Housing typologies and asthma: a scoping review.

Asthma is related to triggers within the home. Although it is recognised that triggers likely occur due to characteristics of housing, these characteristics have not been comprehensively reviewed, and there is a paucity of housing-focused interventions to reduce asthma and asthma symptoms. Following five steps identified by Arksey and O'Malley, we conducted a scoping review of published evidence on the associations between asthma and housing characteristics. We searched three electronic databases (PubMed, Scopus, Web of Science), identifying 33 studies that met our inclusion criteria. Through an iterative approach, we identified nine housing characteristics relevant to asthma onset or exacerbation, categorised as relating to the surrounding environment (location), the house itself (dwelling), or to conditions inside the home (occupancy). We conceptualise these three levels through a housing typologies framework. This facilitates the mapping of housing characteristics, and visualises how they can cluster and overlap to exacerbate asthma or asthma symptoms. Of the three levels in our framework, associations between asthma and locational features were evidenced most clearly in the literature reviewed. Within this category, environmental pollutants (and particularly air pollutants) were identified as a potentially important risk factor for asthma. Studies concerning associations between dwelling features and occupancy features and asthma reported inconsistent results, highlighting the need for greater research in these areas. Interpreting housing-related asthma triggers through this framework paves the way for the identification and targeting of typologies of housing that might adversely affect asthma, thus addressing multiple characteristics in tandem rather than as isolated elements.

Estimating cardiovascular health gains from eradicating indoor cold in Australia.

BACKGROUND: Exposure to cold indoor temperature (< 18 degrees Celsius) increases cardiovascular disease (CVD) risk and has been identified by the WHO as a source of unhealthy housing. While warming homes has the potential to reduce CVD risk, the reduction in disease burden is not known. We simulated the population health gains from reduced CVD burden if the temperature in all Australian cold homes was permanently raised from their assumed average temperature of 16 degrees Celsius to 20 degrees Celsius. METHODS: The health effect of eradicating cold housing through reductions in CVD was simulated using proportional multistate lifetable model. The model sourced CVD burden and epidemiological data from Australian and Global Burden of Disease studies. The prevalence of cold housing in Australia was estimated from the Australian Housing Conditions Survey. The effect of cold indoor temperature on blood pressure (and in turn stroke and coronary heart disease) was estimated from published research. RESULTS: Eradication of exposure to indoor cold could achieve a gain of undiscounted one and a half weeks of additional health life per person alive in 2016 (base-year) in cold housing through CVD alone. This equates to 0.447 (uncertainty interval: 0.064, 1.34; 3% discount rate) HALYs per 1,000 persons over remainder of their lives through CVD reduction. Eight percent of the total health gains are achievable between 2016 and 2035. Although seemingly modest, the gains outperform currently recommended CVD interventions including persistent dietary advice for adults 5-9% 5 yr CVD risk (0.017 per 1000 people, UI: 0.01, 0.027) and persistent lifestyle program for adults 5-9% 5 yr CVD risk (0.024, UI: 0.01, 0.027). CONCLUSION: Cardiovascular health gains alone achievable through eradication of cold housing are comparable with real-life lifestyle and dietary interventions. The potential health gains are even greater given cold housing eradication will also improve respiratory and mental health in addition to cardiovascular disease.

Evidence to guide ethical decision-making in the management of older people living in squalor: a narrative review.

Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision-making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty-seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision-making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non-interventional approach is likely to contravene the principles of non-maleficence, beneficence and justice. Adequate assessment of decision-making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.

Methods for accounting for neighbourhood self-selection in physical activity and dietary behaviour research: a systematic review.

