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.

Preferences for rehabilitation service delivery: a comparison of the views of patients, occupational therapists and other rehabilitation clinicians using a discrete choice experiment.

BACKGROUND/AIM: Understanding the differences in preferences of patients and occupational therapists for the way in which rehabilitation services are provided is important. In particular, it is unknown whether new approaches to rehabilitation such as high intensity therapy and virtual reality programs are more or less acceptable than traditional approaches. METHODS: A discrete choice experiment was conducted to assess and compare the acceptability of these new approaches, relative to other characteristics of the rehabilitation program. The study included patients participating in a stroke or medical rehabilitation program (n = 100), occupational therapists (n = 23) and other clinicians (n = 91) working in rehabilitation settings at three hospitals in South Australia. Data were analysed using a conditional (fixed-effects) logistic regression model. RESULTS: The model coefficient attached to very high intensity therapy programs (defined as six hours per day) was negative and highly statistically significant for both patients and therapists indicating aversion for this option. In addition, other rehabilitation clinicians and patients were strongly averse to the use of virtual reality programs (as evidenced by the negative and highly statistically significant coefficient attached to this attribute for both groups) relative to occupational therapists. CONCLUSION: The comparison of the views of patients, occupational therapists and other rehabilitation clinicians revealed some differences. All participants (patients and clinicians) showed an inclination for programs that resulted in the best recovery. However, patients expressed stronger preferences than clinicians for traditional therapy approaches. As a group, occupational therapists were most likely to accept approaches such as virtual reality suggesting changes away from traditional delivery methods will be more readily integrated into practice.

The Shifting Risk of Homelessness among Persons with a Disability: Insights from a National Policy Intervention.

Persons with a disability are at a far higher risk of homelessness than those without. The economic, social and health challenges faced by disabled people are addressed, in Australia, by the recently implemented National Disability Insurance Scheme (NDIS). Using nationally representative, longitudinal household panel data, we construct the Index of Relative Homelessness Risk (IRHR) to track how the risk of homelessness for disabled persons has changed since the introduction of the NDIS. We find that, overall, fewer persons with a disability face moderate risk of homelessness but that many more face high risk. We conclude that the NDIS has not effectively protected disabled people from the risk of homelessness. We reflect on the implications of these findings for policy interventions.

The Relative Risk of Homelessness among Persons with a Disability: New Methods and Policy Insights.

This paper reports on the first phase of an ambitious program of research that seeks to both understand the risk of homelessness amongst persons with a disability in Australia and shed light on the impact of a significant policy reform-the introduction of the National Disability Insurance Scheme (NDIS)-in changing the level of homelessness risk. This first paper, reports on the level of homelessness risk for persons with a disability prior to the introduction of the NDIS, with a subsequent paper providing updated data and analysis for the period post the implementation of the NDIS. In one sense, this paper provides the 'base' condition prior to the introduction of the NDIS but also serves a far broader role in advancing our understanding of how disability and chronic ill-health affects the risk of homelessness. Our research finds that in the period prior to the introduction of the NDIS, a large proportion of people with disabilities were at risk of homelessness, but those whose disabilities affected their schooling or employment were at the greatest risk.

Is Housing a Health Insult?

In seeking to understand the relationship between housing and health, research attention is often focussed on separate components of people's whole housing 'bundles'. We propose in this paper that such conceptual and methodological abstraction of elements of the housing and health relationship limits our ability to understand the scale of the accumulated effect of housing on health and thereby contributes to the under-recognition of adequate housing as a social policy tool and powerful health intervention. In this paper, we propose and describe an index to capture the means by which housing bundles influence health. We conceptualise the index as reflecting accumulated housing 'insults to health'-an Index of Housing Insults (IHI). We apply the index to a sample of 1000 low-income households in Australia. The analysis shows a graded association between housing insults and health on all outcome measures. Further, after controlling for possible confounders, the IHI is shown to provide additional predictive power to the explanation of levels of mental health, general health and clinical depression beyond more traditional proxy measures. Overall, this paper reinforces the need to look not just at separate housing components but to embrace a broader understanding of the relationship between housing and health.

