Housing programme empowers people to make changes: a joint public health and Housing New Zealand programme is leading to some remarkable health improvements for families living in some of the most deprived and crowded areas of Auckland and Northland.

Auckland Regional Public Health Service public health nurses (PHNs) Lynne McCarthy and Claire Doole have been blown away by the response of families after being involved in the Healthy Housing programme. Not only have their homes been made warmer, drier and better ventilated, but people have felt empowered to take charge of their health, making lifestyle changes and seeking medical treatment where required.

McCarthy has been working with the programme, which won Last year's supreme and organisation categories in the New Zealand Health Innovation Awards, for nearly two years, white Doole has been with it three years. Both regard their roles as the best jobs they have ever had. They are currently working with 700 households in the Panmure area, work that is expected to take two to three years to complete.

The programme works as a joint initiative between district health boards in Counties Manukau, Auckland and Northland and Housing New Zealand. It focuses on reducing the risk of infectious diseases related to crowding by improving housing conditions of families living in Housing New Zealand homes. Criteria for selecting suburbs and houses to take part in the programme include areas with high rates of housing-related preventable hospitalisations for diseases such as meningococcal disease, tuberculosis, rheumatic fever, skin infections and respiratory conditions; where there is a high percentage of Housing New Zealand homes; and where there are high rates of crowding and social deprivation. When a neighbourhood is selected, tenants are invited to take part; there is no compulsion to do so.

Strong intersectoral collaboration

"The programme is unique because of its very strong intersectoral collaboration between the DHBs and Housing New Zealand," said McCarthy. "It grew out of research done several years ago into risk factors for meningococcal disease. Improving housing and reducing crowding were the key factors identified.

"When a suburb is selected, every Housing New Zealand household is sent a Leaflet telling them about the programme and inviting them to take part. Once an appointment is made, a PHN and Housing New Zealand staff member visit families in their homes to assess their health and living situations. Written consent is obtained prior to a walk around the home to identify any housing issues, including Levels of crowding and general maintenance required. Once the Housing New Zealand co-ordinator leaves, the PHN undertakes a health assessment. Often we find that the people living in the home are different from those listed. We identify any safety concerns Like windows that can't be opened or electric cords running from the house out to garages, whether water is pooling outside, attracting mosquitoes, and whether rubbish is being left on the property, increasing the risk of disease. Our comprehensive health assessment will include such things as what heating a family has and whether they are using it, whether their washing machine, fridge or telephone are working; and whether the house is adequately fenced.

"We also check whether the family has a doctor, whether their children's immunisations are up to date, whether they are experiencing any domestic violence. We ask them to identify what issues are worrying them and what social support they have. If the family is willing, the whole process can take between two and two-and-a half hours. This is a one-off visit, so we need to be as thorough as we can."

Implementing an action plan

The next stage, said McCarthy, is for both the nurse and Housing New Zealand to draw up an action plan. This will invariably include installing insulation and ventilation, reducing crowding by improving or extending the existing home or even transferring a family to more appropriate housing, but preferably within the same area. PHNs may refer tenants to a range of services including doctors, dentists, government agencies, occupational therapists, food banks, women's health clinics, pre-schools, budgeting services and family planning.

"State houses were originally built with nuclear families in mind," said McCarthy. "Houses are often small with two or three bedrooms and not enough room for families to sit around a table to eat together. Many families are much Larger, both in numbers and body size and do not fit into these homes. This can have major social effects. Removing walls and extending rooms can bring real health benefits."

The Healthy Housing programme has been evaluated a number of times over the Last five years and is currently undergoing another major evaluation. The most exciting finding is that, following an area taking part, hospitalisations for housing-related preventable conditions have been reduced across all ages by 37 percent. Other New Zealand studies have also shown statistically significant improvements in people's health, especially respiratory conditions, following an increase in temperature in the home. McCarthy and Doole can cite many stories showing major health and social improvements to families who have taken part in the programme. One family they worked with included elderly parents, their severely disabled daughter, her sister and children all living in the one house. The disabled daughter had three different wheelchairs, but, because of the design of the kitchen, she wasn't able to get to the fridge or help with cooking. The whole place was eventually redesigned to accommodate her needs, enabling her to contribute to the family's wellbeing. Bedrooms were added to solve the overcrowding issues.

In another house, there was a five-month-old baby who had been sick all winter. Once the house was insulated and the lower branches cut off a tree that was shading the house, the child's health improved out of sight.

"But what has been even more heartening have been stories of people taking charge of their own health, arranging for smears and health check ups, increasing their exercise and attending stop-smoking programmes. Through the intervention of this programme, people have felt empowered to make changes for themselves. As a PHN, you can really see results happening and that is immensely satisfying," said McCarthy.