Does insulation in rental accommodation affect rates of respiratory illness among tertiary students in Dunedin City during the winter period?

Written by Sophie Thompson

  Executive Summary

Total, circulatory and respiratory health are all affected by housing conditions (Telfar-Barnard et al., 2011), though “conditions other than respiratory diseases... are less likely to be related to quality of housing” (Howden-Chapman, 2007, p. 6), hence in this literature review respiratory health will be the main focus; the focus is further narrowed to spotlight the student population and student housing conditions. In order to understand how student-housing impacts on students’ health, an understanding of the effects poor housing has on the health of the general population is required as there is minimal research conducted specifically on the student population.


Temperate climates like that of New Zealand have been found to experience higher mortality rates in winter (Telfar-Barnard, 2009). This suggests that houses in New Zealand do not sufficiently protect residents from its temperate weather conditions (Howden-Chapman et al., 2007). The detrimental effect poor housing has on respiratory illness is irrefutable. An extensive body of research clearly identifies the relationship between damp, cold and mouldy housing and respiratory health (Institute of Medicine of the National Academies, 2004); cold, damp houses can lead to the growth of moulds, which can cause respiratory symptoms (Housing and Health in Auckland, 2004) An additional contributing factor to the correlation between housing and health is that people in developed countries spend 90% of their time indoors, most of that time being in their own homes (Howden-Chapman et al., 2007, pp. 460). The combination of a temperate climate and substantial time spent indoors highlights the importance of a quality indoor environment.

New Zealand now has extensive research evidence supporting the link between housing quality and health with Professor Philippa Howden-Smith leading the way. Trenholme and colleagues found that of approximately 500 children admitted to hospital for lower respiratory tract infection, there were markedly higher hospitalisation rates for those living in the most deprived neighbourhoods (Trenholme et al., 2012). While 59% of parents whose children were admitted to hospital with severe acute respiratory infection described their living conditions as cold, damp, musty or mouldy (Howden-Chapman, Baker, & Bierre, 2013, p. 36). Brimble et al., found a strong association between poor housing conditions and respiratory illnesses (Brimble et al., 2012) with air quality as a significant housing health hazard linked to respiratory symptoms, asthma and lung cancer (Thomson, Thomas, Sellstrom, & Petticrew, 2013). Whilst these studies focus primarily on the affect substandard housing has on children’s health, the World Health Organisation identifies temperatures below 16°C which place all residents at risk of respiratory illness. Such close association is reinforced by over twenty years of research on housing and health (Howden-Chapman, et al., 2013). Therefore it needs to be acknowledged that students’ health is also adversely affected.

In contrast the inverse has also been proven that quality housing has been linked to better health. An Otago University community intervention study found that insulating existing houses in New Zealand increased average indoor temperatures and decreased relative humidity with statistically significant results (Howden-Chapman et al., 2007). Most importantly, insulating existing houses resulted in better self-rated health, fewer incidences of absentia from work and school, fewer visits to the doctor and fewer hospital admissions for respiratory illness (Howden-Chapman et al., 2007). The average indoor bedroom temperature in insulated houses increased to 14.2°C (Howden-Chapman et al., 2007), however the increased temperature fell short of reaching the acceptable standard for health as outlined by the World Health Organization (2015). This is evidenced by the World Health Organization’s thermal zone categories which identified temperatures below 16°C as placing residents at risk of respiratory illness and below 12°C as placing residents at risk of cardiovascular strain Shannon, Lloyd, Roos & Kohlmeyer, 2003). As a result of the Otago University study it was found that less energy is required to heat a house with insulation, thus making it more cost effective and sustainable to heat an insulated home (Howden-Chapman et al., 2007). Therefore, a combination of insulation and effective heating can promote a healthy living environment, in which temperatures offer comfortable living free from risks of respiratory disease. It has been proved that people living in warmer, drier homes experience better health than those living in un-insulated, cold, damp housing.

