11.Housing - Interventions: Preventive Action/Healthy Environments

Team Leaders: Dr Meirion Evans. Mr Alan Bennett
Literature searches completed on 12 February 1998

11: Housing - Interventions:Preventive action

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.

The Statements The Evidence

11.1 Opportunities for action outside the NHS

11.1a. Major efforts have been made to improve housing in Wales. Over £139 million was spent by Local Authorities on renovation grants in 1995-1996ⁱ. For that section of the housing stock for which a comparison can be made, the unfitness rate in 1993 was 13.3% compared with an estimated 19.5% in 1986 (a decrease of 6.2%)ⁱⁱ. However, there is still a significant amount of poor housing in Wales, especially when compared with Englandⁱⁱⁱ. Views as to what is acceptable change as more amenities are classed as essential requirements in a house. Considerable changes have been made in recent years to the statutory fitness standard^iv.
(Health gain notation - 3 "trade off between beneficial and adverse effects")
caveat: A new fitness rating approach is currently under development which would give an overall rating to a property, based on an assessment of a range of housing characteristics, rather than the current pass/fail on one or more requirements^v.
The 1997 Welsh House Condition Survey is due for publication in June 1999. i. Welsh Office Statistics. HEC95-04 (Audit final claim forms)
(Type IV evidence - statistical information)
ii. Welsh Office. 1993 Welsh House Condition Survey. Cardiff: Welsh Office, 1994
(Type IV evidence – statistical information)
iii. Department of the Environment, Transport and the Regions.1996 English House Condition Survey.
http://www.housing.detr.gov.uk/research/ehcs96/index.htm
(Type IV evidence – statistical information)
iv. Local Government and Housing Act, 1989. . London: HMSO, 1989
(Type V evidence – legislation)
v. Press release. Cardiff: Welsh Office. W98305-ho. 17 June 1998.

11.1b. Local Authorities have legislative powers to effect improvements in houses in multiple occupation and private rented accommodation^i,ii,iii,iv. Guidance on the use of these powers to promote healthy housing has been provided by the Audit Commission^v.
(Health gain notation - 2 "likely to be beneficial") i. Housing Act 1985. London: HMSO, 1985.
(Type V evidence - legislation)
ii. Local Government and Housing Act, 1989. London: HMSO, 1989
(Type V evidence - legislation)
iii. Local Government and Housing Act, 1989. Houses in multiple occupation. Standards of fitness. Cardiff: Welsh Office, 1992 (Circular 25/92)
(Type V evidence – expert opinion)
iv. Local Government and Housing Act, 1989. Area Renewal, unfitness, slum clearance and enforcement action. Cardiff: Welsh Office, 1990. (Circular 14/90)
(Type V evidence – expert opinion)
iv. Audit Commission. Healthy housing: the role of environmental health services. London: HMSO, 1991
v. (Type V evidence – expert opinion)
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11.1c. In providing suitable housing for people with special needs, such as those with a disability, close collaboration is needed between Social Services, Housing and Planning Departments, housing providers and the person affected. Older people require particular attention as they are at increased risk of injury in the home and often live in the poorest housing. Local authorities need to look at the balance of sheltered accommodation, modernisation plans and housing available to older people. Disabled facility grants and home repair assistance awards are available for repair and adaptation of property^i,.
(Health gain notation - 2 "likely to be beneficial") i. Housing Grants. Construction and Regeneration Act, 1996. London: HMSO, 1996
(Type V evidence – expert opinion)
http://194.128.65.3/acts/acts1996/1996053.htm

11.1d. Housing is an issue that involves many interests and there is an opportunity for collaborative action on a number of different levelsⁱ. i. Welsh Health Planning Forum. Protocol for Investment in Health Gain: Healthy Environments. Cardiff: Welsh Office, 1993
(Type V evidence - expert opinion)

