Indigenous Environmental Health: Report of the Fifth National Conference 2004
Evaluating the Health Impacts of Housing for Health on Aboriginal Communities in Rural New South Wales
Michael Staff, Director, Environmental Health, New South Wales Health
Evaluating the health impacts of Housing for Health on Aboriginal communities in rural New South Wales is something we need to do to inform policy and to be sure we are getting value for money for the investments we are making. When looking at Indigenous health we need to take an holistic view of health that incorporates social, cultural and spiritual elements as well as the absence of disease.
Today I’d like to outline what data is currently available to evaluate the Housing for Health program, acknowledge its limitations, describe the gaps we need to fill, and highlight some alternatives to addressing these gaps. From the outset it is important to acknowledge that collection of data must be linked to provision of service. However, it is equally important to emphasise that for us to keep delivering a service we need to take away with us some evidence that it’s made a difference.
Within the Housing for Health methodology there are nine healthy living practices, and in New South Wales achieving these forms the basis of delivering our program. The Aboriginal Community Development Program administered by the Department of Aboriginal Affairs is spending $240 million over eight years, with $15 million of that earmarked for Housing for Health. New South Wales Health provides additional funding to implement and manage the Housing for Health program.
Of the nine healthy living practices, the four we are concentrating on are washing people, washing clothes and bedding, removing waste, and improving nutrition. These practices could be considered as basic rights, things you’d think everyone should be able to do. A case could easily be made on social justice grounds that if you can demonstrate a group of people don’t have adequate facilities to perform these practices, and you can demonstrate that a program can help provide them with these facilities, then that program must be improving this group’s health. Unfortunately, this type of argument is not always enough.
There are three potentially useful sources of routinely collected health data that might be helpful in evaluating the Housing for Health program. Firstly, the Inpatient Statistics Collection that records all hospital admissions, the reason for admission, and what procedures were performed. Using this type of data tends to only consider the more severe health problems - you need to be sick enough to be admitted to hospital to be included in the data. Secondly, the emergency department presentations database that records similar information. Individuals recorded in this database do not necessarily need to be sick enough to be admitted to hospital to be recorded. And thirdly, general practitioners also collect patient data. While this last category of data has enormous potential, the systems in place are not well developed and there is limited, if any, data available on a routine basis.
Another factor complicating retrieval of useful data to evaluate Housing for Health is the need to accurately identify the Indigenous status of individuals - this can be difficult for routinely-collected data systems. How good is the recording of Indigenous status in the Inpatient Statistic Collection and emergency department data in New South Wales? It varies quite a bit but is probably only fair at best.
So, if we use routinely collected data, what conditions or diagnoses should we look at? The ones we chose are those we would expect to occur without adequate hardware, such as plumbing and washing facilities. The types of illnesses that public health advances have prevented in the developed world: intestinal infections such as gastroenteritis and viral hepatitis, infections spread by the faecal–oral route, and those associated with close contact, such as acute respiratory illnesses, conjunctivitis and skin infections, which would be reduced by improving healthy living practices. These illnesses all tend to be acute and usually not severe enough to result in hospitalisation.
It is also important to appreciate the number of individuals involved in the Housing for Health program. With only a few staff involved in the program, only a very significant decrease in admissions will be noticeable, given the large data sets. A further limitation of the routinely collected data available is the difficulty of identifying which healthcare provider a person from a specific community might go to for treatment. This is made somewhat easier in our case as the Housing for Health program is delivered in remote communities and geographical limitations make the job of identifying the healthcare provider most likely to be used easier.
Top of page
We have some examples of what routinely-collected admission data is able to tell us. Characteristically there is a wide variation in the number of admissions for the conditions we are considering, and it is difficult to identify any clear pattern. We have concentrated on the figures for children, as we thought they would be the most susceptible to changes in the environment, so perhaps the best marker for improvements in health due to the Housing for Health program.
The data collected as part of the Housing for Health program itself provides convincing evidence that the program makes a significant change in the provision of adequate health hardware. In New South Wales we’ve had three generations of Housing for Health projects that have included a total of 1200 houses, with the second generation being the largest: 550 houses in 20 communities.
We recorded data on 240 survey items at the first visit and, for the purpose of this presentation, have categorised them into seven safety items and the four major healthy living practices, giving a total of 11 indicators. For reporting purposes we have presented figures as either 100 per cent compliance or not. Looking at Generation 2 figures, there are quite dramatic safety improvements following delivery of the program, particularly electricity safety. A similar improvement is seen in the four healthy living practices, although at first pass there does not seem to be much of an improvement in the ‘ability to cook, store and prepare food’ indicator.
The reason for this is that the main focus of the program is on plumbing and electrics, but it does not address issues such as providing freezers and fridges. This has lead to homes not achieving the 100 per cent compliance level at Survey 2 despite improvements in other parts of this category. Overall, you can conclude that the program has made significant gains over the 12 months or so between Survey 1 and Survey 2.
The next question that may be asked is: How sustainable are these observed gains? We have data on one community where a third survey has been conducted two-and-a-half to three years from the initial survey that can help us answer this question. Looking at this data you can see a significant improvement between Survey Fix 1 and Survey Fix 2 data for the majority of the 11 indicators reported. When the community was visited again some two-and-a-half years or so later there had been a decrease in the gains made, but probably not back to pre-program levels. The interesting feature was that this fall was due mostly to easily rectified problems, and the previous high level of functionality was easily regained with modest additional work.
This is perhaps most clearly seen in comparing the average $11 500 spent per house between Surveys 1 and 2, compared to the average $500 spent per house at the time of the third survey to achieve similar gains. The implication is that a modest maintenance program, preferably run by the community itself, is likely to ensure the sustainability of program gains.
Where does all this leave us in relation to making a case that the Housing for Health program is effective and represents value for money? Routinely collected data has limitations: we can show improvements in things we think should make a difference to health, but we have yet to directly measure a definitive health improvement. One suggestion is to look at improvements in an individual’s quality of life or sense of control over their life. This is likely to be an area where we can see some changes if we improve people’s ability to do the activities of daily living, so they have time and energy to focus on other aspects of their own and their community’s life. One of the major challenges is to develop a system of measuring these aspects of an individual’s life in a culturally appropriate manner. This is not insurmountable, as a good deal of work has already been done in this area and it is a matter of adapting it for our particular situation. I see this as a challenge we should take up, and with the help of the communities involved in the program, I am sure we can make significant progress.
In closing I would like to make one last point, a point that I think is vital to the success of a program such as Housing for Health. There is no point going into a community doing surveys for the sake of doing surveys. We need to tie any evaluation of the success of the program in with the direct delivery of a service. By doing this we can clearly demonstrate the purpose of the evaluation and work in partnership to make sure we are investing resources in an efficient and appropriate manner to get the maximum gains for Indigenous communities.
For further information
Michael Staff Director,
New South Wales Health
PO Box 798,
Gladesville, New South Wales, 1675
Phone: 02 9816 0234
Fax: 02 9816 0240