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Objective: This study explores experiences of the Healthy Housing Initiative (HHI). Aimed at children at risk of housing-related illness, the HHI package includes the provision of items such as curtains, heaters, bedding, and insulation, advocacy to encourage landlords to install improvements, and education and advice to help people optimise their home environment. Methods: We conducted semi-structured, in-depth interviews with 20 people living in rental housing who received the HHI intervention. Results: Participants felt heard and supported by HHI assessors. They reported that the intervention increased the warmth and dryness of the home, improved their respiratory and mental health, reduced their bills, and enabled the use of more parts of their home. However, some continued to live in cold and damp conditions due to structural inadequacies and energy poverty. Conclusions: The qualitative evidence presented in this study shows how health-focussed interventions also benefit quality of life. Implications for public health: This research emphasises that healthy housing interventions can yield extensive benefits by adopting a holistic and home-based approach. Such interventions have the potential to create improvements in individuals' lives far beyond health.

ABSTRACTSignificant effort is underway to address the housing crisis in Aotearoa New Zealand (Aotearoa), including rapid investment in public and community housing. As Māori (the Indigenous people of Aotearoa) face many systemic barriers and impediments to home ownership, delivery and development of housing options and make up a significant proportion of public housing tenants, developing and managing housing and associated neighbourhoods that enable and support Māori wellbeing is of critical importance. To support this, we introduce A Whakawhanaungatanga Māori Wellbeing Model for Housing and Urban Environments – for use by researchers, developers, designers, managers and regulators – that emphasises whakawhanaungatanga (relationship building and creating connectedness) as central to wellbeing outcomes for Māori. Here we outline seven key concepts from Te Ao Māori built into our model, and pose questions to help guide researchers and housing and urban development actors in their respective research and development activities. While the model is primarily intended to contribute to Māori wellbeing outcomes in Aotearoa, it may also be of broader international interest to those working toward wellbeing outcomes in relation to housing and urban environments, particularly for Indigenous peoples.

This paper presents outcomes for a Housing First (HF) cohort in Aotearoa, New Zealand. Using integrated governmental administrative data, we analysed outcomes for a cohort of 357 people, comparing health, justice, income, and social welfare indicators the year prior to HF and five years after being housed. In the fifth year after being housed, improved outcomes across each of these sectors were noted, with particularly impressive improvements found in income levels (+38%) and mental health. These results demonstrate the efficacy of this HF programme in improving well-being. Despite such notable improvements, there is room for HF to have a greater impact in the context of wider system changes that support overall well-being, as well as the goal of making homelessness rare, brief, and non-recurring.

Green space is needed in urban areas to increase resilience to climate change and other shocks, as well as for human health and wellbeing. Urban green space (UGS) is increasingly considered as green infrastructure and highly complementary to engineered urban infrastructure, such as water and transport networks. The needs for resilient, sustainable and equitable future wellbeing require strategic planning, designing and upgrading of UGS, especially in areas where it has been underprovided. We explore the implications of these needs for urban development through a detailed review of cited UGS analyses conducted on the larger cities in Aotearoa New Zealand (AoNZ). There are important differences in UGS availability (i.e., quantity), accessibility and quality within and between cities. Some of these differences stem from ad hoc patterns of development, as well as topography. They contribute to apparently growing inequities in the availability and accessibility of UGS. Broader health and wellbeing considerations, encompassing Indigenous and community values, should be at the heart of UGS design and decisionmaking. Most of AoNZ’s cities aim (at least to some extent) at densification and decarbonisation to accommodate a growing population without costly sprawl; however, to date, sprawl continues. Our findings indicate a clear need for the design and provision of high-quality, well-integrated UGS within and servicing areas of denser housing, which are typically areas in cities with a demonstrable UGS deficiency.

