The health benefits of
secure housing:
examining the
evidence
Professor Rebecca Bentley
Centre of Research Excellence in Healthy Housing
1

Overview
1. What is housing security?
2. What do we know about its effects on health?
– Directly
– In the context of housing systems?
– In the context of intergenerational inequalities in housing?
– In the context of climate change adaptation of housing systems?
3. Based on this evidence, I will reframe:
– The benefits to health, health care expenditure and productivity of addressing insecurity in
the housing system – using an example of energy poverty and cold housing.
– The role of housing security as an apex determinant of health.
– The potential for developing an internationally comparable indicators of housing system
health.
4. Draw conclusions 3

Housing insecurity
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Adelle Mansour et al. J Epidemiol Community Health 2022;76:833-838
The guarantee that occupants
can reside in their homes
without fear of forced
eviction, harassment and
other threats.
Precarious
housing

Housing Insecurity and Health (Direct effects)
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Injury hazards
Indoor air
quality
Overcrowding
Indoor
temperature
Noise
Security
Injury Cancer
Mental health
Umbrella: related to
wellbeing
Respiratory
illness
Infectious
disease
Universal
access Toxic material
Cardiovascular
disease
–– Evidence has not been mapped specifically in WHO HHGL (prior evidence links these pathways).
Weak [ – – – ] to strong [ ––– ] evidence.
Diagram based on WHO 2018 healthy housing priorities included in the WHO Healthy Housing Guidelines literature synthesis.
Mould & damp
Health
outcomes
Home
environments

Housing Insecurity and Health (Direct)
Housing Affordability Stress
negatively effects mental
health and wellbeing -
between 1 and 2 points on a
100-point mental health
measure (Bentley et al 2011)
- Particularly so for people in
the rental sector (Mason et al
2013) and people who are
insecurely employed (Bentley
et al 2016).
6
Bentley, R., Baker, E., Mason, K., Subramanian, S.V. and Kavanagh, A.M., 2011. Association between housing affordability and mental health: a longitudinal analysis of a nationally representative household survey in Australia. American journal of epidemiology, 174(7), pp.753-760.
Mason, K.E., Baker, E., Blakely, T. and Bentley, R.J., 2013. Housing affordability and mental health: does the relationship differ for renters and home purchasers?. Social science & medicine, 94, pp.91-97.
Bentley, R., Baker, E., LaMontagne, A., King, T., Mason, K. and Kavanagh, A., 2016. Does employment security modify the effect of housing affordability on mental health?. SSM-population health, 2, pp.778-783.
Av MH=48
Av MH=50

Why does housing affordability stress have a negative
mental health effect?
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Financial hardship
Housing quality and condition
Housing location
Poor health and disability
Energy poverty
Compromise on Suitability

Housing Insecurity and Health
(& the housing system)
Does renting negatively impact
on health?
• In and of itself, NO
• Largely explained by the
composition of people in
rental.
• BUT – where there is
instability or insecurity we
do see a causal effect.
Can renters and owners have
the same health?
• YES
8

Through direct and indirect effects, security is
one of the causes of the causes….
Housing security (affordability, suitability and location) shape home environments which shape health.
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Figure1. Prevalenceof chronichealth problemsby beingable toafford to heat home

Share of young adults age 25-29 living with their parents
Housing Insecurity and Health
(& intergenerational inequalities)
Source: Adapted from Landgeist using Eurostat data from 2020
United Kingdom
The Netherlands
Germany
Australia
25%
16%
18%
29%
Source: Estimate
From HILDA, 2019
18%
55% Spain

Housing Insecurity and Health
(& intergenerational inequalities)
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Housing Insecurity and Health
(& climate change)
Housing
insecurity at
the time of
experiencing
the natural
disasters
impacts on the
length of time
it takes to
recover.
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Reframing Housing Security
– quantifying the benefits of better security
Based on the WHO Healthy Housing Guidelines (2018) literature synthesis

Δ cold housing
Δ blood
pressure
Δ ischaemic heat disease incidence
Δ stroke incidence
Δ asthma severity, children
Δ depression annual period prevalence
Δ health expenditure
Δ population income
Δ chronic kidney disease incidence
Δ hypertensive heart disease incidence
Δ atrial fibrillation incidence
Δ COPD severity
Δ asthma severity, adult
Δ LRTI annual period prevalence
Δ anxiety annual period prevalence
Δ asthma and COPD incidence rate
= Strong evidence
= Moderate evidence
= Weak evidence
Sum
Δ
morbidity
rates,
mortality
rates,
health
expenditure
rates,
and
income
earning
rates
Δ all cause morbidity
Δ all cause mortality
Δ health adjusted life
years (HALYs)
Δ health inequalities
Mishra,, S, Wilson, T, Andrabi, H, Ait Ouakrim, D, Li A, Singh A, Akpan E, Bentley R, BlakelyT. The health gains and cost savings of eradicating cold housing in Australia (Under review)

