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Susan C. Saegert, PhD, Susan Klitzman, DrPH, Nicholas Freudenberg, DrPH, Jana Cooperman-Mroczek, BS and Salwa Nassar, BS

Susan C. Saegert is with the Department of Psychology, City University of New York (CUNY) Graduate Center, New York City. Susan Klitzman and Nicholas Freudenberg are with the Program in Urban Public Health, Hunter College, CUNY, New York City. Jana Cooperman-Mroczek is a doctoral student in the Department of Psychology, CUNY Graduate Center. Salwa Nassar is with the Center on AIDS, Drugs, and Community Health, Hunter College.

Correspondence: Requests for reprints should be sent to Susan Saegert, Director, Center for Human Environments, City University of New York Graduate Center, 365 Fifth Ave, New York, NY 10016 (e-mail: ssaegert{at}gc.cuny.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 

We sought to characterize and to evaluate the success of current public health interventions related to housing.

Two reviewers contentanalyzed 72 articles selected from 12 electronic databases of US interventions from 1990 to 2001. Ninety-two percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Fifty-seven percent targeted children, and 13% targeted seniors. The most common intervention strategies employed a one-time treatment to improve the environment; to change behavior, attitudes, or knowledge; or both. Most studies reported statistically significant improvements, but few (14%) were judged extremely successful.

Current interventions are limited by narrow definitions of housing and health, by brief time spans, and by limited geographic and social scales. An ecological paradigm is recommended as a guide to more effective approaches.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
PUBLIC HEALTH RESEARCHERS and practitioners have long recognized that housing influences health. Over the last 150 years, housing reformers and public health workers have periodically joined forces to improve health by strengthening housing regulations, advocating for better housing conditions, or reducing hazards such as fire, lead poisoning, injuries, or window falls.^1–4 A substantial body of literature demonstrates that poor housing can contribute to infectious disease transmission, injuries, asthma symptoms, lead poisoning, and mental health problems^4,5–7—both directly (e.g., because of environmental hazards)⁵ and indirectly (e.g., by contributing to psychosocial stress that exacerbates illness).⁸

Renewed interest in housing parallels a growing interest in ecological approaches to the study of complex health problems and an examination of the social determinants of health and the causes of persistent socioeconomic, racial, and ethnic disparities in health.^9,10 Several recent reports have demonstrated the value of considering multilevel (e.g., individual, family, social network, community, state) determinants of a variety of health outcomes.^11–14 Public health advocates have emphasized the importance of creating interventions that address these influences on health^15,16 and of utilizing ecological approaches that seek changes in both the physical and the social environment, at various levels of organization.

Applied to housing, the ecological approach suggests the importance of looking at characteristics of and interactions among residents, housing units, buildings, blocks, and neighborhoods, as well as housing owners, policies, and institutions that provide or regulate housing and health, to understand their contributions to population health. It also suggests that environmental factors interact with psychosocial variables at several levels to produce different patterns of health and disease.¹⁷

In this report, we assess the extent to which published studies of interventions designed to improve health by modifying housing reflect these new insights. This study differs from another recent review of the effect of improved housing on health¹⁸ in several ways: (1) we focused on a wider range of housing interventions, (2) we used an ecological paradigm that includes behavior at different levels as producers of both housing conditions and health outcomes, and (3) we restricted the database to US studies over 10 years. Our goals were to

1. Describe the objectives, populations, settings, intervention characteristics, and results of these studies
   
2. Describe and assess the methods used to evaluate these interventions
   
3. Assess the extent to which intervention studies addressed multiple levels of causation or multiple outcomes
   
4. Identify the strengths, limitations, and gaps in the existing literature on housing interventions to improve health
   
5. Identify directions for future research, policy, and practice
   

	IDENTIFYING HOUSING-BASED HEALTH INTERVENTIONS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
To identify relevant studies, a computerized search of 12 bibliographic databases (Cinahl, CSA, EBSCO, ERIC, InfoTrac, MEDLINE, ProQuest, PsycINFO, PubMed, Science Direct, Social Science Abstracts, Sociological Abstracts, and Wiley Intersciences) in the health and social sciences was conducted.

The following key words were used, in various combinations, in the search: asbestos, asthma, allergens (housing-related), cockroaches, child health, dampness, depression, environmental health, falls, formaldehyde, fungi, health, home, housing, infectious disease, intervention, injuries, lead poisoning, mental health, moisture, mold, morbidity, prevention, rodents, stress, and vermin.

