Introduction
This report assesses the potential benefits of insulation against cold in the home environment. This systematic review was conducted to support the development of the World Health Organization’s (WHO) Housing and health guidelines. The aim of this systematic review is to provide the best available evidence from existing research to contribute to the deliberations of the Guideline Development Group (GDG).
The structure of this report is as follows:
Background: provides a brief contextualization of the health effects of cold.
Eligibility criteria and information on participants, intervention, comparator and outcomes (PICO): outlines the PICO for this systematic review, and provides the inclusion and exclusion criteria.
Search strategies and checking of articles: presents the process of searching and identifying articles.
Extraction of information, preparation of narrative summaries, evidence profiles and summary of findings tables: provides the process of data extraction, quality assessment, and outcomes and findings presentation.
Findings and discussion: summarises the results and discusses the findings.
Comprehensive
appendices 1–
8 present detailed information in relation to this systematic review.
Background
A range of previous research has shown that exposure to cold is deleterious to health (Mercer 2003; Nahya 2002; Wilson 2001). The purpose of this review is to contribute to discussion and decisions on the role of housing in preventing such exposure. Two previous reviews have been published including criteria relevant to the PICO for this review, but with additional criteria. Thomson et al.’s 2013 review includes a section covering interventions for “warmth and energy efficiency improvements” (Thomson 2013), while the Maidment et al. meta-analysis covers any study looking at health outcomes of energy-efficiency measures (Maidment 2014).
Thomson et al. found that the “provision of adequate and affordable space and warmth are key determinants of subsequent health and health impacts, in particular respiratory health” (Thomson 2013), while Maidment et al. found that “on average … household energy efficiency interventions led to a small but significant improvement in the health of residents” (Maidment 2014). However, these reviews effectively covered the broader issue of whether a warmer home – achieved through heating or thermal envelope improvements – is healthier, rather than the more specific question covered by this PICO, of whether housing is healthier when the thermal envelope is better at keeping out cold. The matter of indoor temperature and health is covered in a separate review informing the WHO Housing and health guidelines.
Eligibility criteria and PICO
The finalized research question for this review is:
Do people living in housing with insulation have better health outcomes than those living in housing without insulation?
Eligibility criteria were based on a reduced set of Maidment et al.’s inclusion criteria (Maidment 2014). shows the inclusion and exclusion criteria that were used for the first search in 2015. One exclusion criterion was dropped in the 2018 search as detailed in the following section.
Table 1Inclusion and exclusion criteria for the review
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| Inclusion criteria | Exclusion criteria |
|---|
| Context | Domestic houses or flats in the community setting | Studies with modelled outcomes |
|---|
| Participants | People of all age groups | |
|---|
| Intervention | Insulation (loft, cavity, internal and external solid wall insulation)
Other thermal envelope improvements (e.g. draft-stopping, double glazing, thermal curtains) | [2015 only] Studies that reported results of warmth measures without disaggregating results of thermal envelope measures from heating measures were also excluded. |
|---|
| Comparison | Absence of the relevant intervention | |
|---|
| Outcomes | Health related outcomes (as ranked by the GDG):
Respiratory morbidity and mortality All cause-mortality in infants Hospital admissions Cardiovascular morbidity and mortality Depression High blood pressure
Other outcomes were also reported because of the small number of studies | |
|---|
Search strategies and checking of articles
The constraints of time and resources involved in the conduct of this rapid systematic review means that it is not possible to explore all potential sources of information that might be drawn upon in a more comprehensive systematic review. Such activities would require extensive searching for unpublished studies and for studies reported in the grey literature or published in journals that are not well-indexed in the major bibliographic databases. However, the intention behind the search was to try to avoid missing any pivotal study which would transform the overall findings of the systematic review or the conclusions to be drawn from these findings.