11.1e. All those involved in the construction of houses can improve home safety by considering safety as a major requirement in all aspects of house design. The impact of such interventions is untestedⁱ.
(Health gain notation - 4 "unknown"). i. Page M. Child safety and housing. Practical design guidelines for commissioning agencies, architects designers and builders. London: Child Accident Prevention Trust, 1986
(Type V evidence - expert opinion)
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11.1f. Agencies working together can improve home safety.
Publicity campaigns based on education alone are unlikely to be effective^i,ii.
(Health gain notation - 5 "unlikely to be beneficial").
Home assessment and surveillance by a variety of professionals and non-professionals can, however, reduce falls in elderly people^iii,iv. This effect is likely to be enhanced by free or subsidised, simple home safety modifications^v.
(Health gain notation - 1 "beneficial").
Home visiting programmes by professionals and non-professionals can also significantly reduce rates of childhood injury^vi.
(Health gain notation - 1 "beneficial").
Targeted childhood initiatives appear to be more effective, especially if supported by free or subsidised home safety equipment schemes^{vii,v ii i}.
(Health gain notation - 2 "likely to be beneficial").
See also Injury Prevention bulletin in this series^ix. i. Thuen F, Maeland JG. Accident prevention activities in the Norwegian municipalities: the local response to a nationwide campaign. Scandinavian Journal of Social Medicine 1993; 21: 129-134
(Type III evidence – non-randomised trials)
ii. Vineis P, Ronco G, Ciccone G, Gogliani F. Home injuries in children: a population-based intervention trial. Epidemiology 1994; 5: 349-351
(Type III evidence – non-randomised trials)
iii. Preventing falls and subsequent injury in older people. Effective Health Care Bulletin. Vol. 2 No.4. University of York: NHS Centre for Reviews and Dissemination, 1996
(Type I evidence – systematic review)
http://www.york.ac.uk/inst/crd/ehc24.htm
iv. Gillespie LD, Gillespie WJ, Cummings R, Lamb SE, Rowe BH. Interventions to reduce the incidence of falling in the elderly. Cochrane Database of Systematic Reviews Cochrane Library 1998 Issue 2
(Type I evidence – systematic review)
v. Thompson PG. Preventing falls in the elderly at home: a community-based program. Medical Journal of Australia 1996; 164: 530-2
(Type III evidence – non-randomised trials)
vi. Hodnett ED, Roberts I. Home based social support for socially disadvantaged mothers. Cochrane Database of Systematic Reviews Cochrane Library 1998 Issue 2
(Type I evidence – systematic review)
vii. Health Education Authority. Health promotion in childhood and young adolescence for the prevention of unintentional injuries. Health Promotion Effectiveness Reviews Bulletin 2. London: HMSO, 1996
(Type III evidence – non-randomised trials)
http://www.york.ac.uk/inst/crd/ehc25.htm
viii. Preventing unintentional injuries in children and young adolescents. Effective Health Care Bulletin. Vol. 2 No.5. University of York: NHS Centre for Reviews and Dissemination, 1996
(Type III evidence – non-randomised trials)
ix. Health Evidence Bulletins Wales: Injury Prevention. Cardiff: Welsh Office, 1998
http://hebw.cardiff.ac.uk/injury/index.html
(Summaries of evidence classified according to type)
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11.1g. Compulsory use of smoke detectors will reduce burn injuriesⁱ. Free distribution of smoke detectors has been shown to reduce fire deaths by 80%ⁱⁱ.
(Health gain notation - 1 "beneficial").
See also Injury Prevention bulletin in this seriesⁱⁱⁱ. i. Health Education Authority. Health promotion in childhood and young adolescence for the prevention of unintentional injuries. Health Promotion Effectiveness Reviews Bulletin 2. London: HMSO, 1996
(Type III evidence – non-randomised trials)
ii. Mallone S, Istre GR, Rosenburg M. Surveillance and prevention of residential fire injuries. New England Journal of Medicine 1996; 335: 27-31
(Type IV evidence – observational study)
iii. Health Evidence Bulletins Wales: Injury Prevention. Cardiff: Welsh Office, 1998
(Summaries of evidence classified according to type)
http://hebw.cardiff.ac.uk/injury/index.html

11.1h. Carbon monoxide poisoning is best prevented by professional installation and maintenance of fuel-burning appliancesⁱ.
(Health gain notation - 2 "likely to be beneficial").
Although carbon monoxide detectors are inexpensive and widely available the benefits of widescale use are unclear^i,ii.
(Health gain notation - 4 "unknown"). i. Ernst A, Zibrak JD. Carbon monoxide poisoning. New England Journal of Medicine 1998; 339: 1603-1608
(Type V evidence - expert opinion)
ii. Krenzelok EP, Roth R, Full R. Carbon monoxide…the silent killer with an audible solution. American Journal of Emergency Medicine 1996; 14: 484–486
(Type IV evidence – observational study)

