Impact assessment

Adverse weather and health plan equity review and impact assessment 2024

Published 21 March 2024

Executive summary

This review supports UKHSA’s requirement under the Public Sector Equality Duty (PSED) to report on the potential impacts of the Adverse Weather and Health Plan (AWHP) on different populations. It applies NHS England’s CORE20PLUS framework to identify populations at risk (including those with protected characteristics).

The review considers:

• population characteristics contributing to this risk
• differences in how people engage with information on risk
• differences in how and why people are mobilised to act on information provided to them

The review shows that evidence on risk by population is variable both in quantity and robustness. It also shows that there is currently either no, or very little, research to support informed assessment of risks for many groups.

There is clear evidence of increased risk from heat and cold exposure for some populations (for example, those with certain long-term health conditions and older adults). Those who are socioeconomically deprived are at greater risk from all hazards. There are some groups (for example, those with multiple overlapping vulnerabilities) for whom it is reasonable to assume significantly increased risk compared with the general population

There is no evidence in the literature considered in this review to suggest greater risk for other groups (defined according to marital status, religion or belief for example). However, absence of evidence does not necessarily mean an absence of risk.

The UKHSA has consulted and engaged with stakeholders representing some at-risk populations, and at-risk individuals themselves, in formulating the AWHP and its supporting materials. We have focused particularly on those known to be at risk, especially older adults. We will continue this consultation and engagement work to include a broader range of at-risk groups for future versions of this review.

Variations in risk from adverse weather exposure are addressed to some degree through the design of the Weather-Health Alerting system that underpins the AWHP. They are particularly addressed through guidance materials, and through recommendations for professionals working with a range of at-risk populations on specific measures to protect these individuals.

There are known variations in how different population groups perceive risks from adverse weather, and the extent to which they may be mobilised to act as a result. Guidance for the public already published alongside the AWHP has benefitted from behavioural science research work undertaken by UKHSA to help address this. Future work under the AWHP will aim to extend and improve understanding of these variations, and how they can be addressed.

The review outlines a series of next steps spanning work to improve understanding of vulnerability and sources of resilience to adverse weather between different populations; strengthened mechanisms for consultation and engagement; and better monitoring and evaluation.

Introduction

The UKHSA Adverse Weather and Health Plan (AWHP) was published in April 2023 and aims to protect everyone from the health effects of adverse weather, and to build community resilience. It builds on existing measures taken by the UK government, its agencies, NHS England, and local authorities. It is an ambitious plan which seeks to support local and national organisations to prepare, build, and respond to future adverse weather events to protect lives and promote health and wellbeing.

The impacts of adverse weather events can affect everyone and can influence many aspects, including health. However, the extent to which individuals, communities and populations experience the negative health impacts of adverse weather events will vary based on their ability to adapt to the stressors imposed by such events. Certain populations face a disproportionate burden of the adverse health outcomes as a result. Understanding the concerns of these populations as well as factors that underpin their vulnerability to adverse weather events helps to inform the appropriate societal and national responses needed to reduce adverse health outcomes.

These considerations also extend to health and social care professionals (and others) whose responsibilities include the care of people at higher risk from adverse weather. These professionals may themselves experience adverse effects that influence the comprehensiveness and quality of care that they are able to provide.

An equity review enables the evaluation of health inequalities related to a programme of work (in this case, the AWHP) and identifies the action that can be taken to reduce health inequalities and promote equity and inclusion. This review considers the role of the AWHP in reducing the differential health impacts of adverse weather.

Aim and objectives of the equity review

The aim of this review is to identify population groups that may be disproportionately affected by the AWHP and to make appropriate recommendations to mitigate potential inequity in the application of the AWHP and its related materials to reduce inequalities in outcomes from the adverse weather.

