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The Health Wrap: housing, tax cuts, HPV vaccine and bullying of health workers

In this latest edition of The Health Wrap, Associate Professor Lesley Russell focuses on one of the most important determinants of health – housing.

She summarises the current situation in Australia, highlights some innovative approaches to integrating housing and health services in the US and discusses some important aspects of a healthy home.

Also covered in this edition is new research on the relationship between location and life expectancy, the role of ‘nudge units’ in improving clinical decision making in hospitals, the HPV vaccine, the importance of addressing bullying and harassment of healthcare workers – and a shout out to Dr Mangatjay McGregor.


Lesley Russell writes:

In this edition of The Health Wrap I’m focusing on the links between housing and health. I’ve been reading some papers from the US, but they have lessons for Australia.

There are some good articles on homelessness, the interplay between housing and mental health, the role of family violence in housing problems, and stimulating investment in social housing on the website of the Australian Housing and Urban Research Centre.

Government spending does not match the growing problem of homelessness and housing affordability

I’ve written on homelessness before for The Health Wrap (see March 23, 2018). It’s a growing problem in Australia; Australian Bureau of Statistics data show that homeless numbers rose 14 percent in the five years to 2018.

This week it’s on my mind (and on the minds of others) as the Morrison Government enacts $158 billion in tax cuts – none of which will benefit people who are homeless. At least Senator Jacquie Lambie tried to do something about it for Tasmania as part of her support for passing the legislation.

Peak body for the social services sector ACOSS released a statement pointing out the implications of the tax cuts for health and social care. They warned that the cuts will remove tens of billions of dollars needed for the funding of essential services while the community is struggling with rising out-of-pocket costs in health and education, $40 a day unemployment payments, long delays for in-home aged care and dental care, and prohibitively expensive childcare.

On the ABC program The Drum this week it was stated that addressing homelessness in Australia would cost $40 billion (I have not been able to find a reference for that). In contrast, in 2019-20, the Federal Government will commit $1.71 billion for housing and homelessness measures, almost all of this via National Partnership Agreements with the States and Territories.

Our homes are key to our health

This year the annual message from the Robert Wood Johnston Foundation is focused on housing.  It looks at four key issues – neighbourhood, affordability, quality and stability.

The topics covered include:

  • The connection between housing and health equity
  • The growing gap between housing / rental costs and income
  • Driving community-led investment.

Yes, American data, but well worth a read.

How one American city is addressing the intimate links between housing and health

For many people the cost of keeping a roof over their head means there is no money for managing their ongoing healthcare needs. No matter how good the medical treatment provided, people must have their basic needs met if they are to prioritise their health.

A recent article in Health Affairs highlights the approach Portland in Oregon has taken, with significant health investments in housing. Like many cities, Portland has long struggled with persistently high rates of homelessness and substance abuse – both also associated with high rates of mental illness and various infectious and chronic diseases.

Multiple lines of evidence – hospitals reporting increases in emergency department attendances, doctors reporting their patients were losing housing, teachers reporting more students living from couch to couch – converged to demonstrate the magnitude of the housing problem to community health workers.

In 2016, six large healthcare organisations, together with state and local agencies, announced an investment of $21.5 million in Housing is Health. This provides almost 400 units for people who are homeless or at risk of homelessness. It is focused on families displaced by gentrification, people leaving transitional care and people in recovery.

The special building for this last group of people has a primary care clinic, substance abuse and mental health services and an employment office. One of the participants in Housing is Health is Kaiser Permanente, which is also supporting healthcare and peer support workers to help people find and maintain stable housing.

Oregon has long been recognised for its innovation in healthcare. It uses a Section 1115 waiver to invest Medicaid funds (joint state and federal funds) in innovative strategies such as housing, transportation, food and employment, designed to expand the program’s reach.

A paper in Health Affairs in May 2019 looked at Sec 1115 waiver investments in Oregon and California. Sadly, this paper is behind a pay wall, but the abstract gives a sense of what Medicaid can cover.

At its best, in progressive states like Oregon, Medicaid provides the full range of primary health care needs for its low-income clients.

This melding of federal and state funds to deliver health, healthcare and social services, targeted at those with the greatest need, is a model that could be adjusted to Australian circumstances – if only politicians were brave enough.

The ACCHO model shows the way this could be undertaken (and makes you wonder if Indigenous housing issues might be better resolved if ACCHOs had a role?).

