Predictors of fuel poverty and the equity of local fuel poverty support: secondary analysis of data from Bradford, England

AIMS

Addressing fuel poverty is a critical public health issue given its recent rise in prevalence across Europe. Although previous research identifies national risk markers of fuel poverty, evidence is lacking on whether these are consistent across local geographies, and the equity of local interventions. In the UK's current economic climate, it is more crucial than ever that services benefit households in greatest need. This study aimed to determine significant predictors of fuel poverty among households in Bradford, England, comparing them to national-level predictors, and evaluate if households possessing significant fuel poverty predictors were equitably referred to a local fuel poverty service (Warm Homes Healthy People, WHHP).

METHODS

A multivariate logistic regression model determined significant fuel poverty predictors in Bradford using household-level data from the Energy Saving Trust and the Low Income High Costs fuel poverty definition. Statistical testing highlighted significant differences in predictors of fuel poverty between households referred to WHHP and all Bradford households.

RESULTS

Significant (p < .05) predictors of fuel poverty included: living in an area with lower average household incomes and higher proportion of ethnic minority individuals, and living in a property with a lower energy efficiency rating. Households living in a detached or older property, and homeowners were more likely to be fuel poor. Differences in the direction of the relationship with fuel poverty were identified between some national and local predictors. Most predictors were significantly (p < .05) overrepresented among WHHP households, suggesting equitable service reach. Ethnic minorities, younger people, and multiperson households were underrepresented.

CONCLUSIONS

Local fuel poverty predictors were similar to many national-level predictors, but identified differences in the direction of the relationship between some national and local predictors reaffirm the value of locally focused research. WHHP successfully targeted households possessing key predictors, but should ensure that ethnic minorities, younger people, and multiperson households are equitably referred.

Cold comfort: Covid-19, lockdown and the coping strategies of fuel poor households

The number of households experiencing fuel poverty is thought to have risen by at least 600,000 in the UK because of the ongoing Covid-19 pandemic. The concentration of fuel poor households in poor quality, energy inefficient accommodation that they have little power to improve means they are particularly negatively affected by the retreat into the home brought about by successive lockdowns and restrictions. For many such households, the home is not the place of sanctuary that it needs to be at a time like this. However, our empirical research into the lived experiences of fuel poverty reveals additional consequences for fuel poor households, chiefly associated with restricted access to third spaces and other disruptions to their usual coping strategies. Based on our evidence, we highlight three key considerations for policy on fuel poverty in the era of Covid-19: the need to rapidly upgrade the energy performance of the existing housing stock; the need to address the additional financial hardship faced by fuel poor households; and the need to prioritise access to third spaces and high-quality public spaces while restrictions last. This paper develops the concept of energy poverty by considering the role of spaces outside the home as part of the overall experience of energy poverty and the range of ways in which policy makers can mitigate its impacts.

The Association of Energy Poverty with Health and Wellbeing in Children in a Mediterranean City

Children have been identified as being particularly vulnerable to energy poverty (EP), but little empirical research has addressed the effect of EP on children’s health and wellbeing, especially in southern Europe. In this work we aimed to provide an in-depth description of the distribution of EP by sociodemographic, socioeconomic and housing characteristics, as well as to analyse the association between EP and health and wellbeing in children in Barcelona. We performed a cross-sectional study using data from the Barcelona Health Survey for 2016 (n = 481 children under 15 years). We analysed the association between EP and health outcomes through prevalence differences and prevalence ratios (PR) and their 95% confidence interval (CI), using Poisson regression models with robust variance. In Barcelona, 10.6% of children were living in EP and large inequalities were found by sociodemographic, socioeconomic and housing characteristics. EP was strongly associated with poor health in children (PR (95% CI): 7.70 (2.86, 20.72)). Living in EP was also associated with poor mental health (PR (95% CI): 2.46 (1.21, 4.99)) and with more cases of asthma (PR (95% CI): 4.19 (1.47, 11.90)) and overweight (PR (95% CI): 1.50 (1.05, 2.15)) in children. It is urgent to develop specific measures to avoid such serious and unfair health effects on children.