The review’s objectives are to:

• examine the available evidence on the differential impact of adverse weather on health to understand which population groups are most at-risk
• assess the mechanisms by and extent to which various groups, particularly those facing inequity or disparity, are likely to be impacted by the implementation of the AWHP and related materials
• assess the extent to which the AWHP addresses the identified inequities
• identify mitigations to reduce the remaining identified health inequities
• identify areas for future work to support future iterations of the AWHP and the Equity Review, including developing new evaluation methodologies to improve understanding of how action on adverse weather can influence health impacts

Policy and legal context for the review

Adverse Weather and Health Plan

The first edition of the Adverse Weather and Health Plan (AWHP) delivered UKHSA’s commitment under the third National Adaptation Programme to develop a single plan, bringing together and improving current guidance on weather and health. The plan built on the previous Heatwave Plan for England, first published in 2004, and the Cold Weather Plan for England, first published in 2011.

This Equity Review is published alongside a second edition of the AWHP which has been updated based on experience implementing the plan over the past year. The updated AWHP continues to build on measures taken by the government, its agencies, NHS England, and local authorities, to protect individuals and communities from the health effects of adverse weather and to build community resilience.

The plan outlines the important areas where the public sector, independent sector, voluntary sector, health and social care organisations and local communities can work together to maintain and improve integrated arrangements for planning and response to deliver the best outcomes possible during adverse weather.

The AWHP is underpinned by:

• an evidence collection, published in parallel, that underlines the activities and scientific evidence that support the plan
• guidance and support materials on heat, cold and flooding including materials aimed specifically at the public and groups most at risk from the impacts of adverse weather
• the weather health alerts (heat and cold), developed in collaboration with the Met Office

Health equity for health security

Health equity, defined as “the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically” is a core priority for the UKHSA and a cross-cutting goal in the UKHSA strategic plan. The Health Equity for Health Security Strategy launched in 2023 sets out how UKHSA will achieve this, through delivering on its vision to “target the people and places most at risk to achieve more equitable outcomes and deliver health security for all”.

The strategy also supports UKHSA to deliver on its legal duties. As a public sector organisation, UKHSA has a legal duty to pay due regard to the public sector equality duty (PSED). The duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard of the need to:

• eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act
• advance equality of opportunity between people who share a protected characteristic (1), and those who do not
• foster good relations between people who share a protected characteristic, and those who do not

UKHSA also has a legal duty to pay due regard to tackling health inequalities, under the Health and Social Care Act of 2012.

This review supports the health equity strategy by strengthening the evidence base on disproportionately impacted populations, and identifying what actions are required to address the needs of people and places at most risk.

Our approach to assessing equity impacts

UKHSA has adopted the NHS England (NHSE) CORE20PLUS framework to outline the populations we will routinely consider through our work. This includes:

• the most deprived 20% of the population as defined by the Index of Multiple Deprivation
• people who are clinically vulnerable
• people with protected characteristics covered by the Equality Duty as outlined above
• inclusion health groups (1)

The intention of this approach is that CORE20PLUS is used as a lens through which to identify population groups who face the greatest risk from adverse weather events, based on health hazards and how vulnerabilities may interact with each other to exacerbate the impact of a health security hazard or ability to attain benefit from a health protection intervention. Appendix A maps CORE20PLUS population groups to those covered by the Equality Duty.

This review considers evidence on a set of mechanisms that might contribute to increasing individual or group vulnerability to a given adverse weather hazard (for example, adverse hot or cold weather) might be increased (Figure 1). These span:

• risk of exposure to an adverse weather hazard and increased risks to health as a result of this
• barriers to accessing information on how to reduce risk from adverse weather
• barriers to accurately interpreting information
• barriers to taking action to reduce risks from adverse weather

The findings reported below are organised according to the CORE20PLUS categories given above.

Figure 1

Mechanisms linking individual level exposures to adverse weather to health outcomes, taking into account the way people access and interpret information, and how this supports mobilisation to action.

Figure 1 shows how adverse weather can lead to health outcome effects due to community and individual vulnerability, and how risks can be reduced by use of information and mobilisation to action. It shows that, in contexts of adverse weather we should investigate community and individual vulnerability. The first steps are to access and understand information. Based on this, people can take appropriate action and benefit from interventions which lead to improved health outcomes. Throughout this, we need to consider how we’re countering mis/disinformation can help reduce community and individual vulnerability. The aim is to appropriate action based on information can also help reduce community and individual vulnerability. Taking appropriate action can also build resilience, leading to better health outcomes.

