Housing, Indoor Air Pollution, and Health in High-Income Countries
Summary and Keywords
Despite the overwhelming evidence that living in poor-quality housing and built environments are significant contributors to public health problems, housing issues persist and represent a considerable societal and economic burden worldwide. The complex interaction between multiple behavioral, lifestyle, and environmental factors influencing health throughout the “life-course” (i.e., from childhood to adulthood) in high-income countries has limited the ability to develop more salutogenic housing interventions. The resultant, usually negative, health outcomes depend on many specific housing factors including housing quality and standards, affordability, overcrowding, the type of tenure and property. The immediate outdoor environment also plays an important role in health and wellbeing at the population level, which includes air (indoor and outdoor), noise pollution and the quality of accessible natural environments. These exposures are particularly important for more vulnerable populations, such as the elderly or infirm, and those living in insecure accommodation or in fuel poverty (i.e., being unable to heat the home adequately). Being homeless also is associated with increased risks in a number of health problems.
Investigating pathways to protecting health and wellbeing has led to a range of studies examining the potential benefits resulting from accessing more natural environments, more sustainable communities, and housing interventions such as “green construction” techniques. Built environment interventions focusing on the provision of adequate housing designs that incorporate a “life-course” approach, affordable and environmentally sustainable homes, and urban regeneration along with active community engagement, appear capable of improving the overall physical and mental health of residents. While some interventions have resulted in improved public health outcomes in more high-income countries, others have led to a range of unintended consequences that can adversely affect residents’ health and wellbeing. Furthering understanding into four interrelated factors such as housing-specific issues, the immediate environment and housing, vulnerable populations, and natural spaces and sustainable communities can help to inform the development of future interventions.
Evidence linking human health and wellbeing to poor living and housing conditions dates back many decades—from an increased awareness of ecological and sanitation impacts on health during the mid-1800s (Engels, 1845; Green & Labonte, 2008) to a number of evaluation studies and controlled trials in the 1930s, with public health organizations advocating housing strategies as a means to alleviate health inequalities (Krieger & Higgins, 2002; Sharpe et al., 2018). In the 2010s, it is generally accepted that the relationship between health and housing is complex, with many overlapping risk factors that interact and influence resultant health and wellbeing outcomes (Jacobs et al., 2010). Known risk factors influencing the health of residents is the complex interaction between outdoor air pollution, occupant lifestyles and behaviors, housing characteristics, and resultant exposures to indoor air and noise pollution. A range of reviews have assessed the health impacts resulting from residing in inadequate housing (Liddell & Guiney, 2015; Maidment, Jones, Webb, Hathway, & Gilbertson, 2014; Preston, Cantell, Paisley, Peasgood, & Brazier, 2017; Thomson, Petticrew, & Douglas, 2003; Thomson, Thomas, Sellstrom, & Petticrew, 2009, 2013). However, the extent of housing-related risk factors and how these may modify diverse health and wellbeing outcomes are yet to be fully explored. Furthermore, these prior reviews generally fail to illustrate and integrate the diverse nature of indoor and outdoor built environmental risk factors, which can influence physical and mental health outcomes across the life-course.
The World Health Organization (WHO) has adopted a broad definition of housing (the built environment), recognizing that it encompasses four interrelated aspects. These involve an interaction between the house or dwelling (physical structure for human habitation), the home (social, cultural, and economic structure of the household), the neighborhood (immediate housing environment), and the community which comprises of those living, working, and providing services in the neighborhood (WHO, 2010c). The interactions between these factors have a direct and indirect impact on health and wellbeing (Bonnefoy, Braubach, Robbel, Moissonnier, & Ormandy, 2009). As such, the focus will be on the housing risk factors found in high-income countries that can be targeted to ameliorate public health. These have been broken down into four broad categories (Preston et al., 2017):
1. housing-specific issues;
2. the immediate environment and housing;
3. vulnerable populations; and
4. access to natural spaces and sustainable communities.
Housing Specific Issues
While poor housing is a worldwide public health problem, housing conditions and concerns vary greatly between high and lower income countries with this becoming increasingly important with the rise of urbanization globally. These differences result from different cultural attitudes toward housing, different climatic and environmental conditions, and the different resource, administrative, and legal environments. The article will draw from diverse international examples of health and housing-related issues in high-income countries. Consequently, the emerging risk factors to be identified will have important implications for countries experiencing comparable issues with substandard housing (Jacobs, Wilson, Dixon, Smith, & Evens, 2009; Krieger & Higgins, 2002; Ormandy, 2009). Specific housing factors including housing quality and standards, affordability, overcrowding, tenure status (e.g., homeowners versus the private rental sector), and property type will first be described.
Existing legislation and statutory guidelines aim to build and maintain healthy homes that overcome potential health risks. Most countries have a range of building regulations and statutory guidance covering the design of buildings, materials used, ventilation and heating systems, water and energy conservation, fire safety, sanitation access, and prevention of falls (WHO, 2010d). Concurrently, housing supply policy and construction are increasingly being affected by a global shift toward more sustainable building design standards, which encourage greener development including the use of sustainable sites, water and energy efficiency, materials use, indoor environmental quality, emissions, and maintenance (EPA, 2017). Also in response to the various oil and energy crises and climate change risks, sustainable building practices to create more resource-efficient models of construction, renovation, operation, maintenance, and demolition gained momentum in the late 20th Century across the United States and Europe (Sharpe et al., 2018).
However, building codes and national regulations governing new developments are often vague, and do not consider the characteristics needed to provide adequate shelter from the perspective of human health and wellbeing (WHO, 2010d). The retrofitting of properties is also performed without proper scrutiny (Bone, Murray, Myers, Dengel, & Crump, 2010) and can result in a range of unintended consequences (e.g., noise and indoor air pollution) in terms of the living environment, health, and wellbeing (Sharpe et al., 2015; Shrubsole, Macmillan, Davies, & May, 2014). Furthermore, failure to meet guidelines such as those to meet the needs of vulnerable populations (e.g., adaptations including the provision of handrails and bathing aids for older people or those with a disabilities) can increase fall-related injuries (Shier, Trieu, & Ganz, 2016; Svantesson, Babagbemi, Foster, & Alricsson, 2014), which represent a considerable burden on health and social care (Arendht et al., 2016; Carroll, Slattum, & Cox, 2005; David, Shilpa, & Merron, 2016; Houry, Florence, Baldwin, Stevens, & McClure, 2016). Maintaining adequate housing standards is the responsibility of diverse stakeholders including residents, homeowners, communities, private and public landlords, construction firms, architects, and those such as building control and environmental health who are charged with applying housing standards in new and existing builds (Sharpe et al., 2018).
