SSM - Population Health 12 (2020) 100665 Contents lists available at ScienceDirect SSM - Population Health journal homepage: http://www.elsevier.com/locate/ssmph The association of energy poverty with health, health care utilisation and medication use in southern Europe Laura Oliveras a, b, c, *, Lucia Artazcoz a, b, c, d, Carme Borrell a, b, c, d, Laia Palència a, b, d, María José López a, b, c, d, Mercè Gotsens a, b, Andrés Peralta a, e, f, Marc Marí-Dell’Olmo a, b, d a Agència de Salut Pública de Barcelona, Lesseps 1, 08023, Barcelona, Catalonia, Spain b Institut D’Investigació Biomèdica Sant Pau (IIB Sant Pau), Sant Quintí 77, 08041, Barcelona, Catalonia, Spain c Department of Experimental and Health Sciences. Universitat Pompeu Fabra, Doctor Aiguader 88, 08003, Barcelona, Catalonia, Spain d CIBER Epidemiología y Salud Pública (CIBERESP), Spain e Health Inequalities Research Group, Employment Conditions Knowledge Network (GREDS-EMCONET). Department of Political and Social Sciences. Universitat Pompeu Fabra, Ramon Trias Fargas 25-27, 08005, Barcelona, Catalonia, Spain f Johns Hopkins University - Pompeu Fabra University Public Policy Centre, Ramon Trias Fargas 25-27, 08005, Barcelona, Catalonia, Spain A R T I C L E I N F O A B S T R A C T Keywords: Energy poverty (EP) is defined as the inability of a household to secure a socially and materially required level of Energy poverty energy services in the home. The main objective of this study was to analyse the association between EP and Fuel poverty distinct indicators of health status, health services utilisation and medication use in southern Europe, using the Health city of Barcelona as a case study. Social determinants of health Health inequalities We conducted a cross-sectional study using the data of the Barcelona Health Survey for 2016 (n = 3519, 53.3% Southern Europe women). We calculated EP percentages according to age, country of birth and social class. We analysed the Urban association between EP and 26 health-related indicators through prevalence ratios (PR), and quantified the impact of EP on health at the population level by calculating the percentage of population attributable risk (PAR %). In Barcelona, 13.3% of women and 11.3% of men experienced EP. The most frequently affected groups were people born in low- and middle-income countries, those from more disadvantaged social classes, and women aged 65 years and older. We found a strong association between EP and worse health status, as well as higher use of health services and medication. For example, compared with women without EP, those with EP reported poor mental health 1.9 (95% CI: 1.6–2.4) times more frequently. Compared with men without EP, those with EP reported poor mental health 2.1 (95% CI: 1.6–2.8) times more frequently. The combination of high EP prevalence and the strong association between EP and negative health outcomes resulted in high PAR%, indicating the striking impact of EP on health and health services at the population level. EP is an important public health problem in southern European urban contexts that should be included in policy priorities in order to address its structural causes and minimise its unfair and avoidable health effects. 1. Introduction countries, recent publications have shown that the countries most affected by EP are those in southern and eastern Europe (Bouzarovski & Energy is essential for life and for safeguarding a broad range of basic Tirado Herrero, 2017; Recalde et al., 2019). Moreover, these countries human rights (Walker, 2015). Energy poverty (EP) is defined as the experienced a rapid increase in EP rates after the start of the economic inability of a household to secure a socially and materially required level crisis in 2008. In 2012, when the impact of the crisis and the policies of energy services in the home (Bouzarovski, 2014). Because of the implemented in response to it became more evident, 20.95% (inter­ increasing number of households experiencing EP in Europe, this com­ quartile range (IQR): 12.95%–25.9%) of the population of southern and plex and multidimensional problem has become a topic in policy and eastern European countries experienced EP, whereas in northern and science agendas. Although EP has mainly been studied in Anglo-Saxon central European countries the median percentage of people living in EP * Corresponding author. Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau), Sant Quintí 77, 08041, Barcelona, Catalonia, Spain. E-mail address: loliveras@santpau.cat (L. Oliveras). https://doi.org/10.1016/j.ssmph.2020.100665 Received 7 July 2020; Received in revised form 5 September 2020; Accepted 7 September 2020 Available online 10 September 2020 2352-8273/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). L. Oliveras et al. SSM - Population Health 12 (2020) 100665 was 2.1% (IQR: 2%–8.2%). Although these percentages dropped slightly were included in the Barcelona city register of inhabitants in 2016. The in 2016 (12.6% (IRQ: 6.15%–18.15%) and 3.5% (IRQ:2.3%–5.9%) survey was conducted by interview in the households of a representative respectively), the economic crisis uncovered the structural vulnerability sample of 3519 individuals (Bartoll et al., 2018). of the root causes of EP, mainly in southern and eastern European countries (Oliveras et al., 2020). 