Asthma and housing
A project in Wrexham has demonstrated the value of improvements to the homes of children suffering from asthma. Phil Walton, Andy Lewis and Louise Woodfine report on the findings
Few rigorous studies have evaluated housing interventions designed to improve health. Many indoor environmental factors are associated with respiratory illness and childhood asthma including, for example, mould, pets, indoor air quality and tobacco smoke. There is the potential to improve these conditions through improving housing and the indoor environment.
CHARISMA is an innovative project that has taken place in Wrexham, North Wales. Through collaborative working this randomised controlled trial looks at improving children’s asthma symptoms and overall quality of life through housing interventions and improving housing conditions. As well as forming a research project to inform the health and housing evidence base, CHARISMA also considers more effective ways of delivering local authority and health services to improve health and wellbeing, particularly with respect to the wider determinants of health and also looks at complimenting existing health care service delivery.
The project was initiated by Wrexham County Borough Council (WCBC), and co-ordinated and implemented in partnership by staff from Public Health Wales, WCBC, Academia in Bangor, Cardiff and Liverpool and Betsi Cadwaladr University Health Board (BCUHB).
Context
Asthma prevalence in Wales is one of the highest in the world with over a quarter of a million people living with the condition (Asthma UK Cymru). It is the most common chronic condition in children worldwide and one in 10 children in Wales are currently being treated. Asthma is also one of the leading causes of hospital admission in children but of these admissions over 75 per cent and as many as 90 per cent could be avoided.
However, for most people with asthma, the condition is rarely characterised by an emergency or hospital admission. For children and their families, the more common experience is the daily burden of asthma and its impact on the general wellbeing of the child, both in school and at home. This impact on both the child and family members can easily be underestimated.
Local health, social care and wellbeing strategies in Wrexham identified respiratory health as a public health priority with concerns regarding the perceived growing increase of children’s asthma. This also supported the implementation of CHARISMA.
The study
The target group for CHARISMA was aimed at children who had moderate or severe asthma in Wrexham and were aged between five and 15. The children were identified through GP records and households were offered housing improvements (central heating and/or good quality ventilation) to improve their asthma. From an inequalities perspective, eligible children from all types of housing and in all geographical areas were offered the housing intervention.
Some 20 out of the 23 general practices in Wrexham took part and identified all eligible children and 197 households participated and received tailored housing improvements free of charge (ventilation and/or central heating as defined by the housing officer). Half of the households had improvements immediately and others were delayed by 12 months so that both groups could be compared to determine the difference made to the children’s asthma and general wellbeing. Throughout the project, information packs were available for the practices and patients, and one-to-one parental advice/support was also available through a support officer. The research project started in 2003 and has now been completed. Follow-on pilot work regarding mainstreaming in 2009/11 has also been successfully completed. Following this, elements of CHARISMA are now being taken forward in other areas of North Wales and England.
A validated paediatric questionnaire was used to measure asthmatic health and general quality of life at 0, four and 12 months. The main measure of improvement was to look at whether the housing improvements had changed the children’s asthma-specific quality of life. This looked at asthma with respect to symptoms, treatment, worry (about their condition) and communication with others.
Other measures of improvement included general health-related quality of life measures associated with physical health, emotional well-being, social factors and issues to do with functioning at school.
Outcomes
- Significantly improved asthma-specific quality of life for all functions (symptoms, treatment, worry and communication).
- Significantly reduced physical problems
- Psychosocial health (emotional, school and social functioning) improved (but not significantly so)
- All measures improved (even those with non-significant results) so less likely to be a chance result
- Improved health and wellbeing (perceived) of the child and other household members.
- Effect of improvement is underestimated due to longer term effects of the intervention which would be greater than at the 12-month follow-up, and also the additional impact on other household family members with asthma or respiratory ill-health.
- A comprehensive cost effectiveness analysis showed that the intervention was cost effective and good use of public money.
This work has now been published in the British Journal of General Practice and has received three national awards.
Phil Walton is strategic and performance director at Wrexham County Borough Council, north Wales, 01978 297002. Andy Lewis is head of housing and public protection, Wrexham County Borough Council, 01978 315501. Louise Woodfine is principal public health officer at Public health Wales, 01978 726701 and also the main contact for the article.
Publications
- Woodfine L, Neal RD, Bruce N. Enhancing ventilation in homes of children with asthma: pragmatic randomised controlled trial. Br J Gen Pract 2011; Nov;61(592):e724-32. doi:10.3399/bjgp11X606636.
- Edwards RT, Neal RD, Linck P. Enhancing ventilation in homes of children with asthma: cost effectiveness study alongside randomised controlled trial. Br J Gen Pract 2011; Nov;61(592):e733-41. doi 10.3399/bjgp11X606645.
Awards
- Novartis and RCGP Awards 2011 Winner in ‘Children’s Medicine’ Category.
- APSE (Association of Public Service Excellence) 2009 winner for ‘Best Healthy Living Initiative’
- NHS Wales 2009 runner up in the ‘Promoting Better Health and Avoiding Disease’ Category
Mainstreaming
- 2009/11; Successfully piloted as a mainstream referral service between housing and primary care in Wrexham
- 2012/13; CHARISMA informed the work of the Welsh Collaboration for Health and the Environment (WCHE) to review the evidence of effectiveness of various health and housing interventions with respect to asthma
- 2013; Elements of CHARISMA are now currently being taken forward in areas of Macclesfield, Nottingham and Sunderland and other areas of North Wales to further explore the health and well-being impact of housing improvements on respiratory ill health and the overall health and well-being impact on family members.