Previous research had already identified the Thomson et al. 2013 Cochrane Review (Thomson 2013) and an initial literature browse using terms based on the Cochrane Review, for papers published after its final search date, identified the Maidment et al. review from 2014 (Maidment 2014).
Both reviews covered a broader range of interventions than the insulation intervention specified in this PICO. Comparison of the two reviews highlighted the fact that the Thomson et al. review covered housing improvements, and therefore excluded studies looking at existing housing conditions, which were included in the Maidment et al. meta-analysis. That meta-analysis included not only intervention studies, but also studies which compared the health of people in insulated dwellings with similar people in non-insulated dwellings (Maidment 2014).
The review presented here took the papers identified under “warmth and energy efficiency improvements” in Thomson et al. (including excluded papers) and Maidment et al. as the starting point, supplemented by a 2015 literature search for eligible papers published after the latter of the two previous reviews’ final search date, and by a 2018 search update. Supplementary literature search terms were based on the Maidment et al. and Thomson et al. searches, but limited to focus on insulation and selected outcomes; and using only the databases PubMed, Reuters Thomson Web of Knowledge and Google Scholar due to resource and time constraints. The 2015 supplementary search identified no new eligible research; the 2018 search identified five new papers.
The searches are described separately below. Decisions about the potential eligibility and need for translation of articles published in languages other than English were made on the basis of the English language abstract. It was presumed that no pivotal papers that would substantially change the findings or conclusions of the reviews would have been missed because of their publication in a language other than English. This is based on the likelihood that any such research would have found its way into the English literature or been clearly relevant from the abstract.
The retrieved records from the two previous reviews, PubMed and Reuters Thomson Web of Knowledge searches were de-duplicated before full-text screening. Google Scholar records were not de-duplicated because of technical constraints. Records retrieved from the bibliographic databases were checked twice to identify potentially relevant articles. These potentially relevant articles were then retrieved in full text, and assessed for eligibility. As expected when the searches were designed, most of the retrieved records were not relevant to this systematic review and this was obvious from scrutiny of their title or abstract. For pragmatic reasons, the reasons for the early exclusion of each of these records were not recorded. The final date for searches for the initial review was 31 March 2015.
Table 2Number of records retrieved and checked from each source
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| Search component | Records identified | Full-texts screened | Eligible studies |
|---|
| PubMed | 17 | 11 | 0 |
| Reuters Thomson Web of Knowledge | 125 | 7 | 0 |
| Google Scholar | 200 | 3 | 0 |
| Identified by previous reviews | 28 | 28 | 6 |
| Identified in 2018 update | 288 | 6 | 5 |
| Total | 658 | 55 | 11 |
In order to bring the systematic review up-to-date, new searches for eligible studies were done on 4 April 2018 to identify articles published since 1 January 2015. We used the original search strategies to re-run the searches in PubMed, Reuters Thomson Web of Knowledge, and Google Scholar. The retrieved records were checked by two authors (RL and MC) and the full text was sought for all studies judged to be potentially eligible.
In conducting the update of the review in 2018, the eligibility criteria were revised to include studies in which the installation of insulation was done as part of a home improvement package, even if the direct health effects of insulation could not be separated from the effects of other interventions in the package. This change was not dependent on the results of these additional studies, having been made in advance of the searches for publications from 2015 onwards, but was intended to broaden the scope of the eligible studies and boost the evidence base for this part of the WHO Housing and health guidelines. The revised eligibility criteria were not applied to the pre-2015 studies for reasons related to practicalities and the risk of bias: (1) the need to focus available resources on the updating of the reviews for the final guideline and (2) concern that any retrospective decision to change the eligibility might be perceived as biased because of detailed knowledge of the studies that had been gathered when excluding such studies from the original review in 2015.
The search strategies used in 2015 and 2018, including the number of articles identified in each of these, are shown in Appendices 1–3. 342 records were retrieved by the 2015 electronic searches; 28 from the previous reviews; and 288 by the 2018 update. The contribution of each of these sources is shown in .
