Today I will cover: 1. Set the scene 2. Over view program of research 3. Research findings: a. Housing affordability b. Tenure c.

Transcription

1 Getting at the causal pathways between housing and health: what have we learnt? Rebecca Bentley 1 and Emma Baker 2 1 Centre for Health and Society, Melbourne Mlb School Sh of Population and Global l Health, Melbourne University, Australia 2 School of Architecture and Built Environment, University of Adelaide, Adelaide, Australia

2 Overview My perspective - housing affordability is a key driver of socio- economic and health inequalities. Today I will cover: 1. Set the scene 2. Over view program of research 3. Research findings: a. Housing affordability b. Tenure c. Housing affordability and tenure d. Comparison with UK e. Housing affordability & employment security f. Mobility and location g. Questioning point in time: Slippers and stickers h. More than point in time: Cumulative exposures 4. Summary and conclusions

3 Setting the scene 1. One of the worlds most unaffordable housing markets 2. A serious housing shortage & predicted to worsen 3. ~1,200, of 7,700, Australian householdsh in unaffordable housing 4. Rent and mortgagecostsincreased dby almost50% ( ) 2011) ,000 Australians homeless at last Census (30% were Indigenous). Housing is our biggest expenditure (lifetime and ongoing).paid first. Not evenly distributed (e.g. Children in single parent households are 9 times more likely to be living in unaffordable housing)

4 Some established housing & health pathways Over crowding, high h density housing Communicable disease (e.g. TB), mental health. Exposure to toxins, allergens, radon, Cancers, respiratory diseases smoke Poor dwelling condition Damp, cold dwellings Unaffordable / poorly located housing Insulation and warmer houses Injury and accidents Respiratory disease Poor mental health and anxiety Self assessed health, GP visits

5 Guiding goals of our research 1. Policy relevant evidence (not based on N=1) 2. Causal or inferring it 3. To make a story across disciplines / funding silos 4. Large structural factors that shape health act together 5. Look beyond the averages and consider length of exposures.

6 Data HILDA: Household Income and Labour Dynamics in Australia National coverage Data collected annually since 1999/2000 Collects social and economic (and health) information from individuals and their households A combination of face-to to-face interviews with trained interviewers and a self-completion questionnaire 13,600 people interviewed in the base sample (+ top ups). Currently up to Wave 13.

7 The challenge of looking at short-term term effects causally Best option is to look at change in housing in relation to change in a health outcomes. Longitudinal datasets with waves close in time. Needed variables measured every year. Conservative approach=underestimation

8 The challenge of looking at longer-term effects causally Again, we need longitudinal datasets with enough waves to look over time. Missing data and attrition. How much is enough?

9 Measuring HAS Unaffordable housing (HAS) - households with rent or mortgage g payments in excess of 30% of gross household income and they are in the lowest 40% of the income distribution. Standard measure used in Australia.

10 Measuring mental health The Mental Component Summary (MCS) score of the Short Form 36 measure (SF-36). Self-completed. Widely used measure of health status that has been validated for use in the Australian population. A higher score on this scale reflects better mental health and wellbeing.

11 Building an evidence base 11

12 1. Does housing affordability influence mental health in Australia? * Adjusted for age, sex, country of birth, educational attainment, highest occupation level in household, disposable income and household structure 12

13 Interpretation of small effect? separated from spouse moving into housing stress fired or made redundant in MH score Difference

14 2) Does tenure influence mental health in Australia? No. Though people in different tenures have different mental health, we did not find evidence that tenure change influences (mental) health per se in the short run MCS Public rental Private rental Ownership

15 All households Lower income households 40.0 % Owner without a mortgage Owner with a mortgage State/territory housing authority Private landlord Total renters All households Housing affordability stress by tenure Data source: Housing Occupancy and Costs,

16 3) Does tenure modify the relationship between affordability and mental health? Working age population (25 to 64 years) At least two consecutive years of data Mortgage holders and private renters Living in households in the lowest 40% of the national income distribution

17 3) Yes! Different for owners and renters MC CS Home purchaser Private rental Affordable Unaffordable Intervention implication = private renters at the forefront of policy concern.

18 Annual Government Expenditure on Housing Policy (B$), 2013 homeowners investors renters Source: Grattan Institute 2013

19 4. Do these relationship hold in other settings? In Australia, there is a long history of a preference for homeownership, while private rental is widely regarded as a tenure of transition towards homeownership; and social housing is solidly seen as a welfare safety net for those unable to own or rent in the private market. UK has proportionally p more social housing, less private rental. Government-provided housing assistance in the United Kingdom has been far more generous than in Australia, with Housing Benefit providing up to three times the assistance available in Australia.

20 Tenure profile in Aus and UK Bentley R J Pevalin D Baker E Mason K Reeves A & Beer A (2015) Bentley, R. J., Pevalin, D., Baker, E., Mason, K., Reeves, A., & Beer, A. (2015). Housing affordability, tenure and mental health in Australia and the United Kingdom: a comparative panel analysis. Housing Studies, 1-15.

21 BHPS The GHQ-12 has been used extensively in the UK and in a variety of other settings as a tool for describing population mental health. Self-completed. A lower score on this measure (which ranges from 0-36) reflects better mental health.

22 Outcomes comparable? The SF-36 and the GHQ-12 have been compared in cross-national research.

23 Different housing systems Similar proportions of observations in each sample (around 22 per cent in Australia and 17 per cent in the UK) were in unaffordable housing between 2001 and More private rental households were in unaffordable housing in Australia than the UK (40 per cent compared to 23 per cent). In both Australia and the UK, the mean mental health score of home purchasers was more favourable than for private tenants, for both those whose housing was affordable and unaffordable.

