"The walls were so damp and cold" fuel poverty and ill health in Northern Ireland: results from a housing intervention

This article reports the findings from an evaluation of a fuel poverty programme in the Armagh and Dungannon Health Action Zone in Northern Ireland. Focusing on a rural community, it adds to the debate surrounding the hidden nature of rural fuel poverty. As part of the programme, energy efficiency measures, including some central heating systems, were installed in 54 homes. Surveys were conducted both pre and post intervention and analysed to assess any changes. The programme demonstrated that energy efficiency intervention can lead to improvements in health and well being, increased comfort levels in the home and a reduction in the use of health services, therefore having potential cost savings for the NHS. Some households, however, remain in fuel poverty after having full central heating installed, reflecting the significant contribution of low income on the production of fuel poverty. The article concludes by suggesting that interventions in this area require commitment from multiple sectors of society, including health professionals and local communities.     

Excess winter morbidity among older people at risk of cold homes: a population-based study in a London borough

BACKGROUND: Fuel poverty frequently affects older low-income households, in homes that are difficult to heat. Excess winter deaths occurring in Britain are widely attributed to effects of cold. This pilot study examined the demonstrability of a relationship between older people's health and fuel poverty risk, using morbidity data. METHODS: An observational, population-based study was made of 25,000 residents aged >or=65 years in the London Borough of Newham (LBN). Using Hospital Episode Statistics (HES) data over 1993-1997, anonymized at enumeration district (ED) level, we calculated excess winter morbidity, based on emergency hospital episodes for all respiratory diagnosis codes. EDs were variously aggregated after ranking against a proposed Fuel Poverty Risk Index (FPR), including factors of energy inefficient housing, low income, householder age and under occupation. RESULTS: FPR is a predictor of excess winter morbidity. In particular, FPR was observed showing a significant relationship with high winter morbidity counts for 2 of 4 years studied. Using FPR as a two-level factor (high and non-high), the model provides odds ratios: for 1993, winter/summer morbidity ratio for high FPR is 1.7 higher than the corresponding ratio for non-high FPR [95% confidence interval (CI)=1.1-2.7], and for 1996, the odds ratio is 1.6 (95% CI=0.9-2.8). In a regression with grouped EDs, having allowed for FPR, no other variables in our set contribute to the difference between winter and summer morbidity counts. CONCLUSIONS: Results may indicate supporting evidence of a relationship between energy inefficient housing and winter respiratory disease among older people, with public health implications for increasing health-driven energy efficiency housing interventions.     

Use of survey data and small area statistics to assess the link between individual morbidity and neighbourhood deprivation.

STUDY OBJECTIVE--The aim of the study was to examine the relationship between sociogeographic factors and health, using a particular social indicator of neighbourhood deprivation. DESIGN--The study analysed the relationship between health problems (reported by randomly selected respondents to a household survey) and an area social indicator for the neighbourhoods where the respondents lived (based on census data). The area social indicator tested was the underprivileged areas indicator developed by the St Mary's Hospital Department of General Practice, London. Generalised linear interactive modelling with a logistic model was used to test the strength of the relationship between social indicators and morbidity, and to calculate the probability of reporting illness or consultations for survey respondents living in different types of area. SETTING--The study population was derived from three London health districts and their corresponding census enumeration districts. PARTICIPANTS--Responses were obtained from 738 households drawn from the local taxation evaluation list (66% of those sampled), and 1384 persons over 16 participated in the survey (94% of eligible adults in households surveyed). Of these, 1221 provided complete data on health problems. The survey population was considered representative of the general population in the areas studied since its characteristics were similar to those reported for the population as a whole in the 1981 census. RESULTS--Within different age and sex groups, those living in very deprived areas, with high underprivileged area scores, were more likely to consult their doctor and to report various indicators of poor health than those living in privileged areas, with low underprivileged area scores. CONCLUSIONS--The underprivileged areas index may provide a useful surrogate indicator to estimate morbidity and use of general practitioner services in small areas. It is likely to be most effective in areas where sociodemographic profiles of the local population are highly contrasting.     

