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Healthy Housing Programme

1.  Background
2.  Partnership Approach
3.  Governance and Management
4.  Key Objectives of the Programme
5.  The Healthy Housing Intervention
6.  Programme Outcomes
7.  Site Selection Criteria
8.  Programme Evolution

In December 2000, Housing New Zealand Corporation (HNZC) and South Auckland Health, now Counties Manukau District Health Board (CMDHB), Auckland Regional Public Health Service (ARPHS), initiated a collaborative health and housing initiative designed to reduce the risk of infectious disease, particularly meningococcal disease, among families residing in HNZC properties. The Healthy Housing Programme (HHP) commenced with an 18 month pilot project which continues today.

The impetus for HHP came from epidemiological research conducted in Auckland during the late 1990s on meningococcal disease. Since 1991; New Zealand has experienced a devastating epidemic of this droplet-borne disease that has had its greatest impact on infants and young children. Campaigns have raised public awareness of this potentially fatal disease to encourage early medical attention.  The research team’s interest lay in shedding light on the factors that propelled the epidemic - the ‘risk factors’ for the occurrence of meningococcal infection among Auckland children.  By far and away the most important determinant of risk for a child was living in a crowded house.  Although not the subject of a local study, similar associations with crowding can be found for tuberculosis, rheumatic fever, gastroenteritis, and skin infections.

It is well established that low quality and crowded housing is linked with poor health status.  Cold, damp and overcrowded houses are associated with higher rates of meningococcal meningitis, tuberculosis, rheumatic fever, measles and mental health problems. Poor quality housing is inextricably linked with poverty, and census data consistently show that Maori and Pacific people are disproportionately affected.

Unsurprisingly, the areas with highest rates of meningococcal disease in Auckland are also those found to be most crowded, based on standard crowding measures derived from census data.  HNZC became concerned, as their houses were over-represented in the areas with highest rates of disease.

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2. Partnership Approach

The HHP is successful due to the cross-sectoral partnership model it has adopted. With a combined health and housing approach we have been able to form a cross-sectoral team building on the expertise and competencies of both sectors.

Implementation of the Healthy Housing Programme involved the established of joint systems, processes and procedures, firstly between HNZC and CMDHB and then with Auckland and Northland DHBs.   Collaborative partnerships started with the establishment of joint governance and management structures followed by joint project and implementation planning.

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3. Governance and Management

The partnership approach and joint commitment to the programme is reflected in the governance and management structure.  The programme is overseen by a National Steering Group, with representatives from both HNZC and the participating DHB’s.

The partnership between HNZC and the DHB’s has been formalised through the signing of a Memorandum of Understanding and commitment to agreed practices and protocols.

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4. Key Objectives of the Programme

The programme has four key objectives which are to:

• Reduce the risk of housing related health problems

• Reduce overcrowding

• Improve access to health and social services

• Increase awareness of healthy living

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5. The Healthy Housing Intervention

The HHP focuses on the delivery of tailored “health solutions in a housing setting” that meet the needs of participating families.

In summary, the HHP has three related dimensions to the intervention:

• a health intervention aimed at improving tenant access to primary health care services and their knowledge / behaviour to improve health outcomes;
   

• a housing intervention, aimed at reducing the risk of housing related health problems; which may include a supply solution, such as an addition to the house, a transfer to a larger home or to  a home that better meets the needs of the family, housing design improvements or healthy environments which include insulation and ventilation
   

• a joint intervention that identifies issues of a more social/welfare nature and provides a linking and facilitation service to the appropriate social service agencies.

Table 1: HHP interventions (health and housing)

Intervention components	Description
Housing
Healthy environments	Insulation, ventilation and heating (IVH)
Design improvements	Upgrading kitchen, upgrading bathroom, creation of open plan living, etc.
Crowding reduction -enlargements	Enlargement (built extension*, wing attachment, etc.)
Crowding reduction - transfers	Transfer (part or whole) of the household to alternative existing HNZC houses, new-build**, redevelopment*** or purchase
Other	Moved to private sector
Health
Health	Health education and/or referral to health agencies and/or welfare agencies

*    Extension means rooms are added to existing properties to increase the availability of living space.
**  A new-build occurs when HNZC erects a new house on newly bought land.
***A redevelopment occurs when HNZC erects a new house on existing HNZC land.
(Source: The Healthy Housing Programme: Report of the Outcomes Evaluation (Year One) August 2005)

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In order to determine the level of crowding and health risk within families in the priority sites a Joint Assessment Tool (JAT) was developed. The tool is administered by a Public Health Nurse (PHN) and an Area Coordinator (AC) in conjunction with participating families, in order to determine the level of crowding as well as housing, health and social service needs. The AC focuses on the property – suitability of the house for the family, maintenance needs, ‘health hardware’ such as the condition and function of toilet and kitchen, the presence of mould, and adequacy of fencing on the property.  The PHN’s focus is on the health and wellbeing of the family and their linkage with appropriate health and social support services.

A joint action plan is then developed by the AC and PHN, and agreed to by the family.  This is further refined and enhanced through regular discussions with PHN co-ordinators, project managers and clinicians.  The responses in the joint action plan include referral to health and social service agencies (sometimes requiring crisis interventions such as emergency food provision or hospital admission), design improvements to the house, extensions to accommodate the size of the family, transferring families to larger homes, and installation of insulation and ventilation systems.

Table 2:         The Programme Processes

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6. Programme Outcomes

The Healthy Housing programme contributes to the New Zealand Health Strategy’s overarching goals of improving the overall health status of New Zealanders reducing inequalities in health and advocating for intersectoral collaboration to improve health outcomes. 

