Housing improvements for health and associated socio-economic outcomes.

BACKGROUND: The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts. OBJECTIVES: To assess the health and social impacts on residents following improvements to the physical fabric of housing. SEARCH METHODS: Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status. SELECTION CRITERIA: Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language. DATA COLLECTION AND ANALYSIS: Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model. MAIN RESULTS: Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis. AUTHORS' CONCLUSIONS: Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Shared physical custody after family split-up: implications for health and well-being in Swedish schoolchildren.

AIM: In Sweden, shared physical custody following a parental separation has emerged as means for children to keep close relationships with both parents. Previous studies show that children benefit from regular contact with both parents, who share responsibility for their social, emotional and economic welfare. In this study, we investigate any associations between family arrangements, that is, two-parent, single and shared physical custody families and child health outcomes and whether this association was modified by parent-child communication. METHODS: Data on 11- to 15-year-old children from the 2005/2006 and 2009/2010 Swedish Health Behaviour in School-aged Children survey were analysed using multivariate logistic regression. RESULTS: Children in shared physical custody were more likely than children in two-parent families to report multiple health complaints (OR 1.26) and low well-being (OR 1.71). When variables of parent-child communication were entered in the model, the initial differences remained between children living in shared physical custody and those living in two-parent families. CONCLUSION: Children in shared physical custody and single-parent families are more at risk of negative outcomes compared with children in two-parent families. This association was not modified by parent-child communication in children in shared custody families, indicating that the communication equals that in two-parent family children.

Risk behaviour in Swedish adolescents: is shared physical custody after divorce a risk or a protective factor?

BACKGROUND: The increase in shared physical custody in Sweden has been dramatic; 20 years ago only a small percentage of adolescents lived in shared physical custody, but currently ∼30% of the adolescents whose parents have separated or divorced divide their residence between parents. We hypothesized that living in shared physical custody or in a single-parent family is associated with a higher prevalence of adolescent risk behaviour than living in a two-parent family. METHODS: Data on 15-year-old adolescents from the 2005/2006 to 2009/2010 Swedish Health Behaviour in School-aged Children (HBSC) survey were analysed using logistic regression. RESULTS: Adolescents living in shared physical custody had slightly higher rates of risk behaviour compared with adolescents from two-parent families, but significantly lower rates than their counterparts from single-parent families. Their odds of being a smoker or having been drunk were 60 and 50% higher, respectively, than those of their counterparts in two-parent families. CONCLUSION: Shared physical custody after marriage break-up seems to constitute a health protective factor for adolescents' health and problem behaviour. In order to deepen our understanding of the positive and negative aspects of shared physical custody, our study should be followed by qualitative analyses and longitudinal studies of adolescents' experiences.

Health outcomes among Swedish children: the role of social capital in the family, school and neighbourhood.

AIM: The aim of the study was to explore the extent to which Swedish children's perceptions of social capital in the family, school and neighbourhood predicted health complaints and well-being. METHODS: The study used data from the Swedish Health Behaviour in School-aged Children survey. The sample consisted of 3926 children aged 11-15 years. Correlations and hierarchical multiple linear regression were performed. RESULTS: Higher degrees of family, school and neighbourhood social capital corresponded to lower levels of health complaints and higher levels of well-being. Social capital in these three spheres had a cumulative effect on children's health and well-being. CONCLUSIONS: Social capital in the family, school and neighbourhood matters for children's health and well-being and the contributions from each context seem to be additive. Besides the family context, investments for improving child health should primarily be in the school, focusing on social relations and on creating safe and cohesive school environments. Neighbourhood social capital is also of importance and so must be taken into consideration when planning child health promotion interventions.

Perceptions of community trust and safety - consequences for children's well-being in rural and urban contexts.