Significance of Increasing Poverty Levels for Determining Late-Stage Breast Cancer Diagnosis in 1990 and 2000

We examine the association between late-stage breast cancer diagnosis and residential poverty in Detroit, Atlanta, and San Francisco in 1990 and 2000. We tested whether residence in census tracts with increasing levels of poverty were associated with increased odds of a late-stage diagnosis in 1990 and 2000 and found that it was. To test this, we linked breast cancer cases from the Surveillance, Epidemiology, and End Results cancer registries with poverty data from the census. Tracts were grouped into low, moderate, and high poverty based on the percentage of households reporting income below the poverty level. While late-stage breast cancer rates and the number of women living in high and moderate-poverty areas declined absolutely between 1990 and 2000, estimates from our combined three-city model showed that odds of a late-stage diagnosis remained stubbornly elevated in increasingly poor areas in both years. Non-Hispanic black women faced higher odds of a late-stage diagnosis relative to non-Hispanic white women in both years. In separate regressions for each city, the odds ratios affirm that combining data across cities may be misleading. In 1990 and 2000, only women living in moderately poor neighborhoods of San Francisco faced elevated odds, while in Detroit women in both moderate- and high-poverty areas faced increased likelihood of late-stage diagnosis. In Atlanta, none of the poverty measures were significant in 1990 or 2000. In our test of physician supply on stage, an increase in the number of neighborhood primary care doctor's offices was associated with decreased odds of a late-stage diagnosis only for Detroit residents and for non-Hispanic whites in the three-city model.     

Teenage childbearing in Great Britain and the spatial concentration of poverty households

STUDY OBJECTIVE: To investigate the association between the spatial concentration of deprived households and teenage non-marital childbearing. Associations with area deprivation are tested before and after allowing for levels of personal deprivation. DESIGN AND SETTING: The individual data are derived from the 2% sample of anonymised records (SAR) from the census of 1991 in Great Britain, and are combined with area data from the 278 districts of residence identifiable in the SAR. PARTICIPANTS: Sample is restricted to unmarried women living at home (with at least one parent) and aged 16 to 19. MAIN RESULTS: The results suggest generally higher risk of teenage childbearing for women who are economically inactive, women from households with no access to a car or households resident in local authority accommodation. Without adjusting for personal circumstances, the risk of teenage pregnancy shows a clear, significant and approximately linear association with social deprivation of area of residence in 1991. Residual analysis shows that many urban areas have much higher levels of teenage childbearing than expected. When adjustment is made for personal disadvantage the simple association with local area deprivation is attenuated. A higher risk of teenage childbearing is still seen in urban areas while the areas having the highest negative differentials are heterogeneous. CONCLUSIONS: Both individual and spatial characteristics are important in influencing levels of teenage childbearing. Teenage childbearing shows an association with residence in more deprived areas. The association seems to be largely because residence in more deprived areas is associated with personal disadvantage, which increases the risk of teenage childbearing. Area characteristics are of lesser significance in determining teenage non-marital childbearing than individual and household characteristics.     

Predicting smoking behaviour in census output areas across Scotland

Spatially disaggregated surveys of smoking behaviour are rare and hence estimating the geography of the incidence of smoking is difficult. The main aim of this study is to develop a technique for estimating smoking probability for different age/sex groups in small areas across the whole of Scotland using information on smoking behaviour from the Scottish Household Survey. This is useful not only in its own right, but as an aid to studies of geographical variations in diseases such as lung cancer that, as a first step, need to control for smoking behaviour. The method developed uses individual-level characteristics from the Scottish Household Survey combined with a set of output area and pseudo-postcode sector measures from the 1991 census to model the probability of smoking. The parameters from this model are then used to make smoking predictions by age and sex for output areas across Scotland. This is the first time that such geographically detailed estimates of smoking have been made available.     

USE OF STONE'S METHOD IN STUDIES OF DISEASE RISK AROUND POINT SOURCES OF ENVIRONMENTAL POLLUTION

The Small Area Health Statistics Unit is a national facility funded by the U.K. government for the analysis of disease risk around sources of environmental pollution. It holds cancer incidence (from 1974) and mortality data (from 1981) for Great Britain. Data retrieval is based on the postcode of residence, relating on average to 14 households. Population data for the calculation of disease rates and small area measures of socioeconomic deprivation are from census small area statistics for 1981 and 1991. Isotonic regression methods first described by Stone are used to test for declines in disease risk with distance from point sources of environmental pollution. This paper describes modifications of the method to include adjustments for socioeconomic confounding, a conditional approach to allow for generally elevated risks near the source, and methods to deal with pooling of data around a number of point sources. Examples from recent studies are given.     

Homes and health in the Outer Hebrides: A social prescribing framework for addressing fuel poverty and the social determinants of health

Health services are increasingly being reshaped with reference to addressing social determinants of health (SDoH), with social prescribing a prominent example. We examine a project in the Outer Hebrides that reshaped and widened the local health service, framing fuel poverty as a social determinant of health and mobilising a cross-sector support pathway to make meaningful and substantive improvements to islanders' living conditions. The ‘Moving Together’ project provided support to almost 200 households, ranging from giving advice on home energy, finances and other services, to improving the energy efficiency of their homes. In so doing, the project represents an expansion of the remit of social prescribing, in comparison with the majority of services currently provided under this banner, and can be seen as a more systemic approach that engages with the underlying conditions of a population's health. We present a framework through which to understand and shape initiatives to address fuel poverty through a social prescribing approach.     