This is important to consider because residing in poor-quality homes has been identified as the strongest predictor of children’s wellbeing. For example, individuals who live in low-quality homes tend to have greater emotional and behavioral problems than those in higher-quality homes (Papi, Brightling, Pedersen, & Reddel, 2018). Resultant health outcomes can be modified by other societal issues such as being able to afford to own or rent and ability to maintain a home.
Affordability in terms of owning your own home or the ability to maintain a safe living environment are key factors influencing health and wellbeing (Thomson et al., 2013). Affordability becomes an issue when housing supply fails to keep pace with demand, which means that purchasing a property has become increasingly unaffordable for low- and moderate-income earners (Ball, 2011; Gurran & Phibbs, 2013). While housing prices can fall (e.g., after the U.S. banking crisis), rising energy prices, food inflation, and increased rents further compound the impact of higher house prices, as people struggle to raise the deposit to buy and/or run (e.g., maintain adequate shelter and heating) a home (Tsai, 2015). Policy changes can also create uncertainty and impact housing supply.
An additional pressure on housing supply includes, for example, an increasing shift toward infill development and decreasing provision of government-owned social housing in countries such as the United Kingdom (van den Nouwelant, Davison, Gurran, Pinnegar, & Randolph, 2015). The impact of affordability also influences household ability to afford the maintenance of a safe home environment, which can lead to major societal problems such as fuel poverty.
The impact on health and wellbeing is influenced by housing tenure, in essence, whether a home is owner-occupied (with or without a mortgage) or rented from a private or public sector landlord. For example, higher levels of psychological distress are found in those renting their home; while those who own their home without mortgages have the lowest distress levels (Cairney & Boyle, 2004). Home ownership is often assumed to have universal health benefits (including physical and mental health) compared with those residing in the rental sector (Ellaway, Macdonald, & Kearns, 2016), However, the size of this housing sector can often mask pockets of deprivation (Wallace, 2016). Tenants in some countries such as Germany enjoy better rights and protection under law, ostensibly to the benefit of population health. Despite this, renting a home in Germany has also been associated with poorer self-rated health, which can be influenced by the need for household renovation, the perception of air/noise pollution and social isolation (Pollack, von dem, & Siegrist, 2004).
There is also a mounting concern (particularly in the private rental sector) for the health and wellbeing of households living in what are commonly termed houses multiple occupation (HMOs) where living areas such as the bathroom and kitchens are used by more than one household (Rhodes, 2015). The quality and maintenance of these properties (e.g., cold and damp homes) are in general lower than those found in the social or public housing sector, which are more tightly regulated. For example, in the United States, residents of public and multi-family housing are less likely to enjoy fair health and experience a greater incidence of poor physical and psychological health. This is not mediated by neighborhood-level characteristics or by housing choice voucher recipients (Fenelon et al., 2017). In combination, the distribution of tenures and affordability in any location can lead to higher levels of overcrowding. Consequently, these are highly intertwined and are among the most commonly reported pathways for poorer physical and mental health outcomes (Anderson, White, & Finney, 2012; Pierse, Carter, Bierre, Law, & Howden-Chapman, 2016).
Overcrowding (also referred to as “crowding”) refers to the number of people sleeping in a dwelling that contravene standards based on the number rooms or space for a given dwelling (National Archives, 2017). In lower-income households, overcrowding can also be exacerbated by additional families living, concealed, within a property, i.e., different families living together in the same dwelling (Heath, 2014). Current trends in building smaller-sized properties (indoor and outdoor space inequalities), increased number of one-person households, a reduction in social housing and changing occupation thresholds further impact problems associated with overcrowding (Tunstall, 2015). For example, in the United Kingdom, it is estimated that overcrowding affects around 1%, 5%, and 6% of households in the owner-occupied, privately rented, and social sectors respectively (DCLG, 2016). Overcrowded homes can impact on educational attainment and employment opportunities later in life (Lopoo & London, 2016), as well as affect indoor air quality (e.g., dampness-related agents discussed below), which can have a direct impact on residents physical and mental health status (Sharpe, Thornton, & Osborne, 2014). Resultant exposures are influenced by the age, type, location, and orientation of a property.
Building age and property type have an impact on health, through the presence of antiquated building materials, variable levels of maintenance, and the types of building (e.g., detached, semi-detached houses or flats), although the specific mixture of risk factors varies from country to country. On the one hand, due to the construction and design of their homes, those living in flats may be protected against the infiltration of outdoor air pollutants (Taylor et al., 2016). On the other hand, such households may also experience greater problems associated with increased condensation and dampness-related agents (e.g., mold growth) as flats or apartments (e.g., reduced natural ventilation) require higher air exchange rates (0.5–0.75 l/sm2 compared to 0.35–0.49 l/sm2) than other building types (detached or semi-detached households), to control the indoor environment. However, the exact ventilation recommendations vary greatly between countries and can be difficult to compare (Das et al., 2013). Appropriate heating and ventilation are key determinants of resultant indoor air quality (IAQ), which is further influenced by outdoor air pollution.
Property type influences the infiltration and circulation of outdoor air pollution into the home, which is dependent on building volume and ventilation rates and include diverse sources such as leakage through the fabric of the building (infiltration and exfiltration), airflow through open windows and doors (natural ventilation), and mechanical ventilation (MV). Ventilation options may include mechanical exhaust ventilation (MEV), or mechanical supply and exhaust ventilation with heat recovery (MSEV) (Arvela, Holmgren, Reisbacka, & Vinha, 2014). Air quality resulting from mechanical ventilation depends on the type, location, and maintenance of a range of exhaust or supply only systems. Whereas infiltration and exfiltration, and natural ventilation rates are driven by resident behaviors and pressure gradients across the building envelope—the latter is dependent on indoor–outdoor temperature differences and wind speed (Hodas et al., 2016). Low ventilation rates (e.g., lower than the recommended ventilation rate of 0.5 air exchanges per hour (ACH-1)) can impact IAQ, particularly when combined with inadequate heating (Sharpe et al., 2014). Conversely, there is some evidence supporting the enhancement for the capacity of buildings to protect occupants against exposure to outdoor particulate matter (PM) (Ji & Zhao, 2015).