11.1i. Lead poisoning is uncommon. Efforts to reduce lead exposure are best aimed at high-risk groups living in older housing. Measures to replace lead plumbing and lead-based paint should reduce exposureⁱ.
(Health gain notation - 4 "unknown"). i. Juberg DR, Kleiman CF, Kwon SC. Position paper of the American Council on Science and Health: lead and human health. Ecotoxicology and Environmental Safety 1997; 38: 162-180
(Type V evidence - expert opinion)
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11.1j. Remedial action is recommended by the National Radiological Board in homes with high radon levels (above 200 Bq/m³). These include a variety of measures to improve ventilation including a radon sumpⁱ. The cost-effectiveness of these measures in reducing the risk of lung cancer compared with smoking prevention initiatives is unprovenⁱⁱ.
(Health gain notation - 4 "unknown"). i. National Radiological Protection Board. Board statement on radon in homes. Documents of the NRPB Vol.1 No. 1. Chiltern: National Radiological Protection Board, 1990
(Type IV and V evidence - review of observational studies and expert opinion)
ii. Chaffey CM, Bowie C. Radon and health – an update. Journal of Public Health Medicine 1994; 16: 465-470
(Type IV and V evidence – review of observational studies and expert opinion)

11.2 Opportunities for action within the NHS

11.2a. The NHS has a role, with other agencies (e.g. Local Authority and Environmental Health Departments) in helping to ensure that houses are safe places to live. Health visitors, district nurses and other members of the primary health care team working with families and older people can reduce injuries^{i,ii,iii,iv,v}.
(Health gain notation - 1 "beneficial").
See also Injury Prevention bulletin in this series. i. Preventing falls and subsequent injury in older people. Effective Health Care Bulletin. Vol. 2 No.4. University of York: NHS Centre for Reviews and Dissemination, 1996
http://www.york.ac.uk/inst/crd/ehc24.htm
(Type I evidence – systematic review)
ii. Preventing unintentional injuries in children and young adolescents. Effective Health Care Bulletin. Vol. 2 No.5. University of York: NHS Centre for Reviews and Dissemination, 1996
(Type III evidence – non-randomised trials)
iii. Hodnett ED, Roberts I. Home based social support for socially disadvantaged mothers. Cochrane Database of Systematic Reviews Cochrane Library 1998 Issue 2
(Type I evidence – systematic review)
iv. Health Promotion Research Programme. Health visitor prevention of home accidents. Bristol University. Department of Social Science, 1996
(Type III evidence – non-randomised trials)
v. Clamp M, Kendrick D. A randomised controlled trial of general practitioner safety advice for families with children under 5 years. British Medical Journal 1998; 316: 1576-9
http://www.bmj.com/cgi/content/full/316/7144/1576
(Type II evidence – randomised controlled trial)
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11.2b. A number of community development projects have been set up to support communities in tackling housing issues. Communities for Better Health led by Health Promotion Wales is an example of this, though its impact has not yet been formally evaluatedⁱ.
(Health gain notation –4 "unknown"") i. Health Promotion Wales. Communities for better health. Cardiff: Health Promotion Wales, 1995

11.2c. A high proportion of asthma sufferers have an allergy to specific allergens, particularly house-dust mites and cats. However, methods currently available for reducing exposure to the house-dust mite tend to be ineffective, at least in the way that they are usually employed^i,ii.
(Health gain notation – 5 "unlikely to be beneficial")

There is a need for trials of more rigorous methods of mite eradication in mite-sensitive asthmatics.
See also Respiratory Diseases bulletin in this seriesⁱⁱⁱ.
i. Hammarquist C, Burr ML, Gotzsche PC. House dust mite control measures in the management of asthma in adults and children. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 2 (Type I evidence – systematic review of randomised controlled trials)
ii. Gotzsche PC, Hammarquist C, Burr M. House dust mite control measures in the management of asthma. British Medical Journal 1998; 317: 1105-1110
http://www.bmj.com/cgi/content/full/317/7166/1105
(Type I evidence – systematic review of randomised controlled trials)
iii. Health Evidence Bulletins Wales: Respiratory Diseases. Cardiff: Welsh Office, 1998
(Summaries of evidence classified according to type)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk