Are fuel poverty reduction schemes associated with decreased excess winter mortality in elders? A case study from London, U.K

Effectiveness of financial support interventions to reduce adverse health outcomes among households in fuel poverty in the United Kingdom

Objectives

This systematic review intended to assess the effectiveness of financial support interventions for household fuel poverty in the UK in terms of reducing adverse impacts on the health and wellbeing of recipients.

Methods

Bibliographic databases and grey literature sources were searched from the UK for studies that evaluated the health and wellbeing of participants following financial support to optimize indoor heating. Two independent reviewers carried out screening, data extraction and quality assessment of the articles. The outcomes included direct health-related outcomes such as Excess Winter Mortality (EWM), physical/mental health, health services utilization, well-being, and quality of life. Indirect health related outcomes included temperature, condensation/mould/dampness (CMD), fuel efficiency/expenditure and satisfaction with warmth. Due to the heterogeneity of interventions and outcomes, a narrative synthesis of the data was carried out.

Results

Twenty studies were included in the review: randomized controlled trials (n = 1), before and after evaluation of interventions (n = 14), ecological studies (n = 1) and modelling studies (n = 4). Sixteen studies assessed impacts of home energy efficiency improvements (HEEI) only, three studies assessed impacts of Winter Fuel Payment (WFP) only while one study assessed impacts of both HEEI and WFP. HEEI studies reported improved indoor temperatures (n = 4), reduced CMD (n = 6), reduced fuel expenditure (n = 4), improved thermal comfort (n = 7), improvements in general health (n = 4), increased wellbeing (n = 4), improved physical health (n = 2), improved mental health (n = 3), reduced new health events (n = 1) and improved existing medical conditions (n = 2). Two HEEI were reported cost effective with added years to life. During modelling studies WFP was found to significantly reduce EWM (n = 2) and fibrinogen levels (n = 1).

Conclusions

Most financial support interventions included in this review demonstrated positive impacts on health and wellbeing of recipients supporting their implementation with robust evaluations to better understand the cost effectiveness and long-term impacts in the future. Implementation of these interventions will require cross-sector collaborations, with consideration of which populations are most likely to benefit.

The Mortality Effects of Winter Heating Prices

This paper examines how the price of home heating affects mortality in the United States. Exposure to cold is one reason that mortality peaks in winter, and a higher heating price increases exposure to cold by reducing heating use. Our empirical approach combines spatial variation in the energy source used for home heating and temporal variation in the national prices of natural gas and electricity. We find that a lower heating price reduces winter mortality, driven mostly by cardiovascular and respiratory causes. Our estimates imply that the 42% drop in the natural gas price in the late 2000s, mostly driven by the shale gas boom, averted 12,500 deaths per year in the United States. The effect appears to be especially large in high-poverty communities.

Assessing the impact of energy and fuel poverty on health: a European scoping review

BACKGROUND

The burden of energy and fuel poverty (EFP) in Europe is increasing in the face of the cost-of-living crisis, the Russian invasion of Ukraine, the coronavirus disease 2019 (COVID-19) pandemic and the climate emergency. While the health impacts of EFP are often the driving reason for addressing it, EFP's association with health is poorly delineated. This review aims to scope the evidence of EFP's association with health in Europe.

METHODS

A scoping review based on Arksey and O'Malley's framework was conducted using search terms relevant to EFP, health and Europe. Five databases were searched, in addition to hand searching. Review selection was performed by two independent reviewers, and articles were thematically analyzed.

RESULTS

Thirty-five articles published between January 2000 and March 2022 were included. The literature varied in definitions and measurements of EFP and in the health indicators examined. The review revealed a negative association between EFP and health, specifically, general unspecified poor health (9 articles), excess winter mortality (3 articles), communicable diseases (3 articles), non-communicable diseases (11 articles), mental health (15 articles) and well-being (12 articles). While women were reported to be at a higher risk of EFP than men, children and older adults were identified as particularly vulnerable to EFP's adverse health repercussions.

CONCLUSIONS

This scoping review illustrates a significant and complex association between EFP and various domains of health. Though heterogeneity across research makes it difficult to compare findings, our review supports the use of health as a justification to address EFP and urges public health to be more involved in EFP mitigation.

Health and Habitability in the Solar Decathlon University Competitions: Statistical Quantification and Real Influence on Comfort Conditions

Medicine and architecture are disciplines with the main objectives of satisfying the fundamental needs of human beings: health, comfort, well-being, safety, and ensuring an acceptable quality of life in a sustainable habitat. In both areas of knowledge, the advances and the most innovative proposals in the fields of research and teaching are focused on transversal knowledge and the use of learning methods through problem solving (learning by doing). The student competitions called "Solar Decathlon" are focused on the development of these concepts, in which prototypes of sustainable and, as far as possible, healthy social housing are tested. In these university competitions, the design of energy-efficient and comfortable living environments that contribute to the health of the occupants are encouraged; however, the methodology for evaluating the "comfort conditions" stipulated in the competition rules considers only parameters that can be monitored by sensors. For this article, the prototypes presented by the "Solar Decathlon Team of the University of Seville" to the editions of said competition held in Latin America and Europe (in 2015 and 2019, respectively) are being studied. The present research starts from the fact that the unique consideration of measurable indices (such as temperature, humidity, etc.), is clearly insufficient when it comes to evaluating the real conditions of habitability and comfort that a domestic architectural space presents. For this reason, a theoretical-practical analysis is carried out by means of surveys, with the final objective of determining a methodology for evaluating comfort-complementary to that of the competition-which assesses other relevant issues and which, in short, takes into account the repercussion on people's health. From our analysis, we conclude that at least these two methodologies should be used to evaluate comfort because they are individually considered incomplete in terms of the data provided by each one of them. The survey-based methodology provides complementary information on comfort and health that could be taken into account in future editions of Solar Decathlon.