Summary of evidence considered

The Adverse Weather and Health Plan: Supporting Evidence presents preliminary findings and assessment of the approach to health inequalities taken in the previous Cold Weather and Heatwave Plans for England which was conducted by UKHSA to inform the development of the AWHP. This review builds on and updates those findings using the latest available evidence and research. This review is concerned with evidence relevant to the four main adverse weather hazards with which the AWHP is concerned – that is, hot weather, cold weather, flooding and drought.

Findings bring together three strands of evidence:

• material from a review of research literature on what is known about differences in risk from adverse weather exposure for different population groups
• evidence on what is known about the differential impact of different kinds of intervention to reduce adverse weather risks, on population groups
• evidence on what is known about the ways different population groups engage with, and then act on, guidance and other forms of public health advice

To inform assessment of risk for different populations, a mapping review of the evidence on the impact of adverse weather on health was undertaken as part of a wider exercise supporting the AWHP. Literature was drawn from keyword-structured searches in Embase, Medline, Web of Science and Scopus databases. Due to the large volume of literature retrieved and time available, a keyword search was undertaken using EPPI Reviewer and EndNote to identify relevant papers for this review from the mapping search results. Papers deemed relevant were those that evaluated and described mechanisms of vulnerability to adverse weather of different population groups. The identified papers from this review and a small number of papers from a separate review on adverse weather and protected characteristics were then summarised without critical appraisal. Where systematic review and metanalysis level evidence on the vulnerability of different groups was available, this was summarised in preference to primary studies, where there was insufficient evidence at that level, primary studies were summarised to illustrate the potential vulnerabilities. We are aware of the limitations of this method of synthesising the evidence and aim to incorporate more robust review methods in subsequent iterations of this review.

Grey-literature evidence was also sought in some discrete areas. Quantitative evidence was incorporated from annual reporting on adverse weather-related mortality and morbidity from UKHSA and from the Office for National Statistics (ONS). Grey-literature also included evidence from across government on the way in which different populations engage with, and are mobilised by, online information including on health-related topics.

Three important caveats to the assessments provided in this review should be noted. Firstly, evidence on the impact of adverse weather on UK populations is limited overall, and therefore it was necessary to use both UK and international evidence to provide a sufficient assessment of the impact of adverse weather on different groups. Narrative in the remainder of this report makes clear where evidence cited refers wholly or predominantly to settings outside the UK.

Secondly, while later sections in this report outline groups for whom evidence of increased risk due to adverse weather exposure has been identified, it should not be assumed from this that no risk exists for those groups for which no evidence was identified. Evidence on the impact of adverse weather on specific population groups (for example inclusion health groups) is, in general, in short supply including from the UK. Available evidence also indicates that, at extremes of temperatures, the health of all people can be affected. This is why public health guidance under the AWHP provides advice both for the general public, and for those known to be at higher risk.

Thirdly, evidence presented in this review is not (as outlined above) based on formal systematic reviews, and included papers were not assessed for quality. Future iterations of the review will strengthen the methods applied, and include formal quality assessment of the research evidence cited.

At the end of the review, a series of areas are identified where better understanding of health risks from adverse weather for different populations is needed. Recommendations for addressing these are also set out.

Known inequalities in relation to adverse weather health risks

Everyone is potentially at risk from the health consequences of adverse weather, but there are certain factors that increase risks for individuals, groups and communities. The sections below summarise evidence on health risks associated with different types of adverse weather exposure based on the review of published literature outlined above.

Socioeconomic deprivation

Available evidence suggests that deprivation is a modifier of the temperature effect on health (1, 2). UK research on the effects of temperature on hospital admissions suggests that those in the most deprived income quintile are at greatest risk of temperature-related hospital attendance and mortality (1 to 3). Analysis shows that for every 1°C increase in temperature above a threshold of 16°C (the comparator) there is a 1.02% increase in all-cause attendance amongst the most deprived (3). There is also evidence of a deprivation gradient in response to temperature for infectious, metabolic circulatory and respiratory diseases, and for injuries (1).

Those living in socioeconomically deprived areas are known to be at greater risk from flooding, and to be less likely to have insurance cover and other forms of protection to reduce the impact of flooding events (4). International evidence suggests that effects on mortality from flooding tend to be more pronounced in socioeconomically deprived populations (5). In England, the majority of the health burden from flooding has historically been on mental health: data from the English National Study of Flooding and Health showed that prevalence rates for mental ill-health were higher in those without insurance (6).

Mechanisms linking socioeconomic status to poorer health outcomes from adverse weather exposure are varied. The increased susceptibility and decreased adaptive capacity of those in deprived areas with lower social economic status is likely due to a combination of thermally inefficient housing, fuel poverty, a lack of air conditioning and particularly in urban areas, distance from cooling environmental greenery (1, 7).

For cold weather, fuel poverty is an important cause of cold homes, and the AWHP Supporting Evidence Document details the range and breadth of resulting effects. Analysis published by the Institute for Health Equity and Public Health England previously suggests that up to 10% of excess winter deaths may be attributable to fuel poverty, and 21.5% to cold homes (8).

People with long-term health conditions

Cardiovascular disease

Researchers have found a positive association between heat and heatwaves on cardiovascular outcomes (9 to 11). Cardiovascular Disease (CVD) includes a range of diseases and conditions affecting the heart and associated circulatory system. Despite the heterogeneity of the evidence, researchers have concluded that extreme heat can increase the overall risk of CVD mortality by 20% and morbidity by 9%. Amongst CVD disease sub-types, ischaemic heart disease and myocardial infarction have elevated risks of mortality from heat exposure (9, 12).

There is also a positive association between spells of cold weather and cardiovascular disease morbidity and mortality (13). According to recent research, for every 1°C drop in temperature the relative risk of cardiovascular disease increases by 1.6%; cold temperatures can increase mortality by 32.4% and morbidity by 13.8% (13). Analysis of factors influencing population susceptibility to cold-induced cardiovascular disease shows that mortality caused by low temperature exposure is more pronounced in the tropical climate zone (that includes the UK) where daily mean temperatures are relatively high. It is suggested that this may be due to insufficient adaptation at a population and individual levels (13).

Respiratory disease

Extreme weather events including heatwaves and cold spells have been shown to play an important role in asthma, increasing the risk of morbidity and mortality among those with this condition (14 to 16). Extreme weather events can also exacerbate asthma symptoms and increase the likelihood of asthma-related hospital attendances and admissions (14). Extreme heat or cold can also trigger asthma symptoms in those who were previously undiagnosed (14, 15). Variations in temperature and relative humidity can increase the levels and persistence of airborne allergens and pathogens that can intensify and trigger symptoms in people with chronic obstructive pulmonary disease (COPD) and asthma (16).

Scientists have warned of a possible increase in thunderstorm asthma epidemics due to global changing weather patterns that can put health services under severe pressure (17). The 1994 thunderstorm asthma episode in London affected over 600 people. Evidence from Australia where most thunderstorm asthma events have occurred suggests that those with a history of allergic rhinitis, sensitivity to grass pollen, with undiagnosed and diagnosed asthma and those who are of Asian ethnicity are the most at-risk during such events (17).

Diabetes

Exposure to both hot and cold temperatures can have significant impacts on diabetes outcomes. Cold exposure is associated with increased incidence of myocardial infarction and poor glycaemic control and high temperature thresholds have been shown to increase the risk of diabetes morbidity and mortality (18). The risk of cardiovascular disease amongst those with diabetes is 2 to 4 times that of those without diabetes and acute myocardial infarction is the main cause of mortality amongst diabetics (18). Comorbidities and the intersection of vulnerabilities may explain why older people aged over 60 have been identified as being the most at risk from poor diabetes outcomes due to temperature extremes (18).

Kidney disease

There is a significant association between hot weather (high temperatures and heatwaves) and kidney disease morbidity and mortality (19). Researchers have found that for every 1°C increase in temperature there is a 1% increase in kidney-associated morbidity and 3% increase in mortality. There is also a correlation between the intensity of heatwaves and the risk of morbidity (19). The population groups identified as being at-risk are those under 64 years of age and males. The explanation for this is unclear but may be because these groups spend more time outdoors and undertake more physically demanding activities and have higher occupational exposure, particularly males.

