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Thousands of children turn up each year in hospitals with respiratory and skin conditions. Many of them return to damp, cold or overcrowded houses that further aggravate or caused the conditions in the first place. FIONA CASSIE talks to two nurses whose focus is working with families to prevent the adverse effects of sub-standard housing on child health.

Technically, not all of healthy housing nurses Tineke Snow and Shirley Pierce’s families have homes to be healthy in. Instead, they alternate week about sleeping on the floors or couches of the already crowded homes of families and friends. Other families live with mushrooms growing in the corners or spend the winter sleeping huddled in the lounge as it is the only heated room.

Snow and Pierce are two of the very few public health nurses in New Zealand whose practice focuses solely on housing and health. Pierce began working in the role in 2013 under the previous Healthy Housing scheme and Snow joined her in 2014 when Wellington’s Housing Assessment and Advice Service was launched.

The pair between them have assessed homes, and advised and advocated for hundreds of families referred to them by health professionals because of concerns that their housing situation is adversely impacting on their health. They check leaks, inspect mould, count heads and beds, ensure the toilet works, help fit curtains, promote smoking cessation, write letters to landlords, liaise with client’s health professionals, ring Housing New Zealand, and advise tenants of their rights and responsibilities.

The pair are passionate about their work and the difference a registered nurse can make after a thorough health and safety check of the house and assessment of the family’s health and housing needs. A research project is also underway to measure the difference their service actually makes (see related article).

The original Healthy Housing scheme operated between 2001 and 2013 and was a collaboration between Housing New Zealand and some district health boards in Auckland and Wellington.

Funding for that scheme ended in 2013 and the rheumatic fever-targeted (called Well Homes in Wellington) scheme was launched in 2014 to work on healthy housing issues facing families with children hospitalised with rheumatic fever, respiratory conditions and some other conditions, whether they live in state or private rentals or their own home (see details in sidebar p.7).

Wellington’s Regional Public Health decided in 2014 to continue to offer in addition a Housing Assessment and Advice Service with wider referral criteria than the quite tightly targeted Well Homes scheme; and Hutt Valley District Health Board employs the two nurses to deliver the service across the region.

That means Snow and Pierce can also work with the families of children with skin infections, older teenagers and adults. The most common referrals are those for eczema, asthma and other respiratory conditions.

Homeless and garage dwelling clients

The pair’s clients may rent rooms in a boarding house, live in their own rundown homes or rent a social or private rental house. Others technically don’t have a home at all.

Pierce says for example one of her clients – a woman with a young baby admitted twice to hospital in three months for respiratory conditions – was living between two families’ properties. One was a three-bedroom home with seven people already living in it and the other property – Pierce stops to count off the inhabitants in her head – stretched to house 11 when the mother and baby were staying. “They are effectively homeless so it is about supporting them into an urgent social housing property.”

Snow had a teenage mum living in a rented converted garage with a seven-month-old baby. Bad leaks meant the carpet was constantly saturated and mushrooms were growing in the corner so the mother and child were forced to retreat into a lean-to area. “And coming into winter we knew there was nothing we could do to make that area warmer or drier.”

An urgent appeal for a dry home for the mother and high-risk child was successful but connection with the family continues still as Snow works through the Tenancy Tribunal process as an advocate for the family and to ensure the property is not rented out as a ‘home’ again.

Another of Pierce’s clients was an 18-year-old rheumatic fever patient referred by the nurse giving him his monthly prophylactic bicillin injection. Pierce arrived to find he was living with his partner and their 14-month-old baby and during the visit it became clear the partner was pregnant with their second child but hadn’t received any maternity care. The young family were shifting from house to house, co-sleeping on a single mattress and with his health history, and the baby to come, Pierce was able to work with Ministry for Social Development (MSD) and Housing New Zealand to get them an urgent home.

“We think of homelessness as being rough sleepers or just people living on the street but we have couch-surfers and people who live in cars too,” says Pierce. ”And that’s where some of our prioritisation comes in. A family needing another bedroom will have less priority than a family living in a car.”

Overcrowding and sharing beds

The waiting lists for social housing are very large and the wait can be very long. When situations are really dire, the pair say MSD and Housing New Zealand are very good at helping them get people into housing quickly. “But for the majority it is getting people on the waiting list,” says Pierce. “So we do a lot of managing expectations and talking to families about what is realistic and what is not.”

That refers not only to being rehoused but also to what is fair to expect from Housing
New Zealand and other social housing providers and what is feasible to expect from private landlords. Requests for curtains or an improved heating source, when backed by a family’s medical history, are often responded to by Housing New Zealand but responses from private landlords to health-based housing requests can vary widely.

“It is very common for landlords to say – I don’t have the money to do that. Or we don’t hear anything back from them,” says Snow. Private tenants are also wary any improvements may see the rent go up.

