The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Interventions for cold homes: a rapid review of the health impacts

BACKGROUND

Cold homes are associated with an increased risk of adverse health outcomes for older people. To mitigate this risk, homes need to be heated to an appropriate temperature. This review aims to identify interventions designed to improve heating and temperatures within homes and summarize its impact on health, health service utilization and cost effectiveness.

METHODS

A rapid review was conducted. Studies assessing the effects of structural, financial, or behavioural interventions designed to improve home temperatures of residents aged 18+ years were eligible. Searches were carried out in four databases. A search for grey literature, and backward and forward citation searching were performed. Data were summarized in a narrative synthesis and mapped using EPPI-Reviewer and EPPI-Mapper software.

RESULTS

Eighteen studies reported across 19 publications were included. Structural interventions were associated with better mental health and quality of life, a reduction in health service utilization, and improvements in satisfaction with internal home temperature, social interactions and financial difficulties. The impact on physical health outcomes varied by age, gender and long-term conditions. Evidence about the impact of behavioural interventions was inconsistent.

CONCLUSION

Structural improvements to increase home temperatures may offer the potential to improve some aspects of health. However, the impact on physical health, including which groups are most likely to benefit, is unclear. Key gaps include the lack of evidence about the impact of financial interventions, and the impact of all types of interventions, on quality of life, mortality and costs.

A Semantic Approach to Describe Social and Economic Characteristics That Impact Health Outcomes (Social Determinants of Health): Ontology Development Study

BACKGROUND

Social determinants of health (SDoH) have been described by the World Health Organization as the conditions in which individuals are born, live, work, and age. These conditions can be grouped into 3 interrelated levels known as macrolevel (societal), mesolevel (community), and microlevel (individual) determinants. The scope of SDoH expands beyond the biomedical level, and there remains a need to connect other areas such as economics, public policy, and social factors.

OBJECTIVE

Providing a computable artifact that can link health data to concepts involving the different levels of determinants may improve our understanding of the impact SDoH have on human populations. Modeling SDoH may help to reduce existing gaps in the literature through explicit links between the determinants and biological factors. This in turn can allow researchers and clinicians to make better sense of data and discover new knowledge through the use of semantic links.

METHODS

An experimental ontology was developed to represent knowledge of the social and economic characteristics of SDoH. Information from 27 literature sources was analyzed to gather concepts and encoded using Web Ontology Language, version 2 (OWL2) and Protégé. Four evaluators independently reviewed the ontology axioms using natural language translation. The analyses from the evaluations and selected terminologies from the Basic Formal Ontology were used to create a revised ontology with a broad spectrum of knowledge concepts ranging from the macrolevel to the microlevel determinants.

RESULTS

The literature search identified several topics of discussion for each determinant level. Publications for the macrolevel determinants centered around health policy, income inequality, welfare, and the environment. Articles relating to the mesolevel determinants discussed work, work conditions, psychosocial factors, socioeconomic position, outcomes, food, poverty, housing, and crime. Finally, sources found for the microlevel determinants examined gender, ethnicity, race, and behavior. Concepts were gathered from the literature and used to produce an ontology consisting of 383 classes, 109 object properties, and 748 logical axioms. A reasoning test revealed no inconsistent axioms.

CONCLUSIONS

This ontology models heterogeneous social and economic concepts to represent aspects of SDoH. The scope of SDoH is expansive, and although the ontology is broad, it is still in its early stages. To our current understanding, this ontology represents the first attempt to concentrate on knowledge concepts that are currently not covered by existing ontologies. Future direction will include further expanding the ontology to link with other biomedical ontologies, including alignment for granular semantics.