(1) Background: Fall injuries in the home present a major health burden internationally for all age groups. One effective intervention to prevent falls is home modification, but safety is only increased if opportunities to install safety modifications are taken up. This study sought to identify factors that may lead to a higher uptake of no-cost home modifications when these are offered to people living in the community. (2) Methods: We studied 1283 houses in the New Zealand cities of New Plymouth and Wellington. Using logistic regression, we modelled the odds of uptake according to the number of access steps, the provider who was undertaking the modifications, occupant ethnicity, prior fall injury history, and age group. (3) Results: Homes with older residents (age 65+) had higher uptake rates (35% vs. 27% for other homes). Larger numbers of access steps were associated with higher uptake rates. There was indicative evidence that homes with Indigenous Māori occupants had a higher uptake of the modifications for one of the two providers, but not the other. (4) Conclusions: No-cost home safety modifications offered via cold calling are likely to have relatively low uptake rates but the households that do consent to the modifications may be those who are more likely to benefit from the concomitant increased safety.

With the impact of climate change, the use of both energy and resources that lock in future energy use is receiving heightened attention. New Zealand has lagged behind many similar countries in not requiring an explicit energy certification for dwellings. This paper reviews the form of energy certification used by similar countries and discusses the potential impact of applying the various forms to New Zealand dwellings. Specifically, it compares how different forms of comparison, or normalisation, value the features of a home and implicitly rate which dwellings are considered ‘like’ each other. Of the 85 buildings compared none received consistent rankings across all the normalisation methods and only one was in the ‘better’ half of the data under all nine of the normalisation methods used. Some of the forms of normalisation systematically advantaged large dwellings, and others small dwellings. Since normalisation methods can be chosen to value certain aspects of dwelling design, there needs to be a discussion about what we value in dwellings in order to determine which method(/s) would be appropriate for New Zealand. The main purpose of this paper is to alert social scientists of the need to have this value-based discussion.

Highlights Urban areas are highly complex systems, with interconnections between their political, economic, social, natural and built environments components, and each with its own unique priorities and contexts. They are also facing key global and local sustainability challenges such as a changing climate, air pollution and waste, all of which also present risks for population health. Improving urban sustainability can provide co-benefits for population health; however, the effectiveness—or unintended consequences—of policies or actions can depend on the behaviours and relationships in the wider urban system. The papers published in this special issue explore issues related to urban sustainability and health, including urban design and environmental justice, scale, and informal settlements. The papers also describe issues at the interface of different system components, demonstrating the systemic challenges that can act to enhance or prevent sustainable change. The complexity of urban environments presents challenges for research and policy, both of which can be reductive, and conducted independent from other disciplines or government departments. However, by moving from this siloed approach towards a broader systemic understanding, there are opportunities to develop and implement evidence-based solutions that have the potential to lead to significant improvements in sustainability and health.

Summary: Background: As with many Indigenous populations internationally, Māori in New Zealand suffer health inequity. We aimed to assess the rate of fall injuries at home with and without home modifications in houses with Māori occupants. Methods: We did a single-blind randomised controlled trial in the Wellington and Taranaki regions of New Zealand and enrolled owner-occupied households with at least one Māori occupant. Only households who stated they intended to live at that address for the subsequent 3 years were eligible for participation. We randomly assigned (1:1) households to either the intervention group, who received home modifications (handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, repairs to window catches, high-visibility and slip-resistant edging for outside steps, fixing of lifted edges of carpets and mats, non-slip bath mats, and slip-resistant surfacing for outside areas such as decks) immediately, or the control group, who received the modifications 3 years later. Data on home injuries were obtained from the Accident Compensation Corporation and coded by study team members, who were masked to study group allocation. The primary outcome was the rate of medically treated fall injuries at home per household per year, analysed according to intention to treat. This Māori Home Injury Prevention Intervention (MHIPI) trial is now completed, and is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613000148774. Findings: Between Sept 3, 2013, and Oct 1, 2014, 824 households were assessed for eligibility and 254 were enrolled, of which 126 (50%) were assigned to the intervention group and 128 (50%) were assigned to the control group. After adjustment for previous falls and geographical region, there was an estimated 31% reduction in the rate of fall injuries at home per year exposed to the intervention compared with households in the control group (adjusted relative rate 0·69 [95% CI 0·47–1·00]). Interpretation: Low-cost home modifications and repairs can be an effective means to reduce injury disparities. The high prevalence of modifiable safety issues in Māori homes merits considerable policy and community effort. Funding: Health Research Council of New Zealand.