During the search in 2015, a total of 49 full text articles were retrieved, checked for relevance and had their reference lists screened for additional potentially eligible studies. A list of the 43 articles that were obtained as potentially eligible and then excluded, along with the reason for their exclusion is provided in Appendix 4. The flow diagram for the identification of studies is shown in . The update search in 2018 led to the checking of six potentially relevant full-text articles, of which five were included in the systematic review. presents the flow of studies during the updating process.
Extraction of information, preparation of narrative summaries, evidence profiles and summary of findings tables
If an article was judged to be eligible, the following information was extracted, where available:
Location and date of study
Type and number of participants
Details of the intervention and any comparator
Design, including the methods used for any comparison
Results for all outcomes reported.
In addition, assessments were made in relation to the following characteristics based on information available in the report and using a domain approach for assessing quality:
This information was then used to complete an evidence profile for each study, along with a narrative summary (Appendix 5). Summary of Findings tables were also prepared, which describe the evidence in narrative terms, reflecting the types of study that were identified (Appendix 6).
Findings
As had been expected, only a small number of potentially eligible studies were identified for the systematic review. These studies provided evidence on the PICO ranked outcomes “respiratory illness”, “hospital admissions”, and “all-cause mortality”; the unranked PICO outcome “depression” and the related “mental health”; and also some non-PICO health outcomes, which are tabled for completeness in Appendix 7. The characteristics of the included studies are presented in Appendix 8. No studies were found covering the PICO- ranked outcomes “cardiovascular morbidity or mortality” or “high blood pressure”.
Respiratory outcomes measured were:
Self-reported respiratory symptoms over previous month (
Poortinga 2017)
Hospital admissions (all-cause) were measured in two studies (Howden-Chapman 2007; Telfar Barnard 2011); all-cause mortality (Telfar Barnard 2011, Preval 2017) in two studies using the same data; and adult mental health (Howden-Chapman 2007, Poortinga 2017) were measured in one study each.
The geographic distribution of studies was limited to Carmarthenshire, Wales, the United Kingdom (Poortinga 2017); Denmark (Iversen 1986); Greenland (Homøe 1999); Manchester, England, the United Kingdom (Tavernier 2006); New Zealand (Howden-Chapman 2007; Telfar Barnard 2011; Preval 2017) and Scotland, the United Kingdom (Austin 1997).
Interventions/exposures were:
installation of external wall insulation (
Poortinga 2017); including in combination with heating upgrades (
Grey 2017);
healthy home intervention package including air sealing, new insulation and exterior cladding, and window replacement (
Breysee 2015);
double-glazing and new boiler installation (
Bray 2017)
self-reported drafts (as proxy for insulation) (
Homøe 1999).
Risk of bias assessment
Of the 11 eligible studies, only one was judged to be of high quality. This was Howden-Chapman et al.’s randomised trial of the effects of insulation and draft-stopping on respiratory illness (Howden-Chapman 2070). Two studies were judged to be of low quality: Homøe et al 1999 had incomplete data for a self-reported indirect measure of insulation (“presence of drafts”), while Iversen et al.’s 1986 study of the effects on health of replacing windows to improve air-tightness had a high risk of selection bias.
The other eight studies, and one outcome of the Howden-Chapman study, were judged to be of medium quality. Austin and Russell 1997 had a risk of bias in its reliance on self-report of insulation status. Tavernier et al 2006 used a matched case-control study design, and self-report of “glazing system”. Telfar Barnard et al 2011 and Preval et al 2017 had some risk of bias in their selection of control members for their cohorts, and, in relation to the “all-cause mortality” outcome, risk of treatment bias, since decision to insulate could be modified by severity of health status. Poortinga et al.’s 2017 study was not randomized, and may have included some effect from non-insulation interventions installed at the same time. In Bray 2017, Breysse 2015, and Grey 2017, the results are also likely to have included effects of non-insulation co-interventions. The sample size in Howden-Chapman et al. 2007 was insufficient to measure an effect on hospital admissions.
