important influences.” (Kasl, 1990:
481) Housing is clearly not an independent variable, as many other
socio-economic factors, even including health status, play a role in the
quality of housing one enjoys. In some respects, poor housing and health can be
seen as a cycle of cumulative causation, as ‘health selections’ exist “which
ensure that the sickest people are least able to negotiate their way into
better housing; as a consequence their health may be further jeopardised by
their placement in sub-standard dwellings.”(Kearns and Smith, 1994: 419) Just
as housing is affected by other socio-economic factors, it is possible to
explore the role of housing in each of the other related health determinants.
Education and housing are clearly linked, as someone with a better education is
more likely to earn a higher salary and afford a better house, while poor
housing conditions (especially overcrowding) may limit a child’s ability to
engage in the education system, inevitably having negative consequences in the
future. Employment influences housing, through income levels, while the
location of housing may inhibit some employment opportunities (lack of public
transport facilities etc.). Income is strongly linked to housing, as generally
higher income levels both allow the purchase of a higher quality dwelling in a
‘better’ neighbourhood.
Other determinants of health, are they
related to housing?
Housing can also
have an impact upon other, non socio-economic, health determinants such as
behavioural patterns and, as I have already mentioned, access to healthcare
facilities. Health related behaviours, such as those shown in Figure 1, could
be influenced by housing, as well as other socio-economic factors. High rents
may make it impossible to afford a healthy nutritious diet, while overcrowding
may lead to inadequate sleep and the inability to engage in regular exercise.
Byrne and Keithley (1993: 49) discovered that many women even explain their own
smoking behaviour in terms of the miserable nature of their domestic
environment, that smoking “helps them get through the day”. Alcohol abuse,
which is also a key behaviour associated with poor health, is often used by
those suffering from depression (which could potentially be related to
housing), or particularly by the homeless. Once again, while homelessness may
be a cause of alcoholism, the reverse is also true as people who spend more
money on alcohol have less left over for accommodation, and are also in a
poorer state to apply for a job.
Figure one illustrates how complex the determinants of health are,
and how housing plays a central role in this matrix. While Kasl (1990) and
others have pointed out the difficulty in establishing a direct and clear link
between housing and health, this may not actually be a sign that this link is
insignificant, but merely that it is deeply woven into all the other
determinants of health – perhaps increasing its importance not only for health
but other societal ‘problems’ such as crime and poverty. Byrne and Keithley
(1993: 44) emphasise this point by questioning “how can the effects of housing
be separated out from the effects of many other factors which influence health
and which are likely to co-vary with housing such as class, occupation, income,
consumption habits, environmental pollution and so on?” The time-lag between
living in poor housing conditions and experiencing the health effects may be
quite significant, although stress and depressive illness would probably be
linked to current housing conditions, long-term illnesses experienced later in
life may have a causal link back to bad housing during childhood (Byrne and
Keithley, 1993). The integrated way in which the home environment has an
adverse impact upon human health means that integrated solutions are required,
bringing together housing, health and other determinants to establish long term
solutions to health inequalities.
What policy changes could be made?
Housing and health
were integrated under British law until well into the twentieth century, but
the subsequent division has meant that policymakers are often uninterested in
the social origins of poor health. Each determinant, when considered by itself,
has been found to have important, but not easily identified effects on health
status, and therefore emphasis upon improving health status has focused
elsewhere – in areas such as medical research or behaviour adjustment. The
individualisation of health can be seen as a product of late twentieth century
neo-liberalism, famously captured in the quote “Nobody is responsible for my
health but me” from former National Party Health Minister Simon Upton. However,
the integrated nature of health determinants and the strong socio-economic
links to health status, mean that closer collaboration between sectors –
especially public health and housing – will be required to bring about any real
progress, as happened in the late nineteenth century (Matte and Jacobs, 2000).