An examination of race and poverty for populations living near industrial sources of air pollution

This study examines the sociodemographic characteristics of people living near industrial sources of air pollution in three areas of the United States: (1) the Kanawha Valley in West Virginia: (2) the Baton Rouge-New Orleans corridor in Louisiana: and (3) the greater Baltimore metropolitan area in Maryland. Using data from the 1990 Toxics Release Inventory (TRI) and the 1990 Census, we analyze relationships between variables assumed to be independent, such as location of single or multiple industrial emission sources, and the dependent variables of race (black/white) and poverty status (above/below poverty level). Results from all three study areas are consistent and indicate that African Americans and those living in households defined to be below the established poverty level are more likely, on average, to live closer to the nearest TRI facility and to live within 2 miles of multiple TRI facilities. Conversely, whites and those living in households above the poverty level are more likely, on average, to live farther from the nearest TRI facility and to live within 2 miles of fewer facilities, compared to African Americans and poor people.     

An approach to locating a family practice office in a metropolitan area.

A simple, economically feasible approach to locating a family practice office within a metropolitan area is presented. The Grand Rapids area serves as the population base for this investigation. An Office Location-Population Profile is determined from census tract population data and known physician office distrubution. Based on this information, a subsegment of the total area is delineated as a possible neighborhood for an office location and a physician-opulation ratio for this subsegment is determined. This is compared with recommended ratios. A statistical profile of the population, within the area considered as a possible site location, is developed using information available through census bureau statistics. Finally, a direct survey of a random sample of households within the selected area is performed. This format provides an objective approach to facilitate rational decision making in locating a family practice office in a metropolitan area.     

Small area statistics as markers for personal social status in the Scottish heart health study.

OBJECTIVE: To evaluate a deprivation index, calculated from small area statistics for postcode sectors, as a measure of individual social status in an epidemiological study of coronary heart disease (CHD). DESIGN: A baseline, cross sectional survey. SETTING: Twenty two local authority districts of Scotland surveyed between 1984 and 1986. SUBJECTS: A total of 10359 men and women aged 40-59 years randomly selected to the Scottish heart health study. MAIN RESULTS: The Scottish deprivation categorisation, derived from small area statistics, exhibits a strong linear trend (p = 0.001 or below) for individual prevalent CHD for men and women, unadjusted, and adjusted for major cardiovascular risk factors. The degree of association with CHD is similar to that for measures of social class based upon occupation. CONCLUSIONS: The Scottish deprivation categorisation is an effective measure of individual social status in the current study, broadly comparable in its effect with the more traditional classification derived from occupations. The latter has important problems in definition, especially for women. Small area statistics may provide a useful marker of individual social status in a more general epidemiological setting.     

The health benefits of a targeted cash transfer: The UK Winter Fuel Payment

Each year, the UK records 25,000 or more excess winter deaths, primarily among the elderly. A key policy response is the “Winter Fuel Payment” (WFP), a labelled but unconditional cash transfer to households with a member above the female state pension age. The WFP has been shown to raise fuel spending among eligible households. We examine the causal effect of the WFP on health outcomes, including self‐reports of chest infection, measured hypertension, and biomarkers of infection and inflammation. We find a robust, 6 percentage point reduction in the incidence of high levels of serum fibrinogen. Reductions in other disease markers point to health benefits, but the estimated effects are less robust.     

Interpreting the new illness question in the UK census for health research on small areas.

STUDY OBJECTIVE--The study aimed to identify the various factors that seem to influence the average response to the new census question on limiting, long standing illness at the small area level, to assess the extent to which the new questions adds to information already available in the census and elsewhere, and to discuss how useful the data are likely to be for those planning health and social services. DESIGN--This was a cross sectional analysis of the relationship between rates of limiting, long standing illness (standardised for age and sex) and a large number of indicators of health and socioeconomic status at the small area level. SETTING--The study used data relating to 4985 small areas covering the whole of England. The average population was about 10 000. PARTICIPANTS--The 1991 census of population was addressed to the entire population of England. MAIN RESULTS--There are wide variations in the levels of self reported long standing illness between small areas, 70% of which are explained by demographic factors. Variation in age/sex standardised responses to the new census question at the small area level can largely be explained by census data on self reported disability among those of working age, standardised mortality ratio, and by indicators of socioeconomic circumstances relating to social class, ethnicity, and the elderly living alone. These does not seem to be a significant reporting bias due to underemployment. CONCLUSION--Unlike the disability question in the census, the standardised, self reported long standing limiting illness ratio covers the entire population and it is not skewed towards men. Although the variable is a synthesis of the health and social determinants of perceived morbidity, it does not provide much information that was not already available. In addition, it is available every 10 years only and thus may be rather inaccurate as an indicator of relative need towards the end of the decade. Moreover, in future censuses, individuals' answers might be influenced by the knowledge that their responses will affect the volume of resources allocated to the area in which they live.     