2.2. Study variables Insufficient energy for lighting, cooking, and washing and the inability to achieve a comfortable temperature at home (between 18 ◦ C The dependent variables were 26 dichotomous health-related in­ and 20 ◦ C in winter and around 25 ◦ C in summer (Ajuntament de Bar­ dicators that could be affected by EP. Indicators were selected according celona, 2018)), as well as the financial stress of being unable to pay to the literature and by subsequent consensus in a meeting with experts. energy bills, can obviously affect physical and mental health. Until now, The indicators selected were as follows: most research on this topic has been carried out in Anglo-Saxon coun­ tries, where EP has been related principally to cold housing (Marmot - Health status (13 variables): Review Team, 2011). Those studies reported that EP and low indoor • Self-reported health, dichotomised into 2 categories: good health temperatures were associated with: i) greater cardiovascular and res­ (excellent, very good or good) and poor health (fair or poor) piratory morbidity and mortality (Osman et al., 2008; Power et al., (Manor et al., 2000). This variable is known to be a good indicator 2010; Rudge & Gilchrist, 2005); ii) a higher risk of infections and minor of current overall health and a predictor of morbidity and mor­ illnesses such as colds and flu (Howden-Chapman et al., 2007); iii) tality (Idler & Benyamini, 1997; Quesnel-Vallée, 2007). exacerbation of existing health conditions such as arthritis and rheu­ • Mental health, measured using the General Health Questionnaire matism (Shortt & Rugkasa, 2007); iv) mental health problems such as (GHQ-12) and classified as either good mental health (GHQ-12 < anxiety, depression and stress (Gilbertson et al., 2012); v) a higher risk 3) or poor mental health (GHQ-12 ≥ 3) (Rocha et al., 2011). of accidents and injuries at home (Regional Public Health Group, 2009); • Quality of life, assessed through the Euroqol 5D-5L. We used a and vi) fewer dietary opportunities and choices (Bhattacharya et al., calculation adapted for the Spanish population by Ramos-Goni 2003). et al. that identifies people with and without problems To contextualise this evidence, there are substantial differences be­ (Ramos-Goñi et al., 2017). tween southern European and Anglo-Saxon countries. On the one hand, • Self-reported chronic morbidity: people completing the Barcelona southern European countries have milder winters, but warmer summers. Health Survey are asked if they suffer from any of the chronic On the other hand, there are major differences in the economic, housing disorders included on a list. Of this list we included the following 8: and energy models, which are recognised as the structural determinants high blood pressure; myocardial infarction and/or stroke; asthma; of EP (Marí-Dell’Olmo et al., 2017). For example, southern European chronic bronchitis; arthrosis, arthritis and/or rheumatism; al­ countries have higher unemployment and in-work poverty rates, less lergies; migraine or frequent headaches; diabetes. developed social protection systems, an insignificant social rental • Overweight: defined as a body mass index (obtained through self- housing stock, dwellings that are poorly insulated and without adequate reported weight and height) equal to or greater than 25. heating systems, and less active energy markets (Bouzarovski & Tirado • Domestic injuries: computed variable which included having Herrero, 2017; Csiba et al., 2016; Ferrera, 1996; Recalde et al., 2019). In experienced burns, cuts, blows and/or falls at home in the past 12 addition, like the post-socialist countries of central and eastern Europe, months. they have experienced an increase in domestic energy prices above the - Health services use (8 variables): EU average (Bouzarovski & Tirado Herrero, 2017). Although a few • Emergency services: 2 or more visits to an emergency service in the recent studies at the European level have shown that EP also negatively last 12 months. affects health in southern European countries, they have focused on a • Hospitalisations: one or more hospitalisation in the last 12 months. single or few health outcomes (Bosch et al., 2019; Oliveras et al., 2020; • Contact with other health services: people completing the Barce­ Recalde et al., 2019; Thomson et al., 2017, 2019). There is therefore a lona Health Survey are asked if they have visited any of the health need for empirical evidence on the specific health consequences of EP and social health professionals included on a list in the past 12 and what it represents for health services in the southern European months. Of these professionals, we included the following 5: pri­ setting. mary care physician, nurse, psychiatrist, psychologist, social Questions on EP were included in the Barcelona Health Survey for worker. the first time in 2016, providing a unique opportunity to explore this • Unmet medical need: if respondents reported having had in the last field using Barcelona as a case study. The city of Barcelona is a clear 12 months a health problem that they believed required