There are 5 mechanisms by which these projects may improve health:
4.1. Reduction life threatening safety risks
With national survey data from over 7,000 houses showing that only 10 per cent of houses have safe electrical systems, electrocution has to be considered a serious risk to residents. The reason for failure could be as simple as one faulty light switch or one faulty power point, or could be an extreme combination of mice severed cabling, no earth connection of the house, faulty safety switches giving no earth leakage protection and exposed electrical cables.
Data shows that gas is only available in a quarter of houses surveyed. The most common system was bottled gas (not reticulated mains gas) and less than 50 per cent of these systems were safely installed and maintained.
The causes of fire may be greatly increased in overcrowded houses where data show gas installations are poor, with only 48 per cent safe. Electrical faults may also lead to fires and data show that only 42 per cent of houses had all power points tested as safe. The impact of vermin attacking electrical cables can also increase fire risk and data show that mice and rats were present in almost 15 per cent of houses.
Detection of fire is limited by the fact that 57% of houses have any smoke detectors fitted and, of those houses with any detector fitted, only 36% of houses had one smoke detector functioning.
Escape from house fires will be difficult if, as data show, security screens are often fixed to windows resulting in 46 per cent of houses with the only emergency escape route possible through external doors.
The immediate collapse of buildings causing injury to people is rare in Australia, but termites, reactive soils and water damage over prolonged periods has resulted in data that indicate many houses need urgent repair.
4.2. Reduction in infectious disease, especially in children, many of which impact on health in later life.
The strong focus on hygiene and washing is primarily targeting infectious diseases in children We have set as a goal that every mother would have the functioning hardware to wash their child every day and wash their hands and face frequently. There are studies which support an effect of washing and hygiene practice in reduction of all the major infectious diseases in childhood including acute respiratory infection, diarrhoeal disease, ear disease, trachoma and skin infection. Acute respiratory infections can lead to chronic respiratory disease in adult life; chronic ear disease can lead to hearing impairment in later life and trachoma can have long term consequences. In addition chronic inflammation is a possible contributor to vascular disease and in such populations may be one cause of the very high rates of coronary artery and cerebrovascular disorders.
4.3. Provision of the essential prerequisites for improved nutrition.
There are of course many factors which influence eating patterns in poor communities. High fat and sugar containing take away foods are increasingly consumed by Aboriginal people in remote communities (28). One issue which drives this behaviour is the lack of ability to store, prepare and cook food in houses. Our nutrition focus is on this area of health hardware provision. Poor nutrition is important in its role in infectious disease in children but is a major determinant of diabetes and vascular disease in adults. There is also increasing evidence that poor nutrition in pregnancy is a major driver of the foetal origins of adult chronic disease (29,30) The risk of developing conditions such as diabetes and renal failure are substantially determined in pregnancy and early life. In addition these effects often involve epigenetic changes and the initiation of increased genetic risk that will be intergenerational (29,30)
4.4. Improved ‘control’ of the living environment and reduction in the daily ‘problem list’ for Aboriginal people in communities.
Poor housing is often discussed as a potential confounder in studies linking low socioeconomic status. However it may be that poor housing is one of the factors which mediates the negative effect on health of low socioeconomic status. There are obviously a large number of major stressors on people living in Aboriginal communities. But poor housing, which we would define as lack of functioning health hardware, is one obvious, constant and profound stressor. Since psychosocial resource – resilience, is tested by stressors, it seems reasonable that reducing stressors is likely to enable control and agency. We hypothesise that improving health hardware will have a beneficial effect on control and mastery. Consider a mother in a house with her children and grand children. She will have to deal with children who have chest infections, diarrhoea, skin sores and they will all need feeding; adolescents and young adults with drug and alcohol problems; general community violence; the demands of multiple government departments to attend meetings and of course her own chronic health problems.
If we could provide a house environment where the toilet works, children can be consistently washed and food can be stored, prepared and cooked, then we could substantially reduce the number of major stressors for that mother and others in the household.
It is commonly proffered that Aboriginal housing programmes should be key drivers of Aboriginal employment. One major problem with this approach is that these programmes are time limited, usually with a small number of houses being constructed in any community. External building contractors have difficulty in training, and hence employing, local staff when the projects are only likely to last for a period of months. On the other hand, maintenance work is a constant need in communities and the skills learnt in Housing for Health programmes can serve as a basis for long term employment in addition to the short term benefits of real work on the projects themselves. Lack of employment is of course associated with poorer health status.