The resultant exposures are a function of housing design, quality, type of building materials used, levels of maintenance, heating, and ventilation (Sharpe et al., 2014). Changes to the type of property can influence both exposures and health outcomes. For example, changes to the building envelope (e.g., draft proofing and insulation) have resulted in some mixed outcomes because of a lack of consideration of resident lifestyles, heating, and ventilation patterns. When combined with adequate ventilation, it is thought that these household improvements (i.e., energy efficiency measures) can improve indoor air quality and resident health (Hamilton et al., 2015; Maidment et al., 2014; Milner, Chalabi, Vardoulakis, & Wilkinson, 2015). Conversely, these home improvements can also be detrimental to indoor air quality with the return of mold growth following these home improvements (Richardson et al., 2005) for example. Potential impacts on indoor dampness are a concern because it affects around 16% of European housing stock (Haverinen-Shaughnessy, 2012), and up to 50% of homes worldwide (WHO, 2014b). What is also particular is public health interest because of its relationship to air quality issues.
The Immediate Environment and Housing
The characteristics of the wider environment (climate, weather, pollution levels, noise, etc.) can have a profound effect on health and wellbeing. Despite the recognition of the acute health effects of a range of pollutants, since the mid-20th century pollution has slipped down the public health agenda. This has been driven by legislation, the eradication of many contaminants that have the most visible health impacts and rise in other threats, perceived as unrelated to pollution, such as the obesity epidemic. A number of threats remain, and there must be a renewed focus on pollution, particularly concerning longer-term risk factors for a range of non-communicable diseases (cardiovascular disease, cancer, asthma, and chronic obstructive pulmonary disease). In addition, there is growing evidence that projected global climate change has the potential to affect public health further. Predominantly through its impacts on the outdoor (e.g., pollen and mold sporulation, food security, growing seasons; Watts et al., 2016) and indoor environments (e.g., increased risk of flooding, overheating and/or increased condensation and biological contamination [molds, house dust mites, and bacteria]; Vardoulakis et al., 2015).
The nature, accumulation and dispersal of pollutants inevitably vary according to location and in so doing contribute to a range of pollution-related health inequalities. Exposure to pollution (e.g., most notably air pollution) has been associated with socioeconomic status and ethnicity, with higher concentrations and negative health effects (a so-called “triple jeopardy” effect) being found in more socially disadvantaged areas (CMO, 2017). Mitigating such risk factors and improving the quality of housing reduces exposure to a range of pollutants (e.g., air and noise pollution) and is recognized as essential to improving human health outcomes. With respect to housing, an overview of those factors that are deemed important to health outcomes will be provided. Outdoor air pollution is, indeed, important to summaries because of its potential to affect indoor air quality.
Outdoor Air Pollution
Since the ancient Greeks, it had been believed that ambient air pollution (via miasma theory (Vandenbroucke, 1988) could bring disease to humans (e.g., cholera and plague) and crops. During the 19th century via the use of microscopes and other new chemical techniques, it was recognized that air transported a range of pollutants and biological agents (Flannigan, Samson, & Miller, 2011). During this period John Snow and his groundbreaking epidemiological approach (Fine et al., 2013) demonstrated that precautionary principle interventions could reduce disease burden (Snow, 2013). By the 20th century, it was recognized that poor ambient air quality was associated with excess deaths. Notably the 1952 London smog, which killed over 12,000 people (e.g., the effects of soot and sulfur dioxide) and led to increased legislation in the United Kingdom. Knowledge about the adverse health effects of exposure to carbon monoxide, lead, and ozone developed during the 1960s–1980s, which was followed by increased awareness of the impacts associated with nitrogen dioxide and particulates during the 1980s and 2000s. While dramatic reductions in emissions have been observed (e.g., from coal burning) in many high-income countries, pollution sources such as those associated with increased urbanization and transport are gaining greater attention (RCP, 2016). For example, 14% of the cases of incident asthma in children and 15% of all exacerbations of childhood asthma have been attributed to traffic pollution across ten European countries (Guarnieri & Balmes, 2014).
Ambient air pollution from a range of sources (Table 1) is important to consider because of the associated health risks, including cancer, asthma, stroke and heart disease, diabetes, obesity, and changes linked to dementia (RCP, 2016). The extent of exposure around the home environment depends on several factors, which includes the local environment and individual’s lifestyle (Salthammer et al., 2016). Furthermore, it is thought that there are no safe exposure limits where no adverse health effects may occur (Festy, 2013). Consequently, this adds to the pressure for governments and individuals to continue to reduce exposure to air pollutants (Clifford, Lang, Chen, Anstey, & Seaton, 2016).
Table 1. Outdoor Air Pollutant Concentrations Safety Guideline
Health Risks Leading to Guideline Limits
Outdoor Guideline Concentrations µg/m3
Consistency of Evidence
Mainly from combustion processes
Respiratory and cardiovascular diseases
20 (24-hr mean)
Consistent evidence of adverse effects experienced by urban populations
Mechanical processes such as construction activities, road dust re-suspension and wind
10 (annual mean)
50 (24-hr mean)
20 (annual mean)
Formed in the atmosphere by photochemical reactions in the presence of sunlight and precursor pollutants, e.g., oxides of nitrogen and VOCs
100 (8-hr mean)
Some consistent evidence from epidemiological time-series studies
Combustion processes (e.g., energy and transport from industry, commercial and domestic activities)
Toxic effects and respiratory effects, e.g., reduced lung function
40 (annual mean)
Experimental studies show that NO2 is a toxic gas, but it is difficult to separate the effects from highly correlated co-pollutants such as PM
200 (1-hr mean)
Combustion processes (e.g., energy and transport from industry, commercial and domestic activities)
Reduced pulmonary function and respiratory symptoms
20 (annual mean)
Difficult to separate the effects of SO2 from other co-pollutants such as PM
500 (1-min mean)
Adapted from the WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide (WHO, 2005)
In the context of housing, ambient air pollution is important to consider because it is easily transferable to the indoor environment. Between 20% and 100% of ambient air pollution concentrations are transferred inside buildings. For example, traffic remains a key source and can account for up to 90% of airborne PM (Jiang, Mei, & Feng, 2016). Consequently, it is thought that most exposure to so-called outdoor air pollution occurs indoors (Carrer, 2008). In indoor environments, pollutant concentrations can be as much as ten times higher indoors than those outdoors because of variable ventilation rates and the presence of internal sources of formaldehyde, particulate matter, and nitrogen dioxide, for example (Brown, Crump, & Harrison, 2013; RCP, 2016). Health effects depend on the inhalable fraction of any air pollutant (depending on age, sex, body weight, fitness, and activity levels) (Hodas et al., 2016), and the type of air pollutants present and indoor environment (Morawska et al., 2013). There is now growing interest in indoor air pollution as a health determinant (Brown et al., 2013), particularly because every year in the European Union an estimated 2 million Disability Adjusted Life Years (DALYs) are lost due to poor IAQ (Asikainen et al., 2016).
