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

Abstract

BackgroundCold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.ObjectivesTo determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.DesignA mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.SettingLow-income areas across Wales.ParticipantsResidents who received energy efficiency measures through the intervention programme and matched control groups.Main outcome measuresPrimary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.MethodsAnonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.Data sourcesThe Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.ResultsThe study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.LimitationsThis was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.ConclusionAlthough there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.Future workOur research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.FundingThe National Institute for Health Research Public Health Research programme.

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

“…Improvements to indoor temperature may also affect the psychosocial pathway, by improving householder perception of his home, reinforcing social interaction with family and friends, based on the increasing use of his house. For instance, Poortinga et al [29] have reported evidence that improvements to indoor temperatures were associated with increased use of more rooms in the house, enabling frequent visits from relatives and friends.…”

“…building envelope-indoor temperature [27,29,40,44,[46][47][48] Energies 2020, 13, x FOR PEER REVIEW 7 of 23…”

“…This means that most studies take into consideration the influence and interconnection with outdoor temperatures or climate (link 1). The higher relevance assigned to socioeconomic factors-indoor temperature and indoor temperature-health outcome (links 4 and 5) socioeconomic factor-indoor temperature [27,29,[39][40][41][42][43][44][45][46][47][48][49][50] Energies 2020, 13, x FOR PEER REVIEW 7 of 23…”

“…For content analysis, particular focus was given to non-communicable diseases (NCD) health outcomes, namely from the cardiorespiratory system, given their relevance under the Sustainable Development Goals (SDG's) scope ( [37,38]) and the increasingly focused contribution of energy efficiency measures to improve these health outcomes ( [27,29]). Indoor temperature is considered to be influenced by environmental, technological and socio-economic aspects (direct relation: links 1 to 4) which then impacts health directly (link 5) or indirectly (links 6 to 9).…”

“…Table 1 presents the studies addressing each one of the links described in Figure 3 and 264 summarises the identified energy efficiency-indoor temperature-health outcomes. [22] energy efficiency upgrade-low indoor temperature-emergency hospital admissions cardiovascular and respiratory conditions and injuries [27] energy efficiency upgrade-low indoor temperature-cardiovascular and respiratory health related conditions outdoor temperature-cardiovascular and respiratory-related mortality and morbidity [29] high indoor temperature-emergency hospital admissions cardiovascular and respiratory conditions; psychosocial impacts [39] low indoor temperature-emergency care for cardiovascular and respiratory conditions [40] low indoor temperature-cardiovascular and mental health related biomarkers [41] low indoor temperature-cardiovascular and mental health related biomarkers [42] low indoor temperature-cardiovascular and mental health related biomarkers [43] low indoor temperature-cardiovascular related biomarkers [44] high indoor temperature-heat-related health symptoms [45] low indoor temperature-long term health disabilities [46] energy efficiency upgrades-low indoor temperature cardiovascular and respiratory-related mortality [47] energy efficiency upgrade-low indoor temperature general health; respiratoryrelated conditions and general practitioner's hospital admissions [48] energy efficiency upgrade-low indoor temperature-respiratory related conditions, general health status hospital admissions [49] low indoor temperature-cardiovascular related biomarkers [50] low indoor temperature-cardiovascular related biomarkers…”