1. 1 Name: Louise M Tanner Organisation: Newcastle University Research funder: ESRC (North-East Doctoral Training Centre)

2. Outline 1. Background 2. Methods 3. Results 4. Discussion 2

3. Background (i): Excess Winter Mortality Mortality rates in many countries are higher during the winter period (December to March / June to September) than at other times of the year. Deaths mainly attributable to cardiovascular and respiratory illnesses. Spatial and temporal variations in excess winter mortalities ‘Paradox of EWM’. 1 Causes not fully understood. 3

4. Research context (ii): wider health and social impacts Indirect health effects include: Impaired nutrition and lifestyle choices (‘heat or eat’; social exclusion); Immune suppression; Exacerbation of existing illnesses; Impact on emotional health and wellbeing; Effects felt across the lifespan. Wider socio-economic costs:  Cold housing associated with educational under-attainment, fuelling a cycle of poverty in poorer communities. 2-3  Costs to the NHS in treating people suffering from a wide range of illnesses linked directly to living in cold, damp and often dangerous homes: > £2bn a year. 2-3  Cost of police responses to crimes associated with substandard housing: ~£1.8bn a year. 2-3 4

5. Background (iii): Socio-economic and behavioural risk factors. Complex interplay of risk factors, some of which are modifiable Socio-economic and housing factors: Measures of socio-economic status and deprivation Housing: condition, thermal efficiency, location, occupancy and tenure Fuel poverty Behavioural factors: Physical activity levels Smoking Clothing Diet Excursion patterns Vaccination status 5

6. Research aims / plan 1. A systematic review to identifying key socio-economic and behavioural risk factors for adverse winter health and social outcomes 2. Development of a theoretical model of causal pathways 3. Test and refine the model using existing datasets. 4. Model the impact of interventions. 6

7. Methods (i) Searches Systematic methods used to identify, synthesise and evaluate quantitative, observational research Medical, social science and grey literature sources; expert contacts. Key words relating to climatic and mediators. Outcomes not specified. 7

8. Methods (ii) Inclusion criteria: Primary observational studies and systematic reviews Quantify associations between cold exposure, SE/Housing/behavioural factors and health or social outcomes. Published 2001-11 in English 8

9. Results (i) 2745 unduplicated records identified; titles and abstracts screened for relevance 365 full texts screened against inclusion criteria 33 records included in review 9

10. Results (ii) Low income, Fuel Poverty; low indoor temperature and poor thermal efficiency were most consistently associated with adverse health outcomes. Most studies conducted in the UK, Northern Europe or New Zealand. Socio-demographic effect modifiers identified: age, (female) sex, health status, smoking status, psychological variables. 10

11. Discussion Review identified socio-economic, housing and behavioural factors associated with adverse winter health outcomes. Limitations: heterogeneous studies – hard to generalize results; exclusion of qualitative and intervention studies; study limitations, see below Further research: individual level studies, larger samples, longer duration, more control for confounders, wider socio-economic impacts. 11

12. Populated model… 12

13. Questions or Comments? 13

14. References 1. Healy, JD. Excess winter mortality in Europe: a cross country analysis identifying key risk factors. J Epidemiol Community Health. 2003;57:784-9. 2. Friedman D. Social impact of poor housing. Friedman, Ecotec March 2010 Available from: http://www.settledhousing.co.uk/Portals/0/Socialmpactpoorhousing%5B1% 5D.pdf (Accessed 19 11 2012) 3. Mawle A. Healthy Housing, Healthy People? Presented at the Keeping Warm in Later Life conference, Rotherham. 2011. Available from: http://www.kwillt.org/index.php/consultation-event (accessed 20 October 2011). http://www.kwillt.org/index.php/consultation-event 14

15. Additional references (i) Telfar-Barnard LF, Baker MG, Hales S, Howden-Chapman PL. Excess Winter Morbidity and Mortality: Do Housing and Socio-Economic Status Have an Effect? Reviews on Environmental Health 2008;23:203- Thomson H, Thomas S, Sellstrom E, et al. The Health Impacts of Housing Improvement: A Systematic Review of Intervention Studies From 1887 to 2007. Am J Public Health 2009;99:S681-92. Lawlor D A, Maxwell R, Wheeler B W. Rurality, deprivation, and excess winter mortality: an ecological study J Epidemiol Community Health 2002;56:373-374 Goodwin J, Taylor RS and Pearce VR. Seasonal cold, excursional behaviour, clothing protection and physical activity in young and old adults. Int J Health 2000; 59: 195-203. 15

16. Additional references (ii) Wilkinson P, Pattenden S, Armstrong B, Fletcher, A, Kovats RS, Mangtani P and McMichael AJ. Vulnerability to winter mortality in elderly people in Britain: population based study. BMJ 2004; 329: 647. Donaldson GC, Rintamaki H and Nayha S Outdoor clothing: its relationship to geography, climate, behaviour and cold-related mortality in Europe. International Journal of Biometeorology 2001; 45: 45-51. International Journal of Biometeorology 16