AIM: To explore the associations between subjective well-being and perceptions of community trust and safety amongst children in rural and urban areas. METHODS: The study used self-reported data from the 2001/2002 Swedish cross-national WHO study Health Behaviour in School-aged Children. The sample consisted of 3852 children aged 11-15 years, living in different residential areas. Bivariate analyses and multivariate logistic regression were performed. RESULTS: The results indicated that a greater proportion of children in urban areas perceived low community trust and safety, compared with children in rural areas. Further, the multivariate analysis revealed that perceived community trust and safety significantly impacts upon children's subjective well-being in both rural and urban contexts. CONCLUSION: Children's perceptions of trust and safety have different magnitudes in urban and rural areas. The associations of perceptions of community trust and safety for children's subjective well-being are relevant in both urban and rural areas. As perceptions of low trust and safety in the community seem to be related to low subjective well-being, efforts to encourage community trust and safety should be included amongst the key priorities in community health promotion.

Growing up in rural community--children's experiences of social capital from perspectives of wellbeing.

INTRODUCTION: People are influenced by the neighborhood in which they live. The neighborhood may be particularly important for children's wellbeing because of the constraints it imposes on their patterns of daily activities. Furthermore, the neighborhood is a central context for social development, being a place where children form networks and learn social skills and values. The aim of this study was to describe how social capital in the neighborhood is perceived by children living in rural areas, and to reveal what this adds to their sense of wellbeing. METHODS: The study had a descriptive research design with a qualitative approach. Seven single-sex focus group interviews were conducted with children the in 6th grade (aged 11-12 years). Data were analyzed using deductive content analysis. RESULTS: The children perceived a lack of social capital due to environmental and social constraints in their everyday lives. However, their wellbeing was enhanced by strong cohesion in the neighborhood. In addition, settings such as the school, the natural environment, and sporting associations were highly valued and emerged as crucial factors for enhancing the children's wellbeing. The spatial isolation that characterizes rural areas created a special context of social network structures, cohesion and trust, but was also a breeding ground for exclusion and social control. The stories revealed paradoxical feelings of living in a good and safe area that simultaneously felt isolated and restricted. CONCLUSIONS: From a rural perspective, this study reveals the complexity of the children's perceptions of their social environment, and the ways in which these perceptions have both positive and negative effects on wellbeing. The results highlight how important it is for health professionals in rural areas to consider the complex influence of bonding social capital on children's wellbeing, and to be aware that it can promote exclusion as well as cohesion.

School demands and subjective health complaints among Swedish schoolchildren: a multilevel study.

OBJECTIVES: As children spend a great deal of their time in school, the climate in the classroom can constitute a resource, but also a risk factor in the development of the pupils' health. The aim of the present study was to determine the extent to which demands in the classroom are associated with subjective health complaints in Swedish schoolchildren. METHODS: Data from the 2001/2002 and 2005/2006 Swedish cross-national Health Behaviour in School-aged Children (HBSC) survey were analysed using a multilevel logistic regression technique. RESULTS: The study demonstrated a substantial variation between school classes in pupils' subjective health complaints. In school classes with high demands, the odds of having subjective health complaints was about 50% higher than in school classes with low demands. Further, the results indicated that these effects were mediated by sex so as to girls being more affected by high levels of demands in the school class. CONCLUSIONS: The findings are important since they point at the crucial role that teachers play in creating a favourable school climate. Therefore interventions aiming at supporting teachers to set realistic demands and expectations are one way to improve the school climate. Such interventions should also make clear the need to take into consideration the fact that the school class effect was mediated by sex, i.e. girls being more vulnerable to high level of school class demands.

The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007.