medical example of how EP is becoming increasingly important in the urban attention but did not ask for it. contexts of southern Europe. In 2016, 10.6% of the city’s population - Medication use (5 variables): experienced EP (Ajuntament de Barcelona, 2018). EP has also become • People completing the Barcelona Health Survey are asked if that an explicit priority of the current city council of Barcelona (Tirado have used any of the medications included on a list in the last 2 Herrero, 2018). days. Of this list, we included the following 5 medications or group Therefore, the main objective of this study was to analyse the asso­ of medications: painkillers, allergy medication, antibiotics, asthma ciation between EP and distinct indicators of the health status, health medication, psychotropic drugs (which include tranquillisers, services utilisation, and the use of medication in the city of Barcelona in sedatives, antidepressants, and sleep medication). 2016. A secondary objective was to assess the impact of energy poverty on health, that is, the burden of poor health outcomes that can be The main independent variable was living in EP, defined as living attributed to energy poverty at the population level. in a household that could not afford to maintain the dwelling at an adequate temperature during the cold and/or warm months. 2. Methods Other covariables used were sex, age (dichotomised into <65 and ≥ 65 years), country of birth (dichotomised into high income [HI] versus 2.1. Design, study population and information source low- and middle-income [LMI] countries according to the 2018 World Bank classification) (The World Bank, 2018) and social class. Social We performed a cross-sectional study using data from the Barcelona class was based on the current or last occupation of the interviewee, or of Health Survey for 2016. The study population consisted of non- the head of the household if the interviewee had never worked, and was institutionalised individuals aged 15 years or older who resided and dichotomised into non-manual (including management positions in the 2 L. Oliveras et al. SSM - Population Health 12 (2020) 100665 public administration, large or small companies, professionals and 2.4. Supplementary analyses administrative positions, security staff and manual worker supervisors) and manual class (skilled, semi-skilled and unskilled manual workers) As a sensitive analysis, we repeated all the analyses selecting the (Domingo-Salvany et al., 2013). individuals that could not afford to meet an unforeseen expenditure of €750 with their own resources. The results can be found in the supple­ 2.3. Data analysis mentary information (S1 to S3). First, we described EP percentages according to age, country of birth 2.5. Ethical considerations and social class and used chi-square tests to detect whether the distri­ bution of EP changed depending on these axes of social inequalities. This study was approved by the Clinical Research Ethics Committee Then, we calculated the prevalence of the 26 dependent variables among of Hospital del Mar (2015/6155/l). people living with and without EP. To analyse the association between health outcomes and EP, we calculated prevalence ratios (PR) and their 95% confidence intervals (CI) using Poisson regression models with 3. Results robust variance (Barros & Hirakata, 2003; Espelt et al., 2017). These models provide correct estimates and are a preferred alternative to lo­ Table 1 shows the sex-stratified distribution of EP by age, country of gistic regression for analysing cross-sectional studies with binary out­ birth and social class. In Barcelona, 13.3% of the women and 11.3% of comes. We adjusted these models for age and social class, as both can act the men experienced EP. The most affected groups were those born in as confounders because they are related to health and EP. The Poisson LMI countries (24.7% in women and 23.0% in men), people from more models are formulated as follows: disadvantaged social classes (22.2% in women and 17.7% in men) and women aged 65 years and older (15.0%). ln(λi ) = β0 + β1 EPi + β2 AGEi + β3 SCi , where λi is the Poisson mean for each individual i (this mean approxi­ 3.1. EP and health status mates the probability of presenting the studied health outcome), β0 is the model intercept and β1, β2 and β3 are the associated coefficient to the Table 2 shows the prevalence of each of the 13 health status in­ individual variables energy poverty (EPi), age (AGEi) and social class dicators among people with and without EP, as well as the respective (SCi) respectively. crude and adjusted PR and PAR%. EP was consistently associated with Finally, to quantify the impact of EP on health at the population worse health outcomes in both women and men. In women, the stron­ level, we calculated the population attributable risk percent (PAR%). gest association was found with respiratory and cardiovascular diseases. PAR% can be interpreted as the proportion of negative health outcomes Compared with women not experiencing EP, women living in EP re­ (e.g. poor self-reported health) in the population that is attributable to ported chronic bronchitis 2.2 (95% CI: 1.3–3.6) times more frequently EP and that, theoretically, could