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

      a , b , a , a , a , c , d , e ,   f , g , a , *
      Environment International
      Elsevier Science
      CCG, Clinical Commissioning Group, COA, Census Output Areas, COPD, chronic obstructive pulmonary disease, CVD, cardiovascular disease, EPC, energy performance certificate, EST, Energy Saving Trust, HA, Home Analytics, HEED, Household Energy Efficiency Database, IMD, Index of Multiple Deprivation, LSOA, Lower-layer Super Output Areas, MEDMI, The Medical and Environmental Data Mash-up Infrastructure, NHS, National Health Service, ONS, Office of National Statistics, SAP, Standard Assessment Procedure, Household energy efficiency, Fuel poverty, COPD, Asthma and cardiovascular disease

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          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.


          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.


          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.


          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.


          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.


          • People living in areas with higher energy efficiency levels had increased risk of hospitalisation for asthma, COPD and CVD.

          • Admission rates were also associated with location/climate, the type of dwelling, and tenure status.

          • Findings suggest there may be need for whole house approaches when retrofitting existing housing stock.

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          Most cited references63

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          Meta-analyses of the associations of respiratory health effects with dampness and mold in homes.

          The Institute of Medicine (IOM) of the National Academy of Sciences recently completed a critical review of the scientific literature pertaining to the association of indoor dampness and mold contamination with adverse health effects. In this paper, we report the results of quantitative meta-analyses of the studies reviewed in the IOM report plus other related studies. We developed point estimates and confidence intervals (CIs) of odds ratios (ORs) that summarize the association of several respiratory and asthma-related health outcomes with the presence of dampness and mold in homes. The ORs and CIs from the original studies were transformed to the log scale and random effect models were applied to the log ORs and their variance. Models accounted for the correlation between multiple results within the studies analyzed. Central estimates of ORs for the health outcomes ranged from 1.34 to 1.75. CIs (95%) excluded unity in nine of 10 instances, and in most cases the lower bound of the CI exceeded 1.2. Based on the results of the meta-analyses, building dampness and mold are associated with approximately 30-50% increases in a variety of respiratory and asthma-related health outcomes. The results of these meta-analyses reinforce the IOM's recommendation that actions be taken to prevent and reduce building dampness problems, and also allow estimation of the magnitude of adverse public health impacts associated with failure to do so.
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            Climate change effects on human health: projections of temperature-related mortality for the UK during the 2020s, 2050s and 2080s.

            The most direct way in which climate change is expected to affect public health relates to changes in mortality rates associated with exposure to ambient temperature. Many countries worldwide experience annual heat-related and cold-related deaths associated with current weather patterns. Future changes in climate may alter such risks. Estimates of the likely future health impacts of such changes are needed to inform public health policy on climate change in the UK and elsewhere.
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              COPD exacerbations .1: Epidemiology.

              The epidemiology of exacerbations of chronic obstructive pulmonary disease (COPD) is reviewed with particular reference to the definition, frequency, time course, natural history and seasonality, and their relationship with decline in lung function, disease severity and mortality. The importance of distinguishing between recurrent and relapsed exacerbations is discussed.

                Author and article information

                Environ Int
                Environ Int
                Environment International
                Elsevier Science
                1 December 2019
                December 2019
                : 133
                : Pt A
                [a ]European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, United Kingdom
                [b ]Public Health, Cornwall Council, 1E, New County Hall, Truro TR1 3AY, United Kingdom
                [c ]Health Statistics Research Group, Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, EX1 2LU, United Kingdom
                [d ]NHS NEW Devon Clinical Commissioning Group, County Hall, Exeter EX2 4QD, United Kingdom
                [e ]Regen, Bradninch Court, Castle Street, Exeter EX4 3PL and Energiesprong UK Limited, National Energy Centre, Davy Avenue, Knowlhill, Milton Keynes MK5 8NG, United Kingdom
                [f ]UCL Institute for Environmental Design and Engineering, UCL, 14 Upper Woburn Plc, London WC1H 0NN, United Kingdom
                [g ]Environmental Change Institute, University of Oxford, South Parks Road, Oxford OX1 3QY, Oxford, United Kingdom
                Author notes
                [* ]Corresponding author. B.W.Wheeler@ 123456exeter.ac.uk
                S0160-4120(19)31963-4 105164
                © 2019 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).


                ccg, clinical commissioning group,coa, census output areas,copd, chronic obstructive pulmonary disease,cvd, cardiovascular disease,epc, energy performance certificate,est, energy saving trust,ha, home analytics,heed, household energy efficiency database,imd, index of multiple deprivation,lsoa, lower-layer super output areas,medmi, the medical and environmental data mash-up infrastructure,nhs, national health service,ons, office of national statistics,sap, standard assessment procedure,household energy efficiency,fuel poverty,copd,asthma and cardiovascular disease


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