OBJECTIVES: We conducted a systematic review of the health impacts of housing improvement. METHODS: Forty-two bibliographic databases were searched for housing intervention studies from 1887 to 2007. Studies were appraised independently by H. T. and S. T. or E. S. for sources of bias. The data were tabulated and synthesized narratively, taking into account study quality. RESULTS: Forty-five relevant studies were identified. Improvements in general, respiratory, and mental health were reported following warmth improvement measures, but these health improvements varied across studies. Varied health impacts were reported following housing-led neighborhood renewal. Studies from the developing world suggest that provision of basic housing amenities may lead to reduced illness. There were few reports of adverse health impacts following housing improvement. Some studies reported that the housing improvement was associated with positive impacts on socioeconomic determinants of health. CONCLUSIONS: Housing improvements, especially warmth improvements, can generate health improvements; there is little evidence of detrimental health impacts. The potential for health benefits may depend on baseline housing conditions and careful targeting of the intervention. Investigation of socioeconomic impacts associated with housing improvement is needed to investigate the potential for longer-term health impacts.

Obesity prevalence in a cohort of women in early pregnancy from a neighbourhood perspective.

BACKGROUND: The evidence of an association between neighbourhood deprivation and overweight is established for different populations. However no previous studies on neighbourhood variations in obesity in pregnant women were found. In this study we aimed to determine whether obesity during early pregnancy varied by neighbourhood economic status. METHODS: A register based study on 94,323 primiparous pregnant women in 586 Swedish neighbourhoods during the years 1992-2001. Multilevel technique was used to regress obesity prevalence on socioeconomic individual-level variables and the neighbourhood economic status. Five hundred and eighty-six neighbourhoods in the three major cities of Sweden, Stockholm, Göteborg and Malmö, during 1992-2001, were included. The majority of neighbourhoods had a population of 4 00010 000 inhabitants. RESULTS: Seven per cent of the variation in obesity prevalence was at the neighbourhood level and the odds of being obese were almost doubled in poor areas. CONCLUSION: Our findings supports a community approach in the prevention of obesity in general and thus also in pregnant women.

The neighbourhood they live in: does it matter to women's smoking habits during pregnancy?

Socioeconomic factors in the neighbourhood are associated with smoking habits in various populations. We studied a 10-year cohort to determine whether women's smoking behaviour during pregnancy can similarly be determined by neighbourhood economic and ethnic factors. The cohort included 127,074 primiparous pregnant women in 592 Swedish neighbourhoods during the years 1992-2001. Multilevel technique was used to regress pregnancy smoking on socioeconomic individual-level variables and neighbourhood characteristics. Seven percent of the variation in pregnancy smoking was at the neighbourhood level and the odds of smoking during pregnancy were doubled in poorer areas. Health education and smoking cessation interventions should be directed at maternity care units in deprived neighbourhoods.

Are there differences in birth weight between neighbourhoods in a Nordic welfare state?

BACKGROUND: The objective of this cohort study was to examine the effect on birth weight of living in a disadvantaged neighbourhood in a Nordic welfare state. Birth weight is a health indicator known to be sensitive to political and welfare state conditions. No former studies on urban neighbourhood differences regarding mean birth weight have been carried out in a Nordic country. METHODS: A register based on individual data on children's birth weight and maternal risk factors was used. A neighbourhood characteristic, i.e. an aggregated measure on income was also included. Connections between individual- and neighbourhood-level determinants and the outcome were analysed using multi-level regression technique. The study covered six hundred and ninety-six neighbourhoods in the three major cities of Sweden, Stockholm, Göteborg and Malmö, during 1992-2001. The majority of neighbourhoods had a population of 4 000-10 000 inhabitants. An average of 500 births per neighbourhood were analysed in this study. RESULTS: Differences in mean birth weight in Swedish urban neighbourhoods were minor. However, gestational length, parity and maternal smoking acted as modifiers of the neighbourhood effects. Most of the observed variation in mean birth weight was explained by individual risk factors. CONCLUSION: Welfare institutions and benefits in Sweden might buffer against negative infant outcomes due to adverse structural organisation of urban neighbourhoods.

Primiparas with or without oxytocin augmentation: a prospective descriptive study.