0 10000 20000 30000 40000 50000 60000 70000
Ischaemic hearth disease incidence
Stroke incidence
Chronic kidney disease incidence
Hypertensive heart disease incidence
Atrial fibrillation incidence
Depression prevalence
Anxiety prevalence
Asthma severity
COPD severity
LRTI event rate
Hypertension-related
disease
Mental
health
Respiratory
HALYs gained
20 years Lifetime
Health gains ≈6 times greater
amongst most deprived
$5.8B (range 2.5 to 13.1)
increase in income earnings
2021-40
$1.16B (range 0.5 to 2.6) in
health care savings 2021-40
Mishra,, S, Wilson, T, Andrabi, H, Ait Ouakrim, D, Li A, Singh A, Akpan E, Bentley R, BlakelyT. The health gains and cost savings of eradicating cold housing in Australia (Under review)
We can conclude that the
contribution of eradicating cold
housing to better health
through improved mental
health is likely large.
• Health gain of 202,000 (range
113,000 to 373,000) HALYs

0,00 5,00 10,00 15,00 20,00
Smoke-free generation
Tight limits on sodium in bread
Taxing alcoholic beverages
Eradication of indoor cold
Statin for adults (5%-9% CVD risk next 5 yrs)
Mandatory Tick food labelling program
ACE inhibitor for adults (5%-9% CVD risk next 5 yrs)
Beta-blocker for adults (5%-9% CVD risk next 5 yrs)
Community heart health program
Lifestyle program for adults
HALYs gained (log scale) over the remaining lifetime of the population, per 1000 people, 3% annual discount rate
Mishra,, S, Wilson, T, Andrabi, H, Ait Ouakrim, D, Li A, Singh A, Akpan E, Bentley R, BlakelyT. The health gains and cost savings of eradicating cold housing in Australia (Under review)

Interventions to reduce energy poverty, and other housing
interventions, are cost-effective:
- We could spend up to $7.6 billion* to eradicate cold
housing and still be cost effective.
- If we add in other gains, like productivity gains, energy
and environmental savings, we would be prepared to
spend $7.6 billion ++.
Cost-effectiveness insights
* Given lifetime discounted health expenditure savings of $1.3 billion, and 89,600 discounted life time HALY gains, as society we would spend up to 1.3 +
$70k*89600 = $7.6 billion to eradicate cold housing and still be cost effective (valuing a HALY at GDP per capita) – just on health outcomes alone

Contextual drivers
Housing Systems
Healthy Housing
Indicators
Home
environments
Cardiovascular,
respiratory,
mental health,
injury
Reframing housing security – Apex determinant
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Affordability
•Cost of renting
•Cost of purchasing
•Cost of maintenance
•Cost of utilities
Security
•Housing
supply/demand
•Social housing
availability
•Informal settlements
Suitability
•Housing size and
condition
•Accessible housing
Location
•Green space
•Access to transport
•Access to jobs

Reframing Housing Security
Useful internationally comparable indicator of
housing system health
ASPIRATIONAL
By Socio-Economic Position:
Age-cohort patterns of housing
occupancy by tenure
Social housing (% stock) relative to need
Housing affordability (%HAS) in rental
and owner-occupied sectors
Distance to jobs and transport for
affordable housing developments
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AVAILABLE
Indoor air quality (from global burden of disease
measures)
Number of informal settlements (monitored as
part of the Sustainable Development Goals).

Conclusions
Housing security is an apex determinant of how people are housed.
Security of tenure is a critical characteristic of healthy housing in the rental sector.
Improving security, at the population level is potentially a cost-effective prevention strategy for health.
With the rise of intergenerational inequalities and the threat of our changing climate – its importance has
increased as a prevention and mitigation strategy.
Recommend developing internationally comparably indicators of the health of our housing systems that we
can use to generate and evaluate policy.
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Thank you
Professor Rebecca Bentley
Director, NHMRC Centre of Research
Excellence in Healthy Housing
Melbourne School of Population and Global
Health
T: +61 3 8344 0639