Abstract Objective: To assess homeowners’ intentions to make voluntary improvements to their homes following a warrant‐of‐fitness (WOF) assessment to highlight health and safety issues. Methods: We recruited 83 homeowners, including nine landlords, in Taranaki, New Zealand, who agreed to have a WOF assessment carried out on their homes. We interviewed 40 of the homeowners to ascertain what improvements they planned to make, and barriers to improving their homes. Results: Of the 83 properties, 76 (92%) failed the WOF. Of the 40 interview participants, 31 (76%) had addressed or planned to address at least one of the identified issues with the home. Participants were least likely to address identified issues with security stays on windows, and absence of ground vapour barrier. Reasons for not addressing identified issues included cost, and a belief that making the improvement would not benefit health and safety. Conclusions: Information about housing defects appears insufficient to encourage people to make improvements to their homes to meet a specified health and safety standard. Implications for public health: Better understanding of how particular housing defects pose a risk for health and safety, and provision of funding support in some cases, may encourage people to invest in safer, healthier homes.

New Zealand (‘Aotearoa’) is a highly urbanised country with one of the first governments in the world to adopt a wellbeing budget framework. That framework, in combination with the architecture for decarbonisation provided by New Zealand’s 2019 ‘Zero Carbon’ Act, means there are now institutional and policy incentives in place, and developing incrementally, to combine the pursuit of wellbeing and decarbonisation. These incentives also align with the outcomes highlighted in the United Nations’ Sustainable Development Goals (SDGs). This paper considers the way policy and institutional approaches to carbon mitigation are being linked to wellbeing in three interconnected urban, non-agricultural domains responsible for much of New Zealand’s carbon emissions: building, urban form and transport. Looking beyond the current Covid-19 recovery process, emerging evidence is presented to ascertain whether the wellbeing-focused policy approach, with its associated attention to co-benefits, is creating a clear institutional refocusing. In addition, other evidence suggests that New Zealanders see health and wellbeing as improving, at the same time as the country is moving towards the net zero carbon emissions target. 'Policy relevance' In New Zealand, a new emphasis by the government on wellbeing now provides a powerful policy framing. At the same time, attention to the critical issue of climate change is strongly influencing many aspects of public policy. This paper investigates, for three related economic domains—building, urban form and transport—how the new framing is being manifested in institutions and policy. Attention to co-benefits, highlighting elements of wellbeing, appears to be shifting the policy debate away from economic growth towards a richer set of concerns more relevant to an era in which managing environmental, social and health crises (such as Covid-19), decarbonisation, and housing affordability are more prominent. The paper also outlines a new research programme that measures outcomes from a set of major public housing and urban regeneration investments in terms of wellbeing metrics.

Objectives The aims of this study are to describe area deprivation levels and changes that occur during residential moves involving New Zealand children from birth to their fourth birthday, and to assess whether these changes vary by ethnicity.Design Longitudinal administrative data.Setting Children born in New Zealand from 2004 to 2018.Participants All (565 689) children born in New Zealand with at least one recorded residential move.Outcome measures A longitudinal data set was created containing lifetime address histories for our cohort. This was linked to the New Zealand Deprivation Index, a measure of small area deprivation. Counts of moves from each deprivation level to each other deprivation level were used to construct transition matrices.Results Children most commonly moved to an area with the same level of deprivation. This was especially pronounced in the most and least deprived areas. The number of moves observed also increased with deprivation. Māori and Pasifika children were less likely to move to, or remain in low-deprivation areas, and more likely to move to high-deprivation areas. They also had disproportionately high numbers of moves.Conclusion While there was evidence of mobility between deprivation levels, the most common outcome of a move was no change in area deprivation. The most deprived areas had the highest number of moves. Māori and Pasifika children were over-represented in high-deprivation areas and under-represented in low-deprivation areas. They also moved more frequently than the overall population of 0 to 3 year olds.