AIMS: The aim of this study was to determine during which phase of delivery augmentation is started when used and to establish any correlation that might exist between the oxytocin infusion and the evaluations by primiparas themselves of their labour pain, strength of contractions and fatigue. In addition, we wanted to determine any differences in duration between labour with and labour without augmentation. We finally wanted to measure the incidence of instrumental deliveries, perineal trauma and neonatal outcome among the augmented vs. the non-augmented groups. BACKGROUND: The most commonly diagnosed complication in primiparas is ineffective contractions or protracted labour, otherwise known as dystocia, which literally means arrested or prolonged labour. Different treatments have been tried during the active phase of labour as well as the second stage of labour. The most common treatment today is amniotomy, often used in combination with an intravenous oxytocin infusion. MATERIALS AND METHODS: The study was conducted at the hospital in Ostersund in central Sweden from August 1998 to September 1999. Consecutive primiparas giving birth at full-term were selected to the study. The inclusion criteria were an uncomplicated pregnancy and a spontaneous single delivery with head presentation. The total number of participants was 164. RESULTS: The results showed that 50 of 164 primiparas needed no augmentation, while 88 were augmented during the active phase and 26 during the second stage of labour. The duration of the active phase [median (md) 4 hours 45 minutes, 6 hours 49 minutes and 6 hours 20 minutes respectively for the different groups, P = 0.03], the time between full dilation of the cervix and the start of the second stage (md 20 minutes, 30 minutes and 60 minutes respectively, P = 0.012) and the duration of the second stage of labour (md 40 minutes, 44 minutes and 60 minutes respectively, P = 0.04) were significantly longer in the augmented groups. Operative deliveries, too, were more frequent in the augmented groups. There was a significantly higher rate of perineotomies in the group augmented during the second stage of labour. There were, however, no differences in Apgar score <7 at 1 minute. pH in the umbilical cord and the base deficit were higher in the group which were augmented during the second stage of labour (P = 0.02 and P = 0.06 respectively). Women describing their impression of the experience as a whole generally gave it a high rating, but women who were augmented during the second stage of labour gave the experience a significantly lower score (P = 0.01). CONCLUSION: Augmentation is used in unusually prolonged deliveries. We did not find that augmentation involved a higher frequency of perineal trauma, although it was correlated with a higher frequency of operative deliveries. There was no correlation between the oxytocin infusion and the primiparas' descriptions of the strength of contractions, pain and fatigue, although greater use of epidurals was observed in women with augmented labour. The number of nulliparas in this study was too small to analyse the incidence of ruptures in the sphincter or draw conclusions about differences between the groups with regard to Apgar scores or metabolic acidosis. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, good routines concerning oxytocin augmentation are crucial. Interventions as oxytocin augmentation seem to cause harm to mother and child. To evaluate interventions continuously in obstetric care is therefore important.

The significance of neighbourhood context to child and adolescent health and well-being: a systematic review of multilevel studies.

Growing up in a poor neighbourhood has negative effects on children and adolescents. In the literature it has been concluded that the risk of low birth weight, childhood injury and abuse, and teenage pregnancy or criminality double in poor areas. However, the validity of such studies has been questioned, as they have been associated with ecological or individualistic fallacies. Studies using multilevel technique might thus contribute important knowledge in this field. The present review clarifies the importance of neighbourhood contextual factors in child and adolescent health outcomes, through considering only studies using multilevel technique. Keyword searching of the Medline, ERIC, PsycInfo, Sociological Abstracts, and Social Citation Index databases was performed. Original studies using multilevel technique to examine the effect of neighbourhood characteristics on child and adolescent health outcomes, and focusing on populations in high-income countries were included. Neighbourhood socioeconomic status and social climate were shown to have small to moderate effects on child health outcomes, i.e. birth weight, injuries, behavioural problems, and child maltreatment. On average, 10% of variation in health outcomes was explained by neighbourhood determinants, after controlling for important individual and family variables. This review demonstrates that interventions in underprivileged neighbourhoods can reduce health risks to children, especially in families that lack resources. An analysis of methodological fallacies indicates that observed effects and effect sizes can be underestimated, and that interventions may well have greater impact than this review was able to establish.