What does a healthy home look like?

We know what a healthy meal looks like. We know that exercise is good for you and that pollution is bad for you. But we know a lot less about the homes where we spend so much of our time.

The Healthy Buildings program at the Harvard TH Chan School of Public Health has recently produced the Homes for Health report that looks at this issue. There are thirty-six tips for making homes healthier.

There are some shocking and surprising facts about the home environment in the developed world. These include:

  • Vacuum cleaners without proper filters simply break dirt up into smaller particles and scatter them around the room
  • The average adult uses nine personal-care products each day, exposing him or her to 126 different ingredients, and
  • Cooking with poor ventilation can make kitchen air resemble that of a smog-filled city.

According to the research, one of the top ways people can make their homes healthier is by merely kicking off their shoes before they step inside.

This limits the amount of dirt and dust picked up from streets and other places that harbor an alarming array of bacteria, germs, and chemicals that people then bring into their home.

A second priority is a bedroom that encourages quality sleep (that includes not taking your cell phone to bed!). The report reminds that most of us spend a third of our life in this one room.

Technology and social housing

I just came across this article in The Mandarin, which I think is worth including. It outlines how creating better outcomes for social housing tenants requires using technology in smarter, more targeted ways.

As examples, most people who are homeless have a smart phone, but they need affordable phone plans and access to broadband services.

Provision of these services can hep ensure that social housing tenants have access to the same services expected by society as a whole, that they can meet their responsibilities as tenants, and more easily integrate into the community.


Postcodes as destiny

This topic is somewhat related to that discussed above: where you live can affect how long you live.

We have long recognised that there is a relationship between where people live, their wealth, their health status and their life expectancy. Australia’s wealthiest postcodes are also the healthiest.

You can check this out using Australia’s Health Tracker by Area, developed by the Australian Health Policy Collaboration. The Australian Institute of Health and Welfare compiles data on health and life expectancy broken down by Primary Health Network and Local Government Area.

In the US the disparities in life expectancy between different locations can be huge and in some cities the difference between dying in your 50s and dying in your 80s can be measured in the span of a few blocks.

Now new research shows how life expectancy is determined by location, even after accounting for income, social status and overall health.

The researchers used an extensive data set of every US Medicare beneficiary from 1999 to 2014 to explore life expectancy differences between people who move after age 65 and those who stay put.

That allowed them to strip away all the factors that affect longevity such as health, lifestyle and genetics to isolate the effect of location on life span. It shows a causal relationship between where you live when you are over 65 and longevity.

In this news article about the research you can see the traditional maps for life expectancy in US and compare these with maps of life expectancy after 65. Moving as a retiree from a place in the bottom ten percent to one in the top ten percent would extend the average retiree’s life by a little more than a year.

The five places with the most positive effects on life expectancy were all in New York (Yonkers, New York City and Syracuse) or Florida (Port St. Lucie and Naples). The bottom five were scattered: Gulfport, Mississippi; Las Vegas, Nevada; Bakersfield, California; Beaumont, Texas; and Lake Charles, Louisiana.

So what is it about certain places that helps people live longer? More research is needed to answer this question, but some factors stand out. These include:

  • The availability and quality of health care
  • Weather and climate, and
  • Air pollution.

The authors emphasize that by far the biggest determinant to longevity in any given place is what they call “health capital” — the prior health behaviours, medical care and genetic inheritances people accumulate throughout their lives.

It’s interesting to postulate what such a study looking at Australian retirees might reveal.


The effectiveness of the HPV vaccine – an international analysis

The Lancet has just published a global analysis which reviewed the findings of 65 studies that looked at the health outcomes of 66 million people below the age of 30 who had received the vaccine against the human papilloma virus (HPV) in 14 high-income countries, including Australia.

It found vaccination has resulted in plummeting rates of pre-cancerous lesions and genital and anal warts – powerful evidence that these vaccines will ultimately cause major drops in cervical, throat and oral cancers.

The vaccines are so effective that when given to enough young girls, they also give partial protection to both unvaccinated girls and boys, simply because fewer people in sexual networks are carrying HPV.

These result show that the World Health Organization’s calls to eliminate cervical cancer may be possible in many countries if sufficient vaccination coverage can be achieved.

The vaccine is also expected to eventually lower rates of death from mouth and throat cancers caused by HPV when it is transmitted by oral sex.