The criteria for inclusion in this study were housing interventions to improve health, conducted in the United States and published in peer-reviewed journals between January 1990 and December 2001. Housing interventions were defined as intentional, systematic efforts to improve residential conditions, either directly or indirectly, through 1 or more of the following measures: rehousing (moving to new housing); changes in physical infrastructure; changes in indoor equipment or furniture; changes in participants’ knowledge or behavior; changes in community norms or collective behavior; changes in housing policy and regulatory practices; and changes in health practitioners’ behavior related to housing effects on health. To be included, studies had to describe both the intervention and the evaluation.

Interventions involving persons diagnosed with conditions that were not directly related to housing—for example, HIV infection, schizophrenia (but not depression)—were excluded. Interventions directed at homeless populations were also excluded because they have been reviewed elsewhere.^19–22

From the database search, a total of 3204 titles were generated. Of these, 258 were deemed to be potentially eligible, based on the title or abstract. The full articles were then retrieved and carefully reviewed to determine whether they fit the inclusion criteria. The bibliographies of these articles were also searched to identify additional relevant articles. This process yielded a total of 72 housing studies designed to improve health or designed for another purpose but including health as a measurable outcome. Of the 72 studies, 3 interventions were included twice but were related to different outcome measures.

Interventions that met the criteria for inclusion were coded, using an instrument adapted from a similar project.¹⁶ At least 2 of the authors carefully reviewed each of the articles identified by the searches. At least 3 authors discussed and resolved disagreements among the 2 primary reviewers. All coding was based on the authors’ account. When the article was not clear about a particular coding category, at least 3 reviewers assigned the categories based on a close reading of the text.

	THE NATURE OF HOUSING–HEALTH INTERVENTIONS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
The intervention settings and target populations included in these studies are summarized in Table 1. Housing interventions were largely carried out in urban settings: more than half the studies took place in large or medium-sized cites. Only 2 studies were carried out in exclusively rural settings. The majority of projects were conducted in either mid-Atlantic (22%); Midwest/Great Plains (21%); or New England (18%) states.

Sponsorship, staff, and funding characteristics are described in Table 2. Colleges and universities, medical centers, and health departments were the most frequent lead or co-sponsors. Almost three quarters of the studies reported receiving full or partial funding from governmental sources. Among public funders, the federal government predominated (47%) over state or local sources (11%). Funding was more likely to be health-related (58%) than housing-related (10%) or environmentally related (6%). Many interventions were staffed by multidisciplinary teams, comprising health care providers (44%), housing or environmental specialists (35%), health educators (15%), and community residents or community health workers (18%).

Most interventions focused narrowly on a particular health or exposure condition, in part because of the specificity of public policies (as in the case of lead or firearms storage) and funding streams (as indicated in authors’ acknowledgments to funders). Many public health interventions focused on specific technologies or diseases. In comparison, rehousing^17,26,27 or home visit interventions^25,28–30 emphasized well-being, broadly defined, suggesting disciplinary and methodological differences in conceptions of how housing affects health. Many authors reported that budgetary and administrative constraints on interventions and analyses also played a part in narrowing the focus of interventions.

	EVALUATION CHARACTERISTICS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
All interventions reviewed here included an evaluation component. Characteristics of the evaluation are described in Table 4. More than three quarters of the projects were evaluated by persons hired by the agency or organization conducting the intervention. The most common evaluation methods were environmental sampling; surveys and interviews; and physiological measures. More than 80% employed a quantitative evaluation methodology. About half used a randomized design, and about 60% included a comparison group. Eighty-five percent collected information on outcome measures before the intervention (preintervention measures), 43% collected information on outcome measures immediately after the intervention (postintervention measures), and 78% collected information on outcome measures several months after the intervention was completed (follow-up measures). Eighty-three percent of the studies reported tests of statistical significance. Sixty-eight percent reported statistically significant results. More than 80% documented improvements in the main outcome measures; 11% showed that outcomes either remained the same or worsened. Only about half the studies demonstrated that effectiveness could be sustained over time. Although findings reached statistical significance, relatively few authors (14%) rated the interventions as highly successful. However, the vast majority of authors (73%) concluded that their projects were at least somewhat successful. More than three quarters of the authors discussed barriers to successful implementation/maintenance. A wide range of factors were cited, including those related to participant characteristics and environmental, structural, technical, and larger economic and social factors.