Racial disparities in low birthweight and the contribution of residential segregation: a multilevel analysis

This study investigates the geography of racial disparities in low birthweight in New York City by focusing on racial residential segregation and its effect on the risk of low birthweight among African-American infants and mothers. This cross-sectional multilevel analysis uses birth records at the individual level (n=96,882) and racial isolation indices at the census tract or neighborhood level (n=2095) to measure their independent and cross-level effects on low birthweight. This study found that residential segregation and neighborhood poverty operate at different scales to increase the risk of low birthweight. At the neighborhood scale residential segregation is positively and significantly associated with low birthweight, after controlling for individual-level risk factors and neighborhood poverty. Residential segregation explains neighborhood variation in low birthweight means and race effects across census tracts, which cannot be accounted for by neighborhood poverty alone. At the individual scale-increasing levels of residential segregation does not significantly reduce or exacerbate individual-level risk factors for low birthweight; whereas increasing levels of neighborhood poverty significantly eliminates the race effect and reduces the protective effect of being foreign-born on low birthweight, after controlling for other individual-level risk factors and residential segregation. These findings are contradictory to previous health research that shows protective mechanisms associated with ethnic density in local areas. It is likely that structural factors underlying residential segregation, i.e., racial isolation, impose additional stressors on African-American women that may offset or disguise positive attributes associated with ethnic density. However, as poverty is concentrated within these neighborhoods, differences between races in low birthweight cease to exist. This study demonstrates that residential segregation and neighborhood poverty are important determinants of racial disparity in low birthweight in New York City.     

Block observations of neighbourhood physical disorder are associated with neighbourhood crime, firearm injuries and deaths, and teen births

STUDY OBJECTIVE: To provide reliability information for a brief observational measure of physical disorder and determine its relation with neighbourhood level crime and health variables after controlling for census based measures of concentrated poverty and minority concentration. DESIGN: Psychometric analysis of block observation data comprising a brief measure of neighbourhood physical disorder, and cross sectional analysis of neighbourhood physical disorder, neighbourhood crime and birth statistics, and neighbourhood level poverty and minority concentration. SETTING: Pittsburgh, Pennsylvania, US (2000 population=334 563). PARTICIPANTS: Pittsburgh neighbourhoods (n=82) and their residents (as reflected in neighbourhood level statistics). MAIN RESULTS: The physical disorder index showed adequate reliability and validity and was associated significantly with rates of crime, firearm injuries and homicides, and teen births, while controlling for concentrated poverty and minority population. CONCLUSIONS: This brief measure of neighbourhood physical disorder may help increase our understanding of how community level factors reflect health and crime outcomes.     

Changes in the quality of cause-of-death statistics in Brazil: garbage codes among registered deaths in 1996–2016

There are likely to be differences in alcohol consumption levels and patterns across local areas within a country, yet survey data is often collected at the national or sub-national/regional level and is not representative for small geographic areas. This paper presents a method for reweighting national survey data—the Health Survey for England—by combining survey and routine data to produce simulated locally representative survey data and provide statistics of alcohol consumption for each Local Authority in England. We find a 2-fold difference in estimated mean alcohol consumption between the lightest and heaviest drinking Local Authorities, a 4.5-fold difference in abstention rates, and a 3.5-fold difference in harmful drinking. The method compares well to direct estimates from the data at regional level. The results have important policy implications in itself, but the reweighted data can also be used to model local policy effects. This method can also be used for other public health small area estimation where locally representative data are not available.     