Poor housing quality: Prevalence and health effects.

Housing is a central component of productive, healthy, and meaningful lives, and a principle social determinant of health and well-being. Surprisingly, though, evidence on the ways that housing influences health in Australia is poorly developed. This stems largely from the fact that the majority of the population are accommodated in good quality housing. The dominance of a "good housing paradigm" means that households living in poor quality and unhealthy housing are doubly disadvantaged-by the quality of their housing and because policy makers in Australia do not acknowledge the health effects of housing. In this article, we examine the relationship between health outcomes and quality of housing. We base our analysis on data from the Household Income and Labour Dynamics in Australia (HILDA) survey, a panel dataset that is representative across Australia. We find a sizeable, policy-important, and to date under-acknowledged cohort of Australians whose health is influenced by poor-condition dwellings.

An assessment of the relationship between informal caring and quality of life in older community-dwelling adults - more positives than negatives?

The main objective of the study was to apply the recently developed Index of Capability (ICECAP-O) instrument to measure and value the quality of life of a representative sample of the older South Australian population (aged ≥ 65 years) according to carer status. A Health Omnibus survey including the ICECAP-O instrument, carer status (informal carer vs. non-carer) and several socio-demographic questions was administered in 2009 as a face-to-face interview to 789 individuals aged 65 years or older in their own homes. A total of 671 individuals (85%) characterised themselves as a non-carer and 115 individuals (15%) characterised themselves as an informal carer. In general, carers exhibited relatively high quality of life as measured by the ICECAP-O, with carers having comparable mean ICECAP-O scores to non-carers in the general population [carers: mean (SD) 0.848 (0.123), non-carers: mean (SD) 0.838 (0.147)]. The results of the multivariate regression model for the total sample indicated statistically significant variations in overall ICECAP-O scores according to age (with younger participants tending to have slightly higher scores on average), country of birth (with those participants who were born in Australia having higher scores on average than those who were born elsewhere) and household income (with participants with higher income levels having higher scores on average). The results of the multivariate regression model differentiated by carer status also indicated some important differences. Specifically, average ICECAP-O scores were noticeably lower for carers who are separated or divorced and for carers who lived alone and these differences were statistically significant. The study findings provide support for the existence of process utility in informal care-giving. The provision of informal care may be associated with a positive impact upon quality of life for many caregivers, which may mediate the negative aspects arising from the burden associated with informal care-giving.

Early rehabilitation management after stroke: what do stroke patients prefer?

BACKGROUND: Stroke rehabilitation is moving towards more intense therapy models that incorporate technologies such as robotics and computer games. It is unclear how acceptable these changes will be to stroke survivors, as little is known about which aspects of rehabilitation programmes are currently valued. Discrete choice experiments are a potential approach to assessing patient preferences, as they reveal the characteristics of programmes that are most important to consumers. METHODS: A discrete choice experiment was presented as a face-to-face interview to assess the priorities and preferences of stroke survivors (n=50, mean age 72 years) for alternative rehabilitation service configurations. The discrete choice experiment was presented to the participants while they were on the stroke rehabilitation ward (approximately 3-4 weeks following stroke). RESULTS: Participants were highly focused on recovery and expressed strong preferences for therapy delivered one-to-one, but they did not favour very high intensity programmes (6 hours per day). While the attitudinal statements indicated high levels of agreement for programmes to incorporate the latest technology, the results from the discrete choice experiment indicated that participants were averse to computer-delivered therapy. CONCLUSION: Whilst rehabilitation therapy is highly valued, stroke survivors exhibited stronger preferences for low-intensity programmes and rest periods. High-intensity therapy protocols or approaches dependent on new technologies will require careful introduction to achieve uptake and acceptability.