Introduction High residential mobility has been shown to have a negative impact on young children, with long-term consequences for their physical and mental health, and social outcomes. Understanding the broad trends in moves and differentiating between moves to neighbourhoods which are likely to have ‘positive’ or ‘negative’ consequences is an important question in the residential mobility literature, with important implications for public policy and children’s health. Objectives and Approach The aims of this study are to describe the level and changes in neighbourhood deprivation that occur during residential moves involving children aged 0–4 years of age in New Zealand, and to assess whether these changes differ for children of different ethnicities. Our cohort is 565,689 children born in New Zealand from 2004 to 2018. The dataset of residential moves is created using the full address notification table from the Integrated Data Infrastructure, a set of government data tables that have been linked and anonymised by Statistics New Zealand. Results While there is a reasonable amount of mobility in terms of the deprivation of the area in which a child lives, the most likely outcome of a move is that it will be to an area with the same level of deprivation. This is especially true for the most and least deprived areas. Areas of high deprivation have the highest levels of churn and residential mobility. Māori and Pasifika children have lower levels of socioeconomic mobility and are more likely to move into and to stay in, areas of high deprivation. Conclusion / Implications Children living in highly deprived areas are likely to stay in high deprivation areas. Children living in these areas also move more frequently than the general population. Māori and Pasifika children are overrepresented in high deprivation areas, and on average they move more frequently than the group of all children aged 0 – 4.

Resilience appears within diverse literatures across the physical and social sciences, pervades social, and ecological systems models and has been mobilized in the quest to change environmental practices at local and international levels. Yet common language is needed to enable cross-disciplinary conversations. We discuss a novel interdisciplinary process identifying shared terminology and developing a framework to facilitate the integration of physical and social science understandings of urban infrastructure and resilience in urban systems. Drawing on bicultural knowledge traditions unique to Aotearoa/New Zealand, we reflect on resilience as a system property having ecological, social, economic and technical dimensions that influence well-being and sustainability outcomes.

Background: Living in cold housing conditions and risk of fuel poverty presents a range of physiological and psychosocial health risks. Limited research has specifically investigated the effects of fuel poverty on children and young people, and even less has been conducted with youth input into the research process. Methods: The Cool? Study used mixed methods, participatory action research carried out with youth researchers involved at all stages through questionnaire design, analysis, qualitative design, e-interviewing and dissemination of results. This article reports on results of an online survey of 656 adolescents aged 14–16 years completed at 17 schools in New Zealand. Sampling was based on selecting schools for invitation, with the probability of selection weighted proportional to school size, within strata defined by climate zone. Results from a small e-mail interview study of survey respondents who consented to follow-up are also reported. Results: The study found that almost half of the survey respondents (47%) felt their home was sometimes cold during the winter; a further 40% felt their home was often or always cold. More than two thirds of respondents (70%) had shivered inside at least once during winter. Respondents were more likely to report key indicators of fuel poverty depending on their self-reported ethnicity, with Māori at increased risk. Living in private rental housing or state-owned housing also increased risk of fuel poverty compared to those in owner-occupied dwellings. Participants of email interviews expressed concern about the widespread problem of cold housing for youth and a desire for Government intervention. Conclusion: The integrated results confirm that cold housing and risk of fuel poverty are important problems for young people in New Zealand. Results contribute to the evidence-base for policy targeting of schemes such as the Government-sponsored retrofitting of insulation to households with dependent children.

Objective: The objective of this research was to develop a principles framework to guide action on Māori/Indigenous homelessness in Aotearoa incorporating Rangatiratanga (Māori self-determination), Whānau Ora (Government policy that places Māori families at the center of funding, policy and services) and Housing First. Method: Three pathways were identified as creating opportunities for action on Māori homelessness: Te Tiriti o Waitangi/Treaty of Waitangi is the Māori self-determination pathway; Whānau Ora, a government-sponsored policy supports whānau/family as the pathway for Māori wellbeing and disparities reduction; and Housing First, an international pathway with local application for homelessness that is being implemented in parts of Aotearoa. The potential opportunities of the three pathways shaped interviews with authoritative Māori about Māori principles (derived from the three pathways) for addressing Māori homelessness. Twenty interviews were conducted with Māori experts using Kaupapa Māori research processes, eliciting advice about addressing Māori homelessness. A principles framework called Whare Ōranga was developed to synthesise these views. Results: Addressing Māori homelessness must be anchored in rights-based and culturally aligned practice empowered by Māori worldviews, principles and processes. Te Tiriti o Waitangi, which endorses Māori tribal self-determination and authority, and Whānau Ora as a government obligation to reduce inequities in Māori homelessness, are the foundations for such action. Colonisation and historical trauma are root causes of Māori homelessness. Strong rights-based frameworks are needed to enact decolonisation and guide policy. These frameworks exist in Tino Rangatiratanga/Māori self-determination and Whānau Ora. Conclusion: Whare Ōranga: An Indigenous Housing Interventions Principles Framework was developed in Aotearoa/New Zealand to end Māori homelessness. Future research is needed on the practical application of this framework in ending Māori homelessness. Moreover, the use value of the Whare Ōranga Framework as a workable approach to ending homelessness in other indigenous populations is yet to be considered. Keywords: Housing first, Homelessness, Indigenous, Māori, Treaty of waitangi, Whānau ora, Kaupapa māori, Colonisation, Wellbeing

