title: Fuel poverty increases risk of mould contamination, regardless of adult risk perception & ventilation in social housing properties.
abstract: BACKGROUND
  Fuel poverty affects 2.4 million UK homes leading to poor hygrothermal conditions and risk of mould and house dust mite contaminations, which in turn increases risk of asthma exacerbation. For the first time we assess how fuel poverty, occupants' risk perception and use of mechanical ventilation mediate the risk of mould contamination in social housing.
  
  
  METHODS
  Postal questionnaires were sent to 3867 social housing properties to collect adult risk perception, and demographic and environmental information on occupants. Participant details were linked to data pertaining to the individual properties. Multiple logistic regression was used to calculate odds ratios and confidence intervals while allowing for clustering of individuals coming from the same housing estate. We used Structured Equation Modelling and Goodness of Fit analysis in mediation analyses to examine the role of fuel poverty, risk perception, use of ventilation and energy efficiency.
  
  
  RESULTS
  Eighteen percent of our target social housing populations (671 households) were included into our study. High risk perception (score of 8-10) was associated with reduced risk of mould contamination in the bedrooms of children (OR 0.5 95% CI; 0.3-0.9) and adults (OR 0.4 95% CI; 0.3-0.7). High risk perception of living with inadequate heating and ventilation reduced the risk of mould contamination (OR 0.5 95% CI; 0.3-0.8 and OR 0.5 95% CI; 0.3-0.7, respectively). Participants living with inadequate heating and not heating due to the cost of fuel had an increased risk of mould contamination (OR 3.4 95% CI; 2.0-5.8 and OR 2.2 95% CI; 1.5-3.2, respectively). Increased risk perception and use of extractor fans did not mediate the association between fuel poverty behaviours and increased risk of mould contamination.
  
  
  CONCLUSIONS
  Fuel poverty behaviours increased the risk of mould contamination, which corresponds with existing literature. For the first time we used mediation analysis to assess how this association maybe modified by occupant behaviours. Increased risk perception and use of extractor fans did not modify the association between fuel poverty and mould contamination. This suggests that fuel poor populations may not benefit from energy efficiency interventions due to ineffective heating and ventilation practices of those occupants residing participating households. Our findings may be modified by a complex interaction between occupant behaviours and the built environment. We found that participant age, occupancy, SES, pets, drying washing indoors, geographic location, architectural design/age of the property, levels of insulation and type of heating regulated risk of mould contamination.
  
  
  CONCLUSIONS
  Fuel poverty behaviours affected around a third of participating households and represent a risk factor for increased exposures to damp and mouldy conditions, regardless of adult risk perception, heating and ventilation practices. This requires multidisciplinary approach to assess the complex interaction between occupant behaviours, risk perception, the built environment and the effective use of heating and ventilation practices.
  
  
  BACKGROUND
  Our findings have implications for housing policies and future housing interventions. Effective communication strategies focusing on awareness and perception of risk may help address indoor air quality issues. This must be supported by improved household energy efficiency with the provision of more effective heating and ventilation strategies, specifically to help alleviate those suffering from fuel poverty.
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, United Kingdom.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Sharpe
authors.affiliation: College of Life and Environmental Sciences, University of Exeter, Stocker Road, Exeter EX4 4QD, United Kingdom.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Thornton
authors.affiliation: University of Exeter Medical School, The Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, United Kingdom.
authors.forename: Vasilis
authors.initials: V
authors.lastname: Nikolaou
authors.affiliation: European Centre for Environment and Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, United Kingdom; Department of Paediatrics, University of Melbourne, Flemington Road, Parkville, Melbourne, Australia; Department of Clinical Pharmacology, Sydney Medical School, University of Sydney, Australia. Electronic address: n.j.osborne@exeter.ac.uk.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Osborne
mesh_terms: D000328:Adult; D000368:Aged; D016902:Air Pollution, Indoor / Q000032:analysis*; D003080:Cold Temperature / Q000009:adverse effects; D003430:Cross-Sectional Studies; D005260:Female; D005658:Fungi / Q000302:isolation & purification*; D007722:Health Knowledge, Attitudes, Practice; D006361:Heating / Q000191:economics*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011203:Poverty; D011638:Public Housing; D012306:Risk; D012307:Risk Factors; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D006113:United Kingdom; D014691:Ventilation / Q000592:standards*
keywords: Asthma; Fuel poverty; Health; Mould; Risk; Ventilation