Influences of Indoor Air Temperatures on Empathy and Positive Affect

The consequences of climate change are already visible, and yet, its effect on psychosocial factors, including the expression of empathy, affect, and social disconnection, is widely unknown. Outdoor conditions are expected to influence indoor conditions. Therefore, the aim of this study was to investigate the effect of indoor air temperature during work hours on empathy, positive and negative affect, and social disconnection. Participants (N = 31) were exposed, in a cross-over design, to two thermal conditions in a simulated office environment. Questions on empathy and social disconnection were administered before and after the exposure to each condition, while affect was measured throughout the day. Subjective thermal sensation and objective measures of mean skin temperature were considered. The results indicated a significant difference in empathy (F(1, 24) = 5.37, p = 0.03, with an η2 = 0.126) between conditions. Participants reported increases in empathy after exposure to the warm condition compared to the cool condition, in which reductions in empathy were reported. Although the same pattern was observed for positive affect, the difference was smaller and the results were not significant. Thermal sensation had a significant effect on changes in empathy too (F(1, 54) = 7.015, p = 0.01, with an R2 = 0.115), while mean skin temperature had no effect on empathy (F(1, 6) = 0.53, p = 0.89, with an R2 = 0.81). No effects were observed for positive and negative affect and social disconnection. Longitudinal studies are needed to support these findings.

Priorities for research to support local authority action on health and climate change: a study in England

BACKGROUND

Evidence is needed to support local action to reduce the adverse health impacts of climate change and maximise the health co-benefits of climate action. Focused on England, the study identifies priority areas for research to inform local decision making.

METHODS

Firstly, potential priority areas for research were identified from a brief review of UK policy documents, and feedback invited from public and policy stakeholders. This included a survey of Directors of Public Health (DsPH) in England, the local government officers responsible for public health. Secondly, rapid reviews of research evidence examined whether there was UK evidence relating to the priorities identified in the survey.

RESULTS

The brief policy review pointed to the importance of evidence in two broad areas: (i) community engagement in local level action on the health impacts of climate change and (ii) the economic (cost) implications of such action. The DsPH survey (n = 57) confirmed these priorities. With respect to community engagement, public understanding of climate change's health impacts and the public acceptability of local climate actions were identified as key evidence gaps. With respect to economic implications, the gaps related to evidence on the health and non-health-related costs and benefits of climate action and the short, medium and longer-term budgetary implications of such action, particularly with respect to investments in the built environment. Across both areas, the need for evidence relating to impacts across income groups was highlighted, a point also emphasised by the public involvement panel. The rapid reviews confirmed these evidence gaps (relating to public understanding, public acceptability, economic evaluation and social inequalities). In addition, public and policy stakeholders pointed to other barriers to action, including financial pressures, noting that better evidence is insufficient to enable effective local action.

CONCLUSIONS

There is limited evidence to inform health-centred local action on climate change. More evidence is required on public perspectives on, and the economic dimensions of, local climate action. Investment in locally focused research is urgently needed if local governments are to develop and implement evidence-based policies to protect public health from climate change and maximise the health co-benefits of local action.

Health gains from home energy efficiency measures: The missing evidence in the UK net-zero policy debate

Objectives

This study examined the health gains from a programme of external wall insulation works to homes in south-west Scotland, and in particular the impact upon hospitalisations for respiratory and cardiovascular conditions. Furthermore, to consider how evidence on health outcomes could form part of the debate around actions to meet net-zero goals in the UK.

Study design

This was a two-part study. Part one involved before-and-after interviews with 229 recipient households. The second part comprised an observational study of hospital admissions in 184 postcode areas.

Methods

Across three years, interviews collected thermal comfort and self-reported health data(Sf-36) in the winter months prior to installation, and again in follow-up interviews the next winter. Standarised monthly data on non-elective admissions for each set of conditions were compared between the intervention postcodes and the wider health board area over a ten year period.

Results

Following receipt of wall insulation, inability to achieve thermal comfort in winter reduced by two-thirds. Improvements in thermal comfort were associated with gains in physical health scores. Relative standardised admissions fell in the treatment areas, remaining lower than the district-wide standardised rate for the majority of a five year period, this effect ending during the Covid-19 pandemic. The impact on admissions was greater for respiratory conditions than for cardiovascular conditions.