Integration of population census and water point mapping data—A case study of Cambodia,Liberia and Tanzania

Sustainable Development Goal (SDG) 6 has expanded the Millennium Development Goals’ focus from improved drinking-water to safely managed water services. This expanded focus to include issues such as water quality requires richer monitoring data and potentially integration of datasets from different sources. Relevant data sets include water point mapping (WPM), the survey of boreholes, wells and other water points, census and household survey data. This study examined inconsistencies between population census and WPM datasets for Cambodia, Liberia and Tanzania, and identified potential barriers to integrating the two datasets to meet monitoring needs. Literatures on numbers of people served per water point were used to convert WPM data to population served by water source type per area and compared with census reports. For Cambodia and Tanzania, discrepancies with census data suggested incomplete WPM coverage. In Liberia, where the data sets were consistent, WPM-derived data on functionality, quantity and quality of drinking water were further combined with census area statistics to generate an enhanced drinking-water access measure for protected wells and springs. The process revealed barriers to integrating census and WPM data, including exclusion of water points not used for drinking by households, matching of census and WPM source types; temporal mismatches between data sources; data quality issues such as missing or implausible data values, and underlying assumptions about population served by different water point technologies. However, integration of these two data sets could be used to identify and rectify gaps in WPM coverage. If WPM databases become more complete and the above barriers are addressed, it could also be used to develop more realistic measures of household drinking-water access for monitoring.     

Hepatitis A in the city of Rio de Janeiro, Brazil: epidemiological pattern and socio-environmental variables. Cross-analysis of SINAN and population census data

This article discusses the linking of data from SINAN (the Reportable Diseases Database) and population census in Brazil to identify the socio-environmental context of hepatitis A, analyzing the contribution by environmental and socio-demographic variables to reported and confirmed cases of hepatitis A. Also, based on individual case data provided by SINAN, we discuss the pattern of hepatitis A endemicity in the city of Rio de Janeiro. At the aggregate level, the unit of analysis was the census tract and census data, associated with the location of 1,553 cases in the city from 1999 to 2001. The observed pattern was high to medium endemicity, indicating a less favorable situation than observed by sero-epidemiological studies. The mean rank of number of households with unfavorable conditions was higher in the census tracts with excess risk of hepatitis A (two or more cases), a statistically significant result according to the Mann-Whitney Test. Socio-demographic variables had more impact than environmental ones (poverty and children in the household less than 5 years of age showed the highest mean ranks).     

Quantitative indicators from a food expenditure survey can be used to target the food insecure in South Africa

Recent work on assessing household food insecurity has focused mainly on experiential-based measures using qualitative survey questions. In this paper, we employed two quantitative measures to estimate prevalence rates for household food insecurity in South Africa. One measure, termed food poverty, assessed whether the amount spent by a household on food was inadequate to purchase a low cost food plan. Low energy availability assessed whether the food energy available to a household, through its purchases and home production, was less than the sum of its members' recommended energy intakes. The 1995 Income and Expenditure Survey, a large representative survey of South African households (n = 28,704), was used for this secondary data analysis. Results showed that 43% of households were in food poverty in October 1995, and 55% had a low energy availability. These indicators allowed classification of households into four groups: food poverty only; low energy availability only; food insecure on both measures; and food secure. These groups differed on various aspects of household food consumption, suggesting that these indicators can be used to target different types of interventions to meet specific needs. Both bivariate and multivariate analyses showed that households that were food insecure on both measures were more likely to be in rural areas, have low incomes or large household sizes, and be headed by Africans or individuals of mixed ancestry. These patterns of food insecurity were corroborated by previous research on income poverty and nutritional status, suggesting that food poverty and low energy availability are useful, quantitative indicators for assessing food insecurity in South Africa.     

Small area random effects models for capture/recapture methods with applications to estimating coverage error in the U.S. Decennial Census

The synthetic estimation approach currently in use for estimating net coverage error in the U.S. Census is evaluated using random effects models. The synthetic estimates from the 2000 Accuracy and Coverage Evaluation (ACE) Revision II are evaluated in two parts. First, a model is used, which produces the synthetic estimate components and, second, the model is enlarged to include random effects at the small area level. Retaining all the fixed effects that characterize the synthetic model produces an extremely large, saturated random effects model. Hence, we selectively reduce the random effects model with an aim towards keeping all fixed effects in order to fairly evaluate the synthetic model. A super-population model is used for the bivariate outcome of erroneous enumeration rate and census omission rate. Both these outcomes were previously estimated using the current synthetic estimation approach. A major hurdle in this project was the development of defensible input data for the small areas due to the large number of effects in the synthetic model, which render simple design-based estimates for small areas crossed with post-strata, mostly, unusable. For this initial approach, the small areas were the 540 local census offices. Bayesian methods are employed to evaluate these models. The advantage of this model is that it can evaluate a key assumption about the homogeneity of rates within a post-stratum and if the assumption holds, then this model reduces to the current synthetic model.