The "inverse housing law" and respiratory health

Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum

The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.

Cold homes and mental health harm: Evidence from the UK Household Longitudinal Study

Cold homes are associated with a range of serious health conditions as well as excess winter mortality. Despite a comparatively mild climate cold homes are a significant problem in the UK, with a recent estimate finding that over one-quarter of low-income households had been unable to adequately heat their home in winter 2022. The magnitude of cold housing in a country that benefits from a mild climate indicates indifference towards, or acceptance of, a significant minority of people living in inadequate conditions on the part of policy makers. Cold homes are therefore a source of social harm. Recent changes to the household energy price cap, the rising cost of living, the ongoing effects of the benefit cap, and below inflation uprating to social security benefits is likely to greatly exacerbate this issue. In this research we use data from the UK Household Longitudinal Study to explore whether living in a cold home causes mental health harm. We control for mental distress and housing temperature on entry to the survey in order to account for the potentially bi-directional relationship. Multilevel discrete-time event history models show that the transition into living in a home that is not suitably warm is associated with nearly double the odds of experiencing severe mental distress for those who had no mental distress at the beginning of the survey; and over three times the odds of severe mental distress for those previously on the borderline of severe mental distress. These results show the significant costs of failing to ensure that people are able to live in homes in which they are able to live comfortably by even the most basic standards. These costs will be felt not just individually, but also more broadly in terms of increased health spending and reduced working.

Housing and health in vulnerable social groups: an overview and bibliometric analysis

Previous studies have confirmed that poor living conditions can lead to a wide range of health problems. However, in the context of the COVID-19 pandemic, vulnerable groups in unstable housing are more susceptible to disease. This study aims to systematically examine the housing and health problems of vulnerable groups using a bibliometric approach to explore how housing causes health problems, types of health illnesses, and coping strategies. It is found that the poor housing mechanism, persistent inequalities, and poor housing environments have a significant impact on the health of vulnerable groups. Therefore, the government must make concerted efforts across all sectors to ensure that the housing and health care needs of vulnerable groups are improved, and that housing security standards and related policies are improved; targeted safety plans are formulated with community as the carrier, taking into account the characteristics of vulnerable groups; and new information technology is widely used to provide medical convenience for vulnerable groups. It is hoped that the research in this paper can arouse social attention to the health of vulnerable groups and improve their health from the perspective of housing, so as to point out the direction for solving the housing health problems of vulnerable groups in the future.

A Comparative Analysis of the Status Anxiety Hypothesis of Socio-economic Inequalities in Health Based on 18,349 individuals in Four Countries and Five Cohort Studies

The status anxiety hypothesis proposes that systematic inflammation as a consequence of chronic psycho-social stress is a possible pathway linking socio-economic position (SEP) to premature ageing and is a possible explanation for cross-national variation in patterns of health and well-being. Harmonised data from the LIFEPATH consortium on 18,349 individuals aged 50 to 75 and 30,632 observations are used to measure variation in the association between inflammation measured as C-reactive protein and SEP across four countries (Britain, Ireland, Portugal and Switzerland) and five studies (ELSA, Whitehall II, TILDA, EPIPorto and SKIPOGH). Adjusting for population composition, mean concentrations of CRP are highest in Portugal, the country with the highest income inequality and lowest in Switzerland, a lower income inequality country. Across all of the studies, lower SEP groups have higher mean concentrations of CRP and, as predicted by the theory, absolute differentials between SEP groups reflect the pattern of societal income inequality. Adjustment for lifestyle indicators reduces SEP differentials by between 45% and 52% but cannot account for country variation in mean inflammation.

Neighborhood deprivation and biomarkers of health in Britain: the mediating role of the physical environment

BACKGROUND

Neighborhood deprivation has been consistently linked to poor individual health outcomes; however, studies exploring the mechanisms involved in this association are scarce. The objective of this study was to investigate whether objective measures of the physical environment mediate the association between neighborhood socioeconomic deprivation and biomarkers of health in Britain.