be prevented by eliminating EP. We and myocardial infarction and/or stroke 2 (95% CI: 1.1–3.5) times more obtained PAR% adjusted by age and social class for each of the 26 health frequently. In men, the strongest association was observed in domestic outcomes directly from the Poisson regression models with robust injuries (aPR [95% CI]: 2.7 [1.5–4.7]) and poor mental health (aPR variance by subtracting the expected cases if EP were absent from the [95% CI]: 2.1 [1.6–2.8]). In both sexes, EP was strongly associated with observed cases and dividing these by the observed cases (Gefeller, 1990; more often having migraine or frequent headaches, which were 2 (95% Rückinger et al., 2009). We used the bootstrap resampling method to CI: 1.6–2.4) times more frequent in women and 1.9 (95% CI: 1.3–2.8) calculate the respective 95%CI. times more frequent in men. Women and men living in EP also self- All analyses were conducted separately for women and men and we reported poor health around 2 times more frequently than women and took into consideration the complex sample design by using sampling men without EP (aPR [95% CI]: 1.8 [1.5–2.2] and 2.0 [1.6–2.6] weights and strata. We used the R software (version 3.4.4, R Foundation respectively). As reflected by PAR% estimates, EP had a major impact on for Statistical Computing). health and well-being at the population level. For example, regarding poor mental health, 12.3% (95% CI: 7.6–17.1) of the cases in women and 12.5% (95% CI: 7.1–18.2) in men could be attributable to EP. Table 1 Energy poverty distribution by age, country of birth and social class, stratified by sex. Barcelona, 2016. Women (n = 1847) Men (n = 1629) p-valuea cases % 95%CI cases % 95%CI Total 244 13.3 (11.8–14.9) 186 11.3 (9.8–12.9) 0.076 Age (years) Less than 65 162 12.7 (10.9–14.5) 158 12.2 (10.4–14.0) 0.691 65 or more 82 15.0 (11.9–18.0) 28 8.1 (5.2–11.0) 0.003* p-valueb 0.201 0.035* Country of birth HI 159 10.7 (9.1–12.3) 116 8.7 (7.2–10.3) 0.086 LMI 85 24.7 (20.1–29.4) 70 23.0 (18.2–27.7) 0.598 p-valueb <0.001* <0.001* Social class Non-manual 64 6.1 (4.7–7.6) 57 6.3 (4.7–7.9) 0.901 Manual 162 22.2 (19.2–25.3) 124 17.7 (14.9–20.6) 0.037* p-valueb <0.001* <0.001* n: sample size; cases: number of energy poverty cases; CI: Confidence interval; HI: High income: LMI: Low and middle-income; *: statistically significant p-value (<0.05). a Chi-square test assessing sex differences within each category. b Chi-square test assessing differences between categories within each sex; there were 43 missing values in the EP indicator; the final sample consisted of 3476 individuals. 3 L. Oliveras et al. SSM - Population Health 12 (2020) 100665 Table 2 Prevalence of health status indicators among people with and without energy poverty, crude prevalence ratios (cPR), adjusted prevalence ratios (aPR) and adjusted population attributable risk percent (PAR%), stratified by sex. Barcelona, 2016. Women Energy poverty (n = 244) No energy poverty (n = 1603) c % 95%CI c % 95%CI cPR 95%CI aPR 95%CI PAR% 95%CI Poor self-reported health 113 45.3 38.9–51.6 346 21.2 19.2–23.2 2.1 1.8–2.5 1.8 1.5–2.2 10.8 7.0–14.7 Poor mental health 86 38.0 31.5–44.4 267 17.5 15.6–19.5 2.2 1.8–2.7 1.9 1.6–2.4 12.3 7.6–17.1 Poor quality of life 178 72.5 66.8–78.2 827 51.2 48.7–53.7 1.4 1.3–1.6 1.3 1.2–1.4 4.0 2.4–5.7 High blood pressure 80 31.8 26.0–37.7 321 20.1 18.0–22.1 1.6 1.3–2.0 1.4 1.2–1.8 5.9 2.3–9.6 Myocardial infarction and/or stroke 17 6.6 3.5–9.7 42 2.6 1.8–3.4 2.6 1.5–4.5 2.0 1.1–3.5 13.1 0.4–27.1 Asthma 25 10.2 6.3–14.0 81 5.0 3.9–6.1 2.0 1.3–3.1 1.6 1.0–2.5 8.1 -1.4–18.2 Chronic bronchitis 24 9.6 5.8–13.3 60 3.6 2.7–4.5 2.7 1.7–4.2 2.2 1.3–3.6 15.5 4.2–27.4 Arthrosis, arthritis, rheumatism 83 32.7 26.8–38.6 389 24.0 21.9–26.2 1.4 1.1–1.7 1.3 1.0–1.5 3.4 0.3–6.6 Allergies 59 24.0 18.6–29.5 240 15.0 13.3–16.8 1.6 1.2–2.1 1.6 1.2–2.1 7.4 2.6–12.4 Migraine or frequent headaches 91 37.7 31.5–43.9 296 18.2 16.3–20.1 2.1 1.7–2.5 2.0 1.6–2.4 11.4 7.0–15.9 Overweight 124 50.1 43.7–56.5 605 37.8 35.4–40.2 1.3 1.2–1.5 1.2 1.0–1.3 2.1 -0.2–4.5 Diabetes 32 13.2 8.9–17.5 87 5.5 4.3–6.6 2.4 1.6–3.5 1.9 1.3–2.9 12.3 3.6–21.5 Domestic injuries 23 8.6 5.2–12.0 98 5.9 4.7–7.1 1.5 0.9–2.3 1.4 0.9–2.3 4.9 -2.7–13.1 Men Energy poverty (n = 186) No energy poverty (n = 1443) c % 95%CI c % 95%CI cPR 95%CI aPR 95%CI PAR% 95%CI Poor self-reported health 57 30.1 23.5–36.8 226 15.2 13.3–17.1 2.0 1.5–2.6 2.0 1.6–2.6 10.1 5.5–15.0 Poor mental health 57 33.9 26.7–41.1 195 14.0 12.2–15.8 2.4 1.9–3.1 2.1 1.6–2.8 12.5 7.1–18.2 Poor quality of life 115 61.8 54.8–68.9 581 39.5 36.9–42.0 1.6 1.4–1.8 1.6 1.4–1.8 5.9 3.8–8.2 High blood pressure 39 21.3 15.3–27.3 274 18.8 16.7–20.8 1.1 0.8–1.5 1.4 1.0–1.9 3.4 -0.2–7.2 Myocardial infarction and/or stroke 13 6.6 3.1–10.1 71 4.6 3.6–5.7 1.4 0.8–2.5 1.6 0.9–2.9 5.3 -2.5–13.9 Asthma 20 10.7 6.2–15.1 86 6.1 4.9–7.4 1.7 1.1–2.8 1.6 1.0–2.7 6.6 -0.9–14.7 Chronic bronchitis 12 6.3 2.8–9.8 57 3.9 2.9–4.9 1.6 0.9–3.0 1.7 0.9–3.2 7.6 -2.0–18.4 Arthrosis, arthritis, rheumatism 31 16.9 11.4–22.4 165 11.0 9.4–12.6 1.5 1.1–2.2 1.9 1.3–2.7 7.8 2.7–13.4 Allergies 43 24.0 17.7–30.3 200 14.2 12.4–16.1 1.7 1.3–2.3 1.7 1.2–2.2 6.9 2.0–12.0 Migraine or frequent headaches 36 19.3 13.6–25.0 126 9.0 7.5–10.5 2.2 1.5–3.0 1.9 1.3–2.8 10.5 3.6–17.6 Overweight 109 58.4 51.2–65.5 760 52.2 49.6–54.8 1.1 1.0–1.3 1.1 0.9–1.3 1.0 -0.7–2.7 Diabetes 13 6.5 3.1–10.0 102 6.9 5.6–8.2 1.0 0.5–1.7 0.9 0.5–1.7 -1.1 -7.3–5.7 Domestic injuries 15 8.3 4.2–12.3 45 3.0 2.1–3.9 2.7 1.5–4.8 2.7 1.5–4.7 16.8 4.6–30.0 N = sample size; c = number of cases with the health outcome; CI: Confidence interval. 