6.1   Healthcare results

The evaluation identified the following key results:

• Participating families have improved health knowledge (awareness of the signs and symptoms of meningitis and increased early care-seeking behaviour)

• Increase in visits to General Practice (Primary care)

• Increased immunisation rates

• Increased attendance at outpatient clinics

• Decrease in hospitalisations

• Changes to the rate of infectious disease is a long-term outcome which will require ongoing monitoring

• High participation rates by Pacific Families in the programme

• Reduction in the rate of crowding within HNZC homes in the intervention sites.

6.2   Benefits of the programme to the Housing sector

The merits of the programme to HNZC include:

• Improving the quality of the overall standard of public rental housing stock

• Ensuring homes meet the needs of larger families

• Increased tenant satisfaction.

 6.3    Joint Benefits

• Providing access for health professionals into high risk households with potentially unmet health needs – often homes previously inaccessible

• Providing co-ordinate housing and health joint solutions to identified issues for common clients, allowing a more holistic approach to identified need (including budgeting advice, dental care etc)

• Facilitating tenants into existing agency and community networks as appropriate

• Families/tenants with improved health, knowledge and understanding.

 6.4       Intersectoral Benefits

• The development of referral pathways

• Increased welfare benefit uptake and families receiving their full benefit entitlements including Disability Allowances, etc.

• Linkage with a wide range of social services including budgeting, food banks, churches and community providers

• Cross-sectoral case management

• Improved intersectoral collaboration.

By effectively communicating with all key stakeholders about the key elements or core components of the programme we have been able to manage expectations. An easy to understand priority system we established which can be understood by community, families and professionals. This aids expectation management.  The process is transparent and all members of the team are able to articulate clearly why certain households are prioritised over others – and this has been accepted by the community. The key elements are as follows:

 Table 3: Key Elements of the Programme

Process/definition required	How they were addressed
Working definition of overcrowding	Initially developed an overcrowding ratio (OCR) identifying the number of occupants per bedroom.  Now use HNZC Social Allocation System, based on Canadian National Occupancy Standards which identifies numbers per bedroom based on relationships, gender and age.
Intervention area selection (site selection)	Sites for the programme are selected by reviewing "Potentially Avoidable Hospitalisations" rates of disease associated specifically with crowded living conditions, numbers of HNZC houses in the CAU, deprivation rates and census reported overcrowding
House selection	Originally identified and targeted potentially overcrowded households, using HNZC tenant data and Over Crowding Risk ratio.  Today the programme assesses all households in an intervention area.
A joint health and housing assessment tool “Joint Assessment Tool”	A "Joint Assessment Tool" (JAT) was developed.  The JAT is in two parts.  The first, administered by the HNZC Area Co-ordinator, focuses on housing issues related to the house itself, the composition of the family, and any tenancy issues.  The second, administered by the Public Health Nurse, focuses on the health and wellbeing of the household and their linkage with appropriate health and social support agencies
Joint Action Plan	A joint action plan is developed by the Area Coordinator (AC) and Public Health Nurse (PHN), and agreed to by the family. Possible actions include: referral to health and social service agencies (sometimes requiring crisis interventions such as emergency food provision or hospital admission), health education, transferring families to larger HNZC homes, assisting families to seek accommodation in the private sector where appropriate, house extensions to accommodate the size of the family, design improvements to the house, and/or installation of insulation and ventilation systems.
Disease risk assessment	A “Meningococcal Disease Risk Ratio” (MDRR) was developed by Public Health Clinicians.  This ratio is based on the findings of the case-study of meningococcal disease.  The MDRR recognises the increase in risk to children of high numbers of adults, as potential carriers of disease, living in crowded conditions. It was one of the indicators used to determine the level of risk and gave the project team a mechanism to prioritise cases
Intersectoral responses	Co-ordinated by the District Health Boards based on the findings from the Joint Assessment and review of a clinician.  Families referred to particular agencies as appropriate and overseen by an Intersectoral Steering Group.
Healthy housing design	When a decision is made to renovate a house and a brief is prepared for an Architect, it is the Area Coordinator who is responsible for household liaison and co-ordination of building renovations.  Emphasis is placed on ensuring that house design is appropriate for the family and that relevant health information is included when designing the home.  The design elements include: site, size and space number of bedrooms and bathrooms required for the size, age and gender mix of families living spaces required taking into consideration the size of  the family structural aspects (such as access, storage, indoor/outdoor flow, orientation to sun) insulation, ventilation and heating health hardware (bathroom and kitchen fittings, hazard protection) social and cultural requirements property –fencing, driveways and outdoor storage Basic design standards for extensions to HNZC homes have been developed from architectural and clinical input.

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7. Site Selection Criteria

During the pilot phase it was decided that programme would concentrate in specific geographic areas, with high concentrations of HNZC homes, high rates of infectious diseases in particular meningococcal avoidable hospitalisations and high levels of crowding using the census information. This selection criteria is still used –with the focus being on the health status of children.

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8. Programme Evolution

HHP is constantly evolving as a result of the changing health and housing needs of the communities in which the programme operates. The core elements of Healthy Housing remain; however, the programme is flexible and adaptable to the needs of community and the culture context in which it is being delivered.  This flexibility enables it to be rolled out into other identified priority areas.

Table 4: Healthy Housing Programme Sites

2001/03	2003/04	2004/05	2005/06	2006/07
Otara Onehunga Glen Innes Mangere	Pt England Glen Innes Mangere Wiri Tikipunga & Otangarei (Whangarei) Kaitaia	Pt England Glen Innes Mangere Tikipunga (Whangarei) Kaitaia	Mangere Pt England Tamaki Kaikohe	Mangere Tamaki Kaikohe Moerewa Kawakawa

Published:  27-Nov-2006  |  Website enquiries:  Web Content Manager