Abstract:: Background: The Ending Homelessness in New Zealand: Housing First research programme is evaluating outcomes for people housed in a Housing First programme run by The People's Project in Hamilton, New Zealand. This baseline results paper uses administrative data to look at the scope and duration of their interactions with government services. Methods: We linked our de-identified cohort to the Integrated Data Infrastructure (IDI). This database contains administrative data on most services provided by the New Zealand Government to citizens. Linkage rates in all datasets were above 90%. This paper reports on the use of government services by the cohort before being housed. We focus on the domains of health, justice and income support. Results: The cohort of 390 people had over 200,000 recorded interactions across a range of services in their lifetime. The most common services were health, justice and welfare. The homeless cohort had used the services at rates far in excess of the general population. Unfortunately these did not prevent them from becoming homeless. Conclusion: These preliminary findings show the homeless population have important service delivery needs and a very high level of interaction with government services. This highlights the importance of analysing the contributing factors towards homelessness; for evaluation of interventions such as Housing First, and for understanding the need for integrated systems of government policy and practice to prevent homelessness. This paper also provides the baseline for post-Housing First evaluations. Keywords: New Zealand, Housing first, Homelessness, Service usage, Linked data

Substandard housing is a major public health issue in New Zealand. Approximately, two-thirds of the housing stock is uninsulated and many homes are inadequately heated, with an average indoor temperature of 14.5°C. Cold, damp, and mouldy housing results in poor health; each year, respiratory hospital admissions are 74% higher during winter, and excess winter mortality is 20% higher than other seasons. The relationship between injury and housing conditions is also well established. Each year, 500,000 New Zealanders suffer falls requiring medical treatment in their homes. As a step towards improving the quality of existing housing, an evidence-based warrant of fitness has been developed. This article outlines the evidence base to each criterion in the warrant of fitness. We conclude that introducing and properly enforcing a housing warrant of fitness will ensure that basic minimum standards are met, which could mitigate the disease burdens and injuries associated with, or caused, by poorer quality housing. In addition, there are potential fiscal and economic advantages of the scheme, including reduced hospitalisations and increased productivity.

Abstract Objective: Report on a field test of a rental housing warrant of fitness (WOF) to assess its practicality and utility for supporting improved quality of housing. Methods: Five councils each recruited at least 25 rental houses to undergo a WOF assessment. The assessment included housing features that, based on a combination of research and practicality, were considered to have an important impact on health, safety and energy efficiency. Assessors were interviewed to get their feedback on the process. Landlords representing 81% of the rental properties were interviewed on their attitudes to the WOF. Results: Of the sample of 144 houses, 94% failed at least one of 31 criteria. The most common reasons were: unsafe water temperature; no security stays; no smoke alarms; no fixed heating; and unsuitable handrails/balustrades. If items that required little (