BACKGROUND: Self-selection into residential neighbourhoods is a widely acknowledged, but under-studied problem in research investigating neighbourhood influences on physical activity and diet. Failure to handle neighbourhood self-selection can lead to biased estimates of the association between the neighbourhood environment and behaviour. This means that effects could be over- or under-estimated, both of which have implications for public health policies related to neighbourhood (re)design. Therefore, it is important that methods to deal with neighbourhood self-selection are identified and reviewed. The aim of this review was to assess how neighbourhood self-selection is conceived and accounted for in the literature. METHODS: Articles from a systematic search undertaken in 2017 were included if they examined associations between neighbourhood environment exposures and adult physical activity or dietary behaviour. Exposures could include any objective measurement of the built (e.g., supermarkets), natural (e.g., parks) or social (e.g., crime) environment. Articles had to explicitly state that a given method was used to account for neighbourhood self-selection. The systematic review was registered with the PROSPERO International Prospective Register of Systematic Reviews (number CRD42018083593) and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. RESULTS: Of 31 eligible articles, almost all considered physical activity (30/31); few examined diet (2/31). Methods used to address neighbourhood self-selection varied. Most studies (23/31) accounted for items relating to participants' neighbourhood preferences or reasons for moving to the neighbourhood using multi-variable adjustment in regression models (20/23) or propensity scores (3/23). Of 11 longitudinal studies, three controlled for neighbourhood self-selection as an unmeasured confounder using fixed effects regression. CONCLUSIONS: Most studies accounted for neighbourhood self-selection by adjusting for measured attributes of neighbourhood preference. However, commonly the impact of adjustment could not be assessed. Future studies using adjustment should provide estimates of associations with and without adjustment for self-selection; consider temporality in the measurement of self-selection variables relative to the timing of the environmental exposure and outcome behaviours; and consider the theoretical plausibility of presumed pathways in cross-sectional research where causal direction is impossible to establish.

Mental health and prolonged exposure to unaffordable housing: a longitudinal analysis.

PURPOSE: When housing is insufficient, or poor quality, or unaffordable there are well established health effects. Despite the pervasiveness of housing affordability problems (widely referred to as Housing Affordability Stress-HAS), little quantitative work has analysed long-term mental health effects. We examine the mental health effects of (prolonged and intermittent) patterns of exposure to housing affordability problems. METHODS: We analysed a large, nationally representative longitudinal population sample of individuals, following them over five-year periods to assess the relative mental health effects of different patterns of exposure to housing affordability problems. To maximise the number of observations and the robustness of findings, we used 15 years (2002-2016) of data, across three pooled exposure windows. Longitudinal regression analysis with Mundlak adjustment was used to estimate the association between prolonged (constant over a 5-year period) and intermittent exposure to HAS, and mental health (as measured using the SF-36 MCS). RESULTS: We found that, on average, both prolonged and intermittent exposure were associated with lower mental health (Beta = - 1.338 (95% CI - 2.178-0.488) and Beta = - 0.516 (95% CI - 0.868-0.164), respectively). When we additionally adjusted for baseline mental health, thereby accounting for initial mental health status, coefficients were attenuated but remained significant. CONCLUSIONS: Both prolonged and intermittent exposure to HAS negatively impact mental health, irrespective of baseline mental health. Interventions that target affordable housing would benefit population mental health. Mental health interventions should be designed with people's housing context in mind.

Do financial hardship and social support mediate the effect of unaffordable housing on mental health?

PURPOSE: Unaffordable housing has a negative impact on mental health; however, little is known about the causal pathways through which it transmits this effect. We examine the role of financial hardship and social support as mediators of this relationship. METHODS: We identified households where housing costs changed from affordable to unaffordable across two waves of the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2014-2015). The sequential causal mediation analysis was used to decompose the total effect of unaffordable housing on mental health into the portion attributable to financial hardship and social support [natural indirect effect (NIE)] and the portion not occurring through measured pathways [natural direct effect (NDE)]. Mental health was measured using the Mental Health Inventory (MHI) and Kessler psychological distress (KPD) scale. Baseline covariates included age, sex, household income, financial hardship, social support, marital status and employment status. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs). Multiple imputations using chained equations were applied to account for missing data. RESULTS: Unaffordable housing led to a change in mean mental health score on the MHI scale (- 1.3, 95% CI: - 2.1, - 0.6) and KPDS scale (0.9, 95% CI: 0.4, 1.4). Financial hardship accounted for 54% of the total effect on MHI scale and 53% on KPD scale. Collectively, financial hardship and social support explained 68% of the total effect on MHI scale and 67% on KPD scale, respectively. CONCLUSIONS: In conclusion, the negative mental health effect of unaffordable housing is largely mediated through increased financial hardship.