	QUALITIES OF SUCCESSFUL INTERVENTIONS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

	LIMITATIONS OF RESEARCH

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
Our study had several limitations. It is based only on articles published in peer-reviewed journals and thus represents a limited portion of interventions actually carried out. It is restricted to those studies that intended to improve health by modifying housing, excluding interventions that might have had this unintended consequence, for example, income support policies that provide resources that can be used to improve housing conditions. Given the limitations of search engines and electronic databases, it is possible that our criteria missed some articles that would have met our inclusion criteria. In addition, we did not correspond with authors of the studies to collect additional information. Because the studies examined different housing exposures and health outcomes at different levels of organization (e.g., individual, housing unit, building, and block) and used different research methods, it was not possible to conduct a meta-analysis using pooled data. Despite these limitations, the interventions we did review met 2 important criteria: they succeeded in obtaining funding from public or private sources to carry out the interventions, and the reports were accepted by peer-reviewed journals. Thus, the articles represent what key stakeholders (e.g., funders, reviewers, and editors) deemed to be important findings on US housing interventions to improve health.

	STRENGTHS AND WEAKNESSES OF INTERVENTION LITERATURE

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
Our review of evaluation methods suggests some strengths and several weaknesses. Most studies met the basic standards of identifying measurable objectives, collecting systematic data on specific housing conditions and health outcomes, and using acceptable methods to assess success in achieving outcomes. In part, the ability to meet these standards was facilitated by a narrow conceptualization of the research.

Few studies provided detailed information on the content of interventions or provided adequate contextual information (e.g., race/ethnicity and socioeconomic status of the target population were unspecified in more than half the studies), limiting generalizability. Most studies measured only the outcomes of interventions, not the processes that led to them, thus limiting their utility for designing other interventions or replication. As noted in another recent review, although several studies showed gains in individual health outcomes, confidence in findings is limited by small study populations and lack of controlling for confounders.¹⁸

	TOWARD ECOLOGICAL INTERVENTIONS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
The published housing interventions primarily sought to improve a single health condition by ameliorating environmental conditions, changing individual behavior or knowledge, or both. Only a few studies incorporated ecological paradigms, as many researchers now advocate.³⁸ In the ecological paradigm, behavior, the physical and social environment, and health dynamically connect the individuals, households, buildings, and communities.^39,40 An ecologically sensitive intervention takes into account the nested structure of the environment in which different scales influence each other. Physically, this includes housing conditions (e.g., vermin, lead dust),⁴¹ homes within multifamily buildings,⁴² all located in neighborhoods within particular settlement forms.¹⁷ Socially, target individuals are situated in households, communities, and political units.⁴³

This principle is illustrated in several of the successful home visit interventions, in which the home was seen as an important setting in which multiple health-related behaviors occur and that potentially contains both health-promoting and hazardous elements. These interventions^25,28–30 support changes in the physical environment and the recipient’s behavior within the context of the habits, abilities, and life goals of the individual and the family. For example, the Department of Housing and Urban Development’s Moving to Opportunity demonstration project showed that families who moved away from public housing found better dwelling conditions and safer neighborhoods, leading to less crime victimization, injury, and asthma attacks among children.^17,26,27 These findings suggest that interventions could lead to more significant environmental and health effects if they were directed toward the broader goals of decent and affordable housing for all households and better opportunities for human development.

Ecological interventions are conceived as functional relationships among professionals, household members, communities, and political units. Some successful injury-reduction interventions illustrate this approach by connecting elderly participants more closely with supportive friends and family who reinforced the training and provided social rewards.^25,30 Only a few interventions incorporated participatory approaches, in which various stakeholders join in identifying goals, implementing research, and interpreting findings.^44–46

Apart from these examples, most studies intervened on single, individual-level factors, in isolation; examined only 1 or 2 levels of social organization; and failed to use the more sophisticated analytic techniques such as multilevel modeling to understand the separate influences of different levels of analysis and interactions among levels.⁴⁷ These omissions may account, in part, for the lack of sustained improvements in, for example, interventions to eliminate cockroaches and rodents. Because many studies failed to examine the effectiveness of interventions over time, ecological constraints on the long-term efficacy of other interventions may have gone undetected.