METHODS

We linked individual-level biomarker data from Understanding Society: The UK Household Longitudinal Survey (2010-2012) to neighborhood-level data from different governmental sources. Our outcome variables were forced expiratory volume in 1 s (FEV1%; n=16,347), systolic blood pressure (SBP; n=16,846), body mass index (BMI; n=19,417), and levels of C-reactive protein (CRP; n=11,825). Our measure of neighborhood socioeconomic deprivation was the Carstairs index, and the neighborhood-level mediators were levels of air pollutants (sulphur dioxide [SO2], particulate matter [PM10], nitrogen dioxide [NO2], and carbon monoxide [CO]), green space, and proximity to waste and industrial facilities. We fitted a multilevel mediation model following a multilevel structural equation framework in MPlus v7.4, adjusting for age, gender, and income.

RESULTS

Residents of poor neighborhoods and those exposed to higher pollution and less green space had worse health outcomes. However, only SO2 exposure significantly and partially mediated the association between neighborhood socioeconomic deprivation and SBP, BMI, and CRP.

CONCLUSION

Reducing air pollution exposure and increasing access to green space may improve population health but may not decrease health inequalities in Britain.

Socioeconomic deprivation increases the effect of winter on admissions to hospital with COPD: retrospective analysis of 10 years of national hospitalisation data

Background:

Admission to hospital with chronic obstructive pulmonary disease (COPD) is associated with deprivation and season. However, it is not known whether deprivation and seasonality act synergistically to influence the risk of hospital admission with COPD.

Aims:

To investigate whether the relationship between season/temperature and admission to hospital with COPD differs with deprivation.

Methods:

All COPD admissions (ICD10 codes J40-J44 and J47) were obtained for the decade 2001–2010 for all Scottish residents by month of admission and 2009 Scottish Index of Multiple Deprivation (SIMD) quintile. Confidence intervals for rates and absolute differences in rates were calculated and the proportion of risk during winter attributable to main effects and interactions were estimated. Monthly rates of admission by average daily minimum temperatures were plotted for each quintile of SIMD.

Results:

Absolute differences in admission rates between winter and summer increased with greater deprivation. In the most deprived quintile, in winter 19.4% (95% CI 17.3% to 21.4%) of admissions were attributable to season/deprivation interaction, 61.2% (95% CI 59.5% to 63.0%) to deprivation alone, and 5.2% (95% CI 4.3% to 6.0%) to winter alone. Lower average daily minimum temperatures over a month were associated with higher admission rates, with stronger associations evident in the more deprived quintiles.

Conclusions:

Winter and socioeconomic deprivation-related factors appear to act synergistically, increasing the rate of COPD admissions to hospital more among deprived people than among affluent people in winter than in the summer months. Similar associations were observed for admission rates and temperatures. Interventions effective at reducing winter admissions for COPD may have potential for greater benefit if delivered to more deprived groups.

Fuel poverty and the health of older people: the role of local climate

BACKGROUND

Fuel poverty is a risk factor for ill-health, particularly among older people. We hypothesized that both the risk of fuel poverty and the strength of its detrimental effects on health would be increased in areas of colder and wetter climate.

METHODS

Individual data on respiratory health, hypertension, depressive symptoms and self-rated health were derived from the 2008/09 wave of the English Longitudinal Study of Ageing. Climate data for 89 English counties and unitary authorities were obtained from the UK Met Office. Multilevel regression models (n = 7160) were used to test (i) the association between local climate and fuel poverty risk, and (ii) the association between local climate and the effect of fuel poverty on health (adjusted for age, gender, height, smoking status and household income).

RESULTS

Individual risk of fuel poverty varied across counties. However, this variation was not explained by differences in climate. Fuel poverty was significantly related to worse health for two of the outcomes (respiratory health and depressive symptoms). However, there was no significant effect of climate on fuel poverty's association with these outcomes.

CONCLUSIONS

Although there is regional variation in England in both the risk of fuel poverty and its effects on health, this variation is not explained by differences in rainfall and winter temperatures.