Conclusion

A weak policy commitment to energy efficiency could be strengthened with further evidence of the cost-savings and reduced hospital bed demand resulting from insulations works. The potential health gain may also encourage more home owners to participate.

Understanding the mechanisms linking holistic housing renovations to health and well-being of adults in disadvantaged neighbourhoods: A realist review

Holistic housing renovations combine physical housing improvements with social and socioeconomic interventions (e.g. referral to social services, debt counselling, involvement in decision-making, promoting social cohesion). This realist review aimed at understanding underlying mechanisms linking holistic housing renovations to health and well-being of adults in disadvantaged neighbourhoods. Following systematic and iterative searching, and relevance and quality appraisals, 18 scientific articles and reports were analysed. We identified three pathways via which physical housing improvements affect health, four pathways via which social and socioeconomic interventions affect health, and two pathways via which both reinforce each other in their health effects. Our findings are theoretically novel, relevant for those conducting holistic housing renovations, and point towards gaps in the literature.

"It's changed my life not to have the continual worry of being warm" - health and wellbeing impacts of a local fuel poverty programme: a mixed-methods evaluation

BACKGROUND

Living in a cold home and being fuel poor can contribute to adverse physical and mental health. Energy efficiency interventions are considered the simplest ways of tackling fuel poverty and preventing associated negative health, wellbeing, and socio-economic consequences. The overall aim of the current study was to provide a greater understanding of the impact of a locally administered programme, which funded the installation of major heating/insulation measures in areas of high fuel poverty, on the health and wellbeing of beneficiaries of the programme.

METHODS

A mixed-methods approach to explore the health and wellbeing impacts of a fuel poverty programme in East Sussex that took place between October 2016 and March 2018. Beneficiaries completed the Warwick-Edinburgh Mental Wellbeing Scale before and after any heating/insulation work had been completed in their home. Beneficiaries were also asked to retrospectively rate their health pre- and post-installation. Interviews with 23 beneficiaries of the programme were conducted to explore in-depth the impact of the programme on people's health and wellbeing and the wider social determinants of health.

RESULTS

A major heating/insulation measure was installed in 149 homes. The majority of measures installed were boilers (57.7%) and new central heating systems (32.2%). Self-rated health and wellbeing were significantly higher post-installation. Interviewees described clear examples of the positive impacts on physical health and wellbeing such as fewer chest infections, reduced pain, feeling less anxious and depressed, and generally feeling happier and more relaxed. Interviews also highlighted broader areas of impact such as reduced social isolation and increased use of domestic space. Many of the beneficiaries also reported a reduction in their energy bills since their new heating systems had been installed.

CONCLUSIONS

The findings from the evaluation suggest that the installation of major heating or insulation measures such as new boilers have substantial benefits for the health and wellbeing of beneficiaries. The findings also suggest that the programme had a positive impact on wider determinants of health including reduction in stress and isolation that are likely to be part of the pathways between fuel poverty interventions and mental and physical health outcomes.

An Assessment of the Key Performance Indicators (KPIs) of Energy Efficient Retrofits to Existing Residential Buildings

Quantifying the wider benefits of energy efficient building retrofits is crucial to incentivise householder retrofit investments. This research recognises the value of key performance indicators (KPIs) for assessing and demonstrating retrofitting benefits and provides an assessment of KPIs for evaluating retrofits. An integrated framework for evaluating retrofits using a set of economic, social, and environmental KPIs is proposed. This KPI framework is then applied in a pre- and post-retrofit assessment of five case study dwellings located in Ireland, revealing its usefulness in demonstrating the wider benefits of retrofitting to householders, with a view to driving retrofit investment. Three of these case study dwellings had state-of-the-art retrofit technologies installed as part of the works, including heat pumps and solar PV systems. In addition to demonstrating the wider benefits of retrofitting, the framework allowed for the identification of potential causes for differences in performance of these technologies across households, as well as patterns of underperformance. Such insights are useful for the future design of these technologies and retrofit packages, as well as policy measures, which support householders in the adoption and use of these measures. The results demonstrate that householders experience various benefits from retrofitting. Showcasing the different benefits that householders receive from retrofitting, and their satisfaction with the retrofit works, can serve to de-risk retrofit investments, and inspire others to seek similar benefits through retrofitting. Applying the developed framework to a larger, comparable sample size, can distinguish the retrofit packages, which perform best across the KPIs and various household profiles. Furthermore, the application of the developed framework can serve as an evidence base for retrofit designers, contractors, and policy makers in the design of retrofit packages and policy measures that will maximise the benefit for householders.