Does the effect of disability acquisition on mental health differ by employment characteristics? A longitudinal fixed-effects analysis.

PURPOSE: Longitudinal studies have suggested a causal relationship between disability acquisition and mental health, but there is substantial heterogeneity in the magnitude of the effect. Previous studies have provided evidence that socioeconomic characteristics can buffer the effect but have not examined the role of employment characteristics. METHODS: We used data from 17 annual waves of the Household, Income and Labour Dynamics in Australia Survey to compare the mental health of working age individuals before and after disability acquisition, using the Mental Health Inventory, a subscale of the SF-36 health questionnaire. Linear fixed-effects regression models were used to estimate the effect of disability acquisition on mental health. We tested for effect modification by two characteristics of people's employment prior to disability acquisition: occupational skill level and contract type. Multiple imputation using chained equations was used to handle missing data. RESULTS: Disability acquisition was associated with a substantial decline in mental health score (estimated mean difference: - 4.3, 95% CI - 5.0, - 3.5). There was evidence of effect modification by occupational skill level, with the largest effects seen for those in low-skilled jobs (- 6.1, 95% CI - 7.6, - 4.5), but not for contract type. CONCLUSIONS: The findings highlight the need for social and health policies that focus on increasing employment rates, improving the sustainability of employment, and providing employment services and education and training opportunities for people who acquire a disability, particularly for people in low-skilled occupations, to reduce the mental health inequalities experienced by people with disabilities.

Better transport accessibility, better health: a health economic impact assessment study for Melbourne, Australia.

BACKGROUND: Physical inactivity is a global public health problem, partly due to urbanization and increased use of passive modes of transport such as private motor vehicles. Improving accessibility to public transport could be an effective policy for Governments to promote equity and efficiency within transportation systems, increase population levels of physical activity and reduce the negative externalities of motor vehicle use. Quantitative estimates of the health impacts of improvements to public transport accessibility may be useful for resource allocation and priority-setting, however few studies have been published to inform this decision-making. This paper aims to estimate the physical activity, obesity, injury, health and healthcare cost-saving outcomes of scenario-based improvements to public transport accessibility in Melbourne, Australia. METHODS: Baseline and two hypothetical future scenario estimates of improved public transport accessibility for Melbourne, Australia, were derived using a spatial planning and decision tool designed to simulate accessibility performance (the Spatial Network Analysis for Multimodal Urban Transport Systems (SNAMUTS)). Public transport related physical activity was quantified by strata of age group and sex from Melbourne travel survey data (VISTA survey) and used with the SNAMUTS Composite Index to estimate input data for health impact modelling for the Melbourne population aged 20-74 years. A proportional multi-state, multiple cohort lifetable Markov model quantified the potential health gains and healthcare cost-savings from estimated changes in physical activity, body weight and injuries related to walking to access/egress public transport under two scenarios: (S1) public transport accessibility under current policy directions, and (S2) multi-directional, high-frequency network improvements. RESULTS: Multi-directional, high-frequency improvements to the public transport network (S2) resulted in significantly greater health and economic gains than current policy directions (S1) in relation to physical activity (mean 6.4 more MET minutes/week), body weight (mean 0.05 kg differential), health-adjusted life years gained (absolute difference of 4878 HALYs gained) and healthcare cost-savings (absolute difference of AUD43M), as compared to business as usual under both scenarios (n = 2,832,241 adults, over the lifecourse). CONCLUSIONS: Based on our conservative analyses, improving accessibility to public transport will improve population health by facilitating physical activity and lead to healthcare cost savings compared with business-as-usual. These wider health benefits should be better considered in transport planning and policy decisions.

Defining patterns of care in the management of patients with brain metastases in a large oncology centre: A single-centre retrospective audit of 236 cases.