By and large, the studies do not evaluate the multiple pathways by which housing influences health, comparing, for example, the relative roles of the physical and social environment in housing-related health problems. Consequently, there is now no way of assessing the value of, say, individual-level-only versus policy-only versus multilevel interventions. Nor is it possible to compare the effectiveness of housing versus other healthpromoting interventions (e.g., dietary changes, alcohol and tobacco reduction). Such comparative studies might help policymakers decide how best to invest limited resources.

	FROM EFFICACY TO EFFECTIVENESS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
Finally, few interventions moved from efficacy to effectiveness studies. The greatest public health benefits are likely to result from interventions that can be applied in many settings, overcome common institutional and political obstacles, and reach significant portions of the vulnerable populations. The broad-based health improvements found in studies that had the primary goal of, for example, improving the life chances of poor, at-risk families⁴⁸ suggest that we need to know more about the public health implications of housing ecologies that include educational opportunities and support for child rearing, and so forth, that go beyond the usual definition of housing-based public health initiatives. Future studies on housing and health need to address these questions more systematically.

	CONCLUSIONS AND RECOMMENDATIONS

TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
The studies reviewed here have shown that changes in residents’ knowledge, attitudes, and behavior; the household environment; public policy; and community norms can all contribute to improvements in housing-related health outcomes. The successes and the limitations of the interventions reviewed suggest some new directions that might prove fruitful. It is likely that interventions that combine activities to make changes at several of these levels and examine multiple health outcomes will be more effective than those working at single levels. Unfortunately, this hypothesis has yet to be tested systematically. Most interventions we reviewed could benefit from greater attention to acknowledged basic principles of health promotion such as the use of multiple strategies, the inclusion of participants in planning and implementation, and the importance of intervention intensity and duration.^16,38,49,50 The promising results from the few policy-change studies provide a rationale for increased attention to this strategy and support recent calls for more attention to this arena, especially as it relates to enforcement of housing codes.⁴

More ecologically grounded interventions should be tested to increase efficacy and overcome the limitations identified in this review and in the epidemiological literature.^{16,42,49–51} The interdisciplinary nature of the ecological paradigm⁵² requires understanding the cultural and socioeconomic dynamics of housing markets and housing production that affect housing access, quality, costs, ownership forms, and settlement patterns and have implications for physical health, psychosocial well-being, and the interaction of physical and psychosocial health.^17,53 Intervention and evaluation strategies developed in other fields may have useful applications for public health in addressing multilevel phenomena.^54,55 At the same time, it must be acknowledged that multilevel interventions can be difficult to implement, be more costly in the short run, and require more time to address the concerns of the multiple stakeholders. Public health leadership may be needed to gain support for this approach.

In conclusion, this review of the literature demonstrates that it is possible to design and carry out interventions that can lead to improved health by making changes in housing-related conditions. The successes and limitations of these efforts provide a foundation for designing a more systematic and coordinated research agenda that can inform the next generation of studies. By incorporating ecological approaches and health-promotion principles, future studies may be able to make additional improvements in housing conditions that lead to better health.

	Footnotes

 
Contributors
S. Saegert conceptualized the project; oversaw the coding, analysis, and housing journal database search; wrote the Discussion; and was responsible for the final draft. S. Klitzman conceptualized the project; oversaw the database search, coding, and analysis; wrote the Results; made tables; and edited the final draft. N. Freudenberg conceptualized the project, oversaw the coding and analyses, and wrote the Introduction. J. Cooperman-Mroczek searched databases, screened articles, coded data, performed analyses, wrote the Methods, and participated in discussions of the findings and interpretation. S. Nassar searched databases, screened articles, coded data, performed analyses, worked with S. Klitzman on the Results and tables, and participated in discussions of the findings and interpretation.

Peer Reviewed

Accepted for publication May 6, 2003.

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TOP ABSTRACT INTRODUCTION IDENTIFYING HOUSING-BASED HEALTH... THE NATURE OF HOUSING-HEALTH... EVALUATION CHARACTERISTICS QUALITIES OF SUCCESSFUL... LIMITATIONS OF RESEARCH STRENGTHS AND WEAKNESSES OF... TOWARD ECOLOGICAL INTERVENTIONS FROM EFFICACY TO EFFECTIVENESS CONCLUSIONS AND RECOMMENDATIONS References

 
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