Resisting austerity measures to social policies: multiple explanatory case studies

Since Margaret Thatcher reached power in the United Kingdom, European governments have increasingly turned to neoliberal forms of policy-making, focusing, especially after the 2008 Great Recession on 'austerity policies' rather than investing in social protection policies. We applied a multiple explanatory case studies methodology to examine how and why challenges and resistance to these austerity measures are successful or not in four settings for three different social policy issues: using a gender lens in state budgeting in Andalusia (Spain), maintaining unemployment benefits in Italy and cuts to fuel poverty reduction programs in Northern Ireland and England. In particular, we intended to learn about whether resistance strategies are shared across disparate cases or whether there are unique activities that lead to successful resistance to austerity policies. As our approach drew from realist philosophy of science, we started with initial theories concerning collective action, political ideology and political power of affected populations. Our findings suggest that there are similarities between the cases we studied despite differences in political and policy contexts. We found that joint action between advocacy groups was effective in resisting cuts to social spending. Evidence also indicates that the social construction of target populations is important in resisting changes to social programmes. This was observed in both England and Northern Ireland where pensioners held significant political clout.

Use of Simple Telemetry to Reduce the Health Impacts of Fuel Poverty and Living in Cold Homes

INTRODUCTION

In Great Britain, roughly half of people with at least one long-standing illness (LSI) live in low-income households. Lower-income households are at risk of fuel poverty and living in a colder house, which can worsen certain health conditions, causing related morbidity and mortality. This pilot study aimed to assess whether raising occupants' awareness of indoor temperatures in the home could initiate improved health and well-being among such vulnerable residents.

METHODS

Thermometers were placed inside a manufactured bamboo brooch to be worn or placed within homes during the winter of 2016/17. These devices were supplied to households (n = 34) already assisted by Community Energy Plus, which is a private social enterprise in Cornwall, United Kingdom (UK), using initiatives aimed at maintaining "healthy homes". Questionnaires were supplied to households before devices were supplied, and then again at the end of a three-month period, with further questions asked when devices were collected. Temperatures were recorded automatically every half-hour and used to draw inference from questionnaire responses, particularly around health and well-being.

RESULTS

Questionnaires were completed by 22 households. Throughout the winter, those declaring the poorest health when supplied with devices maintained homes at a higher average temperature. There were also indications that those with raised awareness of interior temperatures sought fewer casual medicines.

CONCLUSION

Simple telemetry could play a role in the management of chronic health conditions in winter, helping healthcare systems become more sustainable. The need for higher indoor temperatures among people with an LSI highlights the need to consider this approach alongside more sustainable household energy-efficiency improvements. A larger study is needed to explore this further and quantify the cost benefit of this approach.

Making the Case for "Whole System" Approaches: Integrating Public Health and Housing

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and "place" where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the "triple win" of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the "triple win." This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

Illuminating austerity: Lighting poverty as an agent and signifier of the Greek crisis

Light - whether natural or artificial - plays multiple roles in the home: both as a material enabler of everyday life and as a device for exercising a variety of social relations. The post-2008 Greek economic crisis has endangered those roles by limiting people's ability to access or afford adequate energy services. This paper focuses on the enforced lack of illumination in the home, and the strategies and tactics undertaken by households to overcome this challenge. I connect illumination practices and discourses to the implementation of austerity, by arguing that the threat of darkness has become a tool for compelling vulnerable groups to pay their electricity bills. The evidence presented in the paper is based on two sets of interviews with 25 households (including a total of 55 adult members) living in and around Thessaloniki - Greece's second largest city, and one that has suffered severe economic consequences as a result of the crisis. I have established that the under-consumption of light is one of the most pronounced expressions of energy poverty, and as such endangers the ability to participate in the customs that define membership of society. But the emergence of activist-led amateur electricians and the symbolic and material mobilization of light for political purposes have also created multiple opportunities for resistance.

Seasonal variation in mortality secondary to acute myocardial infarction in England and Wales: a secondary data analysis

BACKGROUND

Acute myocardial infarction (AMI) is a leading cause of death globally. Increase in AMI mortality during winter has also been identified in existing literature. This has been associated with low outdoor and indoor temperatures and increasing age. The relationship between AMI and other factors such as gender and socioeconomic factors varies from study to study. Influenza epidemics have also been identified as a contributory factor.

OBJECTIVE

This paper aims to illustrate the seasonal trend in mortality due to AMI in England and Wales with emphasis on excess winter mortality (EWM).

METHODS

Monthly mortality rates per 10 000 population were calculated from data provided by the UK Office for National Statistics (ONS) for 1997-2005. To quantify the seasonal variation in winter, the EWM estimates (EWM, EWM ratio, Excess Winter Mortality Index) for each year were calculated. Negative binomial regression model was used to estimate the relationship between increasing age and EWM.