AIMS: The role of selected treatments for brain metastases (BM) is well documented; however, the prevalence of these is not. We report on the patterns of care in the management of BM in a large oncology centre. MATERIALS AND METHODS: We retrospectively audited 236 cases of newly diagnosed BM from January 2016 to December 2017 by looking at 2 years of radiology reports and gathered data on primary site, survival, treatment received, palliative care input and brain metastases-related admissions. RESULTS: Eighty-two per cent of cases were related to lung, breast and melanoma primaries. Half of patients received a form of treatment with the other half receiving best supportive care. Of these, whole-brain radiotherapy (39%) and stereotactic radiosurgery (40%) were the most common treatment modalities. Most common reasons for admissions were headaches, seizures, weakness and confusion. CONCLUSION: This is the first study in the UK that gives an in-depth overview of the real-world management of brain metastases. We have demonstrated the prevalence of treatment across the spectrum of brain metastases patients. Radiotherapy is the mainstay of treatment in nearly 80% of cases; however, care needs to be taken in ensuring that SRS is offered to those who are suitable.

The levonorgestrel intrauterine device in Australia: analysis of prescribing data 2008-2012.

BACKGROUND: Unplanned pregnancy is a significant problem in Australia. Local data pertaining to use of the levonorgestrel-releasing intra-uterine device (LNG-IUD), and associated factors are limited. The aim of this analysis was to calculate prescribing rates of the LNG-IUD in Australia, including trends in prescribing and associations with socio-demographic factors, in order to increase understanding regarding potential use. METHODS: We examined prescriptions for the LNG-IUD recorded in the national Pharmaceutical Benefits Scheme (PBS) from 2008 to 2012. Prescribing trends were examined according to patient age, remoteness of residential location, and proximity to relevant specialist health services. Associations between these factors and prescription rates were examined using poisson regression. Analyses were stratified by 5-year age-groups. RESULTS: Age-adjusted prescription rates rose from 11.50 per 1000 women aged 15-49 (95% CI: 11.41-11.59) in 2008 to 15.95 (95% CI:15.85-16.01) in 2012. Prescription rates increased most among 15-19-year-olds but remain very low at 2.76 per 1000 women (95% CI: 2.52-3.01). Absolute increases in prescriptions were greatest among 40-44-year-olds, rising from 16.73 per 1000 women in 2008 (95% CI: 16.12-17.34) to 23.77 in 2012 (95% CI: 22.58-24.29). Rates increased significantly within all geographical locations (p < 0.01). Non-metropolitan location was significantly associated with increased prescribing rates, the association diminishing with increasing age groups. CONCLUSIONS: Prescription of LNG-IUD in Australia is very low, especially among young women and those in major cities. Service providers and young women may benefit from targeted education outlining use of the LNG-IUD, strengthened training and referral pathways. Disparities in prescription according to location require further investigation.

The impact of persistent poor housing conditions on mental health: A longitudinal population-based study.

Living with housing problems increases the risk of mental ill health. Housing problems tend to persist over time but little is known about the mental health consequences of living with persistent housing problems. We investigated if persistence of poor housing affects mental health over and above the effect of current housing conditions. We used data from 13 annual waves of the British Household Panel Survey (1996 to 2008) (81,745 person/year observations from 16,234 individuals) and measured the persistence of housing problems by the number of years in the previous four that a household experienced housing problems. OLS regression models and lagged-change regression models were used to estimate the effects of past and current housing conditions on mental health, as measured by the General Health Questionnaire. Interaction terms tested if tenure type modified the impact of persistent poor housing on mental health. In fully adjusted models, mental health worsened as the persistence of housing problems increased. Adjustment for current housing conditions attenuated, but did not explain, the findings. Tenure type moderated the effects of persistent poor housing on mental health, suggesting that those who own their homes outright and those who live in social housing are most negatively affected. Persistence of poor housing was predictive of worse mental health, irrespective of current housing conditions, which added to the weight of evidence that demonstrates that living in poor quality housing for extended periods of time has negative consequences for mental health.

Invited Commentary: Harnessing Housing Natural Experiments Is Important, but Beware Differential Misclassification of Difference in Difference.