These cancers are much more common among men than women: a 2017 study found that in the US the number of men with HPV-related throat cancer had surpassed the number of women with cervical cancer.

In poor countries, cervical cancer is a leading cause of female mortality, killing about 300,000 women a year.

Australian results

The free national HPV vaccination program was first rolled out to Australian schoolgirls aged 12 to 13 in 2007 as a three-dose course and was expanded to boys in 2013.

Rates of HPV infections in Australian women have dropped by 92 percent in the past eight years. Pre-cancerous cervical lesions have also fallen, with diagnoses dropping by 70 percent in Australian women aged under 20 and by about 50 percent in women aged between 20 and 24.

Earlier this year the Cancer Council predicted that cervical cancer will soon become a rare disease in Australia and by 2028 will be so uncommon that it will be deemed eliminated as a public health problem – an international first. Cancer Council statistics on cervical cancer are here.

But more work is needed to ensure that Indigenous women receive these benefits equally. Current AIHW data show cervical cancer rates are more than double in Indigenous women, with the five-year survival rate 56 percent (vs 74 percent) and the death rate three times higher.  In part this is due to lower screening rates.


Can Nudge Units improve the quality and lower the costs of care?

Penn Medicine (the University of Pennsylvania Health System) in Philadelphia has instituted what is described as the world’s first Nudge Unit (nudge – to prod, coax, gently encourage).

This is a behavioural design team that helps clinical staff deliver care in a way that improves medical decision-making.

The Nudge Unit steers healthcare delivery toward higher value and better patient outcomes using a number of approaches including defaults, financial incentives, gamification, information framing, social incentives, active choice and prediction.

The greatest successes of the Nudge Unit are cited as:

  • Using default options to increase generic prescribing rates from 75 percent to 99 percent; reduce unnecessary opioid prescribing in emergency departments by 50 percent; and increase referrals to cardiac rehabilitation programs from 15 percent to 85 percent
  • Using active choice to increase influenza vaccination rates by 10 percentage points
  • Using peer comparison feedback to triple statin prescription rates by primary care physicians.

There is growing evidence that behavioral design improves health outcomes, but mostly it’s used mostly for one-off experiments. What makes this Penn Medicine initiative different is that it has staff dedicated to introducing, testing, and then scaling behavioural interventions.

This article in Behavioural Scientist argues that building behavioral science teams and methodologies into health systems would create more and better solutions to some of the toughest problems in health. Food for thought!


Bullying and harassment of healthcare workers and patient safety

There’s been (justifiably) a lot of attention recently to the workplace environment for healthcare professionals, in particular, to overwork, bullying and harassment of junior doctors.

This must be a priority for action from all stakeholders – governments, hospital administrators, medical colleges and clinical supervisors – not just for the sake of the physical and mental wellbeing of healthcare staff but for the safety and health outcomes of their patients.

As outlined in a paper published last year in The Medical Journal of Australia (it’s behind a pay wall but there’s a summary here), between one-quarter and half of doctors and nurses in Australia have been bullied, discriminated against or harassed at work. This impacts on the way they do their work, and the quality and safety of the care they’re able to provide patients.

But the doctors and nurses who inflict this violence on others are also treating patients – does their harassment and discrimination carry over to the sick and frail people in their care?

It seems that might be the case. A study in the US showed that patients whose surgeons received a high number of unsolicited patient reports of unprofessional behaviour had higher surgical and medical complication rates compared with surgeons with few such reports.

Patients whose surgeons had one to three reports of unprofessional behaviour were at 18 percent higher estimated risk of experiencing complications, and those whose surgeons had four or more reports were at nearly 32 percent higher estimated risk compared to patients whose surgeons had no reports.

In a perspectives piece in the MJA last December, unprofessional behaviour in healthcare was described as “endemic” and the authors wrote that “investment and research evidence to achieve fundamental change in the high level of unprofessional behaviour in the health system have been absent, despite widespread calls for action”.

While a multifaceted approach to addressing this entrenched and endemic problem is needed, part of the solution could entail appropriately staffed and resourced Nudge Units (as described above) in every hospital setting.


The good news story

There is so much to celebrate in this wonderful story about Dr Mangatjay McGregor, the first Yolngu doctor, now working at Royal Darwin Hospital.

His path was not easy, but he persevered. I can only imagine the comfort he brings to his patients when he speaks to them in their own language.

Hopefully he will inspire other young Indigenous students to follow in his footsteps.


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. You can follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.

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