RESULTS

The decline in mortality rate for AMI was 6.8% yearly between August 1997 and July 2005. Significant trend for reduction in AMI-associated mortality was observed over the period (p<0.001). This decline was not seen with EWM (p<0.001). 17% excess deaths were observed during winter. This amounted to about 20 000 deaths over the 8-year period. Increasing winter mortality was seen with increasing age for AMI.

CONCLUSION

EWM secondary to AMI does occur in England and Wales. Excess winter deaths due to AMI have remained high despite decline in overall mortality. More research is needed to identify the relationship of sex, temperature, acclimatisation, vitamin D and excess winter deaths due to AMI.

Encountering energy precarity: Geographies of fuel poverty among young adults in the UK

This paper develops the notion of "energy precarity" in order to uncover the governance practices and material conditions that drive and reproduce the inability of households to secure socially- and materially-necessitated levels of energy services in the home. The overarching aim is to foreground a geographical approach towards the study of domestic energy deprivation, by emphasizing the complex socio-spatial and material embeddedness of fuel poverty. The paper operationalizes these ideas via a field-based study of a group that has received limited attention in research and policy on fuel poverty: young adults living in privately rented accommodation. In evoking the experiences of such individuals, I employ energy precarity as a means of unpacking the spaces where energy deprivation is produced, experienced and contested. Among other findings, I highlight that people's fluid lifestyles and specific end-use energy demand patterns mean that energy deprivation metaphorically and physically overflows the limits of home, creating multiple performativities of precarity that have received very little attention to date.

Impact of energy efficiency interventions in public housing buildings on cold-related mortality: a case-crossover analysis

Background

Interventions to mitigate fuel poverty and particularly energy efficiency façade retrofitting (EEFR) have demonstrated positive impacts on health but the impacts of EEFR interventions on cold-related mortality have not been studied in depth. We evaluated the impact of EEFR interventions in Barcelona on the association between cold outdoor temperatures and mortality (from all natural causes and from neoplasms, circulatory system and respiratory system causes) from 1986 to 2012.

Methods

A time-stratified case-crossover analysis was used. Relative risks (RR) for death related to extreme cold (lowest fifth percentile) in the no-intervention and intervention groups were obtained for temperature lag windows covering the day of the death and the previous 20 days (0-2, 3-5, 6-8, 9-11, 12-14, 15-17, 18-20). The statistical significance of the observed changes was evaluated using the RR for the cold temperature-intervention interaction.

Results

In men, interventions significantly increased the extreme cold-death association for the lag window 15-17 [interaction RR 2.23, 95% confidence interval (CI) 1.14-4.36]. The impacts were stronger for respiratory system causes and in men aged 75 or older. In women, on lag window 0-2, the extreme cold-death association was not significantly reduced when analysing all natural causes of death (interaction RR 0.46, 95% CI 0.21-1.01), but it was reduced significantly when analysing only deaths from neoplasms, circulatory system and respiratory system causes together. The impacts were stronger in women who died from circulatory system causes, in women with no education and in those aged 75 or older.

Conclusions

EEFR interventions had differentiated effects on cold-related mortality in men and women. Differentiated effects were also observed by cause, educational level and age.

Health, Well-Being and Energy Poverty in Europe: A Comparative Study of 32 European Countries

Despite growing pan-European interest in and awareness of the wide-ranging health and well-being impacts of energy poverty—which is characterised by an inability to secure adequate levels of energy services in the home—the knowledge base is largely British-centric and dominated by single-country studies. In response, this paper investigates the relationship between energy poverty, health and well-being across 32 European countries, using 2012 data from the European Quality of Life Survey. We find an uneven concentration of energy poverty, poor health, and poor well-being across Europe, with Eastern and Central Europe worst affected. At the intersection of energy poverty and health, there is a higher incidence of poor health (both physical and mental) amongst the energy poor populations of most countries, compared to non-energy poor households. Interestingly, we find the largest disparities in health and well-being levels between energy poor and non-energy poor households occur within relatively equal societies, such as Sweden and Slovenia. As well as the unique challenges brought about by rapidly changing energy landscapes in these countries, we also suggest the relative deprivation theory and processes of social comparison hold some value in explaining these findings.