  Student flats

It is a well-established fact that students living in Dunedin rent neglected flats. The majority of old houses in Dunedin are located in the student quarters; 86% of houses in Dunedin were built before 1977 when no insulation was required to be installed (Shannon et al., 2003, p. 4). A study in England found winter deaths were directly linked to the age of the dwelling and the highest risk associated with dwellings built before 1850 (Wilkinson et al., 2001, p. 10); thus indicating student flats pose a greater health risk due to the age of building. The average indoor temperatures of student flats surveyed in an Otago University study measured 13°C (Shannon et al., 2003) with average outdoor winter temperatures in Dunedin measuring between 9°C and 12°C (“Dunedin Weather”, n.d., para. 1). The indoor temperatures sat below the 16°C threshold identified in the World Health Organisation thermal guideline for placing residents at risk of developing respiratory illness and even dipped below 12°C imposing increased cardiovascular strain (Shannon et al., 2003). These findings paint a picture of the quality of past and present student housing in Dunedin and the relative health risk for the occupants.

A vast number of students stated their heating regime was sufficient for their needs yet they experienced risky temperatures; this suggests students’ attitudes toward health are ill informed. On the other hand, 61% of students thought their accommodation was uncomfortable during the winter; a significant percentage of those interviewed in the Otago University study stated that they would like to live in a better-insulated house and believed this would improve their health outcomes (Shannon et al., 2003). Whilst this study shows some understanding among students of the link between housing and health, it also reflects either an inability to afford a warmer flat or un-phased attitude toward unhealthy living conditions.

Most housing studies have been undertaken with regard to the ‘at risk’ groups in our population, these being children, the elderly and sick people (Howden-Chapman et al., 2007). Exploration of the risk factors associated with the student population is needed. The student lifestyle is typically characterised by low income, under-nutritious diets and often excess alcohol. The average age of the student population means they are generally at less risk of developing illness as they tend to have relatively robust thermoregulatory systems, however binge drinking promotes immunosuppression and predisposition to and delayed recovery from infection (Molina, Happel, Zhang, Kolls, & Nelson, 2010). This is not to say that all students subscribe to an unhealthy lifestyle, though it is reasonable to suggest a significant number of students are at actual risk of developing respiratory tract infections and may take longer to recover due to lifestyle associated risks. Whilst the wide scope of studies on housing and health strengthens the statement that inadequate housing conditions can affect any individual’s health, further quantitative research is needed among the student population group.

Students are generally identified in the low-income bracket which has been recognised in many studies as a contributing factor to poor respiratory health due to inadequate housing (Institute of Medicine of the National Academies, 2004). Findings from the “Warm Up New Zealand: Heat Smart programme” which finished in 2013, found that those on low-incomes faced greater risks of poor health and experienced the “greatest benefit from insulation” (Energy Efficiency and Conservation Authority [EECA], n.d.). The evaluation stated that avoided health costs to the Government are annually nearly double for those holding Work and Income Community Service Cards (EECA, n.d.) with card holders who received insulation, experiencing improved rates for circulatory, respiratory and asthma hospitalisations (Telfar-Barnard, 2011). Students survive on low-incomes usually in the form of student loans or allowances, many receiving an allowance and hold a Community Services Card. The evidence suggests Community Service Card holders represent a large proportion of occupants who are vulnerable to the adverse effects of cool, damp housing. In another report it was found that the treatment group of 15 to 29 year olds who received insulation installation experienced significantly lower hospitalisation rates than those in the control group without insulation installation (Telfar-Barnard, 2011); thus showing that students who are representative of this age group are more susceptible to adverse health outcomes in colder homes.

There has been no collection of data from which to draw a statistical conclusion that students do experience decreased rates of respiratory illness during the winter period in Dunedin City when residing in insulated housing. However, due to students living in substandard, un-insulated housing experiencing temperatures below those recommended for optimal health, in which health care providers saw a higher proportion of respiratory system disease presentations by students in the winter period relative to the rest of 2014 (personal communication). These facts suggest that rates of respiratory illness would likely decrease if students resided in insulated homes, as was the case in the intervention groups from the wider population studies.