Indoor Air Pollution
Increased attention to the indoor environment and resultant exposures has been driven by the acknowledgement of the amount of time people spend indoors; and that exposure to poor IAQ is a preventable risk factor contributing to the global burden of disease (Torres-Duque, 2008). The general population in North America or Europe spend on average around 89% of their time indoors (McGratha et al., 2017) including the home and educational and occupational settings. Approximately 69% of this time is spent in the residential indoor environment (Klepeis et al., 2001; Schweizer et al., 2006; Torfs et al., 2008), with homemakers or the elderly spending up to 90% of their time in the residential indoor environment (Torfs et al., 2008). Consequently, IAQ in the domestic setting is a key determinant of health.
Aside of the importance of ambient air pollution infiltrating the home through windows, doors, and general building leakiness (RCP, 2016), a range of sources and risk factors influence IAQ (Figure 1; Court et al., 2017) and increase the risk of a range of health outcomes (Table 2). In summary, IAQ is influenced by biological agents such as the presence of plants, pets, and rodents (cockroaches, mice, and rats), and the presence of dampness; the latter promotes mold growth (leading to exposure to spores and hyphal fragments), the proliferation of house dust mites, and bacteria (Sharpe et al., 2014). These dampness-related agents are key sources of allergens known to be associated with the exacerbation and/or development of allergic diseases (e.g., eczema, allergy, and asthma) (Dales, Liu, Wheeler, & Gilbert, 2008; Gaffin & Phipatanakul, 2009), which affect around 30% of people in high-income countries (Crameri, Garbani, Rhyner, & Huitema, 2013).
Other indoor anthropogenic sources of indoor air pollution include: combustible by-products resulting from smoking indoors and heating/cooking appliances, electrical appliances, household products (e.g., cleaning products, air fresheners, and furnishings), and construction materials (paints, glues, and carpeting). Resultant indoor pollutants may include: carbon monoxide, formaldehyde, volatile organic compounds (e.g., aromatic hydrocarbons, aldehydes, aliphatic halogenated hydrocarbons, and terpenes and other microbial sources), PAHs, oxides of nitrogen, particulates, ozone, phthalates, polychlorinated biphenyls, and other persistent organic compounds, lead (from old paints and water pipes), mineral dusts and fibers, including asbestos and those from other building materials and insulation (RCP, 2016). Elevated exposure to these indoor air pollutants can have a range of adverse health effects such as respiratory and cardiovascular conditions, cancer, and allergic diseases.
Table 2. Summary of Indoor Air Pollution and Health Risks
Combustible by-products (e.g., NO2, PM, and CO)
Environmental tobacco smoke (ETS), poorly designed, fitted and/or maintained heating and cooking appliances
Respiratory tract infections, chronic obstructive lung disease, chronic bronchitis, asthma (allergic and non-allergic), lung cancer, and cardiovascular events. Additionally, CO can cause fatigue, dizziness, headaches, confusion, nausea, disorientation, and be fatal
PM of outdoor origin
Natural and anthropogenic, particularly transport related and diesel fumes
Increased risk of the development and/or exacerbation of asthma
Evidence from outdoor PM
Majority of the evidence comes from exposure to outdoor PM, which has been associated with the development and/or exacerbation of asthma and some evidence of lung cancer. Adverse health effects of outdoor PM exposure have been found at concentrations between 3µg/m3 and 5µg/m3, which is less than existing levels found in many higher-income countries
Volatile organic compounds
Household furnishing, products, building materials, and presence of dampness, which leads to the degradation of building materials and fungal growth (release of microbial VOCs)
Sensory effects, cognitive decline, thyroid toxicity, effects on the immune system, cancer, reproductive and endocrine system. There is also some and inconsistent evidence linking VOCs to the exacerbation of allergic, dermatological and respiratory effects
In higher-income countries, there has been significant progress in the removal of lead-based products such as paints. However, lead is still found in consumer products, water and old paint
A toxin that can have permanent and possibly fatal consequences, particularly in young children. It can affect many body systems, including neurological, haematological, gastrointestinal, cardiovascular, and renal systems. It can also lead to increased aggression and crime
A natural radioactive gas found in phosphate rock, shales, and igneous and metamorphic rock such as granite
Lung cancer with an additive effect when combined with ETS exposure. Some evidence linking radon with non-melanoma cancer and squamous cell carcinoma
Antiquated building designs, materials and those brought into the home via occupational routes
Asbestosis and lung cancer. In an occupational setting, asbestos is the most widely known and most common cause of pleural mesothelioma. There is also an additive effect when combined with ETS exposure
Evidence from occupational setting
Poorly designed and/or maintained freshwater systems, showers, hot tubs, cooling towers, and humidifiers
Legionnaire’s disease, especially in susceptible individuals (increased age, illness, and immunosuppressed) and those exposed to ETS. Accounts for 0.5–10% of hospitalizations of community-acquired pneumonia, with an associated case fatality rate of 10%
Pollen, fungi, HDM, bacteria, pets, rodents, and indoor dampness
Multiple allergic and respiratory effects. Associated with the development and/or exacerbation of allergic diseases. However, some of the evidence is inconsistent and potentially result in divergent health outcomes (e.g., endotoxin), which is dependent on the timing and extent of exposures. The inconsistency of evidence is owing to the complex nature of these heterogeneous diseases, interactions between a diverse indoor microbiome and gene and environmental factors
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Many of these air pollutants are regulated and have indoor guideline concentrations (Table 3), which can help protect the health of residents. However, these guidelines fail to adequately address hazards associated with increased dampness, related biological agents, and associated health risks. This is important to consider in the context of indoor air pollution because of the associated dampness-related agents including mold growth, bacteria, volatile organic compounds, and house dust mites. For this reason indoor damp is recognized as a category one housing hazard by the UKs Health and Safety Rating System (DCLG, 2006).