Health and Housing Energy Expenditures: A Two-Part Model Approach

Interest in the interaction between energy and health within the built environment has been increasing in recent years, in the context of sustainable development. However, in order to promote health and wellbeing across all ages it is necessary to have a better understanding of the association between health and energy at household level. This study contributes to this debate by addressing the case of Portugal using data from the Household Budget Survey (HBS) microdata database. A two-part model is applied to estimate health expenditures based on energy-related expenditures, as well as socioeconomic variables. Additional statistical methods are used to enhance the perception of relevant predictors for health expenditures. Our findings suggest that given the high significance and coefficient value, energy expenditure is a relevant explanatory variable for health expenditures. This result is further validated by a dominance analysis ranking. Moreover, the results show that health gains and medical cost reductions can be a key factor to consider on the assessment of the economic viability of energy efficiency projects in buildings. This is particularly relevant for the older and low-income segments of the population.

A Review of the Relation between Household Indoor Temperature and Health Outcomes

This paper provides a review of research that addresses the relationship between indoor temperatures and health outcomes, taking into consideration studies that focus heat or cold exposure within the household context. It aims to extend previous research by considering both indoor temperatures from existing housing, and empirical studies that focus on energy efficiency measures and subsequent health impacts. To achieve this aim, a literature review was undertaken, combining engineering and health databases. The review established that, overall, inadequate indoor temperatures are associated with poor health status, whereas energy efficiency measures have been associated to improved indoor temperatures and occupant’s health namely regarding cardiovascular, respiratory and mental health disorders. These health conditions are among the most prevalent non-communicable diseases (NCD). The review also highlighted the need for more empirical studies with an extended timeframe to deal with climate change challenges. It underlined the potential advantages of the convergence between health and energy efficiency studies, for better modelling and planning.

Household energy efficiency and health: Area-level analysis of hospital admissions in England

INTRODUCTION

Fuel poverty affects up to 35% of European homes, which represents a significant burden on society and healthcare systems. Draught proofing homes to prevent heat loss, improved glazing, insulation and heating (energy efficiency measures) can make more homes more affordable to heat. This has prompted significant investment in energy efficiency upgrades for around 40% of UK households to reduce the impact of fuel poverty. Despite some inconsistent evidence, household energy efficiency interventions can improve cardiovascular and respiratory health outcomes. However, the health benefits of these interventions have not been fully explored; this is the focus of this study.

METHODS

In this cross sectional ecological study, we conducted two sets of analyses at different spatial resolution to explore population data on housing energy efficiency measures and hospital admissions at the area-level (counts grouped over a 3-year period). Housing data were obtained from three data sets covering housing across England (Household Energy Efficiency Database), Energy Performance Certificate (EPC) and, in the South West of England, the Devon Home Analytics Portal. These databases provided data aggregated to Lower Area Super Output Area and postcode level (Home Analytics Portal only). These datasets provided measures of both state (e.g. EPC ratings) and intervention (e.g. number of boiler replacements), aggregated spatially and temporally to enable cross-sectional analyses with health outcome data. Hospital admissions for adult (over 18 years) asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) were obtained from the Hospital Episode Statistics database for the national (1st April 2011 to 31st March 2014) and Devon, South West of England (1st April 2014 to 31st March 2017) analyses. Descriptive statistics and regression models were used to describe the associations between small area household energy efficiency measures and hospital admissions. Three main analyses were undertaken to investigate the relationships between; 1) household energy efficiency improvements (i.e. improved glazing, insulation and boiler upgrades); 2) higher levels of energy efficiency ratings (measured by Energy Performance Certificate ratings); 3) energy efficiency improvements and ratings (i.e. physical improvements and rating assessed by the Standard Assessment Procedure) and hospital admissions.

