EHJ November 2004, pages 332-335
Last month, housing professionals gathered in Vilnius, Lithuania for the second WHO international housing and health symposium. Nick Warburton reports on the event and reveals a major study that underlines the important links between housing and health

Like its Baltic neighbours, Latvia and Estonia, Lithuania has thrown off its communist shackles with a vengeance and embraced a market driven economy. In the centre of Vilnius, a cluster of brash new skyscrapers now jostles with dilapidated church spires and ugly Stalinist office blocks for centre play on the city's skyline.

A short walk across the River Neris, the city's old town, one of the largest in eastern Europe, has undergone a major facelift with its rich and diverse mix of Baroque, Gothic, Renaissance and Neo-classical architecture seemingly restored to its historic splendour. The contrast with the grim, communist panel block housing that greets the visitor from the airport, however, could not be starker.

But Vilnius, like any other city, is a place of contrasts. This is particularly evident in its living conditions where local authorities come to grips with largely old and neglected housing stock and the challenges posed by building modern sustainable developments, which require new approaches to planning and construction.

Creating healthy, good quality, sustainable and affordable housing for everyone is a priority for the World Health Organisation, which is why Lithuania's capital city provided such a relevant and timely backdrop to its second international housing and health symposium.

Three session-packed days ensued with local authorities, politicians, decision makers and members of the scientific community coming together to thrash out policies and research ideas that further develop healthier housing. The symposium also built on the Budapest conference on environment and health where European ministers committed themselves to take action to ensure health and the environment are placed at the core of all housing policies.

But as Xavier Bonnefoy, regional adviser for the WHO's European office for environment and health, underlined in his opening speech in Vilnius, politicians have yet to properly acknowledge housing conditions as health determinants, despite widespread recognition that they have an "affect on health status". After all, people spend most of their time in the home environment where they are susceptible to a wide range of factors that can impact on their health, for example, noise disturbance, poor indoor air quality, humidity, asbestos and accidents.

Part of the problem is that, despite a plethora of research studies centred on housing, recent studies have tended to focus on specific areas, narrowing the focus on the link between housing and health. To date, there has been no holistic approach to housing, which is why there is no commonly agreed definition of healthy housing.

In Vilnius, Mr Bonnefoy highlighted other pressing issues. While it is widely acknowledged that housing conditions affect health status, there are still major knowledge gaps in exactly how it is affected. The link between housing and psychosocial and mental health issues has also been relatively neglected and needs further research.

To help tackle these issues, the WHO has funded a novel survey called the Lares project (large analysis and review of European housing and health status), which is centred around the WHO's definition of housing - the dwelling, the household, the immediate housing environment and the community.

The Lares project has four clear objectives. In a nutshell, these are to assess housing stock quality in a holistic way, identify priorities for housing and health both locally and nationally, create a tool that allows authorities to assess prevailing housing and health conditions and develop guidelines and recommendations for policy-making.

To meet these objectives, the WHO carried out a large survey in eight European cities - Angers in France, Bonn in Germany, Bratislava in Slovakia, Budapest in Hungary, Geneva in Switzerland, Ferreira do Alentejo in Portugal, Forli in Italy and Vilnius in Lithuania. The cities that participated were partly chosen to reflect variations in housing stock, climate and cultural differences (see map below).

Housing and health experts have devised a novel survey tool for the project, consisting of three questionnaires. Teams of surveyors visit households and carry out face-to-face interviews with occupants to collate data on the occupants' perception and evaluation of their housing conditions. Building on this data, they also carry out an independent inspection looking at the quality and physical condition of the housing environment. In both approaches, a range of housing aspects, such as household size, damp, humidity and moulds, natural light and safety and risks of accidents are taken into consideration.

Occupants are approached to provide data on their health behaviour, so that influencing factors such as alcohol consumption, smoking behaviour and levels of physical activity can also be considered. Occupants also contribute information on any chronic and acute illnesses and symptoms they have, both reported and diagnosed and whether they suffer from sleep disturbance as a result of noise annoyance.

The Lares study stimulated lively debate at Vilnius and some intriguing findings emerged across and within the study cities. Rebecca Miles from Florida State University, who investigated links between housing types, housing conditions and cockroach infestations found that residents of panel block housing (prevalent in eastern Europe) reported higher rates of cockroach infestations - 20 per cent compared to 9 per cent of residents in large multifamily buildings and 3 per cent in small multifamily buildings.

Ms Miles says that having a waste chute in the stairwell increases the odds of an infestation almost three-fold while having a shared open space doubles the odds. The Lares results also underline an important link between building maintenance and infestation rates. Ms Miles revealed that when the government, rather than a cleaning service company, was responsible for maintaining corridors, the prevalence of pest infestations was 3.5 times higher.