In this issue of the Journal, Reeves et al. (Am J Epidemiol. 2016;184(6):421-429) present the findings of a natural experiment analyzing the association between reduced housing affordability and mental ill health. Their difference-in-difference analysis of cross-sectional, quarterly population health surveys administered before and after implementation of a policy to reduce Housing Benefit payments in the United Kingdom in April 2011 represents an important way to assess the impact of a national housing policy shift on public health. It is a well-conducted study harnessing a natural experiment and adds to the weight of evidence supporting an association between housing costs and mental health. However, quantitative bias analysis based on the reported findings suggests that a small amount of differential (by unblinded Housing Benefit status) misclassification bias in the outcome may be enough to explain the observed association. Our analysis of possible misclassification bias in the outcome used in the study highlights the need for caution when a difference-in-difference estimate is small, the population is not blinded to its postintervention exposure status, and the outcome measure is subjective and prone to differential (by unblinded exposure or treatment status) misclassification.

Socioeconomic position in young adulthood is associated with BMI in Australian families.

BACKGROUND: Low socioeconomic position (SEP) is associated with increased cardiovascular (CV) disease risk, but the relative importance of SEP in childhood and adulthood, and of changes in SEP between these two life stages, remains unclear. Studies of families may help clarify these issues. We aimed to assess whether SEP in young adulthood, or change in SEP from childhood to young adulthood, was associated with five continuously measured CV risk factors. METHODS: We used data from 286 adult Australian families from the Victorian Family Heart Study (VFHS), in which some offspring have left home (n = 364) and some remained at home (n = 199). SEP (defined as the Index of Relative Socioeconomic Disadvantage) was matched to addresses. We fitted variance components models to test whether young adult SEP and/or change in SEP was associated with systolic blood pressure, diastolic blood pressure, body mass index (BMI), total cholesterol or high-density lipoprotein cholesterol, after adjustment for parental SEP and within-family correlation. RESULTS: An increase in SEP of 100 SEIFA units from childhood to adulthood was associated with a lower BMI (ß = -0.49 kg/m(2), P < 0.01) only. CONCLUSIONS: These results suggest that a change in SEP in young adulthood is an important predictor of BMI, independent of childhood SEP.

Inequalities in socio-economic characteristics and health and wellbeing of men with and without disabilities: a cross-sectional analysis of the baseline wave of the Australian Longitudinal Study on Male Health.

BACKGROUND: Internationally, men with disabilities have higher rates of social and economic disadvantage and poorer health and wellbeing than men without disabilities. No single study has provided comprehensive, population-level information about the magnitude of such differences among adult men using a well-validated instrument to measure disability. METHODS: We analysed baseline data from Ten to Men - an Australian longitudinal study of male health. Ten to Men used a stratified multi-stage cluster random sample design to recruit a national sample of males aged 10 to 55 years residing in private dwellings. Data were collected between October 2013 and July 2014 from 15,988 males. This analysis was restricted to 18-55 year old participants with data available on age and disability (n = 13,569). We compared the demographic, socio-economic characteristics and health and wellbeing of men with and without disabilities using chi squared tests for proportions and t tests for continuous variables. Linear regression adjusted for age was used to assess the association between disability status and health and wellbeing, which were measured using the SF-12 mental and physical health component scores and the Personal Wellbeing Index. RESULTS: Men with disabilities were older and more likely to be born in Australia, speak English at home, be Aboriginal and Torres Strait Islander and were less likely to be married or de facto, or to live in urban areas. They were less likely to have completed secondary school, be employed and live in affordable housing, and were more likely to live on low incomes, in more socio-economically disadvantaged areas, and in rental accommodation and to experience shortages of money. Among employed men, those with disabilities were less likely to be in high skilled jobs, worked less hours on average, and were more likely to report that they would prefer to work more. Men with disabilities had lower levels of social support and community participation and poorer mental and physical health and overall wellbeing. CONCLUSION: Adult men with disabilities experience marked social and economic disadvantage and poorer health and wellbeing. Improving the health and wellbeing of disabled men should be a priority for public health researchers and policy-makers.