RESULTS

In the national analyses, household energy performance certificate ratings ranged from 37 to 83 (mean 61.98; Standard Deviation 5.24). There were a total of 312,837 emergency admissions for asthma, 587,770 for COPD and 839,416 for CVD. While analyses for individual energy efficiency metrics (i.e. boiler upgrades, draught proofing, glazing, loft and wall insulation) were mixed; a unit increase in mean energy performance rating was associated with increases of around 0.5% in asthma and CVD admissions, and 1% higher COPD admission rates. Admission rates were also influenced by the type of dwelling, tenure status (e.g. home owner versus renting), living in a rural area, and minimum winter temperature.

DISCUSSION

Despite a range of limitations and some mixed and contrasting findings across the national and local analyses, there was some evidence that areas with more energy efficiency improvements resulted in higher admission rates for respiratory and cardiovascular diseases. This builds on existing evidence highlighting the complex relationships between health and housing. While energy efficiency measures can improve health outcomes (especially when targeting those with chronic respiratory illness), reduced household ventilation rates can impact indoor air quality for example and increase the risk of diseases such as asthma. Alternatively, these findings could be due to the ecological study design, reverse causality, or the non-detection of more vulnerable subpopulations, as well as the targeting of areas with poor housing stock, low income households, and the lack of "whole house approaches" when retrofitting the existing housing stock.

CONCLUSION

To be sustainable, household energy efficiency policies and resulting interventions must account for whole house approaches (i.e. consideration of the whole house and occupant lifestyles). These must consider more alternative 'greener' and more sustainable measures, which are capable of accounting for variable lifestyles, as well as the need for adequate heating and ventilation. Larger natural experiments and more complex modelling are needed to further investigate the impact of ongoing dramatic changes in the housing stock and health.

STUDY IMPLICATIONS

This study supports the need for more holistic approaches to delivering healthier indoor environments, which must consider a dynamic and complex system with multiple interactions between a range of interrelated factors. These need to consider the drivers and pressures (e.g. quality of the built environment and resident behaviours) resulting in environmental exposures and adverse health outcomes.

Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: a controlled longitudinal study using data linkage

INTRODUCTION

This study will evaluate the effectiveness of home adaptations, both in preventing hospital admissions due to falls for older people, and improving timely discharge. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and fall prevention.

METHODS AND ANALYSIS

All individuals living in Wales, UK, aged 60 years and over, will be included in the study using anonymised linked data from the Secure Anonymised Information Linkage Databank. We will use a national database of home modifications implemented by the charity organisation Care & Repair Cymru (C&R) from 2009 to 2017 to define an intervention cohort. We will use the electronic Frailty Index to assign individual levels of frailty (fit, mild, moderate or severe) and use these to create a comparator group (non-C&R) of people who have not received a C&R intervention. Coprimary outcomes will be quarterly numbers of emergency hospital admissions attributed to falls at home, and the associated length of stay. Secondary outcomes include the time in moving to a care home following a fall, and the indicative financial costs of care for individuals who had a fall. We will use appropriate multilevel generalised linear models to analyse the number of hospital admissions related to falls. We will use Cox proportional hazard models to compare the length of stay for fall-related hospital admissions and the time in moving to a care home between the C&R and non-C&R cohorts. We will assess the impact per frailty group, correct for population migration and adjust for confounding variables. Indicative costs will be calculated using financial codes for individual-level hospital stays. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and prevention.

ETHICS AND DISSEMINATION

Information governance requirements for the use of record-linked data have been approved and only anonymised data will be used in our analysis. Our results will be submitted for publication in peer-reviewed journals. We will also work with lay members and the knowledge transfer team at Swansea University to create communication and dissemination materials on key findings.