3.2. EP and the use of health services and medication 4. Discussion Table 3 shows the prevalence of each of the 13 health services and 4.1. Main findings medication use indicators among people with and without EP, as well as the respective crude and adjusted PR and PAR%. We observed a This study shows that EP is a major public health problem in the generalised increase in the use of general health services, such as visits urban contexts of southern Europe, such as the city of Barcelona. We to emergency services, primary care physicians, nurses and hospital­ found that Barcelona has above EU average rates of EP and with an isation in both sexes. Specialised mental health services were those most unequal distribution, affecting above all people with a more disadvan­ strongly associated with EP, especially in women with EP, who, taged social class, people born in LMI countries, and women aged 65 compared with women without EP, reported having seen a psychiatrist years and older. The results show a strong association in women and 2.5 (95% CI: 1.6–3.9) times more frequently and a psychologist 3 (95% men between EP and worse health status, as well as with a higher use of CI: 2.0–4.6) times more frequently in the last 12 months. In men, the aPR health services and medication. Because of the combination of the high (95% CI) were 2.3 (1.4–3.9) and 1.7 (0.9–3.3) respectively. Women and prevalence of EP and its strong association with poor health outcomes, men living in EP also used social work services significantly more than EP has a substantial impact on health and health services at the popu­ women and men not experiencing EP: 2.7 (95% CI: 1.7–4.1) and 3.6 lation level. (95% CI: 2.2–6.0) times more, respectively. These results translated into a significant burden on health services. We observed high PAR% esti­ 4.2. Interpretation of results mates for numerous indicators, such as social work visits, with 20.4% (95% CI: 9.7–31.6) of the visits in women and 24.4% (95% CI: We found a strong association between EP and poor self-reported 11.9–37.3) of those in men being attributable to EP. Of note, even with health. This is consistent with 3 previous European studies that have this higher use of health services, women with EP reported unmet needs also reported this association in southern European countries (Bosch 1.5 (95% CI: 1.2–1.9) times more frequently and men 1.2 (95% CI: et al., 2019; Oliveras et al., 2020; Thomson et al., 2017). So far, almost 0.9–1.6) times more frequently than people without EP. all the evidence of the negative effects of EP on health in southern Eu­ Medication use in the last 2 days was higher in women with EP than ropean countries is based on European studies at the country level that in those without. The strongest associations were found for allergy have mainly used this indicator. The present study also shows a strong medication (aPR [95%CI]: 2.5 [1.5–4.3]) and antibiotics (aPR [95%CI]: association between EP and poor mental health. In a previous European 2.8 [1.5–5.0]). In men, EP was strongly associated with asthma medi­ study, we found that the effects of EP were stronger on mental health cation (aPR [95%CI]: 2.2 [1.1–4.3]) and psychotropic drugs (aPR [95% than on self-reported health (Oliveras et al., 2020). Some Anglo-Saxon CI]: 2.0 [1.4–2.8]). studies have discussed the multiple, and sometimes short-term, mech­ anisms and pathways through which EP affects mental health, which 4 L. Oliveras et al. SSM - Population Health 12 (2020) 100665 Table 3 Prevalence of health services and medication use indicators among people with and without energy poverty, crude prevalence ratios (cPR), adjusted prevalence ratios (aPR) and adjusted population attributable risk percent (PAR%), stratified by sex. Barcelona, 2016. n= sample size; c=number of cases with the health outcome; CI: Confidence intervals; *Two or more visits to emergency services. may also apply to the southern European context. Some examples are association between EP and high blood pressure, myocardial infarction, chronic thermal discomfort, worries about energy bills, the experience stroke, asthma and chronic bronchitis. Although winters are milder in of falling into debt (or fear of it) and the absence of any solution or sense southern Europe, respiratory function appears to be impaired at tem­ of control over the problem (Anderson et al., 2012; Gilbertson et al., peratures below 16 ◦ C, while the cardiovascular system becomes 2012; Liddell & Guiney, 2015; Tod et al., 2012). In southern European impaired at temperatures below 12 ◦ C (Marmot Review Team, 2011). countries, the increase in housing insecurity and household financial Furthermore, the housing stock in southern European countries is debt in the wake of the economic crisis, which are strongly related to EP characterised