Secular trends in improvement of housing conditions have been regarded as a major factor behind advances in population health. Research has shown the positive impact on health outcomes of interventions focused on improving conditions of existing housing. In SOPHIE, we adopted a broader vision of access to housing as a social good and one of the largest monthly costs for many EU citizens, putting the lens on the issues of fuel poverty and tenure instability.


Main findings

In Europe, housing conditions related to fuel poverty are unevenly distributed and affect health
Housing policies can reduce health inequalities
A large body of literature shows the link between inadequate housing conditions and poor physical and mental health. Access to adequate housing conditions is determined by the interaction between the housing system and the welfare state. A country's housing system is in turn the result of the interaction between the housing market and housing policies developed over time (1).

One of the important aspects of housing related to health, mainly during the economic recession, has been the presence of and increase in fuel poverty, defined as having difficulties keeping a house at a comfortable temperature and meeting its energy needs at an affordable cost. Major reviews have compiled abundant evidence on the association between fuel poverty -and related temperature and dampness-related discomfort- and cardiovascular and respiratory diseases, depression, and anxiety. Moreover, a significant percentage of elevated winter mortality may be related to fuel poverty (2).

Using 2012 European Union Statistics on income and living conditions (EU-SILC), we obtained the prevalence of poor housing conditions related with fuel poverty (dampness, house not adequately warm, arrears on utility bills) and their association with self-rated health, among the population aged 16 or over in the two lower equalised income quintiles. The data were collected from 29 European countries and by the 5 welfare state regimes in which they are classified (social democratic, corporatist, liberal, southern and transition). We also calculated the 2011-12 Excess Winter Deaths Index (EWDI) for these countries (3).

In all countries, poor housing conditions related to fuel poverty were associated with poor health, even after adjustments for material deprivation were made. These conditions are worse and the EWDI is higher in transition countries and in southern European countries mainly due to the poor quality of the housing stock, rises in fuel prices, and low levels of expenditure on housing items, particularly on instruments such as housing or fuel benefits (3). Compared to estimations for previous years, the EWDI has worsened in countries most affected by the global financial crisis such as Greece and Spain (3).

(1). Novoa AM, Bosch J, Díaz F, et al. Impact of the crisis on the relationship between housing and health. Policies for good practice to reduce inequalities in health related to housing conditions. Gac Sanit. 2014; 28 Suppl 1:44-50.

(2). Camprubí L, Malmusi D, Mehdipanah R, et al. Façade insulation retrofitting policy implementation process and its effects on health equity determinants: a realist review. Energy Policy, 2016; Apr; 91:304

(3). Bosch J, Palència L, Malmusi D, et al. Impact of fuel poverty upon self-reported health status among low-income population in Europe. Forthcoming.

Housing insulation for fuel-poor households can improve health
Energy efficiency interventions such as façade retrofitting can address fuel poverty from structural and long-term perspectives. Despite evidence of the health benefits of insulation, little is known about the political and social contexts contributing to social inequalities in receiving and benefitting from it (2).
We used a realist review methodology to better understand the mechanisms that explain how and why variations in receiving façade retrofitting interventions and in their impact on health determinants occur across different social groups. We reviewed 124 articles considering four stages of implementation: public policy approach; policy; intervention; and impact on health determinants (2).
Social groups such as low-income people, renters or elderly people who suffer most from fuel poverty experience more barriers in obtaining a building retrofitting. This is due to factors such as the inability to afford initial costs, a lack of incentives for landlords to improve energy efficiency, or (even in cases of public intervention) insufficient attention to residents' needs or preferences. Energy efficiency policies that do not address these factors may exacerbate these inequalities (2).
Housing policies can reduce health inequalities

Façade insulation in social housing and cold-related mortality in Barcelona.

