Award Title: Housing and health: improving understanding of how energy-inefficient housing affects health through novel data linkages with large UK health datasets and economic modelling
Funder: Department of Health and Social Care

Abstract: Background Cold homes are a major public health problem, contributing to a high proportion of the health and mortality impacts of cold weather. People who are vulnerable (e.g. due to age or disability) also tend to spend more time at home. Cold and hard-to-heat homes are an important driver of socioeconomic health inequalities, but their full impact on the development of chronic conditions over many years remains poorly understood and potentially underestimated. Approach My proposed programme of research aims to directly address these gaps, using a range of methods, in order to inform better decision-making and improve public health. This will involve the following work programmes: WP1. A review of the evidence for associations between long-term exposure to energy inefficient or uninsulated homes and/or cold indoor temperatures and chronic health problems, focusing on key health risk factors and new onset or diagnosis of common chronic diseases (cardio and cerebro-vascular disease, asthma and COPD, obesity, diabetes, anxiety, depression, dementia). This review will include epidemiological studies with 1 year follow-up, from countries with temperate or continental climates. WP2. A: Anonymised data linkage of the UK Biobank and SAIL Databank to household-level Energy Performance Certificate (EPC) energy efficiency data, which exist for over half of UK homes. These novel linkages will in turn enable detailed investigation of the associations between housing energy inefficiency (a key predictor of both cold indoor temperatures and fuel poverty) and health, as well as enhancing both resources for future research. B: Using linked UK Biobank data, I plan to analyse associations of home energy efficiency with risk factors such as blood pressure, cholesterol levels and BMI. I will then investigate longitudinal associations between exposure to energy inefficient housing and new diagnoses of a range of chronic health conditions. C: Using linked SAIL data, I plan to investigate longitudinal associations between housing energy efficiency and severe health outcomes such as heart attacks, strokes, COPD and asthma exacerbations, and on mortality, using causal inference approaches. WP3. Updating the Health module of the HIDEEM (Health Impact of Domestic Energy Efficiency Measures) model, using WP1 and WP2 findings, which informs national policy and spending decisions. Patient and Public Involvement An NIHR Patient Involvement Fund supported me to involve 12 people with lived experience of difficult-to-heat homes in developing this proposal, and they have shaped it in several ways, including the range of outcomes and use of a new health dataset. My fellowship plans have PPI woven throughout, including through PPI panels who will meet every 3-4 months, and regular involvement of two lay advisors. This will shape each project's methods, and how findings are interpreted and communicated. Dissemination, engagement and impact I have planned a series of dissemination and engagement activities involving policy-makers, charities, advocacy groups and members of the public, and will develop summaries tailored policy briefs, blogs and infographics. This will facilitate translation of the findings into public health benefits, by influencing housing policy and expenditure decisions, minimum housing quality standards, and informing local health-focused warmer housing schemes.

Lay Abstract: The problemOver 3.5 million people in the UK struggle to keep their home warm, and the impacts on health can be severe. Spending time in a cold home, often caused by an inability to pay for heating and/or living in poor-quality 'energy inefficient' housing - affects both mental and physical health. It can even result in severe illness or death. Much is known about these kinds of short-term health effects, but cold, difficult-to-heat housing may also be harming long-term health, with the impacts unfairly spread across society. Hard-to-heat housing also harms the environment and our economy. It costs the NHS alone approximately 1.3 billion/year, but even this may be underestimated. What research is needed and why? We do not yet fully understand exactly how cold homes affect longer-term health and people's chances of developing chronic illnesses, or what this costs the NHS. This is partly because it has been hard to study this issue in the past because housing and health data are often not linked together, and/or because previous studies have only included small numbers of people (so they can only look at very common health problems), or don't cover a long time. In turn, this makes it harder to be confident about how to tackle the problem most effectively. This research project will help to improve understanding of the longer-term health impacts, and what they cost. Research proposal In my PhD research, I plan to provide evidence to help inform action to reduce the health impacts of cold or difficult-to-heat housing. I will do this through three projects:· A study bringing together all available evidence about longer-term impacts of energy-inefficient or cold housing on the risk of developing a range of health problems over a year or more.· Two studies of how living in cold and difficult-to-heat homes affects chronic illness risks, over several years, using data from two very large-scale datasets linked to information about housing energy efficiency:	The UK Biobank study (using a major existing research study of >500,000 people aged approximately 40-80) will look at the impact of living in an energy-inefficient home on important risk factors like blood pressure and cholesterol, and on the chance of people developing chronic health problems. 	A study using housing data linked to SAIL (Secure Anonymised Information Linkage) Databank will look at the impact of living in an energy-inefficient home on the risk of severe problems such as heart attacks, strokes and asthma attacks, and on the risk of dying.· Updating an existing model that estimates the costs and benefits of making housing more energy-efficient, helping to influence Government spending decisions. Patient and public involvement and sharing findingsPPI activities so far have confirmed the importance of this research. They have also informed this application, including	shifting the focus to a wider range of health outcomes (including mental health); 	prompting my decision to use the SAIL databank, with a more diverse group of people; 	and taking a closer look at the underlying causes.I am committed to involving people with lived experience of cold/difficult-to-heat homes and chronic health problems closely, including through a PPI panel for each project, who will meet every 3-4 months, and monthly calls with two lay advisors with lived experience, who will join the advisory panel. This will shape the questions and approach for each project, and how the findings are interpreted and communicated. I will use a plain English summary for each project (developed with PPI involvement), blogs and infographics, media articles and interviews, and a series of public events to share the research findings.

Research Activity Codes: 2.2 FACTORS RELATING TO PHYSICAL ENVIRONMENT
Health Categories: GENERIC HEALTH RELEVANCE