While many studies have demonstrated clear links between indoor damp and mold contamination and allergic diseases such as asthma (Fisk et al., 2007), the causal mechanisms are yet to be fully explored (Sharpe et al., 2015). Understanding the relationship between these biological agents (e.g., endotoxin) is further complicated by some evidence linking early exposure to divergent health outcomes, which depends on the timing and extent of exposure (Braun-Fahrlander, Gassner, Sennhauser, Wuthrich, & Scarpol-team, 1996; Ehrenstein et al., 2000; Heederik & von Mutius, 2012; Strachan, 1989; von Mutius & Radon, 2008).
Table 3. Indoor Air Pollution Safety Guideline Concentrations
Typical Indoor Concentrations
Indoor Source Typical Indoor Source vs High-End Concentrations with Increased Source Strength
30% to >90%
5 (although no safe level of exposure can be recommended)
40 to >75%
0% to >99%
>90 to >99%
20 to >75%
polycyclic organic matter (most common are PAHs)
No threshold can be determined, and all indoor exposures are considered relevant to health
Not stated but concentrations can be higher indoors
>90 to 99.9%
0.1 to 7.7 μg/m3
Unit risk estimate of 4.3 × 10–7 per μg/m3
Not stated but outdoor concentrations are higher in urban areas
0.4 to 3.5 μg/m3
0.25 mg/m3—annual average
Not stated but generally higher outdoors
Prevalence of affected homes ranges from 10 to 50%
Avoidance of persistent damp and microbial growth
Not stated and dependent on indoor and outdoor sporulation rates
Some of the important pollutants include increased exposure to combustible by-products (i.e., from incomplete combustion processes or formation of new products). This can vary considerably and depends on the type of heating and cooking appliances, and environmental tobacco smoke (ETS); a key source of particulates, and a mixture of chemical agents. For example, smoking has been found to increase PM2.5 by six times above the 25 µg/m3 guideline level (Semple et al., 2012). Whereas, if installed correctly and adequately maintained, pollutants from heating and cooking appliances (Semple et al., 2012) generally remain within guideline concentrations, which is largely due to building regulations (Planning Portal, 2015). Conversely, poorly designed, installed and maintained or faulty appliances can lead to elevated concentrations of carbon monoxide (odorless and tasteless toxic gas; Iqbal et al., 2012; Levy, 2015), nitrogen dioxide and particulate matter (Carrer, 2008; PHE, 2015).
Another important source of air pollution in homes includes naturally occurring radon, which is a risk in poorly ventilated homes (Samet & Eradze, 2000) located in areas with phosphate rock, shales, and igneous and metamorphic rock. Also, while lead persists in the home environment and poses a risk for lead poisoning (Dixon et al., 2009), there has been significant progress in removing lead exposures. Similarly, the use of asbestos as a fire retardant and a range of construction material remains a key risk factor in older homes (Gilham et al., 2016; Schwartz & Cote, 2016). Importantly, there can also be a synergistic effect on resultant health outcomes when smokers are exposed to elevated radon or asbestos concentrations (Darby et al., 2005; Schwartz & Cote, 2016).
Volatile organic compounds (VOCs) are a concern when they are continually reintroduced into the home with new products, cleaning materials, and furnishings. While VOCs generally decay within two to eight weeks (Herbarth & Matysik, 2010), they can remain more persistent in the presence of indoor dampness and result from the degradation of building materials (Sharpe et al., 2014). In addition to the dampness-related agents, exposure to increased concentrations of VOCs (both from the presence of damp, mold growth [microbial VOCs] and/or from new furnishings and cleaning chemicals, etc.) increases the risk of asthma (Arif & Shah, 2007) and enhances bronchial responsiveness to house dust mite allergens (Casset et al., 2006).
Exposure to poor IAQ has been associated with more deprived communities. Findings from the United States and Europe have demonstrated that low-income populations are exposed to higher concentrations of indoor pollutants because of the dwelling proximity to industrial and traffic pollution sources, increased indoor tobacco smoking, adverse building envelope conditions such as dampness and contaminated dust (Kolokotsa & Santamouris, 2015). Low-income households are also less likely to adequately heat and ventilate their home to reduce the cost of heating, i.e., “fuel poverty.” This a public health concern because around 20% of European homes are thought to be in fuel poverty, and face problems with keeping their homes warm during winter months (Braubach & Ferrand, 2013). The resultant IAQ also depends on many of the housing- (e.g., standards and property type) and behavioral- (e.g., overcrowding and occupant lifestyles) related factors. Health outcomes resulting from the living environment can also be influenced by a range of other environmental exposures such as noise. The impact and associated health costs of elevated noise exposure are separate to that of air pollution, although these can be a synergistic effect in urban areas (Hammer, Swinburn, & Neitzel, 2014).
Noise Pollution and Health Outcomes
Environmental noise includes all sources except industrial workplaces, and is one of the most prevalent environmental hazards thought to affect one-third of the global population (WHO, 2011). Noise in the home generally comes from external environmental noise; this is an important nocturnal exposure, which can impact the quality of sleep at relatively low levels, particularly in homes of poor acoustics and insulation (Fietze et al., 2016; Hume, Brink, & Basner, 2012). Much of external sources of noise can come from road and rail traffic, air transportation, and occupational and industrial activities, as well as individual or community-noise-level exposures (including amplified music, recreational activities, and firearms; Hammer et al., 2014). In many countries, excessive noise exposures come from predominantly occupational settings (i.e., noise emitted from commercial and industrial premises) and transport, with road traffic being one of the top three stressors affecting public health (Basner et al., 2015; Hammer et al., 2014). This may be compounded by the movement of residents to inner city areas with greater provision of high-density accommodation, which is increasing in some areas such as Australia and the United Kingdom.
Noise exposure is important to consider from a public health perspective as it has been established as an independent risk factor in the generation of ill health (Vienneau et al., 2015). In the United States, as many as 104 million individuals are exposed to an annual LEQ(24) levels of decibels >70 dBA, which is the exposure maximum limit to prevent hearing loss. This exposure means these individuals are at increased risk of noise-induced hearing loss, heart diseases, and other noise-related health effects (Hammer et al., 2014). For example, noise is considered as the primary environmental stressor in relation to cardiovascular morbidity and mortality (Stansfeld & Clark, 2015; Vienneau, Schindler, Perez, Probst-Hensch, & Roosli, 2015). Other health effects include diabetes (Basner et al., 2015), psychophysiological effects (e.g., annoyance, reduced performance, and cognition skills), and changes in social behavior (Stansfeld & Clark, 2015). The resultant impact of noise in the home is dependent on the location of a property and levels of insulation for example.