Effects of an insulated home on health outcomes
Of the 11 studies identified in the systematic review, seven found some association between the benefits of living in an insulated home and improved health. For example, a cluster randomized trial in New Zealand on the effect of insulating existing homes where at least one person in the household had existing chronic respiratory symptoms found that insulation was associated with reduced odds of poor mental health, self-reported wheezing in the past three months, winter colds or flu, and morning phlegm in adults (Howden-Chapman 2007).
While mental health was improved in one controlled trial from the United States of America, the study did not find any differences in general health status between people receiving new insulation and exterior cladding and those in the control group (Breysse 2015). One quasi-experimental study from the United Kingdom found no difference between asthmatic and healthy children with regard to different glazing systems (Tavernier 2006). Another quasi-experimental study in New Zealand found that all-cause mortality was significantly lower in people with a history of cardiovascular disease if they lived in an insulated rather than an uninsulated house and non-significantly lower in people with a history of respiratory disease (Preval 2017). Similarly, a controlled trial from the United Kingdom did not detect any effect of external insulation on general respiratory symptoms, asthma, physical or mental health or subjective well-being (Grey 2017).
A cross-sectional study from the United Kingdom investigated the effects of different types of insulation on a range of health outcomes (Poortinga 2017). The study identified positive effects of loft and external wall insulation on respiratory, mental and general health; but found a negative impact on these outcomes with cavity wall insulation.
Three retrospective cohort studies investigated the effects of living in an insulated home on health. A New Zealand study of 45 000 households, with matched controls, showed no relationship between living in an insulated home and rates of hospitalization. However, mortality rates for adults aged 65 and over who had previously been hospitalized for circulatory illness were lower for people living in insulated dwellings (Telfar Barnard 2011). A study from Scotland, looking at the indoor environment and health outcomes as reported by participants, found that rates of coughing were significantly lower in homes with double-glazed windows but no consistent relationship between wheezing and coughing, and insulation (Austin 1997). A study from Greenland, of households with children aged three to five and eight years who had a previous medical attendance for acute otitis media, found no relationship between episodes of acute otitis media and self-reported poor insulation, defined as “reports of draft along the floors and through doors and windows” (Homøe 1999). An historical cohort study conducted in the United Kingdom reported that double glazing improved the household health status by 4.8% but did not detect effects on quality of life or other measures of well-being (Bray 2017).
One case-control study from Denmark, which had a high risk of bias, found that eye irritation and throat dryness (connected to respiratory health) decreased slightly when windows were replaced, but the results were not statistically significant (Iversen 1986).
Discussion
In summary, of the measured insulation interventions and exposures, installation of ceiling and underfloor insulation and draft-stopping reduced wheeze, likelihood of low self-reported happiness, and all-cause mortality; new windows and doors, loft insulation, and external wall insulation were each associated with reduced respiratory symptoms and improved mental health; and self-reported double-glazing was associated with lower likelihood of current cough. Insulation as part of energy efficiency packages improved general health status, hospital visits, and mental health. Cavity wall insulation, however, was associated with increased respiratory symptoms and worsened mental health. Other interventions or exposures had no statistically significant effect on, nor association with, other health outcomes.
Note
As the single high quality study found for this review also included effects on indoor temperatures, it may be better considered as part of the evidence for the beneficial effect of preventing cold temperatures indoors, in the Cold PECO.
Contributors
Lead: Lucy Telfar Barnard (University of Otago, Wellington and He Kainga Oranga/Housing and Health Research Programme, New Zealand).
Team: Philippa Howden-Chapman (University of Otago, Wellington and He Kainga Oranga/Housing and Health Research Programme, New Zealand), Mike Clarke (Queen’s University of Belfast, Northern Ireland and Evidence Aid, United Kingdom), Ramona Ludolph (Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Switzerland).
