SCIE research briefing 19: What is the impact of environmental housing conditions on the health and well-being of children?

Published December 2005

What is the issue?

This section introduces and defines the scope of the briefing and the topic.

A SCIE research briefing provides up-to-date information on a particular topic. It is a concise document summarising the knowledge base in a particular area and is intended as a 'launch pad' or signpost to more in-depth investigation or enquiry. It is not a definitive statement of all evidence on a particular issue. The briefing is divided into the different types of knowledge relevant to health and social care research and practice, as defined by the Social Care Institute for Excellence (SCIE) (1). It is intended to help health and social care practitioners and policy-makers in their decision-making and practice.

This briefing focuses on how environmental housing conditions can affect the health and well-being of children. The concern is the immediate physical structure or environment rather than other elements of the accommodation, such as the neighbourhood or the appropriateness of the housing for disabled children. Therefore, although it is acknowledged that temporary accommodation and housing tenure also raise issues which can affect the health and well-being of children, the aim of this briefing is to consider only the impact of non-decent or substandard living conditions such as dampness and overcrowding, regardless of the status of the tenants. Poor housing conditions can have an impact on the health and well-being of parents too, and therefore affect their ability to parent (2), but this briefing considers the direct impact of the housing environment on the health of children only. The contribution of environment to household accidents is also not covered by this briefing.

Why is it important?

A recent report found that more than one million children in England are currently in "damp, cold, infested" housing (2,3). More than one million houses in England are considered "unfit to live in" (3,4). However, there is currently no widely accepted definition of what constitutes sub-standard, inadequate or non-decent housing, although a recent Government policy document described decent homes as "homes that are warm and weatherproof with reasonably modern facilities" (5). According to a survey based on the 2001 census, "more than half a million families in Britain live in officially overcrowded housing", which is measured by whether a household "has fewer bedrooms than implied by the [bedroom] standard", as described in the Household Survey for England (4). These statistics are important because a person's physical environment can have an impact on their health and well-being. This is especially the case for young children, who can spend 90% of their time in the home (6). Other groups of children are also particularly vulnerable to environmental conditions within the home, especially children with asthma or related conditions, and small, immature or preterm infants (2,7-9). Substandard housing has also been found by a US study to be one of a number of factors associated with child hunger (10). Finally, a major study has also found that exposure to "adverse housing conditions" in childhood increases the likelihood of certain illnesses in later life, even if these people live in good quality housing in adulthood (11).

What does the research show?

Organisational knowledge

This section lists and briefly summarises documents that describe the standards that govern the conduct of statutory services, organisations and individuals in relation to the housing and health of children.

Office of the Deputy Prime Minister (2005). Housing Health and Safety Rating System
The Housing Health and Safety Rating System (HHSRS) guidance is the basis for action against unacceptable housing conditions
This new standards system is provided for by the Housing Bill 2004 and replaces the housing fitness standard set out in the Housing Act 1985.

Office of the Deputy Prime Minister (2005). Sustainable Communities. Homes for All
This describes a five year plan which offers everyone the opportunity of a decent home at a price they can afford.

Department of Work and Pensions (2005). Opportunity for All. Seventh Report
This Government policy document outlines Government targets in relation to poverty and social disadvantage and poverty, including decent housing.

DEFRA (2004). UK Fuel Poverty Strategy
This is the Government's fuel poverty strategy. It sets out the framework for delivery of the Government's overall goal of seeking an end to the problem of fuel poverty, with the first target being to reach those who are most vulnerable to cold-related ill health by 2010. This includes children.

Department of Health (2004). Making Healthier Choices Easier
This is the Government White Paper which sets out the key principles for supporting the public to make healthier and more informed choices with regard to their health. The aim is "to improve the health of the population" by focusing on all of the determinants of health, including housing. The paper includes details of the Government's Public Service Agreements' (PSA) targets and their supporting strategies. These include bringing all social housing "into a decent condition" by 2010, especially in "deprived areas and... vulnerable households in the private sector, including families with children", with the intention of increasing "the proportion who live in homes that are in a decent condition".

Department of Health (2000). Framework for the Assessment of Children in Need and their Families Guidance.
This document describes a framework for assessing children's and families needs to identify "whether the child being assessed is in need... and which services would best meet the needs of this child and their family". The needs of disabled family members must also be considered when assessing needs. Sections 5.69-5.71 cover housing. The guidance states that Housing Authorities should be "prepared to assist in the provision of accommodation" because "the provision of appropriate housing can make an important contribution to meeting the health and developmental needs of children".

Department of Health (1998). Saving Lives. Our Healthier Nation
This is a government action plan to tackle poor health in the UK. This policy document recognises that "sub-standard housing" is a contributory factor in poor health and a source of health inequalities.

Children Act 1989
If a child does not have the opportunity or is unable to achieve or maintain a "reasonable standard of health or development", then they are regarded as being "in need", which in turn means they are eligible for a range of support services. Under section 17 of this Act, a child is considered to be in need if "he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority" or if his "health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services".