This is not to say that older people are not at high risk. Researchers also found those over 65 to be the most at-risk group during moderate intensity heatwaves (19). Their supposition is that older people tend to suffer from age related renal function impairment and have reduced adaptive capabilities, making them more susceptible to heat related kidney disease(19).

Dementia

The evidence suggests that older people with dementia are particularly at risk from temperature extremes because, in addition to age-related decline in thermoregulation and increased prevalence of comorbidities, they have sub-optimal cognitive awareness to perceive and address the threat from environmental exposures (20, 21).

Modelling evidence from England and literature from elsewhere in the world warns of an increasing burden of hospital admissions from heat-related complications of dementia due to climate change (20). The number of people living with dementia in the UK is anticipated to rise from the current 850,000 to 1.6 million by 2040 and researchers are predicting that heat-related dementia hospital admissions will correspondingly rise, in England by 294% under a high emissions scenario (20). According to the modelling adverse effects are noticeable once daily mean temperatures reached 17°C nationally with the estimated risk in dementia rising by 4.5% for every 1°C rise above 17°C (20). Absolute numbers in this analysis are relatively small in comparison to the total number of hospital admissions, but risks in this group are likely to be high because of the intersection of multiple vulnerabilities that many people experience in later life.

Mental health conditions

There is increasing evidence that adverse weather events such as storms, flooding, and heatwaves can have a detrimental impact on mental health (22, 23). Those who have experienced flooding have reported suffering from a range of mental health conditions including depression, anxiety, mood disorders and post-traumatic stress disorder (PTSD), disrupted sleep and suicide ideation, with impacts continuing to be felt long after the event (22). Displacement and the interruption of essential services appear to be the primary causes of psychological distress in those situations (22 to 24).

Similarly, high environmental temperatures, relative to the norm of the location and season, are associated with an increased risk of suicide, hospital admissions for mental health problems and negative repercussions for community wellbeing (23, 25).

Those who have experienced flooding have reported suffering from a range of mental health conditions including depression, anxiety, mood disorders and PTSD, disrupted sleep and suicide ideation, with impacts continuing to be felt long after the event (22). Displacement and the interruption of essential services appear to be the primary causes of psychological distress in those situations (22 to 24).

People living with multiple, overlapping co-morbidities

Despite the ubiquitous references to comorbidities in the literature on climate and health vulnerabilities, there is little evidence focusing specifically on the impact of adverse weather on comorbidities. The recognition and understanding that comorbidities heighten vulnerabilities is largely based on evidence that those with pre-existing and co-existing conditions are already at risk and that exposure to adverse weather events can exacerbate those conditions and worsen health outcomes for them (18, 20, 26, 27).

Protected characteristics

Age

Systematic review evidence from high income countries shows that infant exposure to higher environmental temperatures is associated with increased mortality, hospital admissions and increased risk of contracting infections in children (28, 29). However, none of this evidence derives from the UK and – as with material presented elsewhere in this report – should therefore be interpreted with caution given climatic, infrastructural, service delivery and other differences between countries.

There is also evidence indicating that heat exposure can have a detrimental effect on the quality and duration of infant sleep (30). Sleep deprivation may lead to impairments in physical and cognitive development.

Exposure to colder temperatures in children, on the other hand, is associated with increased mortality and respiratory episodes (28, 29).

The mechanisms underpinning increased vulnerability to temperature extremes in children relate mainly to their physiology, anatomy, and social context (28). Infants have immature thermoregulatory mechanisms and are dependent on caregivers to protect them. They also tend to spend more time playing outside which increases vulnerability to extreme heat and cold (31).

There is consensus in the literature that older people, generally defined as those over 65 years of age, are at high risk from heat- and cold-related mortality because of social factors and because of their physiology (31). Older people’s tolerance of temperature extremes is often lower than younger adults because efficiency of thermoregulation declines with age (32). This together with the prevalence of limiting long-term illness and co-morbidities such as cardiovascular and respiratory diseases among older adults increases vulnerability to heat (32, 33).