Unfortunately, student housing is not targeted by nationwide insulation schemes. The Government has invested in delivering warmer, drier and healthier homes to those most in need. Eligibility for Warm Up New Zealand: Heat Smart programmes are conditional: the tenants or home-owners must hold a Community Services Card and the house must shelter someone under 17 years or over 65 years of age (EECA, n.d.). To obtain a Community Services Card one must be on a low income (Work and Income, 2015). The eligibility criteria reflect those identified as most “in need”. The eligible age range is mostly exclusive of the age range of tertiary level students, hindering their ability to seek funding for improved housing.

  Health promotion and disease prevention

Policies and interventions that address causes of poor health are an important part of national strategies to improve health (Thomson, Atkinson, Petticrew, & Kearns, 2006).  A positive outcome from the extensive research undertaken in New Zealand is the development of the Healthy Housing Index, which includes a “health, safety and energy efficiency rating scale” (Howden-Chapman, et al., p.37). Recommendations to Government have been made to implement policy to ensure all rental properties hold a current warrant of fitness demonstrating that the properties “meet minimum health and safety standards” (Howden-Chapman, et al., 2013, p. 37). Implementation of the warrant of fitness scheme for student flats could be instrumental in the improvement of substandard student accommodation.

  Practice Issue

It is commonly understood that health is influenced by a multitude of factors. The World Health Organisation outlined the determinants of health as those which comprise the social, economic and physical environment along with a person’s individual characteristics and behaviours (World Health Organization [WHO], n.d., Health Impact Assessment, para. 1). As a student residing in Dunedin for many years I have experienced Dunedin winters and become aware of the close relationship between the physical environment and an individual’s health. It is difficult to separate the entwined determinants and to distinguish the extent to which each factor influences health; in my experience the physical environment is the most easily identifiable contributor to health, whether negative or positive. I have witnessed poor health suffered by students when their accommodation is substandard.

As a public health issue, winter respiratory illness presents indiscriminately to all health care sectors, including primary, secondary and tertiary health care settings. During my second year primary health placement many patients presented with wintertime respiratory illnesses; as a result I became curious as to how our home living environment affect health, specifically to what extent the notoriously low quality condition of student flats affect students’ health, in particular the causal relationship between their substandard accommodation and respiratory health.


As a result of the literature review I have developed recommendations for nursing practice and the student population based on principles of health promotion.

This review has shown that the student population is likely to be at risk of developing poor respiratory health as a result of poor living conditions evidenced by studies conducted within the general population. It is imperative that health practitioners are aware of the association between housing and health so that they can easily recognise ill health among students resulting from their substandard housing; as a result I make the following recommendations for the improvement of student health guided by the evidence-based research discussed above and extended to include health promotion techniques as set down in the Ottawa Charter.

Primary health care practices tend to be the first point of contact and the most regularly accessed health care for students suffering from respiratory illness; community medical centres often have the advantage of established working relationships with clients and so perhaps have greater influence or efficacy when promoting positive health behaviours and change. Primary health care settings are therefore in a pivotal position to implement health promotion and education to address public health issues such as student housing and health. Health promotion can be defined “as a process of enabling people to increase control over and improve their health” (Patterson, 2007, p.138). Successful implementation of health promotion can be attained with guidance from the principles of the Ottawa Charter; these being build healthy public policy, create supportive environments, strengthen community action, develop personal skills and reorient health services.

Student health clinics on campus are easily accessible and approachable to students seeking health care. Each visit by a student to a health practitioner can be used as an opportunity to educate students and provide them with health information to enhance health literacy (World Health Organization [WHO], 2015). People and their environments in relation to health are inextricably linked; community attitudes and beliefs are influential to health (Patterson, 2007). Creating supportive environments whereby ‘good health’ is valued work toward manifesting health as a core focus; “if our living, working and leisure environments are supportive of good health, then it will be easier for us to stay healthy and make healthy choices” (Patterson, 2007, p. 144). Taking every opportunity to engage students in thinking about the state of their flats and how they may be impacting on their health is fundamental to creating change in the beliefs held by the student community.