by low energy efficiency and the lack of adequate heating and are also associated with poorer physical and mental health, could systems (Bouzarovski & Tirado Herrero, 2017), which can result in cold contribute to the association observed between EP and poor housing in mild winters. In Barcelona, for example, the average monthly self-reported and mental health. temperature during the winter of 2016 fluctuated between 9.7 and 13.1 Due to their strong association with cold temperatures, cardiovas­ ◦ C (Meteorològic de Catalunya, 2016) and, according to the census, cular and respiratory diseases have been the most studied EP health 48.2% of inhabitants had no central or individual heating systems effects to date (Marmot Review Team, 2011). We also found a relevant (Ajuntament de Barcelona, 2001). Moreover, the risk of harm is greater 5 L. Oliveras et al. SSM - Population Health 12 (2020) 100665 at lower temperatures, but also during longer periods of exposure to cold people experiencing difficulties in paying fuel bills (Gilbertson et al., indoor temperatures. This could explain the stronger association be­ 2012). Our study adds new and relevant evidence. The results demon­ tween EP and cardiovascular and respiratory diseases that we found in strate that people with EP more frequently use general health services, women. Due to the sexual division of work, women still bear the brunt of such as emergency services, primary health care, nursing and hospital­ the burden of care and housework, tasks that are energy intensive and isations, as well as specialised mental health services. This is consistent involve spending more time at home, whereas men spend much more with the strong association found between EP and poor mental health. time in activities outside the home. This could play a particularly Our study also reveals a higher contact with social workers in people important role in southern European countries, which are characterised with EP. In the Catalan health system, social workers liaise between by traditional family models and low levels of support for female health and social services. One of the many tasks of social services is to participation in the labour force (Artazcoz et al., 2016). issue residential exclusion risk reports. These reports prevent suppliers Furthermore, cardiovascular and respiratory problems have also from cutting off water, electricity or gas due to non-payment due to lack been linked to warm temperatures (Oudin Åström et al., 2011). Ac­ of financial resources, as prescribed by the 24/2015 Catalan law of ur­ cording to the data in this study, 12.1% of the women and 10.1% of the gent measures to tackle housing and energy poverty emergencies, pub­ men living in Barcelona could not afford to maintain their dwelling at an lished on July 29, 2015. adequate temperature during the warm months. In addition, 52.4% of This study also found significantly higher medication use in people the women and 50.4% of the men did not have air conditioning or did living in EP. The importance of this result is that questions about not use it when needed (data not shown). This finding is consistent with medication use in the 2 days prior to the survey can sometimes be a a European study showing that, although countries in southern Europe proxy of acute medical processes. The observed increase in the use of have the highest rates of air conditioning, they had higher percentages antibiotics and other drugs such as painkillers and asthma medication of the population living in a dwelling that was not comfortably cool supports the results of other studies demonstrating that people living in during summertime (Thomson et al., 2019). We believe that the asso­ EP are more at risk of infections and minor illnesses such as colds, as well ciation between EP and cardiovascular and respiratory diseases in Bar­ as of experiencing decompensations of their chronic diseases (Marmot celona is also influenced by the high vulnerability of households to heat. Review Team, 2011). A notable finding of the present study was the high This can be especially critical in the context of extreme heat events, medication use in people living in EP. In the 2 days prior to the survey, which are expected to become more common, more severe and 31.6% of the women and 19.7% of the men with EP had used psycho­ longer-lasting due to climate change (Jessel et al., 2019). tropic drugs, while for painkillers these percentages increased to 51.5% Previous studies have shown that EP can exacerbate existing condi­ in women and 45.7% in men. tions (Marmot Review Team, 2011). In this study, we found a higher A final point is that EP can increase existing health inequalities. This prevalence of arthrosis, arthritis or rheumatism, allergies, and migraine study demonstrates that, as with other material resources, access to or frequent headaches in women and men living in EP. Although this is a domestic energy services and adequate energy levels differ by several cross-sectional study and we cannot assess changes over time, those are axes of inequality such as sex, social class, age and region of birth, all conditions that can remain stable, but can be triggered by cold, heat, reducing the