UN Convention on the Rights of the Child
This Convention was ratified by the UK in 1991. Article 6 states that States' actions should promote a life of human dignity, that is, States should fully ensure the right to an adequate standard of living, including the right to housing, nutrition and the highest attainable standards of health. Article 27.3 states that States Parties, in accordance with national conditions and within their means, shall take appropriate measures to... provide material assistance and support programmes, particularly with regard to nutrition, clothing and housing.

Policy community knowledge

This section summarises documents describing proposed structural models and guidance for the delivery of policy and improved practice. These documents are published by public policy research bodies, lobby groups, think tanks and related organisations.

Shelter (2005). Full House? How overcrowding affects families.
This is a recent report by Shelter examining the nature of overcrowding in homes and its effects on the lives of children.

Shelter (2004). Toying with their Future. The hidden cost of the housing crisis (PDF)
This is a report about the current state of housing problems in the United Kingdom and how they affect children. It records the views of people living with these problems, and the professionals who support them. A series of recommendations to improve the housing situation are provided.

Acheson D. (1998). Independent Inquiry into Inequalities in Health. TSO, London
This review of the evidence on inequalities in health in England was commissioned with the intention of informing the Government's strategy for health and to identify areas for policy development likely to reduce these inequalities. This includes identifying poor quality housing and its consequences, and making recommendations to counter existing inequalities. It calls for the development of policies to improve housing and limit the effects of sub-standard or inadequate housing.

Practitioner knowledge

This section describes studies carried out by health and social care practitioners, documents relating their experiences regarding the topic, and resources produced by local practitioner bodies to support their work.

Liverpool City Council (2003). Housing Strategy Statement. Health Impact Assessment (PDF).

This document reports on initiatives to tackle cold housing conditions by providing central heating and/or insulation for households with asthmatic children and older people, and measures to involve children and young people in the development of housing strategies.

Fletcher P. & Spencer S. (2000). Housing for Health. A Good Practice Guide for Tackling Health Inequalities in Tyne and Wear, and Directory of Health and Housing Initiatives. Health Action Zone Network.

This Guide includes details about the implementation of a "repairs on prescription scheme", in which hospital consultants make recommendations for housing improvements to alleviate asthma among child patients. Another initiative approaches tenants to enquire about the impact of renovations on their lives and well-being.

Research knowledge

This section summarises the best available research literature. The focus is on studies undertaken in the United Kingdom, so that the findings are as relevant as possible to the intended audience of the briefing.

The limitations of the research

There are many good quality case-control studies to provide important data on the relationship between housing conditions and health, regardless of socio-economic status or household income. However, a recent review of the literature on the risks to child health posed by housing conditions found that there was a lack of standardized measures for assessing housing quality and hazards, and a paucity of research on interventions (12). Many of the existing studies also only examine small samples (7) and some rely on self-report measures of dampness and / or respiratory symptoms (7,9). Only a few studies apply objective or validated measures of respiratory symptoms (8,13) or housing quality, such as the degree of dampness, moisture or mould in the home (8,13,14). However, it is also the case that the results of this research are not entirely conclusive, and highlight the need for further work in this field. A recent systematic review found similar limitations among the literature regarding the effect of housing improvements on the health of adults and children (15). Finally, the research has tended to focus almost exclusively on the effects of damp or mould, there is virtually nothing on the psychological, social and behavioural effects of poor physical environments on children (6).

What are the effects of dampness, moisture and mould?

Dampness usually means the presence of water damage, damp stains, visible mould and condensation. Some studies and reviews from the UK and elsewhere have reported an association between dampness, moisture and mould and the prevalence of respiratory symptoms among children of all ages (8,16-21). For example, one review found that children in homes with damp and/or mould are two and a half times more likely to have coughs or wheezing than children in "dry" homes (18). Another UK study found that visible mould was significantly associated with an increased risk of wheezing illness among children aged 9-11 years (8). This significant association between visible mould and damp spots inside the house has also been reported by a large Swedish study of households with children aged 1-6 years (20), a Finnish study of preschool and school-aged children (22), and a wider European study of older children in which the prevalence of asthma and chronic cough was higher in "damp" compared to "dry" homes (13).

Other recent Swedish case-control studies have also found a significant association between asthma or wheezing and dampness in the home, such as the amount and frequency of windowpane condensation (23,24). The association between moisture and cough or respiratory problems is particularly significant with regard to nocturnal symptoms (8,21,22), and more significant still for children who have a predisposition to allergies (8,13,19). The Finnish study also found a significant association between eczema in preschool children and visible moisture and mould in the home, and a relationship between these environmental conditions and nausea in older children (22). All age groups in this study were found to visit primary care more frequently than their counterparts in dryer houses (22). However, some of this research focuses only on children who already have asthma or some form of wheezing, rather than considering the possible effects of dampness on children without this condition (7,17,21,23-25), although, one UK study did find a significant association between wheezing and dampness when compared to controls without a history of wheezing (8).