The objective of this study was to evaluate the impact on the association between cold outdoor temperatures and mortality of the energy efficiency façade retrofitting of 310 poorly insulated social housing blocks in the city of Barcelona between 1986 and 2012. The design of the study was a time stratified case cross-over analysis. The impacts of the interventions were different for men and women. Although women living in a non-insulated block had a higher risk of death when exposed to extremely cold temperatures on the same day of death and the day before, these associations were not present in cases of women living in an insulated block. Associations were stronger in women aged 70-79 with no education. In men, insulation increased the risks of death 14-16 days after an extremely cold temperature day. While façade retrofitting has significantly reduced the risk of cold-related mortality in women, possible negative impacts on men should be studied (4).

(2). Camprubí L, Malmusi D, Mehdipanah R, et al. Façade insulation retrofitting policy implementation process and its effects on health equity determinants: a realist review. Energy Policy, 2016; Apr; 91:304

(4). Peralta A, Camprubí L, Borrell C, et al. Impact of three decades of energy efficiency interventions in public housing buildings on cold-related mortality in the city of Barcelona: a case-crossover analysis. Forthcoming. PPT.

Access to secure and adequate housing can improve health
A common feature of housing systems in Europe is the increase in homeownership in most countries, with rising levels of mortgage debt. In countries like Spain with low levels of social housing, the onset of the financial and economic crisis has worsened problems such as arrears, evictions and substandard housing arrangements and may have had an effect on people's health. Policies to provide affordable housing can improve socioeconomic conditions and in turn health.
In Spain, Caritas is one of the institutions focused on helping people with housing problems. Using a longitudinal study, we aimed to evaluate the effect of relocation to a new house through social programs of Caritas on health determinants and health outcomes in the Barcelona area. The sample consisted of adults from families living in substandard housing who were in need of housing relocation or who were unable to afford their mortgage or rent. They answered a questionnaire interview in 2012 and again one year later (5,6).
Housing policies can reduce health inequalities
The baseline physical and mental health status of Caritas users with housing problems was much worse than that of the general population (5). Relocated people experienced substantial improvements in housing habitability and affordability. They also improved in various health indicators, although they did it in the same way as people who had not been relocated, some of whom also had improved their housing and socioeconomic conditions. Mental health improved more in those who experienced relief regarding their precarious socioeconomic situation as well as improvements in housing conditions (6).

Foreclosures and health: people affected by mortgage in Catalonia.

Housing policies can reduce health inequalities

Since the start of the economic recession, Spain has had very high rates of foreclosures and evictions. Given this situation, organised civil society has produced the Platform for People Affected by Mortgages (PAH in Spanish), one of the most important movements in this area. A self-administered online questionnaire was completed by 905 adults belonging to PAH and living in Catalonia. We found an extremely high prevalence of poor mental health among PAH participants (87%), much higher than the general population of Catalonia (13% in the last health survey). Poor mental health was already significantly higher in the period of non-payment compared with those who were current on payment, while self-rated health status was poorer in later steps of the process such as post-eviction (7).

(5). Novoa AM, Ward J, Malmusi D, et al. How substandard dwellings and housing affordability problems are associated with poor health in a vulnerable population during the economic recession of the late 2000s. Int J Equity Health. 2015 Nov 4;14(1):120. doi: 10.1186/s12939-015-0238-z.

(6). Amat J, Malmusi D, Novoa AM, et al. Changes in housing and health in a vulnerable population Càritas Barcelona, 2015.

(7). Vásquez H, Rodríguez-Sanz M, Palència L, et al. Foreclosure and Health in Southern Europe: Results from the Platform for People Affected by Mortgages Journal of Urban Health. 2016 March, 3. doi:10.1007/s11524-016-0030-4


Policy implications

Public policies that tackle housing instability and their consequences are urgently needed in Southern European countries.

Policies on housing energy efficiency can reduce the health consequences of fuel poverty, but need to be free to users, target the most affected groups and be adapted to their needs.


Research team

Research on housing was part of Work Package 4 (Built environment and housing policies in the local context), which has been led by Giuseppe Costa and Elena Gelormino, Università di Torino.

Other the partners were Agència de Salut Pública de Barcelona, Càritas Diocesana de Barcelona and Universitat Pompeu Fabra.


Click to read the project conclusions in PDF, in

English Spanish Catalan


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