opportunities for good health. According to the data in this damp, mould or stress, common situations in energy poor households. In study, women without EP generally have worse health outcomes than people living in EP, these conditions may become more common and men without EP. This gender gap is further exacerbated among women therefore more frequently self-reported as chronic morbidity. and men experiencing EP. Furthermore, some social groups may be EP has also been linked to food insecurity, due to the constant particularly vulnerable to EP, such as people with no alternative but to dilemma of resource allocation and difficulties in conserving and become squatters (an increasing problem in Barcelona) or children. This cooking food (Hernández, 2016; Nord & Kantor, 2006). In the case of groups are not represented in this study and further research should try Barcelona, data from the 2016 health survey reveal that 35.9% of people to include data from these invisibilized groups. with EP experienced food insecurity compared with 4.9% of people without EP (data not shown). Dietary impoverishment and higher con­ 4.3. Methodological considerations, strengths and limitations sumption of cheap calorific food could explain the greater overweight found in women and men with EP, as well as the higher prevalence of EP is a complex multidimensional phenomenon caused by multiple diabetes in energy poor people. The cases of diabetes identified in the factors that interact with each other and configure different realities. EP survey concerned mainly people with type 2 diabetes, which is usually can be considered as part of a set of widely heterogeneous emerging acquired in adulthood and due to overweight and sedentariness. situations of inequality and precariousness that go beyond the tradi­ As in previous studies, we found an association between EP and tional framework of poverty (Subirats et al., 2005). There is growing domestic injuries, although this finding was statistically significant only concern that income-based poverty indicators are ineffective at identi­ in men. It is known that strength and dexterity decrease as temperatures fying population groups that are most at risk of being unable to meet drop, increasing the risk of unintentional injuries (Marmot Review their basic needs. A good alternative may be material hardship in­ Team, 2011). As well as cold temperatures, both heat and lack of light dicators, such as those of EP (Beverly, 2001). However, even though EP increase the risk of falls in the elderly (Marmot Review Team, 2011). In cannot be explained by income poverty alone, income remains one of its addition, people with EP sometimes have to use less safe energy sources main causes and is also strongly related to health status; consequently, it or to adapt some consumption behaviours that may also be less safe and can act as a confounder in the association between EP and health. In this increase the risk of domestic injuries. Some examples are cooking with a study, we used social class as a proxy of socioeconomic position and portable gas stove, heating water for the bath in the kitchen, restricting adjusted the models by this single variable of socioeconomic position. the use of lights or using candles to light the home, or even irregularly We saw how EP is still associated with worse health and higher use of connect to the electricity grid. In Barcelona, firemen have been involved healthcare and medication, independently of social class. Even so, a in detecting households experiencing energy poverty since 2017 and single measure of socioeconomic position cannot capture the entirety of have introduced indicators in their regular reports to identify risk situ­ its effect on health (Galobardes et al., 2006) and there probably remains ations. In the last 2.5 years, there have been reports of 1100 cases (ara. an unexplained aspect of the association found between EP and health cat, 2020). and healthcare and medication use. To ensure that income is not the There is little evidence of the effects of EP on the use of health ser­ only EP driver that explains the association found between EP and vices. Some studies have reported increased emergency respiratory negative health outcomes, we conducted a sensitivity analysis and hospital episodes among people with EP aged 65 years and older (Rudge repeated all analyses in a subgroup of people with greater financial & Gilchrist, 2007) and an increased likelihood of physician visits in difficulties, identified through their self-reported inability to meet an 6 L. Oliveras et al. SSM - Population Health 12 (2020) 100665 unforeseen expenditure of €750 with their own resources. The analysis priorities to address the structural causes of this public health problem showed how EP disproportionately affects low-income households, and minimise its unfair and avoidable health effects. increasing the percentage of people living in EP in this subgroup to almost 40% (S1). We observed that, in general the association between Declarations of interest EP and the studied health indicators decreased slightly, in some cases losing its statistical significance, but the PAR% increased (S2–S3). By None. contrast, we did not