The importance of excessive noise, particularly nocturnal sources, on health is illustrated in the WHO publications “Night Noise Guidelines for Europe” and “Burden of Disease from Environmental Noise” (WHO, 2009; 2011). Despite evidence linking noise with disturbed sleep and cardiovascular disease and/or other long-term health outcomes, the causal pathways remain unknown and require further research. More vulnerable populations such as those living in the most deprived neighborhoods, the elderly or infirm who spend more time indoors, those living in temporary accommodation, and the homeless are at greater risk. An overview of more vulnerable populations more susceptible to air and noise pollution will be provided. This includes populations living in cold homes (i.e., the societal impact of fuel poverty), which continues to significantly contribute to health inequalities (PHE, 2018).
Vulnerable Populations, Housing, and Health Outcomes
To improve health equity, improved housing may play an important part. Exposures for susceptible and vulnerable populations from poor housing may be greater. For example, it is also estimated that in the United Kingdom around 20% of older adults live in poor-quality housing, resulting in an estimated annual healthcare cost of approximately £624 million. The cost is predominantly due to excess cold hazards and falls (e.g., Garrett, 2015), which is a risk factor among older adults and dependent on the type of accommodation.
Accommodation and Older People
Vulnerable populations include those residing in temporary dwellings such as park homes, or trailers and caravans, which are mobile and moveable (although some park homes may have a reasonably long life, and are not readily moveable). These offer low-cost housing options for all ages; and have increasingly become a lifestyle choice for older people (Bevan, 2010). Temporary dwellings have been shown to result in both positive and negative outcomes, depending largely on people’s perception of the quality of accommodation for example (Bevan, 2011).
A concern for older people living in temporary dwellings such as park homes or caravans is the lack of insulation and poor thermal properties, which currently do not fall within funded energy efficiency schemes and increase the risk of cold-related morbidity and mortality in older people (CFP, 2016). In addition, many caravans are built with fire retardant chemicals and formaldehydes, and with intended exposure times of a few weeks per year, resultant risks will be increased if residing permanently in this accommodation (Comcare, 2014). Vulnerable older people in the United Kingdom and elsewhere may also reside in supported living arrangements such as the provision of “Extra Care Housing,” which is a growing part of the housing and care landscape for an ageing population. A range of co-benefits have been associated with Extra Care Housing, including improved health and wellbeing and reduced unmet needs and social isolation; however, much of the research is in its infancy (Mullins, 2015).
An important public health concern, separate to these vulnerable populations who are susceptible to their living conditions, is the health and social care support required to meet the needs of other vulnerable individuals with a long-term illness or disability (38% of households in the United Kingdom), who require accessible, adapted, or specialist housing, such as supported or sheltered housing. This includes those without a permanent place of residence who are reliant on the provision of temporary accommodation.
Temporary Accommodation and Homelessness
Temporary accommodation differs (but may overlap in some instances) to temporary dwellings and consists of households (or an individual) who have been given somewhere to live temporarily by a local authority or public housing. For example, this may include the provision of temporary Bed and Breakfast or hostel accommodation given to a homeless person or family. Temporary accommodation remains a basic element in the provision of services for those who are homeless across all European countries (Busch-Geertsema & Sahlin, 2007).
Although not necessarily recognized as a “housing issue,” the homeless (including “rough sleepers” and those with no permanent accommodation) are a particularly vulnerable population; their precarious housing circumstances often result in marked deterioration in health and wellbeing, and impacts on both physical and mental health (Bassuk, Richard, & Tsertsvadze, 2015; Please, 2015). The unique distress of lacking a settled home can cause or intensify social isolation; create barriers to education and healthcare, training and paid work; and further undermine chronic health conditions (Please, 2015; White, Logan, & Magwood, 2016). These issues mean that the average life expectancy of someone who is homeless is lower than the general population, resulting from high rates of infections, traffic accidents, falls, drug and alcohol abuse, suicide, and premature mortality (Montgomery, Szymkowiak, Marcus, Howard, & Culhane, 2016). Preventive measures are much less expensive than allowing homelessness to continue for sustained periods or on a repeated basis (Please, 2015). Furthermore, unless housing solutions are implemented to help address homelessness, those receiving specialized alcohol and drug treatment are more likely to return to the streets at the end of a treatment program (Dyb, 2016).
Other vulnerable populations include households residing in fuel poverty. In the United Kingdom, for example, it is thought that around 30% of people reside in poor housing conditions; and around 2.5 million people live in fuel poverty, which contribute towards 25,000 Excess Winter deaths each year (BEIS, 2016). Excess winter deaths may be further compounded by the decline in funding for housing improvements such as those to improve the quality and energy efficiency of older housing stock (Archer, Murie, Turkington, & Watson, 2016). Comparable issues have also been observed in housing across Europe, New Zealand, and the United States (Jacobs et al., 2009; Ormandy, 2009). For example, in New Zealand, around a quarter of households are thought to live in fuel poverty, which is thought to be a result of a poor history of housing regulation (Howden-Chapman et al., 2012).
Vulnerable Populations Living in Fuel Poverty
Fuel poverty is a distinct societal problem. The scale of the problem is dependent on the definition of fuel poverty used, which is important for policy determination. The number of homes classified as being in fuel poverty depends on the country of interest, the definition used, and how a definition changes over time. For example, in the United Kingdom there has been a debate around the definition of fuel poverty, which has changed from a household spending more than 10% of their income on fuel to the low income or high cost definition. This identifies specific households as being fuel poor, in terms of low-income households (low income) with high-modeled energy needs (high costs).
Essentially, fuel poverty is a situation where millions of households across many higher income countries are unable to keep warm at a reasonable cost, which is influenced by interrelated components of low incomes, increasing energy requirements, and high energy costs. It is important to note, however, that not all poor households experience fuel poverty. Some households would not typically be considered poor but may be plunged into fuel poverty in an attempt to meet the high energy costs (BEIS, 2017).
Furthermore, levels of heating depend on a complex interaction between situational and contextual factors, attitudes, values, and barriers that influences people’s ability to access help or to change heating behaviors (Tod et al., 2012). Those households not able to heat or cool their dwelling adequately are a public health concern as they may be living in substandard housing conditions, regardless of their risk perception of the potential health risks, quality of housing, and use of ventilation (Sharpe et al., 2015; Tanner, Moffatt, Milne, Mills, & White, 2013). Living in cold and damp housing has a direct and immediate impact on cardiovascular, mental and respiratory health, as well as poor educational attainment in children (Sharpe et al., 2015; Tod et al., 2016).