Howden-Chapman et. al. (1996) suggest that short-term and long-term policy
changes are needed to bring about any real improvements in population health
status. Public education, house inspections, tightening of building codes, and
incentive schemes to rectify problems have been identified as possible housing
policy changes that could bring about an improvement in health status. The
authors suggest “while poor housing alone is not the major explanation for poor
health and increased demands on health services, the strong association of
housing with health indicates that there may be high payoffs from the provision
of readily available good housing” (Howden-Chapman et. al. 1996: 181).
Conclusion:
It is clear, from the literature I have analysed, that housing indeed
is an important determinant of health status. However, the very nature of both
housing and health means that they are embedded within a multitude of other
factors, each of which influence, and are influenced by, one another. Although
studies have failed to show a clear causal link between housing condition and
health status, there is clear evidence from the many products of poor housing,
that substandard housing conditions adversely affect the occupants’ health. The
W.H.O. definition of health, which is broader than traditional western concepts
by encompassing mental and social well-being, further underlines the impact of
housing on mental illness, as people who live in crowded, cold, noisy and damp
conditions are less likely to be able to cope with major life changes – leading
to stress related illness and depression. In conclusion, health and housing are
strongly and complexly interconnected at a level that appears obvious to common
sense, but can be difficult to discover through scientific experiments. Because
of the integrated nature of this linkage, and of all the health determinants,
an integrated policy approach would be needed to make any major impact into
population health levels. However, the strong correlation between these two
concepts means that if an integrated, sustained policy was adopted, the results
could prove to be quite significant.
LIST OF REFERENCES:
Brown, G. and Harris, T. (1982) Social Origins of Depression, Travistock,
London.
Byrne, D. and Keithley, J. (1993) ‘Housing and Health in the
community’ in R. Burridge and D. Ormandy (eds.) Unhealthy Housing: research,
remedies and reform, Chapman and Hall, London. pp. 41-66.
Conway, J. (1995) ‘Housing as an instrument of health care’ Health
and Social Care in the Community, 3(3), pp. 141-150.
Dunn, J. (2000) ‘Housing and Health Inequalities: review and
prospects for research’ Housing Studies, 15(3), pp. 341-366.
Hopton, J. and Hunt, S. (1996) ‘The Health Effects of Improvements to
Housing: a longitudinal study’ Housing Studies, 11(2), pp. 271-286.
Howden-Chapman, P. and Cram, F. (1998) Social, Economic and
Cultural Determinants of Health, National Health Committee: Health
Determinants Programme Background Paper 1.
Howden-Chapman, P., Isaacs, N., Crane, J. and Chapman, R. (1996)
‘Housing and Health: the relationship between research and policy’ International
Journal of Environmental Health Research, 6(3), pp. 173-185.
Kasl, S. (1990) ‘Quality of the residential environment, health, and
well being’ Bulletin of the New York Academy of Medicine, 66(5) pp.
479-490.
Kearns, R. and Smith, C. (1994) ‘Housing, Homelessness, and Mental
Health: mapping an agenda for geographical enquiry’ Professional Geographer,
46(4) pp. 418-424.
Kearns, R., Smith, C. and Abbot, M. (1993) ‘Housing stressors and
persons with serious mental health problems’ Health, Society and Care in the
Community, 1., pp.263-275.
Lowry, S. (1989) ‘Introduction to Housing and Health’ British
Medical Journal, 299, pp.1261-1262.
Mackenbach, J., Van Den Bos, J., Joung, I.,Van De Mheen, A. and
Stronks, K. (1994) ‘The Determinants of Excellent Health: different from the
determinants of ill-health’ International Journal of Epidemiology, 23(5)
pp. 1273-1281.
Matte, T. and Jacobs, D. (2000) ‘Housing and Health: current issues
and implications for research and programs’ Journal of Urban Health:
Bulletin of the New York Academy of Medicine, 77(1) pp. 7-25.
Takano, T. and Nakamura, K. (2001) ‘An analysis of health levels and
various indicators of urban environments for Healthy Cities projects’ Journal
of Epidemiology and Community Health, 55(4) pp. 263-270.
World Health Organisation, (1948) Basic Documents, The
Organisation, 36ed. Geneva, W.H.O.