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Uncovering the impacts of housing policies on health equity with multiple methods

Uncovering the impacts of housing policies on health equity with multiple methods, by Davide Malmusi. Presented at the 7th European Public Health Conference: "Mind the gap: Reducing inequalities in health and health care". Glasgow, 20th to 22nd November 2014.

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Uncovering the impacts of housing policies 
on health equity with multiple methods 
Davide Malmusi for the SOPHIE housing policies team 
“How to tackle health inequalities?” 
Preconference #EPHGlasgow 20 November 2014
SOPHIE Housing policies team 
Agència de Salut Pública de Barcelona: Ana Novoa, 
Lluís Camprubí, Davide Malmusi, Carme Borrell, 
Laia Palència, Jordi Amat, Roshanak Mehdipanah, 
Julia Ward, Andrés Peralta, Marc Marí-Dell’Olmo, 
Hugo Vázquez, Maica Rodríguez-Sanz 
Càritas Diocesana de Barcelona: Fernando Díaz, 
Carme Trilla, Mercè Darnell, Tere Bermudez 
Universitat Pompeu Fabra: Jordi Bosch
Why housing? (1) 
Secular trends in improvement of housing conditions have been 
regarded as a major factor behind advances in population health. 
Housing as “wobbly pillar” of the welfare state (and social epi?). 
Evidence of positive health impact of interventions improving 
physical housing conditions. Less evidence on: 
- Health equity impacts 
- Policies influencing access to housing and housing cost
Why housing? (2) 
Literature mainly from UK, New Zealand… much less in Spain 
where it has been an increasingly pressing social issue, 
both before and after the burst of the housing bubble
What are we doing? 
European overview 
1. Literature reviews and conceptual framework on housing 
policies, housing conditions and health inequalities 
2. European housing systems and health-related housing 
outcomes: ecological and multilevel analyses 
Focus on fuel poverty 
1. Realist synthesis on energy retrofitting and health equity 
2. Natural experiment on thermal insulation and winter 
mortality in social housing 
3. Resistance to austerity on UK fuel poverty policies 
Focus on people with severe problems of access to housing 
1. Caritas BCN users: survey, rehousing quasi-experiment 
2. “Mortgage affected platform”: online survey, cohort?
What are we doing? 
European overview 
1. Literature reviews and conceptual framework on housing 
policies, housing conditions and health inequalities 
2. European housing systems and health-related housing 
outcomes: ecological and multilevel analyses 
Focus on fuel poverty 
1. Realist synthesis on energy retrofitting and health equity 
2. Natural experiment on thermal insulation and winter 
mortality in social housing 
3. Resistance to austerity on UK fuel poverty policies 
Focus on people with severe problems of access to housing 
1. Caritas BCN users: survey, rehousing quasi-experiment 
2. “Mortgage affected platform”: online survey, cohort?

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Uncovering the impacts of housing policies on health equity with multiple methods