The study results are particularly relevant to Vilnius, where pest infestations are recognised as a significant problem. The results from the Vilnius survey have been fed into the city's strategic housing plan 2002-2011, which contains a broad range of measures to reduce the city's housing-related hazards. Vilnius is the first city in Lithuania to adopt a housing strategy and its priorities include promoting new home developments and speeding up the maintenance and modernisation of existing housing stock.

The Lares results have helped other cities to identify priority areas. In Budapest, the data underlines a significant link between noise annoyance and stress-mediated diseases and the need to improve sound insulation in residential buildings. The survey results have also identified a clear need to improve the accessibility of buildings for handicapped and elderly people.

In Forli, Italy, the municipality has used the survey to set two local priorities - accessibility for disabled people and the prevention of domestic accidents. Two programmes are currently being implemented in the city to target these specific issues, including a "laboratory project", which aims to create a prototype of a housing environment that considers the needs of end-users, especially disabled people.

In Angers, France, the Lares results are being used to support local planning decisions, which are aimed at improving accessibility for disabled people in the town. The Angers results are also being used to improve the quality of buildings and the surroundings and the need for spaces for leisure activities and green areas.

CIEH president elect and chair of the policy development board, Alan Higgins, who attended the symposium, sees great value in the survey methodology and its relevance to UK housing practitioners. "What it does," he says "is to provide some evidence base for the relationship between housing and health, which is quite supportive in the context of the housing health and safety rating system that is about to be introduced.

"I think the problem that we are faced with is that we all know that poor housing has an impact on health," he continues. "But nobody has actually really done a lot of detailed work to quantify the extent of that impact. Lares is a starting point."

Mr Higgins believes any further work should include input from the UK. "There wasn't a UK city that was part of the project but if they are going to extend Lares, I really think we should be involved," he adds. "I gather that part of the problem the WHO had, was that when they talked to the Office of the Deputy Prime Minister the response was 'this is a health issue'. They then talked to the Department of Health and they said, 'oh no, this is a housing issue. I think that really is one of the problems that we face. Trying to get people to make the connections."

He does, however, feel that Lares needs building on. "Although it is a positive methodology, the study was carried out without anyone taking measurements. For instance, in terms of noise, what they had was people self-reporting annoyance with no actual noise measurements attached. There really is a need to get some more solid evidence."

Nevertheless, Mr Higgins argues that similar research using the same methodology should be carried out in the UK because it would give practitioners some ideas about how to progress things in UK housing.

David Ormandy from Warwick University, who developed the housing health and safety rating system, agrees that similar research in the UK would be beneficial, particularly in supplementing existing data on housing conditions. Local authorities currently derive most of their data from stock condition surveys, but they can be costly and time consuming. Also, they do not take into consideration the needs of the occupants themselves.

The advantage of the Lares methodology, according to Mr Ormandy, is that it does exactly that. What's more, it is a simple and quick way of collecting a wealth of valuable information. The survey takes a mere two weeks to complete and the results can be produced within two months. He adds that the information gathered provides a wide range of health-related indicators, which can greatly assist local authorities in terms of informing policies and targeting action at problems areas.

Mr Ormandy, who contributed to the Lares study on home accidents, says that an analysis of the project data revealed important links between many of the subject areas covered by the study. He gives the example of how the affect of noise disturbance on sleep is shown to have a major impact on accidents. The data reveals that a person who lives in a noisy home is nearly twice as likely to have an accident than someone who lives in a quiet home.

But Vilnius was not just about the Lares study. Geoff Green from Sheffield Hallam University stresses the important relationship between investments in housing and health gain and argues that the lack of joined up thinking and action at government level is influenced by who pays and who benefits.

The current emphasis on "silo accounting" means that one sector incurs the costs while another reaps the benefits. What is needed is a new way of accounting, which measures the health gains from investments in housing. To emphasise the sort of cost savings that can be made by encouraging such a cross-sector approach, he points to Neal Rosenblatt's study on lead in the United States, which shows the cost of losing 1 IQ point is the equivalent of a lifetime loss in earnings of US$3,720 (£2,025).

The Vilnius symposium is also significant for the declaration adopted. This recognises, above all, that a decent and healthy home for all citizens, regardless of financial status, should be a priority for all national and local governments. The declaration identifies a number of priorities for the WHO, including domestic accidents, mental health and housing, obesity and housing and how the immediate environment impacts on health.

"These are all areas that are very much part of the public health agenda," says Mr Higgins. "Also, if you look at the 29 hazard areas within the housing health and safety rating system, many of these issues are represented and are all areas the profession has a keen interest in."

Mr Higgins believes that the whole relationship between housing and health in the UK will become more widely recognised once the housing health and safety rating system is phased in next year. What the Vilnius symposium did and what the Lares project offer are powerful messages and supporting evidence that can help local and national governments identify areas where gains in improved health can be made. All that is needed is political willingness and commitment.

For more information about the Lares project and the methodology used, visit: www.euro.who.int/housing

The Vilnius declaration can be accessed at: www.vilnius.lt/housing2004/