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Appendices
Appendix 1. Search strategy for PubMed (including MEDLINE)
2015 search
(insulation OR insulate OR “double glaze” OR “double glazing”) AND (home OR homes OR house OR houses OR housing)
Limited to humans
Limited to publication date 2012/07/01 to 2015/01/01
This search returned 17 results for title screening. Eleven were selected for full-text screening. None of the 11 met eligibility criteria for the review.
2018 update
Date of search: 2018-04-04
(insulation OR insulate OR “double glaze” OR “double glazing”) AND (home OR homes OR house OR houses OR housing)
Limited to humans
Limited to publication date 2015/01/01 to 2018/12/31
This search returned 18 results. After deduplication, 16 results remained for title and abstract screening.
Appendix 2. Search strategy for Thomson Reuters Web of Knowledge
2015 search
((insulation OR insulate OR “double glaze” OR “double glazing”) AND (home OR homes OR house OR houses OR housing)) AND
TOPIC: (reduc* or improve* or decreas* or evaluat* or change* or changing or intervention* or grow* or better or worse* or effect* or achieve* or comfort or morale or harmful or impact* or gain) AND
TOPIC: (health or wellbeing or “well-being” or anxiety or mental or depression or stress or happiness or distress)
Refined by: PUBLICATION YEARS: (2014 OR 2013 OR 2012 OR 2015)
Timespan: 2012–2015.
Search language=Auto
Returned 125 results; of these, 30 were selected for abstract screening. Thirteen of these 30 were duplicates. Of the remaining 17, seven were selected for full-text review. None met eligibility criteria.
2018 update
Date of search: 4 April 2018
((insulation OR insulate OR “double glaze” OR “double glazing”) AND (home OR homes OR house OR houses OR housing)) AND
TOPIC: (reduc* or improve* or decreas* or evaluat* or change* or changing or intervention* or grow* or better or worse* or effect* or achieve* or comfort or morale or harmful or impact* or gain) AND
TOPIC: (health or wellbeing or “well-being” or anxiety or mental or depression or stress or happiness or distress)
Refined by: PUBLICATION YEARS: (2015 OR 2016 OR 2017 OR 2018)
Timespan: 2015–2018.
Search language=Auto
Returned 89 results, 77 of which remained after deduplication.
Appendix 3. Search strategies for Google Scholar
2015 search
insulate AND (home OR house) AND (reduce OR improve OR decrease OR evaluate OR change OR intervention OR better OR worse OR effect OR impact OR gain) AND (health OR wellbeing OR anxiety OR mental OR depression OR stress OR happiness OR distress)
Date range 2012 to March 2015 inclusive
Returned 17 000 results. Results were sorted by relevance and the first 10 pages (100 records) were screened by title. Four results were selected for abstract/summary screening. None were selected for full-text screening.
“double glazing” AND (home OR house) AND (reduce OR improve OR decrease OR evaluate OR change OR intervention OR better OR worse OR effect OR impact OR gain) AND (health OR wellbeing OR anxiety OR mental OR depression OR stress OR happiness OR distress)
Date range 2012 to March 2015 inclusive.
Returned 1740 results. Results were sorted by relevance and the first 10 pages (100 records) were screened by title. Nine results were selected for abstract/summary screening. three results were selected for full text screening. None of these three met eligibility criteria.
2018 update
Date of both searches: 2018-04-04
insulate AND (home OR house) AND (reduce OR improve OR decrease OR evaluate OR change OR intervention OR better OR worse OR effect OR impact OR gain) AND (health OR wellbeing OR anxiety OR mental OR depression OR stress OR happiness OR distress)
Date range 2015 to 2018.
Returned 17 300 results. Results were sorted by relevance and the first 10 pages (100 records) were screened by title.
Eight results were selected for abstract/summary screening. None were selected for full text screening.