The risks of falling, carbon monoxide poisoning, and social isolation are also increased for those residing in such conditions (de Vries & Blane, 2013; Liddell & Morris, 2010). The impacts on health through stressors such as persistent worry about debt and affordability, thermal discomfort, and worry about the consequences of cold and damp for health (Liddell & Guiney, 2015) are also of concern. The combination of low income, housing conditions, and composite fuel poverty measures has been most consistently associated with cold weather-related adverse health or social outcomes (Tanner et al., 2013).
These are likely to be influenced by variable weather patterns and climate. The prevalence of fuel poverty across Europe varies considerably and could affect between 6% and 34% of households. Fuel poverty is thought to be on the increase, depending on the country and the definition used (Liddell & Morris, 2010). The rates of fuel poverty vary with both spatial and social distributions, and with a greater incidence of this phenomenon in southern and eastern European Union Member States (Bouzarovski & Tirado Herrero, 2017; Healy, 2003; Thomson, Snell, & Bouzarovski, 2017). This is influenced by the energy efficiency of a dwelling and the extent of heating behaviors; for example, countries which have more energy-efficient housing have lower excess winter deaths (Marmot Review Team, 2010). Identifying those at greatest risk of fuel poverty has the potential to direct pan-European and national anti-fuel poverty policies and programs of assistance to affected homes (Thomson, Bouzarovski, & Snell, 2017). However, measuring the extent of fuel poverty is challenging due to measurement issues that are compounded by the private nature of households.
While socioeconomic, housing, and behavioral factors are associated with a range of cold weather-related adverse health or social outcomes, more robust studies are needed to address methodological issues and uncover causal associations (Tanner et al., 2013). Furthering the understanding of heating and ventilation behaviors is important because of the potential societal and healthcare benefits. It is also important to consider differences between building types, those living in the private rental sector, and differences between urban and rural environments. Those in more urban areas may experience more persistent fuel poverty problems, whereas the rural fuel poor are more vulnerable to energy prices. Additionally, living in private accommodation or a flat increases their probability of remaining fuel poor (Roberts, Vera-Toscano, & Phimister, 2015). Furthermore, the use of low-cost heating equipment such as wood stoves further deteriorates indoor comfort and air quality. In the summer, the same homes may experience high levels of discomfort and heat stress, especially during heat waves (Kolokotsa & Santamouris, 2015).
All this describes how indoor environments and health outcomes are a function of a range of behavioral (e.g., overcrowding) and built environment (e.g., tenure, build type, housing standards and the immediate environment) factors. These interact and influence a range of health outcomes, which are modified by variable levels of air and noise pollution, particularly among more vulnerable populations such as the most deprived communities residing in fuel poverty. The resultant exposures and health outcomes are consequently a function of “place,” which includes the effects of neighborhoods, the natural environment, and local communities (Sharpe et al., 2018).
Neighborhoods, Access to Natural Spaces and Sustainable Communities
Since the early 2000s, there has been a drive toward urban sustainability as a potential approach to addressing global climate change and rapid urbanization, which is increasingly becoming mainstreamed in policymaking (Joss, 2011). This is important because the surrounding built and natural environment can have a direct and indirect impact on health and wellbeing, which can result from a range of overlapping and interrelated factors (Figure 2; Court et al., 2017).
Sustainable communities involving well-designed buildings and outdoor spaces can enhance the long-term health and wellbeing of those who use them regularly, reduce the risk of falls, promote physical activity, and reduce social isolation (LGA, 2016; Town and Country Planning Association, 2014). Research has focused on the impact of improving the wider neighborhood and environment, for example, increased access to parks and open spaces has been estimated to reduce healthcare treatment costs by £2 billion in the United Kingdom and help reduce crime and residents’ perceived fear of crime (Lorenc et al., 2012). However, this requires a shift toward new alternative forms of sustainable housing development where developers, investors, landowners, and the communities work together to achieve more livable neighborhoods (Shelter, 2016).
This means that widening community development strategies (Komro, Tobler, Delisle, O’Mara, & Wagenaar, 2013) and improving access to more natural environments across the social gradient have the potential to improve health. Results from other wider community interventions to build community resilience and reduce inequalities (Well London, n.d.) have improved chronic health problems (Wall et al., 2009), but have resulted in limited changes to healthy behaviors (e.g., eating, physical activity), or health and wellbeing (Phillips et al., 2014). Despite some inconsistent findings, interventions targeting both internal and external fabric (e.g., internal or external insulation improvements or maintenance) improvements of a property, neighborhood regeneration, and age-friendly environments (including increased access to natural spaces and community engagement) could help improve community resilience and result in positive health outcomes (Bambra, 2010; Curl et al., 2015; Zapata Moya & Navarro Yáñez, 2016). More sustainable interventions could provide demonstrated improvements in aging, physical, mental, and social functioning (Kok, Aartsen, Deeg, & Huisman, 2016).
The provision of improved natural environments and access to “greenspace” or “blue space” plays an important role and can promote health and wellbeing, particularly for more deprived populations (Kondo, South, & Branas, 2015; Mitchell & Popham, 2007; Mitchell & Popham, 2008; Wheeler, White, Stahl-Timmins, & Depledge, 2012; White et al., 2016), representing an opportunity for Public Health bodies and landowners/managers to work collaboratively to improve individual and community health and wellbeing. However, the specific mechanisms by which green and blue space affects health are still not well understood (Kondo et al., 2015) and could result in a number of unintended consequences (e.g., fear of crime or poor perception of the environment) if not properly designed (Hassen & Kaufman, 2016; Kondo et al., 2015; Lorenc et al., 2014). While the evidence is mixed, this raises the need for community participation and more socially cohesive environments (Derges et al., 2014). Future research is required to assess which aspects of these interventions are effective because they can be problematic to deliver and result in uncertain outcomes (Bertotti, Adams-Eaton, Sheridan, & Renton, 2012).
It is important to include wider stakeholders such as local governments who play a vital role in protecting, maintaining, and improving local green spaces, and can create new areas of green space to improve access for all communities (Balfour & Allen, 2014). Spatial planning for health provides an opportunity and framework for designing healthier built environments and living places. For example, these may focus on aspects of the built and natural environment, incorporating neighborhood design, housing, healthier food, transport, and natural and sustainable environments; these reflect the improvements required to address the previous health and housing risk factors.