Given the limitations of these studies, described above, the associations must be considered with caution, however, especially since it is also the case that other studies examining preschool children and adolescents have found no such significant association between damp and respiratory problems (25,26).

What are the effects of other household environmental factors?

Research from the United States has found that indoor allergens, especially dust mites, can exacerbate or cause asthma (27). Also, overcrowding has been found by one study to be associated with lower respiratory tract infection in preterm infants but not term infants (9). Overcrowding has also been found by other studies to have an impact on the psychological health of very young children (6). A US study which used an objective measure of housing quality, which included heating, wall and ceiling surfaces, but not dampness specifically, and the condition of structures such as stairs, found that there was an association between adverse housing conditions and the poor psychological health of children aged 8-11 years (14). As well as depression and anxiety, these children demonstrated less ability to persist with tasks. The study hypothetically explained these children's feelings of helplessness as a response to "chronic exposure to aversive housing conditions that one can do little to change" (14).

Gas cooking has been found by one study to be associated with lower respiratory tract infection in preterm infants at home (9). No such effect has been found for term infants (9) or adolescents (25), but has been reported for young adults (28). Substandard housing conditions can potentially have substantial physical effects on newborns and other babies. A national investigation undertaken by Shelter came across so-called "buggy babies", who are left in their prams either because the surrounding conditions in the home are so bad, or because of overcrowding. These babies can develop deformed skulls because they spend almost all of their time in a lying position in the pram; the soft bone therefore becomes misshapen before setting permanently (2). It has also been found that lead can have an adverse impact on the intellectual development of some very young children under two years of age (29), and that the risk of lead poisoning is greater in older, less expensive housing (30).

Finally, a recent review of the evidence on this topic, commissioned by the Office of the deputy Prime Minister, also reported a possible association between housing conditions and child mortality, and possible relationships between the housing environment and meningitis, tuberculosis and children's mental health. However, once again, the research has clear limitations and its findings are to be treated with caution (31).

What interventions are effective in addressing these issues?

A UK study examined the effectiveness of installing central heating into homes in which the bedrooms of children aged 9-11 years were found to be unheated and in most cases damp (7). The study found that respiratory problems among children with asthma, both cough and more severe symptoms, were significantly alleviated by the installation of central heating. The amount of school-time lost by these children was also significantly and positively affected (7). However, an earlier, similar study investigating the effect of an improved heating system in countering the adverse effect of damp on the health on children found that the intervention prevented further deterioration in their health, but did not improve it (32).

One US study assessed the value of targeting blood lead levels (BLLs) testing at very young (9-24 months) children in older and less expensive housing, and successfully identified higher BLLs among this group, which could then be addressed by safer housing policies (30). Another US review found that children exposed to lead dust as a result of living in substandard housing could be given modest protection by professional visiting dust control teams, but it is unlikely that this service would be available to all relevant people in high-risk housing (33). Rehousing may also have a positive impact on residents' mental health, but the association has not been proven unequivocally (6). Finally, randomized trials of interventions to manage dust-mite levels to reduce their effect on childhood asthmatics have found that only intensive actions such as frequent, intense cleaning and carpet removal can have any effect (33).

User and carer knowledge

This section summarises the issues raised by young people, parents and professionals, both as described by the literature and as defined through local consultation.

The relationship between housing conditions and respiratory illness is a particular concern of parents. The impact of housing conditions can be broader than just a direct effect on a child's respiratory health. One parent told a recent investigation by Shelter that, "My 10 year old's asthma is getting worse because of the damp. Mould is growing on the carpets and I have to spend loads on heating instead of proper food for my kids" (3). Children and parents can also experience social stigma as a result of their living conditions, and this can affect their school and social lives. One mother has said how she had "letters from school telling me the kids smelt really bad... it was their clothes that stank from being in the flat. I'd washed them and everything, but it doesn't help, everything stinks" (3).

Useful links

This section lists sources of information relevant to professionals who work within this field, and may also be of value to service users.

Centre for Housing Policy. University of York
The Centre for Housing Policy at the University of York (CHP) was established in 1990 with the support of the Joseph Rowntree Foundation. It was designed to become a leader in policy relevant research and is one of the leading centres of housing and social policy research in the UK.

Faculty of Public Health, Royal College of Physicians
This faculty has network groups on both Child Public Health and Housing and Homelessness.

NCH
The NCH is a charity which seeks to provide services to support vulnerable and excluded children and young people.

Shelter
Shelter is a registered charity which provides advice and support on housing issues. It also supports research into the housing situation in the UK.

WHO. Children's Environmental Health
This website also includes a section on housing and its impact on children's health.

Acknowledgements

Thank you to experts and service users for their contributions to this briefing.