Social isolation and exposure to adverse weather can interact to increase health risks for older people. During two major heatwaves in Chicago in 1995 and in Paris in 2003, for example, mortality rates amongst socially isolated older adults were significantly higher than those who were socially connected (33). Adverse weather can not only exacerbate disconnectedness, but it can also be the cause of disconnection in that it can discourage older adults from participating in social activities. This may contribute to negative consequences for their well-being (34). Social isolation is now understood to be a key determinant of older people’s vulnerability to adverse weather and temperature extremes (33, 34).

Disability

The term “disability” spans many types including intellectual, sensory and others. There are important limitations to the quality and comprehensiveness of data on disability that limit what we can say about effects of adverse weather on people living with disabilities. However, we know that people living with disabilities are at greater risk from adverse weather events than others because they face systemic challenges in addition to physical and/or mental ones (35). These include a lack of accessible communications during and after a weather event, difficulties in accessing medications, interruptions in healthcare provision and a lack of safe and accessible emergency shelters and housing. International evidence shows that people with disabilities are often not considered in climate adaptation planning, face challenges receiving disaster services, and have limited resources to prepare for and respond to climate change impacts (35).

Sex

There is very little published evidence from the UK on sex-related differences in mortality or morbidity from adverse weather. International evidence from high income settings suggests increased risk of mortality from heat exposure for females relative to males especially in older age groups but with variable effect sizes reported between studies (36).

Analysis of heat episodes from England and Wales show some variations in health impact between genders over time but without a consistent underlying pattern to indicate significantly increased risk for either males or females. Between 2016 to 2022, for example, excess deaths were slightly higher overall among men across all heat episodes recorded across these years than among women. However, there were large variations in observed effects by gender between years and by heat episode, and data in this time series should in any case be interpreted with caution because of delays in death registrations, and the significant skewing effect of COVID-19 in 2020 and 2021 (37).

Turning to cold weather, the winter mortality index for England in 2021 to 2022 was slightly higher for men overall than for women, but with large variations between age groups: the most pronounced effects were seen in men aged 0 to 74 years, and the oldest age groups (aged 90 and over) (38). However, the statistical significance of these differences were not evaluated, and the inclusion of all winter deaths (including influenza) in these data means that it is not possible to attribute mortality exclusively to cold.

Evidence on variations in impact by gender from other adverse weather risks is more limited. Data from the UK point to a higher probability that women report psychological distress and post-traumatic stress disorder following home flooding than men (22), an observation that is also supported by international evidence (39). There is currently very little evidence to inform an assessment of the effects of drought by gender in high income settings. Almost all existing evidence comes from Australia and suggests possibly higher resilience to health-related effects of drought among women than men but differences in climate and context mean that these findings should be interpreted cautiously for relevance to England (40). 

Gender reassignment

The review identified no evidence to suggest that transgender or transsexual people are adversely affected by any of the principal adverse weather hazards because of their gender status.

Marital status

The review identified no evidence to suggest that marital status materially influences risks from any of the principal adverse weather hazards.

Pregnancy and maternity

Both hot and cold temperature extremes present risks to pregnant women (41). When the mother’s core body temperature exceeds the environmental temperature, her body responds by dilating blood vessels in the skin and sweating. This helps to dissipate heat, but it also reduces blood flow to the uterus and umbilical cord resulting in a decrease in oxygen and nutrients to the foetus and maternal dehydration (42). Such pregnancy-related changes in thermoregulation can lead to a number of adverse maternal, foetal, and neonatal outcomes, including preterm birth, low birth weight, stillbirth, congenital anomalies, gestational diabetes, hypertension disorders, and maternal stress (42 to 44).

Researchers have found a correlation between low ambient temperature and adverse birth outcomes including preterm birth, low birth weight and stillbirth (45). The physiological mechanism linking low temperature exposure to worsened pregnancy outcomes is not fully understood but may be due to contraction of blood vessels (to help maintain core body temperature) leading to a reduction in the blood supply to the placenta thereby affecting foetal development. Maternal anxiety due to temperature extremes, particularly in the last trimester of pregnancy has been shown to elevate stress hormone levels increasing women’s vulnerability to preterm birth (45).