However, resolving complex societal, economic, and environmental issues requires multifaceted approaches including sustainable building design, and particularly community engagement and participation and social inclusion (Hassen & Kaufman, 2016). Some evidence suggests that these should include a shift to more person- and community-centered ways of working in public health and healthcare, covering key themes such as strengthening communities, opportunities for volunteering and peer roles, fostering collaboration and partnerships, and access to community resources (South, 2015a). These should be delivered alongside a change in current and future housing policies, which should focus on addressing the condition, affordability, suitability, appropriateness, and security of the existing housing stock, focusing efforts where there is most housing need and demand (Archer et al., 2016).
Sustainable built environments also need to be resilient against future climate change impacts to alleviate climate change-related health risks. These health risks include deaths, cardio-respiratory problems and acute morbidity resulting from exposures to extreme meteorological events, increased ozone levels, trans-boundary particle pollution, and altered the spatial and temporal distribution of allergens (pollens, molds, and house dust mites) (D’Amato et al., 2015). Typical modifiable risk factors that may help alleviate climate change risks include overcrowding, poor ventilation or increased building airtightness, and increased relative humidity, particularly for the most vulnerable populations such as the elderly (especially those living alone), individuals with pre-existing illnesses, and the socioeconomically deprived (Vardoulakis, & Heaviside, 2012). Future strategies should also account for differences between urban and rural environments, associated climate, terrain, and changes in housing stock and resident behavioral characteristics (Taylor et al., 2016).
Similarly, these wider environmental-level public health interventions also need to consider individual lifestyles, cultures, and the immediate built environment, including inside the home. This is because living in poor-quality housing and built environments represents some of the leading causes of global burden of disease throughout the life-course (Vos et al., 2016). Housing and neighborhood characteristics are important contextual social determinants of health via three main pathways: housing conditions, built environment characteristics, and housing tenure (Gibson et al., 2011). Resultant health outcomes are influenced by a complex interaction between multiple direct and indirect housing and built environment factors. The sheer complexity of these relationships requires actions at different levels and across different sectors. Delivering more multifaceted interventions (i.e., addressing both existing and new builds) are necessary to develop guidelines that extend beyond the current best practice of delivering dwellings that are of adequate size and affordable to heat (Thomson et al., 2013).
To become sustainable and avoid potential unintended consequences of some housing interventions (Shrubsole et al., 2014), future interventions must adopt whole system approaches that consider the building characteristics and resident lifestyles, as well as improvements to the wider neighborhood and local natural environments, which intersect with communities and place. Importantly, these need to account for social, economic, physical, cultural, environmental, and historical differences among communities. This requires a greater shift in policy and more holistic and joined up approaches across both the health and housing sectors (Sharpe et al., 2018). However, the delivery of salutogenic multifaceted housing interventions requires more careful evaluation and more complex modeling to further the understanding of the interactions between these complex direct and indirect relationships influencing all dimensions of health (RCP, 2016; Vardoulakis et al., 2015). This includes the evaluation and inclusion of sustainable building design, community engagement and participation (e.g., strengthening communities, fostering collaboration and partnerships), and social inclusion (Hassen & Kaufman, 2016; South, 2015a).
The links between health and housing are complex. In high-income countries, factors that influence health include: air pollution, outdoor and indoor; the role of fuel poverty in exacerbating health inequalities; and the impacts of noise pollution. There are a range of modifiable factors that influence these environmental exposures, which includes resident lifestyles or behaviors (including issues such as social isolation and crime), housing specific issues (e.g., standards, affordability, tenure, overcrowding, and property type, etc.), the surrounding environment (e.g., natural spaces and climate), and the influence of communities (influenced by social, economic, historic, and cultural differences). The resultant negative physical and mental health outcomes of residing in poor living environments are exacerbated among more vulnerable populations, including those in temporary housing and those without a home.
Efforts to alleviate these diverse social determinants of health requires improvements in the policy arena to address these issues along with the adoption of more holistic whole system approaches that consider these diverse factors and housing as a component of place. This requires a better understanding of the intertwined pathways to improve resident and community health and wellbeing, which is needed to help more holistic policy and practice among health and housing professionals. In turn, this will help understand and manipulate the interaction between these complex social, economic, cultural, and environmental factors, which is needed to develop more sustainable health and housing interventions. Developing health and housing a memorandum of understanding with diverse private, public, and voluntary stakeholders has the potential to tackle these housing inequalities and dilivery more sustinable public health outcomes.
This research was supported in part by funding provided by: (a) the South West Academic Health Science Network [grant number SW AHSN G005] and the European Regional Development Fund [grant number SZ07660] for the SMARTLINE Project; (b) the Eaga Charitable Trust; (c) the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Environmental Change and Health at the London School of Hygiene and Tropical Medicine in partnership with Public Health England, and in collaboration with the University of Exeter, University College London, and the Met Office; and (d) the European Commission Horizon 2020 funded INHERIT project, coordinated by EuroHealthNet [grant number 667364].
The views expressed are those of the authors and not necessarily those of the funders or the European Commission, the NHS, NIHR, the Department of Health or Public Health England, none of whom were involved in the research design, data analysis or interpretation of findings and are not responsible for any use that may be made of the information contained within.
The Eaga Charitable Trust provides financial support for work that contributes to understanding and addressing the causes and effects of fuel poverty. It aims to promote a sound evidence base to underpin decisionmaking in relation to the public’s health and wellbeing and combatting fuel poverty. The trust encourages effective action to ensure fair access to energy services and reduced health inequalities for all groups in society.
The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Environmental Change and Health at the London School of Hygiene and Tropical Medicine in partnership with Public Health England (PHE), and in collaboration with the University of Exeter, University College London, and the Met Office. The funders had no role in the study design, analysis, interpretation of data, or decision to submit the article for publication. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, or Public Health England.
The South West Academic Health Science Network (SW AHSN) is dedicated to improving health and care, and spreading innovation across the region. It is part of a national network of 15 AHSNs, set up and part-funded by NHS England to identify, adopt, and disseminate innovative health and care. Their mission is to enable a sustainable health and care system for the South West by supporting and accelerating innovation and quality improvement.
The England European Regional Development Fund is part of the European Structural and Investment Funds Growth Programme 2014–2020. The Department for Communities and Local Government (and in London the intermediate body Greater London Authority) is the Managing Authority for European Regional Development Fund. Established by the European Union, the European Regional Development Fund helps local areas stimulate their economic development by investing in projects which will support innovation, businesses, create jobs, and local community regenerations.
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