A Longitudinal Analysis of Changes in Job Control and Mental Health.

Deteriorating job control has been previously shown to predict poor mental health. The impact of improvement in job control on mental health is less well understood, yet it is of policy significance. We used fixed-effects longitudinal regression models to analyze 10 annual waves of data from a large Australian panel survey (2001-2010) to test within-person associations between change in self-reported job control and corresponding change in mental health as measured by the Mental Component Summary score of Short Form 36. We found evidence of a graded relationship; with each quintile increase in job control experienced by an individual, the person's mental health increased. The biggest improvement was a 1.55-point increase in mental health (95% confidence interval: 1.25, 1.84) for people moving from the lowest (worst) quintile of job control to the highest. Separate analyses of each of the component subscales of job control-decision authority and skill discretion-showed results consistent with those of the main analysis; both were significantly associated with mental health in the same direction, with a stronger association for decision authority. We conclude that as people's level of job control increased, so did their mental health, supporting the value of targeting improvements in job control through policy and practice interventions.

Sickness absence and psychosocial job quality: an analysis from a longitudinal survey of working Australians, 2005-2012.

Sickness absence is associated with adverse health, organizational, and societal outcomes. Using data from a longitudinal cohort study of working Australians (the Household, Income and Labour Dynamics in Australia (HILDA) Survey), we examined the relationship between changes in individuals' overall psychosocial job quality and variation in sickness absence. The outcome variables were paid sickness absence (yes/no) and number of days of paid sickness absence in the past year (2005-2012). The main exposure variable was psychosocial job quality, measured using a psychosocial job quality index (levels of job control, demands and complexity, insecurity, and perceptions of unfair pay). Analysis was conducted using longitudinal fixed-effects logistic regression models and negative binomial regression models. There was a dose-response relationship between the number of psychosocial job stressors reported by an individual and the odds of paid sickness absence (1 adversity: odds ratio (OR) = 1.26, 95% confidence interval (CI): 1.09, 1.45 (P = 0.002); 2 adversities: OR = 1.28, 95% CI: 1.09, 1.51 (P = 0.002); ≥3 adversities: OR = 1.58, 95% CI: 1.29, 1.94 (P < 0.001)). The negative binomial regression models also indicated that respondents reported a greater number of days of sickness absence in response to worsening psychosocial job quality. These results suggest that workplace interventions aiming to improve the quality of work could help reduce sickness absence.

Does the presence and mix of destinations influence walking and physical activity?

BACKGROUND: Local destinations have previously been shown to be associated with higher levels of both physical activity and walking, but little is known about how specific destinations are related to activity. This study examined associations between types and mix of destinations and both walking frequency and physical activity. METHOD: The sample consisted of 2349 residents of 50 urban areas in metropolitan Melbourne, Australia. Using geographic information systems, seven types of destinations were examined within three network buffers (400 meters (m), 800 m and 1200 m) of respondents' homes. Multilevel logistic regression was used to estimate effects of each destination type separately, as well as destination mix (variety) on: 1) likelihood of walking for at least 10 min ≥ 4/week; 2) likelihood of being sufficiently physically active. All models were adjusted for potential confounders. RESULTS: All destination types were positively associated with walking frequency, and physical activity sufficiency at 1200 m. For the 800 m buffer: all destinations except transport stops and sports facilities were significantly associated with physical activity, while all except sports facilities were associated with walking frequency; at 400 m, café/takeaway food stores and transport stops were associated with walking frequency and physical activity sufficiency, and sports facilities were also associated with walking frequency. Strongest associations for both outcomes were observed for community resources and small food stores at both 800 m and 1200 m. For all buffer distances: greater mix was associated with greater walking frequency. Inclusion of walking in physical activity models led to attenuation of associations. CONCLUSIONS: The results of this analysis indicate that there is an association between destinations and both walking frequency and physical activity sufficiency, and that this relationship varies by destination type. It is also clear that greater mix of destinations positively predicts walking frequency and physical activity sufficiency.