24 Different relationships In Australia: Private renters whose housing became unaffordable experienced a small but significant decline in mental health (mean change = -0.45; 95% CI: to ), Home purchasers whose housing became unaffordable experienced, on average, no change in mental health (mean change = 0.00; 95% CI: to 0.37). The p-value for the interaction term for tenure and affordability was In the UK: Home purchasers whose housing became unaffordable experienced a small but significant decline in mental health (mean change = 0.48; 95% CI: 0.03 to 0.94). Private renters whose housing became unaffordable experienced, on average, no change in mental health (mean change = 0.30; 95% CI: t to 1.26). An interaction term for tenure and affordability was not statistically significant.

25 So then.. UK housing context offers a greater level of protection to tenants living in unaffordable housing when compared with Australia, and this finds expression in the mental health of the two populations. Good example of the benefits of cross-national research. Australian governments could improve the mental health of their economically vulnerable populations through more supportive housing policies.

26 5. Does employment security matter? Joe Hockey (previous Treasurer) - all you need to do to afford a house is to get a good job. Employment security provides an economic context for housing costs. It describes employment arrangements (contract type, length and leave entitlements) The extent to which employment security shapes any effect of housing affordability on mental health is not known. This is important because insecurity of employment arrangements is increasing in Australia and globally. Employment insecurity combined with with record high increases housing costs is creating an economic context likely to have consequences of health and health inequalities.

27 Our conceptual model 8 Household Income Housing affordability Mental health Interaction: Household employment security Location Housing quality Note: this means testing the benefit of Note: this means testing the benefit of interventions on HAS that target households based on employment security.

28 Employment security Household-level level employment status was modelled as a 3-level categorical variable securely employed if at least one adult in a household had a permanent or fixed-term job insecurely employed if no one was securely employed but at least one person was insecurely e employed (casual contracts, self-employed) employed) Unemployed if no adults were employed. Households were classified as not in the labour force (NILF) if all the adults in the household were either: carers, students, sick or disabled, and had not sought employment in the past month. Households classified as NILF were excluded from the analysis for that wave.

29 Description of data

30 Results. Mental health effect of HAS Household employmen Beta 95% CI - lower 95% CI - upper t Secure Insecure Unemployed Overall interaction terms, P< Yes, it is a small effect

31 Discussion and conclusion When housing became unaffordable: Insecurely employed households (casually or self-employed) employed) experienced a worsening of mental health. This was not observed for securely employed and unemployed households. Small effects but generated using conservative modeling approach that 1) causally focused 2) deals with residual confounding

32 Beer, A., Bentley, R., Baker, E., Mason, K., Mallett, S., Kavanagh, A., & LaMontagne, T. (2015). Neoliberalism, economic restructuring and policy change: Precarious housing and precarious employment in Australia. Urban Studies,

33 Discussion and conclusion Affordability interventions?: Via the taxation system; the provision of social housing, targetted assistance to private rental households, increased government investment in schemes to supply affordable housing, improving the quality of affordable housing. Target insecurely employed households? Maybe in the way we prioritise access to the above interventions? Possible locational aspect to this that should be explored in intervention ti design. (e.g. implications for some non- metropolitan areas where there are restricted labour market opportunities AND a low supply of affordable housing?)

34 Importantly Insight into how determinants of health act together.

35 6. Does affordability sort people spatially? Yes! (into more or less advantaged areas) Also some key characteristics ti of upward and downward movement couple families, older people, students Eviction, renters, lone parents, health problems What does it mean for the shape of our cities? 35

36 7. Is there a better way to measure housing affordability? How do we measure affordability? Point-in-time? What are we counting? Mixing up slippers and stickers? Stickers in HAS for five years. Slippers made at least one transition into HAS and at least one transition out of HAS in the same five-year period. Baker, E., Mason, K., & Bentley, R. (2015). Measuring Housing Affordability: A Longitudinal Approach. Urban Policy and Research, (ahead-of-print),

37 Slippers and Stickers Stickers - with many of the key indicators of disadvantage in post- industrial society (~11% of people in PHAS) Low incomes. Illnesses or disabilities &/or caring for others in their households. Low attachment to the labour market. The majority lived alone. Less education levels. Policy considerations: high level of need (but maybe not high enough for traditional responses?), many overlapping disadvantages, and how to target interventions? 37

38 8. Long-run effects? FE allows us to explore changes from one year to the next. We know from S&S that t some people p spend long periods of time in HAS. How can we examine this?

39 Approach 1. Measure the number of consecutive waves that people have experienced housing stress. 2. Estimate the association between cumulative exposure and mental health. Bentley, R., Baker, E., & Mason, K. (2012). Cumulative exposure to poor housing affordability and its association with mental health in men and women. Journal of epidemiology and community health, 66(9),

40 Cumulative housing variable (or)

41 Results Initial analysis Years cumulative HAS Coef. p Value 95% CI p for Trend < >= Re-analysis Years cumulative HAS Coef. p Value 95% CI p for Trend >= Ref category: 2 consecutive years no HAS Note: both adjusted for age, sex, years unemployment, long-term health condition

42 Findings 1. A small to moderate effect in the short term 2. No evidence of dose-response effect 3. Currently working on MSM

43 1. Does the amount of time spent in unaffordable housing matter for health? Not really 2. Should we be trying to isolate and measure the effects of housing on (different facets of) health? Probably not 3. Is there a better conceptual framework for collecting evidence and telling the story? Undoubtedly

44 Looking back, how should we move forward? Building a body of evidence that steps beyond association towards causation. Housing as a social determinant of health and wellbeing Interactions with other determinants (e.g. employment). targeting policy across more than one social determinant? Sub-group effects and identifying vulnerable populations The need to move beyond the averages - winners and losers not just one relationship to describe Amenable to policy impact that s t the beauty of it.