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Cover of Health impact, and economic value, of meeting housing quality standards: a retrospective longitudinal data linkage study

Health impact, and economic value, of meeting housing quality standards: a retrospective longitudinal data linkage study

Public Health Research, No. 6.8

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Author Information
Southampton (UK): NIHR Journals Library; .


This study found that meeting national housing quality standards through multiple home improvements was associated with reduced emergency hospital admissions.



Poor-quality housing adversely affects residents’ health but there is a paucity of high-quality evidence to support this.


This research investigated the health impact of bringing housing to a national quality standard.


A natural experiment of improvements to housing quality analysed using repeated measures of health-care utilisation and economic outcomes at an individual person level.


Carmarthenshire, UK.


A total of 32,009 residents registered for a minimum of 60 days at 8558 social homes that received housing improvements between January 2005 and March 2015.


Multiple internal and external housing improvements, including wall and loft insulation, windows and doors, heating system upgrades, new kitchens and bathrooms, garden path safety improvements and electrical system upgrades (adding power sockets, and extractor fans in kitchens and bathrooms).

Main outcome measures:

Emergency hospital admissions for cardiorespiratory conditions and injuries. Primary health-care utilisation for respiratory and common mental health disorders, emergency department injury attendances and health-care utilisation costs.

Data sources:

Carmarthenshire County Council home address and intervention records were anonymously linked within the Secure Anonymous Information Linkage databank to demographic information from the Welsh Demographic Service data set; hospital admission data from the Patient Episode Dataset for Wales; primary care contacts and prescribed medications from general practice data; emergency department attendances from the Emergency Department Data Set; and deaths from the Office for National Statistics mortality register.


The study used a longitudinal panel design to examine changes in standard of eight housing cointervention from intervention records, and linked to individuals registered at intervention homes. Health outcomes were obtained retrospectively for each individual in a dynamic cohort and were captured for up to 123 consecutive months. An additional local authority region could not be utilised as a comparator owing to different reporting pressures resulting in the recording of a different intervention. The exposure group for each cointervention was compared with an internal reference group of people living in homes that did not receive the cointervention during their tenancy. A multilevel modelling approach was used to account for repeated observations for individuals living in intervention homes. Counts of health outcomes were analysed using negative binomial regression models to determine the effect of each cointervention that reached housing quality standards during an individual’s period of tenancy, compared with those living in properties that did not. We adjusted for potential confounding factors and for background trends in the regional general population. A cost–consequences analysis was conducted as part of the health economic evaluation.


Residents aged ≥ 60 years living in homes in which electrical systems were upgraded were associated with 39% fewer admissions than those living in homes in which they were not [incidence rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.53 to 0.72; p < 0.01]. Reduced admissions were also associated with windows and doors (IRR 0.71, 95% CI 0.63 to 0.81; p < 0.01), wall insulation (IRR 0.75, 95% CI 0.67 to 0.84; p < 0.01) and gardens and estates (IRR 0.73, 95% CI 0.64 to 0.83; p < 0.01) for those living in homes in which these cointervention were upgraded. There were no associations of change in emergency admissions with upgrading heating (IRR 0.91, 95% CI 0.82 to 1.01; p = 0.072), loft insulation (IRR 0.98, 95% CI 0.86 to 1.11; p = 0.695), kitchens (IRR 0.98, 95% CI 0.83 to 1.17; p = 0.843) or bathrooms (IRR 0.93, 95% CI 0.81 to 1.06; p = 0.287).


There was no randomisation, there were incomplete data on the scale of the intervention for individual households and there were no estimates for the impact of the whole programme.


This complex interdisciplinary study found that hospital admissions could be avoided through improving housing quality standards.

Future work:

At their initiation, future non-health projects should have a built-in evaluation to allow intervention exposures to be randomly allocated to residents, with the simultaneous analysis of multiple health outcomes in one statistical model.


The National Institute for Health Research Public Health Research programme.


About the Series

Public Health Research
ISSN (Print): 2050-4381
ISSN (Electronic): 2050-439X

Article history

The research reported in this issue of the journal was funded by the PHR programme as project number 09/3006/02. The contractual start date was in April 2011. The final report began editorial review in November 2016 and was accepted for publication in June 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The PHR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Wouter Poortinga, Nikki Jones and Simon Lannon received funding from Carmarthenshire County Council to conduct a health impact survey study from 2009 to 2016. Jonathan Morgan was responsible for delivering the Carmarthenshire Homes Standard improvement programme.

Last reviewed: November 2016; Accepted: June 2017.

Copyright © Queen’s Printer and Controller of HMSO 2018. This work was produced by Rodgers et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK508015PMID: 29965717DOI: 10.3310/phr06080


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