Development of personal skills by enabling access to information and strengthening understanding of environmental factors that determine the health status of the student population are essential for students to assume greater control over their health (Patterson, 2007). Provision of evidence-based research of warmer, drier homes promoting better health empowers students to make change; students equipped with this knowledge can carefully choose flats conducive to an optimal level of wellbeing. A brief intervention of identifiable health hazards such as dampness and mould within the house encourages students to think about the impacts their residence may be having on their own health; nurses can direct students to resources on housing hazards available at the Otago University Student Accommodation Services. Provision of constructive information as to how insulation can decrease humidity causing dampness and simultaneously increase the indoor temperatures should be encouraged.

The Otago University Student Accommodation Services are already working to tackle the root causes of poor health through the introduction of a flat rating scheme whereby landlords and their residential properties are ranked, judged on identifiable health promoting aspects of the flat. Encouraging students to engage in the flat rating scheme brings about change in the student mentality and promotes health centred attitudes which can gradually work toward making landlords more accountable and thereby shifting the balance of power from the landlord to the student. Increased engagement in this flat rating service would serve as a catalyst for change in public health policy; for change to be effective policy level intervention is needed.

Health education should be guided by evidence based research; the best evidence available indicates that housing which is affordable to heat is linked to improved health (Thomson et al., 2013). Affordability is crucial for students on a tight budget and may be a determining factor for a successful intervention. Fortunately living in insulated homes has been proven to be more cost effective for the tenants (Howden-Chapman et al., 2007). It costs less to heat an insulated house; heat is retained more effectively therefore warmth is more sustainable in that the house stays warmer for longer promoting health benefits to the residents. If students were to live in insulated housing they would actually spend less to heat their home than they would in an un-insulated home (Howden-Chapman et al., 2007).

Reorienting health services is another principle of the Ottawa Charter. The Ottawa Charter states health services need to embrace and respect cultural needs (WHO, 2015); meaning health services need to get alongside students and attempt to align health education and services so that they are accessible, appropriate, affordable, available and acceptable (Penchansky & Thomas, 1981). Consideration needs to be given as to how to present housing information to students so that relevance is retained and students remain receptive. The Trans-Theoretical Model conceptualises the different stages of change thus offering insight into an individual’s preparedness to change problematic behaviour  (Boston University School of Public Health, 2013, para. 1); identifying the stage in which each student is placed can assist in the delivery of healthy housing information. Contextualising health education so that it aligns to matters of importance to students will mean the education is more effective; emphasising days missed from school, work or play is relevant to students day-to-day life as are the financial savings to be made.

With a significant number of students residing in Dunedin City it is important for nurses to be aware of the potential risks this population face with regard to substandard accommodation. Nurses are charged to improve health outcomes and continuously improve the quality of the care they provide (Ministry of Health, 2013). Maintaining awareness of the interplay between students’ substandard housing and their health is needed in order for student health practice nurses to be proactive in implementing health promotion to students. Responsiveness, challenges and opportunities are characteristics of community nursing (St John, 2007, p.5). Health promotion is needed to address the current issues in health, thus requiring nurses to be familiar with the health promotion principles in order to improve the health of both students and all other New Zealanders.


Boston University School of Public Health. (2013). The Transtheoretical Model (Stages of Change) [Website]. Retrieved from

Brimble, A. C., Denning-Kemp, G., Feng, S., Geiringer, K., Haminudin, M., Hunter, J., ... & Lundon, N. (2012). Kiwi Pride? A Snapshot of Wellington Paediatric Admissions: An Audit of Potential Risk Factors in Child Hospitalisation. Retrieved from

Dunedin Weather. [Website] (n.d.). Retrieved from DunedinNZ      website:

Energy Efficiency and Conservation Authority. (n.d.). Warm Up New Zealand: Healthy Homes. Retrieved from

Housing and Health in Auckland. (2004). Cold, Damp and Mould. Retrieved from file:///Users/sophiethompson/Documents/Nursing/BN3/706/Articles/Housing/HealthyHousing-Ch6-92004.pdf

Howden-Chapman, P., Baker, M. G., & Bierre, S. (2013). The Houses Children Live In: Policies to improve housing quality. Policy Quarterly, 9(2), 35 - 39. 