Climate Change Mitigation Policies Targeting Households and Addressing Energy Poverty in European Union

Climate change mitigation measures linked to households’ energy consumption have huge greenhouse gases (GHG) emission reduction potential and positive impact on energy poverty reduction. However, measures such as renovation of residential buildings or installation of micro generation technologies based on renewable energy sources have not realized their full energy saving and GHG emission reduction potentials, due to the energy efficiency paradox and other barriers. These climate change mitigation policies targeting the households’ sector can deliver extra benefits such as energy poverty reduction and implementation of the energy justice principle; therefore, they require more attention of scholars and policy makers. The aim of this paper is to analyze the energy poverty and climate change mitigation issues in EU households based on a systematic literature review, and to provide future research paths and policy recommendations. Based on the systematic literature review, this paper develops an integrated framework for addressing energy poverty, just carbon free energy transition and climate change mitigation issues in the EU. Additionally, we argue that more targeted climate change policies and measures are necessary in the light of the shortcomings of current measures to reduce energy poverty and realize climate change mitigation potential linked to energy consumption in households.

The Excess Winter Deaths Measure: Why Its Use Is Misleading for Public Health Understanding of Cold-related Health Impacts

Background:

Excess winter deaths, the ratio between average daily deaths in December–March versus other months, is a measure commonly used by public health practitioners and analysts to assess health burdens associated with wintertime weather. We seek to demonstrate that this measure is fundamentally biased and can lead to misleading conclusions about health impacts associated with current and future winter climate.

Methods:

Time series regression analysis of 779,372 deaths from natural causes in London over 15 years (1 August 1997–31 July 2012),collapsed by day of death and linked to daily temperature values. The outcome measures were the excess winter deaths index, and daily and annual deaths attributable specifically to cold.

Results:

Most of the excess winter deaths are driven by cold: The excess winter deaths index decreased from 1.19 to 1.07 after excluding deaths attributable to low temperatures. Over 40% of cold-attributable deaths occurred outside of the December–March period, leading to bias in the excess winter deaths measure. Although there was no relationship between winter severity and annual excess winter deaths, there was a clear correlation with annual cold-attributable deaths.

Conclusions:

Excess winter deaths is not an appropriate indicator of cold-related health impacts, and its use should be discontinued. We advocate alternative measures. The findings we present bring into doubt previous claims that cold-related deaths in the UK will not reduce in future as a result of climate change.

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.

Towards explaining the health impacts of residential energy efficiency interventions - A realist review. Part 1: Pathways

This paper is Part 1 of a realist review that tries to explain the impacts of residential energy efficiency interventions (REEIs) on householder health. According to recent systematic reviews residential energy efficiency interventions may benefit health. It is argued that home energy improvement are complex interventions and that a better understanding of the latent mechanisms and contextual issues that may shape the outcome of interventions is needed for effective intervention design. This realist review synthesises the results of 28 energy efficiency improvement programmes. This first part provides a review of the explanatory factors of the three key pathways, namely warmth in the home, affordability of fuel and psycho-social factors, and the pitfall of inadequate indoor air quality. The review revealed that REEIs improved winter warmth and lowered relative humidity with benefits for cardiovascular and respiratory health. In addition, residential energy efficiency improvements consolidated the meaning of the home as a safe haven, strengthened the householder's perceived autonomy and enhanced social status. Although satisfaction with the home proved to be an important explanation for positive mental health outcomes, financial considerations seemed to have played a secondary role. Evidence for negative impacts was rare but the risk should not be dismissed. Comprehensive refurbishments were not necessarily more effective than thermal retrofits or upgrades. A common protocol for the quantitative and qualitative evaluation of interventions would facilitate the synthesis of future studies. Householder and contextual influences are addressed in Part 2.

Have winter fuel payments reduced excess winter mortality in England and Wales?

BACKGROUND

The historical series of excess winter mortality (EWM) in England and Wales presents a negative trend. Winter fuel payments (WFPs) are the most important benefits for people aged 65 or over directly related to Winter Mortality in the UK.

METHODS

This study presents a time series analysis of the direct effect of WFPs on EWM in England and Wales.

RESULTS

We find a significant structural break in trend and volatility in the EWM series in England and Wales in 1999-2000. After controlling for a number of covariates, an ARIMA-X model finds that WFPs can account for almost half of the reduction in EWM in England and Wales since 1999/2000.

CONCLUSIONS

Almost half of the reduction in EWM since 1999/2000 is attributable to WFPs.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.