Evaluating health effects of holistic housing renovations

Socioeconomic health inequalities persist and are closely linked to social determinants of health, including housing. Poor housing conditions disproportionately affect socioeconomically vulnerable populations, reinforcing disparities. Holistic housing renovation—combining physical housing improvements with social and socioeconomic support—has emerged as a promising intersectoral intervention. However, evidence regarding its health effects and appropriate evaluation approaches remains limited. This thesis aimed to: 1) increase knowledge about health effects of holistic housing renovation and their underlying mechanisms; 2) apply systems thinking in developing a Causal Loop Diagram to guide evaluation of holistic housing renovation; and 3) design a transdisciplinary, systems-informed, mixed-methods approach to evaluate real-world interventions in deprived neighbourhoods, together with local stakeholders and residents. A realist review demonstrated that studies evaluating combinations of physical renovation with social interventions are rare, and additive or synergistic health effects were rarely examined. The review resulted in a program theory comprising nine pathways through which holistic housing renovation may affect health: three related to physical housing improvements, four to social interventions, and two reflecting reinforcing interactions between both components. Empirical research was conducted in a deprived neighbourhood in Utrecht, the Netherlands. Interviews with residents and professionals showed renovation causes stress, negatively affecting mental health and perceived control. Practical support and clear communication may mitigate these effects. Contrary to expectations, residents were less receptive to broader social support before or during renovation. Instead, renovation primarily raised demand for practical assistance. Support targeting other life domains (e.g., finances, care, social participation) appeared more effective after renovation when residents experienced more headspace. Renovation thus provides an opportunity for social partners to establish contact, offer practical help, and build trust, facilitating acceptance of broader social support later. A pre- and post-renovation survey in an intervention and control flat indicated short-term negative effects on mental health due to construction nuisance and renovation-related stress. Residents also reported reduced housing-related problems, increased housing satisfaction and pride, and improved housekeeping ability. These intermediate changes are expected to contribute to long-term health benefits, although such effects were not observable within the limited follow-up period. A Causal Loop Diagram was developed to guide evaluations of holistic housing renovation. Integrating stakeholder perspectives and scientific literature, the CLD visualizes the complex dynamics through which such interventions can impact health. Six interconnected mechanisms were identified and synthesized into three core dynamics, showing negative health effects likely occur before and during holistic housing renovation, with potential lingering impacts, whereas positive outcomes are mostly expected in the longer term. Constructing a CLD helps formulate hypotheses about impact pathways and the temporal development of expected outcomes. Evaluations limited to short-term outcomes risk underestimating long-term benefits. Key lessons for stakeholder involvement in real-world, neighbourhood-based evaluations include clarifying impact pathways, maintaining flexibility, aligning research with stakeholders’ goals and practices and residents’ lived experiences, and jointly interpreting findings. In conclusion, holistic housing renovation holds potential to improve health and reduce inequalities, if short-term stressors are mitigated and social support is carefully timed. A systems perspective and transdisciplinary collaboration are essential to evaluate and optimize such complex interventions.