For instance, the pair refers eligible clients to Warm Up New Zealand (see sidebar p.7) for free insulation whenever they can. “Our installers are quite good at reminding landlords that it is a free service and they shouldn’t expect to put up rent because of it,” says Pierce. “But it sometimes does happen,” says Snow.

The pair are keen advocates for their clients but pick their battles. “We’re limited in what we can do because of the law around private rental property,” says Pierce. “So we’re not always as successful as we’d like to be.”

The pair would like to see higher expectations of rental properties – including tenants’ rights to simple things like curtain rails. A good heat source, or even a heat source in some cases, would be great too. “At the moment all you need [legally for heating] in a rental property is to supply a plug.”

But they believe the introduction of any minimum standards (or warrant of fitness) needs to be a practical and workable solution for both tenants and landlords.

Vinegar, ventilation and curtain banks

Lobbying landlords for repairs, supporting tenancy disputes and waiting for clients to inch their way up social housing waiting lists all takes time.

So a major focus of the pair’s work is helping families with cheap and faster solutions to make the most of the housing they already have, including, of course, seeking free home insulation.

“We are looking for the cheapest alternatives as we’re not funded to provide a lot of interventions,” says Pierce.

For instance, mould is a major issue that many families have to battle in New Zealand’s very cold and damp housing stock. Mould caused by leaks is not a tenant’s fault and Pierce and Snow will approach landlords about repairs.

But the pair educate tenants that lifestyles can also contribute to the risk of mould and simple housekeeping tips can make a difference, such as opening the curtains every morning, wiping condensation off walls and windows, and opening all windows for at least a few minutes every day for cross-ventilation.

The aim is to reduce moisture inside the house as a drier house helps lower both heating bills and the risk of mould. They also advocate drying washing outside or in a garage or carport (see these and other tips in sidebar).

For mould, they give out simple and cheap mould cleaning packs made up of a spray bottle, white vinegar, a cloth and instructions.

“We found that mould is very common and if you leave them a kit using white vinegar it is not only cheap to replace but it is right there and ready to use,” says Snow. Pierce adds white vinegar is not only cheap and effective it is also less toxic for people with respiratory and skin conditions than alternative mould spray options.

Overcrowding is common in many households they see, so children sharing beds is quite frequent. In most cases it is not for cultural but financial reasons because the family lacks sleeping spaces and beds. The pair have access to some limited funding and resources so when possible they supply extra beds and bedding for children.

But if not, they share practical tips to reduce health risks, such as children sleeping ‘top and tail’ in a bed or other ways to ensure children’s heads are at least a metre apart as they sleep. And if children are sleeping on a mattress on the floor, they advise to try and air it every day. They say up to half of the families they see could benefit from having a larger house (see definitions of overcrowding on p.4).

Being a nurse adds clout

Unlike any other agency walking through the family’s front door, the pair hold an effective combination of both housing and health professional expertise.

As part of their initial one-hour assessment, they touch on wider family needs and work with agencies to links families with budgeting and parenting support and community support, such as food banks.

They also contact the family’s GP and practice nurse to share what support they have been able to give and let the original referring agency know the family has been visited. The pair say this is not only to keep people “in the loop” but also as part of a community education process so general practices and other health providers are aware of what services are available for their patients, such as referrals for free insulation, curtain banks or free fire service checks of homes.

Snow and Pierce says that combined expertise means they can take the time-consuming housing advocacy role off the shoulders of any other health professionals working with the family.
They know how to write to landlords, how the Tenancy Tribunal process works, and who to contact at MSD or Housing New Zealand.

Being registered nurses also adds an extra dimension to the healthy housing service they can provide their clients. At one level it means they access their clients’ hospital notes and, with permission, draw on relevant health information when advocating for their housing needs.

But they can also can draw on their clinical experience when working with clients in a family-centred way. Pierce has a background in mental health and practice nursing while Snow has worked in neonatal care, district and older person nursing.

The pair go into homes with the focus of making houses warmer, safer and drier but their nursing background and experience means they also have the skills to advise on smoking cessation, and talk about the correct use of asthma inhalers and managing a child’s eczema symptoms.

“I think being nurses means we are lucky because people trust the profession and we’re also one group that aren’t afraid to talk to people honestly.”

“We try and be respectful but sometimes we are talking about things that people don’t want to hear – like about the cleanliness of their home, the need for engagement with parenting services or we are screening for domestic violence.

“People disclose a lot more to us than you would probably expect them to disclose to other people,” says Pierce. The pair often have an ongoing relationship with a client for many months where they try to make the most impact they can on health-related housing issues.

But even if they can’t resolve all housing issues for a complex family, they at least have been able to visit their home, make an assessment and their notes are now another piece of the puzzle that provides a more comprehensive picture to the general practices and other agencies working to improve a family’s health and wellbeing.