Abstract Background Despite the importance of adequate, un-crowded housing as a prerequisite for good health, few large cohort studies have explored the health effects of housing conditions. The Social Housing Outcomes Worth (SHOW) Study was established to assess the relationship between housing conditions and health, particularly between household crowding and infectious diseases. This paper reports on the methods and feasibility of using a large administrative housing database for epidemiological research and the characteristics of the social housing population. Methods This prospective open cohort study was established in 2003 in collaboration with Housing New Zealand Corporation which provides housing for approximately 5 % of the population. The Study measures health outcomes using linked anonymised hospitalisation and mortality records provided by the New Zealand Ministry of Health. Results It was possible to match the majority (96 %) of applicant and tenant household members with their National Health Index (NHI) number allowing linkage to anonymised coded data on their hospitalisations and mortality. By December 2011, the study population consisted of 11,196 applicants and 196,612 tenants. Half were less than 21 years of age. About two-thirds identified as Māori or Pacific ethnicity. Household incomes were low. Of tenant households, 44 % containing one or more smokers compared with 33 % for New Zealand as a whole. Exposure to household crowding, as measured by a deficit of one or more bedrooms, was common for applicants (52 %) and tenants (38 %) compared with New Zealanders as whole (10 %). Conclusions This project has shown that an administrative housing database can be used to form a large cohort population and successfully link cohort members to their health records in a way that meets confidentiality and ethical requirements. This study also confirms that social housing tenants are a highly deprived population with relatively low incomes and high levels of exposure to household crowding and environmental tobacco smoke.

Worldwide, injuries due to falls in the home impose a substantial burden and merit considerable effort to find effective prevention measures. The current study is one of very few randomized controlled trials that assess the effectiveness of home modification for preventing falls. It is the first carried out with a minority or indigenous community and focused on reducing inequities. Just over 250 households in Aotearoa, New Zealand, with Māori occupants were recruited in two strata, 150 from the Wellington region and 100 from the Taranaki region. These were randomly allocated to equally sized treatment and control groups within the respective regions, the treatment group receiving a package of home modifications designed to prevent falls at the start of the study, and the control group receiving the package at the end of the study. Injury data came from the Accident Compensation Corporation, a state-owned no-fault injury insurer. This provided coverage of virtually all unintentional injuries requiring medical treatment. Matched injury claims were made available for analysis once all identifying fields had been removed. These data will be pooled with data for Māori households from the already-conducted Home Injury Prevention Intervention (HIPI) study, which tested an identical intervention on the general population. In the analysis, the primary outcome measure will be fall injury rates over time, comparing treatment and control households, adjusting for the stratum and prior falls in the household. A secondary measure will be the rates of specific injuries, which are most likely to be prevented by the package of modifications tested. We anticipate that the findings will provide robust evidence for effective injury prevention measures that can reduce an important contributor to health inequities for indigenous populations such as the Māori.

The relationship between the use of unflued gas heaters (UGH, N = 14) and heat pump heaters (HP, N = 12) located in the living rooms, and mould growth on the living room and bedroom walls, of 26 New Zealand (NZ) occupied homes was investigated during winter. Two methods were employed to evaluate the potential of mould growth on walls: (i) measurement of daily hyphal growth rate using a fungal detector (encapsulated fungal spores); and (ii) estimation of fungal contamination based on a four level scale visual inspection. The average wall psychrometric conditions were significantly different between the two heater type groups, in both the living rooms and the bedrooms with the UGH user homes being colder and damper than HP user homes. The UGHs were found to be a significant additional source of moisture in the living rooms which dramatically increased the capacity for fungi to grow on wall surfaces. The average daily hyphal growth rates were 4 and 16 times higher in the living rooms and in the bedrooms of the UGH user homes, respectively. Results from both mould detection methods gave good agreement, showing that the use of a fungal detector was an efficient method to predict the potential of mould growth on the inside of the external walls in NZ homes.

Home fall injuries amongst the general population are common and costly. In the Home Injury Prevention Intervention (HIPI) trial, we showed that 26% of medically treated home fall injuries could be prevented by a package of home modifications undertaken by qualified builders. This paper describes how we addressed unexpected safety issues associated with the implementation of the programme. Following the intervention, we ensured that participants could contact the builders. We monitored any problems or issues over a two-year period. We also held public meetings to explain the results of the study and record participants’ comments about the trial. Generally, people were satisfied with the modifications. However, there were clear safety issues with particular modifications and we revisited homes to address these. These findings highlight the need to allocate some resources for monitoring and remediation work to follow up interventions, and also a need for some regulation of the quality of safety products.