“double glazing” AND (home OR house) AND (reduce OR improve OR decrease OR evaluate OR change OR intervention OR better OR worse OR effect OR impact OR gain) AND (health OR wellbeing OR anxiety OR mental OR depression OR stress OR happiness OR distress)
Date range 2015 to 2018.
Returned 1990 results. Results were sorted by relevance and the first 10 pages (100 records) were screened by title.
Four results were selected for abstract/summary screening. None of these were selected for full text screening.
Appendix 4. Articles excluded following check of the full text in 2015
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| Reason for exclusion |
|---|
| Author(s) | Population | Study design | Intervention | Comparator | Outcome | Other | Notes |
|---|
| Thomson et al | | | | | | | |
|---|
| Barton et al 2007 (M) | | | X | | | | Insulation intervention could not be separated from package |
| Broder et al 1991 (M) | | | X | X | | | Intervention was replacing UFFI insulation with other insulation, for formaldehyde not temperature |
| Eick 2001 (T) | | | X | | | | Ventilation, not insulation intervention |
| El Ansari 2008 (T) | | | X | | | | Study does not specify what improvements were implemented; insulation not separate from total package |
| Heyman et al 2005 (M) | | | X | | | | Insulation intervention could not be separated from package |
| Infante-Rivard 1993 (M) | | | | X | | | Not clear whether comparator was “no insulation” or insulation other than mineral wool/UFFI |
| Lloyd et al 2008 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Norman et al 1986 (M) | | | | X | | | UFFI insulation; comparator is combined other/no insulation |
| Shortt and Rugkasa 2007 (M) | | | X | | | | Insulation intervention could not be separated from package |
| Vandentorren et al 1991 (M) | | | | | X | | Insulation measured as risk for heat-related death |
| Osman 2010 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Platt 2007 (T) | | | X | | | | Heating intervention |
| Somerville 2000 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Hopton 1996 (T) | | | X | | | | Heating intervention |
| Allen 2005 (Ta) | | | X | | | | Insulation intervention could not be separated from package |
| Health Action Kirklees (T) | | | X | | | | Heating intervention |
| Caldwell 2001 (T) | | | X | | | | Insulation intervention could not be separated from package [N.B. original could not be accessed, assessment based on Thompson summary] |
| Green 1999 (T) | | | | X | | | No assessment of change |
| Roder 2008 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Warm Front 2008 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Winder 2003 (T) | | | X | | | | Insulation intervention could not be separated from package |
| Windle et al 2006 (M) | | | | | X | | Outcome (self-reported general health) was not included in PICO outcomes |
| PubMed | | | | | | | |
|---|
| Amundsen 2013 | | | X | | | | Insulation against noise: no thermal effects measured |
| Bright 2013 | X | X | | X | | | Single case report |
| Huang 2014 | | | X | X | | | Measures faulty application of spray polyurethane foam insulation |
| Jiránek 2014 | X | | | | X | | Effect of thermal retrofitting on radon concentration; direct health effects not measured |
| Laaidi 2013 | | | X | | | | No novel study of insulation |
| Madden 2014 | | | | | X | | No outcome measure |
| Mesa-Frias 2013 | | X | | | | | No novel study of insulation |
| Spear 2012 | | | | X | X | | No health effects reported; not comparing insulated with uninsulated |
| Valsecchi 2014 | | | | | | X | Proposed action, no results |
| Viggers 2013 | | | | | X | | Results not yet available |
| Yarmoshenko 2014 | | | X | X | X | | Measurements of radon concentration only |
| Web of Science | | | | | | | |
|---|
| Liddell 2015 | | | | | | X | Review of other studies; conclusions do not distinguish between insulation and other energy efficiency measures |
| Curl 2015 | | | X | | | | Insulation intervention (if any) could not be separated from package |
| Rivier 2014 | | | | | X | | No health outcomes reported |
| Wilson 2014 | | | X | | | | Insulation intervention could not be separated from package |
| Braubach 2013 | | | | | | | No novel study of insulation |
| Chungkumho 2013 | | | | | | X | No translation available; not clear from abstract that translation warranted |
| Hu 2012 | | | | | X | | Only published as abstract; no health data mentioned |
| Google scholar | | | | | | | |
|---|
| Sowden 2014 | | | X | | | | Insulation intervention could not be separated from package |
| Santamouris 2014 | | | | | | X | Reported health results not disaggregated by insulation levels |
| Cotter 2012 | | | | | | X | Reported illness not disaggregated by insulation status |
Appendix 5. Evidence profiles for potentially eligible insulation studies, with narrative summaries for each study
Download PDF (425K)
Narrative summaries
- 1.