adjust the final models by country of birth because, although people born in LMI experienced much more EP, this result did Funding not modify the association with health status and the use of healthcare and medication. The study is part of the PENSA Project (“Pobreza energética y salud Studying EP as a distinct condition of deprivation has clear advan­ desde multiples perspectivas: análisis individual, geográfico y tempo­ tages. On the one hand, it helps to identify the more structural and ral”), which received a research grant from the Carlos III Institute of systemic factors that go beyond low-income, such as an inefficient and Health, Ministry of Economy and Competitiveness (Spain), awarded on substandard housing stock and the unfair and abusive energy models the 2015 call under the Health Strategy Action 2013–2016, within the (Middlemiss & Simcock, 2019). On the other hand, it can be used to National Research Program oriented to Societal Challenges, within the allow better understanding of the circumstances and mechanisms Technical, Scientific and Innovation Research National Plan 2013–2016, through which it affects health. In this study, we aimed to study health with reference PI15/02006, co-funded with European Union ERDF effects separately in households that could not afford to maintain their funds (European Regional Development Fund)”. LO was supported by a dwellings at an adequate temperature during the cold months and in Rio Hortega grant (CM19/00184 – Contratos Rio Hortega/ Fondo Social those that could not do so during the warm months. We finally analysed Europeo) from the Carlos III Institute of Health. The funders were not these groups together because we found an overlap in 68% of the cases. involved in the research and preparation of the article, including study This indicates that, although It is true that cold and hot homes are 2 design; collection, analysis, and interpretation of data; writing of the different manifestations of EP that can affect health through distinct article; nor in the decision to submit it for publication. mechanisms, they share many of the root causes such as low energy efficiency of dwellings or high energy prices. Therefore, the in­ Ethical statement terventions needed to address the difficulty of keeping the home at an adequate temperature are the same. The authors declare no conflict of interest. This study analysed the effects of EP on health and healthcare and This paper has not previously been published and no similar paper is medication use in Barcelona, a southern European urban setting. in press or under review elsewhere. Although Southern European countries share many similarities in the All authors meet authorship criteria and have contributed as speci­ structural determinants of EP (Recalde et al., 2019), other factors may fied below. affect the extrapolation of EP health implications to similar settings. The results may also not apply to rural contexts, as there are substantial CRediT authorship contribution statement differences between urban and rural contexts. For example, in cities, the heat island effect and a physical context with less green space can Laura Oliveras: Conceptualization, Methodology, Formal analysis, aggravate the effects of EP in the warmer months, while in some rural Writing - original draft. Lucia Artazcoz: Conceptualization, Methodol­ areas, winters are colder, while larger and isolated houses can be more ogy, Writing - review & editing. Carme Borrell: Conceptualization, difficult to keep at an adequate temperature. There is a need to gain Methodology, Writing - review & editing. Laia Palència: Conceptuali­ deeper insight into how EP and its effects on health are embedded in the zation, Methodology, Writing - review & editing. María José López: rural contexts of southern Europe. However, urban spaces and global Conceptualization, Methodology, Writing - review & editing. Mercè cities like Barcelona are privileged settings for studying complex re­ Gotsens: Conceptualization, Methodology, Writing - review & editing. alities and implementing and evaluating innovative and comprehensive Andrés Peralta: Conceptualization, Methodology, Writing - review & interventions. editing. Marc Marí-Dell’Olmo: Conceptualization, Methodology, Finally, is should be notice that this is a cross-sectional study and Writing - review & editing, Supervision. therefore does not allow us to prove causality or rule out reverse cau­ sality. Nevertheless, one of the main strengths of this study is that the Appendix A. Supplementary data inclusion of questions about EP in a population-based health survey allowed us to study the association of EP with multiple indicators of Supplementary data to this article can be found online at https://doi. health status and use of health services and medication. Although some org/10.1016/j.ssmph.2020.100665. of the indicators could be related to each other and this has not been studied in depth, the inclusion of all these indicators allows us to state References more robustly that EP is associated with poorer health and to quantify the strength of this association. Moreover, the results obtained in this Walker, G.. 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