Housing Policies and Health Inequalities

A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. The aim of this paper is to summarize the research on the impact of local housing policies on health inequalities, focusing on the issues of access to housing and fuel poverty as studied in the SOPHIE project. Our case studies in Spain showed that people facing housing insecurity, experienced intense levels of mental distress. We found that access to secure and adequate housing can improve the health of these populations, therefore, public policies that address housing instability and their consequences are urgently needed. Housing conditions related to fuel poverty are associated with poorer health and are unevenly distributed across Europe. We found possible positive effects of façade insulation interventions on cold-related mortality in women living in social housing; but not in men. Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, target the most vulnerable groups and be adaptable to their needs.

Exploring the Housing and Household Energy Pathways to Stress: A Mixed Methods Study

Chronic stress, known to contribute to negative physical and mental health outcomes, is closely associated with broader issues of material hardship, poor neighborhood conditions, residential instability, and inadequate housing conditions. However, few studies have comprehensively explored pathways to stress in a low-income housing environment. A mixed-methods pilot study investigated the concept of energy insecurity by looking at the impacts of weatherization and energy efficiency interventions on low-income households in the South Bronx neighborhood of New York City. In-depth interviews were conducted with 20 low-income heads of household; participants also completed health, housing and budget assessments. Physical deficiencies, economic hardship, and health issues all interacted to directly and indirectly produce living conditions that contribute to chronic stress. Households with higher stress reported more health problems. Poor quality housing led to coping responses that increased expenses, which in turn increased stress around housing and energy affordability. This study provides further support for the connections between both health and the built environment and between low socio-economic status populations and net negative health outcomes. Energy insecurity is an important contributor to chronic stress in low-income households, and isolating pathways to stress where there is potential for interventions is important for future policy and housing-based strategies.

The hidden practices and experiences of healthcare practitioners dealing with fuel poverty

BACKGROUND

Fuel poverty negatively impacts a population's health affecting life chances along the life course. Moreover, it represents a substantial inequality in the UK. Healthcare practitioners (HCPs) have a key role in identifying and supporting patients who are fuel poor.

METHODS

A qualitative inquiry with District Nurses and General Practitioners, to explore their understanding and experiences of dealing with patients living in fuel poverty.

RESULTS

Participants recognize fuel poverty by observing material cues. They perceive their relationship with the patient as pivotal to recognizing the fuel poor. Practitioners' sense of responsibility for their patients' social concerns is determined by their knowledge about the link to health outcomes. The services that they sign-post to are motivated by their experience dealing with the service, or their patients' experiences of the service.

CONCLUSION

Participants' reliance on temporary material cues resulted in few experiences of recognition of the fuel poor. HCPs' perceptions of patient pride and the lack of personal relationship between doctor and patient presented barriers to identifying fuel poor patients. A limitation of this study is the small sample size of nine participants. These came from two professional groups, which afforded more depth of exploration, but may limit applicability to other professionals.

Can a nudge keep you warm? Using nudges to reduce excess winter deaths: insight from the Keeping Warm in Later Life Project (KWILLT)

Nudges are interventions that aim to change people's behaviour through changing the environment in which they choose rather than appealing to their reasoning. Nudges have been proposed as of possible use in relation to health-related behaviour. However, nudges have been criticized as ethically dubious because they bypass peoples reasoning and (anyway) are of little help in relation to affecting ill-health that results from social determinants, such as poverty. Reducing the rate of excess winter deaths (EWDs) is a public health priority; however, EWD seems clearly to be socially determined such that nudges arguably have little role. This article defends two claims: (i) nudges could have a place in tackling even the heavily socially determined problem of EWD. We draw on evidence from an empirical study, the Keeping Warm in Later Life Project (KWILLT), to argue that in some cases the risk of cold is within the person’s control to some extent such that environmental modifications to influence behaviour such as nudges are possible. (ii) Some uses of behavioural insights in the form of nudges are acceptable, including some in the area of EWD. We suggest a question-based framework by which to judge the ethical acceptability of nudges.

Energy Burden and the Need for Integrated Low-Income Housing and Energy Policy

Using detailed sociological and public health qualitative interview data, we demonstrate that energy poverty is more pervasive, and results in a greater energy burden for low-income tenants, than many policymakers would assume. This is due in part to a lack of funding, policy non-coordination, and a lack of understanding of the social and economic benefits of energy conservation, energy education, and flexible utility billing policies. Examining LIHEAP, weatherization, utility, and housing assistance policies, we suggest that a coordinated, regional approach to home energy and housing policy that integrates programs in each area will provide a more coherent policy solution.