Health inequalities

The evidence bearing on the nature and extent of health inequalities documented globally and in the UK is addressed, twin foci within the UK being (a) associations between socioeconomic classification and health and longevity, and (b) the notion of a 'social gradient'. A consideration of the various 'models' that have been developed by sociologists and their allies - most conspicuously social epidemiologists - to account for (a) and (b) is offered, drawing on government-sponsored commissions and reviews as well as the peer-reviewed literature. This is followed by a portrayal of specifically sociological theories of health inequalities, featuring those that hold social structures as well as cultural shifts in convention and behaviour to be causally efficacious for health inequalities. The summary and conclusions of the review incorporate an outline of pertinent questions the sociological community has so far been reluctant to address and an agenda for future research.

The effect of housing on the mental health of older people: the impact of lifetime housing history in Whitehall II

BACKGROUND

This study describes differences in trajectories of self-reported mental health in an ageing cohort, according to their housing, while controlling for confounders.

METHODS

The General Health Questionnaire was measured on six occasions as part of Whitehall II cohort study of office-based British civil servants (1985-2009); 10,308 men and women aged 35-55 at baseline.

RESULTS

Home-ownership was the predominant tenure at baseline and increased over the life-course, but the social gradient remained. In the bivariate analysis, by phase nine, renters had higher (poorer mental health) GHQ scores (55.48) than owner occupiers (51.98). Those who reported difficulty paying bills or problems with housing had higher GHQ scores at baseline (financial difficulties 57.70 vs 54.34; house problems 58.06 vs 53.99) and this relative difference increased by phase nine (financial difficulties 59.64 vs 51.67; house problems 56.68 vs 51.22). In multivariate models, the relative differences in GHQ scores by tenure increased with age, but were no longer significant after adjusting for confounders. Whereas GHQ scores for those with housing problems and financial difficulties were still significantly higher as participants grew older.

CONCLUSION

The social gradient in the effect of home ownership on mental health, which is evident at baseline, diminishes as people get older, whereas housing quality and financial problems become relatively more important in explaining older people's health. Inequalities in housing quality and ability to deal with household financial problems will become increasingly important mental health issues as the population ages.

Does context matter for the relationship between deprivation and all-cause mortality? The West vs. the rest of Scotland

Background

A growing body of research emphasizes the importance of contextual factors on health outcomes. Using postcode sector data for Scotland (UK), this study tests the hypothesis of spatial heterogeneity in the relationship between area-level deprivation and mortality to determine if contextual differences in the West vs. the rest of Scotland influence this relationship. Research into health inequalities frequently fails to recognise spatial heterogeneity in the deprivation-health relationship, assuming that global relationships apply uniformly across geographical areas. In this study, exploratory spatial data analysis methods are used to assess local patterns in deprivation and mortality. Spatial regression models are then implemented to examine the relationship between deprivation and mortality more formally.

Results

The initial exploratory spatial data analysis reveals concentrations of high standardized mortality ratios (SMR) and deprivation (hotspots) in the West of Scotland and concentrations of low values (coldspots) for both variables in the rest of the country. The main spatial regression result is that deprivation is the only variable that is highly significantly correlated with all-cause mortality in all models. However, in contrast to the expected spatial heterogeneity in the deprivation-mortality relationship, this relation does not vary between regions in any of the models. This result is robust to a number of specifications, including weighting for population size, controlling for spatial autocorrelation and heteroskedasticity, assuming a non-linear relationship between mortality and socio-economic deprivation, separating the dependent variable into male and female SMRs, and distinguishing between West, North and Southeast regions. The rejection of the hypothesis of spatial heterogeneity in the relationship between socio-economic deprivation and mortality complements prior research on the stability of the deprivation-mortality relationship over time.

Conclusions

The homogeneity we found in the deprivation-mortality relationship across the regions of Scotland and the absence of a contextualized effect of region highlights the importance of taking a broader strategic policy that can combat the toxic impacts of socio-economic deprivation on health. Focusing on a few specific places (e.g. 15% of the poorest areas) to concentrate resources might be a good start but the impact of socio-economic deprivation on mortality is not restricted to a few places. A comprehensive strategy that can be sustained over time might be needed to interrupt the linkages between poverty and mortality.

Effect of social factors on winter hospital admission for respiratory disease: a case-control study of older people in the UK

BACKGROUND

Every winter, hospitals in the UK and other developed countries experience a surge in respiratory admissions. Ecological studies suggest that social circumstances may be an important determinant.