Howden-Chapman, P., Matheson, A., Crane, J., Viggers, H., Cunningham, M., Blakely, T., …Davie, G. (2007). Effect of insulating existing houses on health inequality: Cluster randomised study in the community. British Medical Journal, 334(7591),460 – 464 doi:10.1136/bmj.39070.573032.80

Institute of Medicine of the National Academies. (2004). Damp indoor spaces and health. Washington D.C., USA: The National Academies Press

Ministry of Health. (2013). Nursing initiatives [Website]. Retrieved from

Molina, P. E., Happel, K. I., Zhang, P., Kolls, J. K., & Nelson, S. (2010). Focus on: Alcohol and The Immune System. Alcohol and Health, 33 (1 & 2), 97-108.

Patterson, E. (2007). Health Promotion. In St John, W., & Keleher, H. (Eds.), Community Nursing Practice: Theory, Skills, and Issues. Crows Nest, Australia: Allen and Unwin.

Penchansky R, Thomas JW. The Concept of Access: Definition and Relationship to Consumer Satisfaction. Medical Care. 1981;19(2), 127 – 140.

Schneider, Z., & Whitehead, D. (2013). Identifying research ideas, questions, statements and hypotheses. In Schneider, Z., Whitehead, D., LoBiondo-Wood, G., & Haber, J (Eds.), Nursing and Midwifery Research: methods and appraisal for evidence-based practice (4 th ed., pp. 57 – 76). Chatswood, Australia: Elsevier.

Shannon, S., Lloyd, B., Roos, J., & Kohlmeyer, J. (2003). EVH3 – Impact of Housing on Health in Dunedin NZ. Retrieved from Otago University website:

St John, W. (2007). Context and Roles in Community Nursing Practice. In St John, W., & Keleher, H. (Eds.), Community Nursing Practice: Theory, Skills, and Issues. Crows Nest, Australia: Allen and Unwin.

Telfar-Barnard, L. (2009). Home Truths and Cool Admissions: New Zealand housing attributes and excess winter hospitalisation (Doctoral dissertation). Retrieved from

Telfar-Barnard, L., Preval, N., Howden-Chapman, P., Arnold, R., Young, C., Grimes, A., & Denne, T. (2011). The impact of retrofitted insulation and new heaters on health services utilisation and costs, pharmaceutical costs and mortality: evaluation of Warm Up New Zealand: Heat Smart. Retrieved from He Kainga Oranga website:

Thomson, H., Atkinson, R., Petticrew, M., & Kearns A. (2006). Do urban regeneration programmes improve public health and reduce health inequalities? A synthesis of the evidence from UK policy and practice (1980-2004). Journal of Epidemiology & Community Health, 108-115. Retrieved from Google Scholar database. 

Thomson, H., Thomas, S., Sellstrom, E., & Petticrew, M. (2013). Housing improvements for health and associated socio‐economic outcomes. The Cochrane Library. doi: 10.1002/14651858.CD008657

Trenholme, A., Vogel, A., Lennon, D., McBride, C., Stewart, J., Best, E.,… Percival, T. (2012). Household characteristics of children under 2 years admitted with lower respiratory tract infection in Counties Manukau, South Auckland. New Zealand Medical Journal, 125 (1367). Retrieved from

Wilkinson, P., Landan, M., Armstrong, B., Stevenson, S., Pattenden, S., McKee, M., & Fletcher, T. (2001). Cold comfort: The social and environmental determinants of excess winter deaths in England, 1986 – 1996. Retrieved from

Work and Income. (2015). Community Services Card: Helping you with the costs of health care [Brochure]. New Zealand: Author.

World Health Organization. (n.d.). Health Impact Assessment: The Determinants of Health. Retrieved from World Health Organisation website:

World Health Organization. (2015). The Ottawa charter for health promotion [Website]. Retrieved from