Austin J, Russell G. Wheeze, cough, atopy and indoor environment in the Scottish Highlands. Archives of Disease in Childhood 1997;76:22–26
This retrospective cohort study surveyed parents to measure associations between self- reported wheeze, and cough and self-reported indoor environment, including roof, cavity and wall insulation, and double glazing. The authors found no consistent relationship between respiratory symptoms and insulation. Rates of cough were significantly lower in homes with double glazing (RR 0.675, 95% CI 0.486–0.936, p=0.018). The authors query whether the – 14 years age range of included children was beyond the age at which household conditions affect the measured health outcomes.
- 2.
Breysse J, Dixon SL, Jacobs DE, t al. Self-reported health outcomes associated with green-renovated public housing among primarily elderly residents. J Public Health Manage Pract 2015; 21(4): 355–67
This quasi-experimental study compared self-reported mental health, physical health and falls before and after an extensive “green renovation” package including new insulation and exterior cladding, air sealing and window replacement. The authors found improvements in self-reported good mental health days (p=0.026), VR-12 mental component score (p=0.023), and a non-significant reduction in falls (p=0.055) and general physical health (p=0.094).
- 3.
Bray N, Burns P, Jones A, et al. Costs and outcomes of improving population health through better social housing: a cohort study and economic analysis. Int J Public Health 2017; 62: 1039–50
In this cohort study, participants received a new boiler and double-glazing. The authors found household health status improved by 3.25% (p=0.009), the main tenant health status improved by 4.85% (p<0.001), and hospital visits declined for outpatients (p=0.001) and accident and emergency (p=0.012). There was no significant effect on main tenant quality of life.
- 4.
Grey CNB, Jiang S, Nascimento C, et al. The short-term health and psychosocial impacts of domestic energy efficiency investments in low-income areas: a controlled before and after study. BMC Public Health 2017; 17: 140
This quasi-experimental study examined health outcomes of adults receiving a home energy performance package including external wall insulation and heating upgrades. Compared to a control group, participants’ subjective well-being improved (p=0.005), but results for mental health, physical health, general respiratory symptoms and asthma symptoms were non- significant.
- 5.
Homøe P, Christensen R, Bretlau P. Acute otitis media and socio-medical risk factors among selected children in Greenalnd. International Journal of Pediatric Otorhinolaryngology 1999;49(1):37–52
This study measured socioeconomic risk factors, including parental-reported poor/good insulation, defined as “reports of draft along the floors and through doors and windows”, in Greenlandic children aged 3–5 and 8 who had a previous medical attendance for acute otitis media (AOM). The insulation standard variable was less likely to be reported than other variables, and was an indirect measure of insulation. Insulation standard showed no relationship with episodes of AOM.
- 6.