  • 1. Uncovering the impacts of housing policies on health equity with multiple methods Davide Malmusi for the SOPHIE housing policies team “How to tackle health inequalities?” Preconference #EPHGlasgow 20 November 2014
  • 2. SOPHIE Housing policies team Agència de Salut Pública de Barcelona: Ana Novoa, Lluís Camprubí, Davide Malmusi, Carme Borrell, Laia Palència, Jordi Amat, Roshanak Mehdipanah, Julia Ward, Andrés Peralta, Marc Marí-Dell’Olmo, Hugo Vázquez, Maica Rodríguez-Sanz Càritas Diocesana de Barcelona: Fernando Díaz, Carme Trilla, Mercè Darnell, Tere Bermudez Universitat Pompeu Fabra: Jordi Bosch
  • 3. Why housing? (1) Secular trends in improvement of housing conditions have been regarded as a major factor behind advances in population health. Housing as “wobbly pillar” of the welfare state (and social epi?). Evidence of positive health impact of interventions improving physical housing conditions. Less evidence on: - Health equity impacts - Policies influencing access to housing and housing cost
  • 4. Why housing? (2) Literature mainly from UK, New Zealand… much less in Spain where it has been an increasingly pressing social issue, both before and after the burst of the housing bubble
  • 5. What are we doing? European overview 1. Literature reviews and conceptual framework on housing policies, housing conditions and health inequalities 2. European housing systems and health-related housing outcomes: ecological and multilevel analyses Focus on fuel poverty 1. Realist synthesis on energy retrofitting and health equity 2. Natural experiment on thermal insulation and winter mortality in social housing 3. Resistance to austerity on UK fuel poverty policies Focus on people with severe problems of access to housing 1. Caritas BCN users: survey, rehousing quasi-experiment 2. “Mortgage affected platform”: online survey, cohort?
  • 6. What are we doing? European overview 1. Literature reviews and conceptual framework on housing policies, housing conditions and health inequalities 2. European housing systems and health-related housing outcomes: ecological and multilevel analyses Focus on fuel poverty 1. Realist synthesis on energy retrofitting and health equity 2. Natural experiment on thermal insulation and winter mortality in social housing 3. Resistance to austerity on UK fuel poverty policies Focus on people with severe problems of access to housing 1. Caritas BCN users: survey, rehousing quasi-experiment 2. “Mortgage affected platform”: online survey, cohort?
  • 7. Conceptual framework Adapted from Ana Novoa et al. Impact of the crisis on the relationship between housing and health. Policies for good practice to reduce inequalities in health related to housing conditions. Gac Sanit. 2014 Jun;28 Suppl 1:44-50.
  • 8. Literature review Large body of literature showing the link between inadequate material housing conditions and poor physical and mental health and mortality. Health benefits of thermal comfort improvement. Adverse impact on health of insecure housing and lack of housing affordability. Evidence of benefits of social housing and rent subsidies on health determinants. Homelessness strongly associated with multiple physical and mental health problems and lower life expectancy. Positive impacts of both “housing first” and “staircase”. Jordi Bosch. Literature review of the relationship between housing systems and health inequalities. Unpublished
  • 9. Housing systems and health inequalities Gap in knowledge on the link between housing systems and health. We have constructed country indices of health-related material and economic housing problems. They are ecologically linked to economic development, welfare regimes and “housing bubble” Now starting a multilevel analysis of the association of country housing systems with the prevalence, social distribution and health impact of these housing problems in the European population
  • 10. What are we doing? European overview 1. Literature reviews and conceptual framework on housing policies, housing conditions and health inequalities 2. European housing systems and health-related housing outcomes: ecological and multilevel analyses Focus on fuel poverty 1. Realist synthesis on energy retrofitting and health equity 2. Natural experiment on energy retrofitting (thermal insulation) and winter mortality in social housing 3. Resistance to austerity on UK fuel poverty policies Focus on people with severe problems of access to housing 1. Caritas BCN users: survey, rehousing quasi-experiment 2. “Mortgage affected platform”: online survey, cohort?
  • 11. Focus on fuel poverty Realist synthesis: energy retrofitting and health equity To explain how and why public policies influence social inequalities in receiving housing energy retrofitting and in its health impacts Key reviews/reports, stakeholders interviews, systematic search of articles (124 read, 70 used) Public resources invested PUBLIC POLICY APPROACH PPOOLLIICCYY Information for consumer Social norms Coping ACCEPTANCE AND AVAILABILITY RECEIVING INTERVENTION BARRIERS IN ABSENCE OF POLICIES POST-RECEIVING INTERVENTION Types: Regulation, Funding, Information Eligibility criteria Upfront costs Split-incentives CCOONNTTEEXXTTSS IINNEEQQUUAALLIITTYY && VVUULLNNEERRAABBIILLIITTYY DDIIMEENNSSIIOONNSS
  • 12. Focus on fuel poverty Realist synthesis: energy retrofitting and health equity Main conclusions: Social categories suffering most from fuel poverty (low-income, renters, elderly) can attain more health benefits from housing retrofitting but experience more barriers (upfront costs and presentism, split incentives, disruption and lack of control) Public policies on housing energy efficiency usually exacerbate these inequalities, unless they are specifically aimed at tackling fuel poverty or social inequities, totally free to users, targeted at most affected groups and adapted to their needs
  • 13. Focus on fuel poverty Natural experiment: Social housing insulation and winter mortality Objective: Evaluate the impact of energy efficiency facade retrofitting interventions on the association between cold outdoor temperatures and mortality in public housing buildings in the city of Barcelona from 1985 to 2013 Methods: Case-crossover design. Buildings geocoded with Regional Housing Agency intervention dates and linked to census and mortality data Results: Spring 2015
  • 14. What are we doing? European overview 1. Literature reviews and conceptual framework on housing policies, housing conditions and health inequalities 2. European housing systems and health-related housing outcomes: ecological and multilevel analyses Focus on fuel poverty 1. Realist synthesis on energy retrofitting and health equity 2. Natural experiment on thermal insulation and winter mortality in social housing 3. Resistance to austerity on UK fuel poverty policies Focus on people with severe problems of access to housing 1. Caritas BCN users: survey, rehousing quasi-experiment 2. “Mortgage affected platform”: online survey, cohort?
  • 15. Focus on Caritas Barcelona users Rehousing quasi-experiment Original design Rehoused (Caritas social renting programme) Waiting list Families living in substandard housing Follow-up survey (1 year after) Baseline survey (Sept-Dec 2012) Survey interview on socioeconomic and housing conditions, health of the respondent and of one of her/his children
  • 16. Focus on Caritas users Health status of people with severe problems of access to housing n=175 Families living in substandard housing … or with difficulties paying rent or mortgage (Housing Mediation Service) n=145 Baseline survey (Sept-Dec 2012)
  • 17. Much worse health status than Barcelona population (overall and manual social classes) 62,2 Poor mental health 75,0 11,5 12,1 66,9 72,6 15,2 17,4 100 80 60 40 20 0 Subst housing HMS BCN BCN SC IV and V % Men Women 24,4 Fair/poor health status 45,8 11,2 12,8 53,1 60,3 15,3 20,5 100 80 60 40 20 0 Subst housing HMS BCN BCN SC IV and V % Men Women Focus on Caritas users Health status of people with severe problems of access to housing
  • 18. Focus on Caritas users Health status of people with severe problems of access to housing Much worse health status than Barcelona population also for children 28,9 Poor mental health (children) 38,9 3,6 62,3 65,8 8,5 100 80 60 40 20 0 Subst housing HMS BCN % Boys Girls
  • 19. Focus on Caritas users Rehoused (Caritas social renting programme) Waiting list Rehousing quasi-experiment The fieldwork n=175 Families living in substandard housing … or with difficulties paying rent or mortgage (Housing Mediation Service) n=145 Follow-up survey (1 year after) Baseline survey (Sept-Dec 2012) Follow-up n=97 n=33 n=108
  • 20. Focus on Caritas users Rehousing quasi-experiment: preliminary results Rehoused (Caritas social renting programme) Waiting list Follow-up Follow-up survey (1 year after) Rehoused adults report more improvements in housing conditions, and similar improvements in health as “controls” (some of whom also move, find job, increase income) Improvements in habitability, tenure security and income significantly associated with improvements in health (especially mental health) n=33 n=108 n=97
  • 22. sophie-project.eu @sophieproject @dmalmusi info@sophie-project.eu dmalmusi@aspb.cat Thank you! Gràcies! Grazie! Photos: Fredi Roig, Alice Sassu, Roberto Malaguti