AIM

To establish the most important factors associated with winter hospital admissions among older people presenting with acute respiratory disease, especially the relative effect of social factors.

DESIGN OF STUDY

case-control study.

SETTING

Seventy-nine general practices in central England.

METHOD

Of a cohort of patients consulting medical services with lower respiratory tract infection or exacerbation of chronic respiratory disease, 157 hospitalised cases were compared to 639 controls. Social, medical, and other factors were examined by interview and GP records.

RESULTS

Measures of material deprivation were not significant risk factors for admission at either individual or area level, although social isolation (odds ratio [OR] 4.5; 95% confidence interval [CI] = 1.3 to 15.8) resulted in an increased risk of admission. The most important independent risk factor was the presence of chronic obstructive pulmonary disease (COPD; OR 4.0; 95% CI = 1.4 to 11.4), other chronic disease (OR 2.9; 95% CI = 1.2 to 7.0), or both (OR 6.7; 95% CI = 2.4 to 18.4). Being housebound was also an independent risk factor (OR 2.2; 95% CI = 1.0 to 4.8).

CONCLUSION

Socioeconomic factors had little relative effect compared with medical and functional factors. The most important was the presence of long-term medical conditions (especially COPD), being housebound, and having received two or more courses of oral steroid treatment in the previous year. This combination of factors could be used by primary medical services to identify older patients most vulnerable to winter admissions. Clinicians should ensure that patients with COPD are better supported to manage their condition.

Housing and public health

This review considers the broad area of housing and public health, one of the traditional and core areas of public health research and intervention. The review takes into account the range of factors, acting at different levels, directly and indirectly, through which housing affects health. In public health terms, housing affects health in a myriad of relatively minor ways, in total forming one of the key social determinants of health. The paper closes by considering how the improvement of housing and neighborhoods has been a core activity of public health and a central component in tackling poverty. Investment in housing can be more than an investment in bricks and mortar: It can also form a foundation for the future health and well-being of the population. Addressing poor-quality housing and detrimental neighborhoods, in the broadest sense, is thus a task that should be grasped with vigor and determination by all those involved in public health.

Elevated risk of high blood pressure: climate and the inverse housing law

BACKGROUND

In previous work the authors identified an 'inverse housing law' in Britain such that housing quality tends to be worse in areas of harsh climate than in areas where the climate is more benign. This study investigates whether an individual's risk of hypertension is associated with such a 'mismatch' between the quality of their housing and the climate to which they have been exposed.

METHODS

Cross-sectional observational study based on Britain. Data came from the 5663 Health and Lifestyle Survey (HALS) participants for whom all relevant items were available. A two-stage study design was employed. First, the relationship between exposure to colder climate and housing quality was established. Second, the impact on risk of hypertension was determined for level of exposure to colder climate and housing quality.

RESULTS

Analysis confirmed that amongst survey respondents, those with greater exposure to colder climate are more likely (1.32, 95% CI: 1.18-1.42) to live in poor quality housing than those with lower exposure to colder climate. This combination of higher exposure to colder climate plus residence in worse quality housing raises significantly the risk of diastolic hypertension (1.45, 95% CI: 1.18-1.77) and, more weakly, systolic hypertension (1.25, 95% CI: 1.01-1.53).

CONCLUSIONS

There appears to be an 'inverse housing law' in Britain, whereby longer term residents of relatively cold areas are also more likely to live in worse quality housing and this combination of circumstances is associated with significantly higher risk of diastolic hypertension. The findings provide an example of how long term exposure to an adverse environment, which may stem from material disadvantage, can damage health.

Characteristics of individuals and characteristics of areas: investigating their influence on health in the Whitehall II study

There is evidence that health is determined by macro-level factors as well as by individual risk factors. Using data from the Whitehall II study we consider area-level determinants of health and ask two related questions. Firstly, are health differences between areas explained by the individual risk profiles of residents in those areas? Secondly, since poorer people tend to live in poorer places, are individual socio-economic effects on health explained by where people live? The demographic characteristics of residents, level of deprivation in the area, housing and neighbourhood quality and social integration were independently associated with health but did not fully explain differences between areas. Although there was considerable residential polarisation, area deprivation did not explain why lower status participants had poorer health.