Howden-Chapman P, Matheson A, Crane J, et al. Effect of insulating existing houses on health inequality: cluster randomized study in the community. British Medical Journal 2007(334):460
This RCT study measured changes in self-reported wheeze and days off school or work; GP-reported doctors’ visits, and national patient identifier-linked hospital admissions following draft-stopping and installation of ceiling and under-floor insulation, in low-income households. The results of the intervention for PCIO outcomes were: self reports of wheezing in the past three months (0.57, 0.47 - 0.70), Hospital admissions for respiratory conditions were also reduced (0.53, 0.22 - 1.29), but this reduction was not statistically significant (P=0.16). Also PICO-relevant was the finding that mean temperatures were raised 5°C, and RH reduced 2.3% in bedrooms. Non-PICO health outcomes were reduced odds of fair or poor self rated health (adjusted odds ratio 0.50, 95% CI 0.38 - 0.68), self reports of children taking a day off school (0.49, 0.31 - 0.80), self reports of adults taking a day off work 62, 0.46 - 0.83), and self-reports of visits to general practitioners (0.73, 0.62 - 0.87).
- 7.
Iversen M, Back E, Lundqvist G. Health and comfort changes among tenants after retrofitting of their housing. Environment International 1986;12:1–4
This study used a questionnaire to measure differences in two less direct respiratory symptoms, eye irritation and dry throat between people who had had windows replaced, and people who had not. ORs for all symptoms were lower, but confidence intervals were not reported; few were significant, and which few were not reported. There was also high risk of selection bias.
- 8.
Poortinga N, Jones N, Lannon S, Jenkins H. Social and health outcomes following upgrades to a national housing standard: a multilevel analysis of a five-wave repeated cross-sectional survey. BMC Public Health 2017; 17: 927
This cross-sectional study measured differences in self-reported respiratory symptoms, mental health, and general health following installation of new windows and doors; loft insulation, cavity wall insulation, or external wall insulation. New windows and doors, loft insulation and external wall insulation were each associated with improved respiratory symptoms and mental health; and external wall insulation was also associated with improved general health. Cavity wall insulation, however, was associated with worsened mental health, respiratory symptoms and general health.
- 9.
Preval N, Keall M, Telfar-Barnard L, et al. Impact of improved insulation and heating on mortality risk of older cohort members with prior cardiovascular or respiratory hospitalisations. BMJ Open 2017;7:e018079. doi:10.1136/bmjopen-2017-018079
This quasi-experimental retrospective cohort study measured post-intervention mortality rates for adults aged 65+ who had previously been hospitalized for respiratory or circulatory illness. Mortality rates in the insulated group were lower for those previously hospitalized for circulatory illness, but not significantly different for those previously hospitalized for respiratory illness. Despite matching, there remains potential bias for the mortality result, in that installing insulation may have reflected better health and/or socioeconomic circumstances.
- 10.
Tavernier G, Gletcher G, Gee I, et al. IPEADAM study: indoor endotoxin exposure, family status, and some housing characteristics in English children. Journal of Allergy and Clinical Immunology 2006;117:656–62
This matched case-control study measured differences in GP-diagnosed asthma rates using a questionnaire-assessed measure of household glazing systems. There was no difference between asthmatic and healthy children in their exposure to different glazing systems.
- 11.
Telfar Barnard L, Preval N, Howden-Chapman P, et al. The Impact of Retrofitted Insulation and New Heaters on Health Services Utilisation and Costs, Pharmaceutical Costs and Mortality: Evaluation of Warm Up New Zealand: Heat Smart. Report to the Ministry of Economic Development. Wellington, 2011
This retrospective cohort study measured differences in hospitalization and pharmaceutical use before and after subsidized insulation was installed, comparing insulated dwellings with control dwellings; and post-treatment mortality rates for adults aged 65+ who had previously been hospitalized for respiratory or circulatory illness. Insulation showed no relationship with rates of hospitalization or pharmaceutical use, though costs were lower. Mortality rates for those previously hospitalized for circulatory illness were lower in the insulated group. Despite matching, there remains potential bias for the mortality result, in that installing insulation may have reflected better health and/or socioeconomic circumstances.
Appendix 7. Non-PICO-ranked health outcomes
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Appendix 8. Characteristics of included studies
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