Ethnicity

The research literature on ethnicity-related risks from adverse weather exposure in the UK is limited. Much existing work on ethnicity and health impacts from adverse weather uses broad ethnic group categories potentially masking significant within-group variations in mortality and morbidity risk – a limitation to existing data collection that has been noted elsewhere (46). However, rates of many of the long-term conditions identified in the section on people with long-term health conditions as predisposing to greater health risk from adverse weather exposures are known to be higher among certain ethnic groups in the UK – including CVD, diabetes and indeed multimorbidity (47, 48).

It is also well recognised that levels of socioeconomic deprivation are higher among most ethnic minority groups than in the general population (49). This is partly reflection in dwelling location: ethnic minority populations in the UK are often concentrated in urban areas and are therefore at high risk of poor health outcomes from the urban heat island effect and fluvial flooding (50, 51). People from certain ethnic minority groups are also disproportionately represented among those living in overcrowded housing conditions that can amplify their vulnerability (52). The mechanism of vulnerability to adverse weather events amongst ethnic minority groups is complex and will vary in important ways by group and locality, but likely includes cultural and language differences that intersect with poverty resulting in a lack of awareness, preparation and the ability to recover after a weather event (50).

Religion or belief

The review identified no evidence to suggest that an individual or community’s religion or belief materially influences risks from any of the principal adverse weather hazards.

Sexual orientation

The review identified no evidence to suggest that sexual orientation materially influences risks from any of the principal adverse weather hazards.

Inclusion health groups

Evidence on adverse weather risks for inclusion health groups is limited. This section provides an overview of current understanding for those groups where evidence is documented.

People in contact with the criminal justice system

Most of what is known about risks from adverse weather exposure among prisoners comes from North America. Differences in climate, the prison estate and other factors mean inferences from these data for England should be made with caution. However, evidence from the United States suggests that high temperatures increase the risk of suicide and mortality in prisons (53, 54). We also know that some populations outside the prison setting are particularly at risk from heat, and that people from these groups are disproportionately represented in the prison population: examples would include those with mental health conditions, and those who are socially isolated (53, 55). Poor ventilation, prisoners’ lack of control over their physical environment and inadequate resources to adapt can amplify the impact of heat on the health. Overall, the intersection of multiple vulnerabilities means that those in detention may be at significant risk of harm from extreme temperature exposures (53).

People who are homeless and those sleeping rough

The term “homelessness” captures a range of living conditions. Data from the UK typically differentiate rough sleeping (people sleeping in the open air and in other locations not designed for living in) from broader forms of homelessness that may include use of temporary sleeping spaces such as shelters, living in insecure housing (due to, for example threat of eviction, or domestic violence), or in inadequate conditions (for example, conditions of extreme overcrowding) (56). In the financial year 2022 to 2023, some 140,790 households were assessed as being threatened with homelessness in England (57). The number of people sleeping rough on a single night in autumn 2022 (the most recent data available) in England was 3,069 (58).

People sleeping rough are at greater risk of exposure because of the fact that they live primarily outside. In hot weather, they are at greater risk of exposure to direct sunlight, to sleeping on hot surfaces, and are less likely to have access to cool spaces. International evidence suggests that are also more likely to stay in urban heat islands. Urban heat islands are defined as a metropolitan area which is significantly warmer than its surrounding rural areas. A systematic review of international evidence on cold weather risks for those homeless and sleeping rough found limited evidence but identified an increased risk of mortality from hypothermia and cold-related injury among people sleeping rough by comparison with the general population. Finally, there is some evidence to suggest that health risks – assessed based on healthcare use – may be relatively greater at higher rather than lower than average temperatures seen in the UK (59).

Vulnerable migrant populations

Evidence on adverse weather risks for vulnerable migrant populations (including, but not limited to, asylum seekers and refugees, undocumented migrants and low-paid migrant workers (60)) is very limited. Migrants living in rented or temporary accommodation are considered to be particularly at risk (50). Evidence on extreme heat exposure and health outcomes among migrants in high income settings comes almost entirely from the United States or from other countries where the probability and intensity of heat periods is greater than in England (for example, Australia, Spain), and there are insufficient data currently to determine whether mortality and morbidity risks are significantly greater among these groups than for the general population (61). International evidence on cold exposure risks including from the UK suggests that migrants moving from warmer to colder climates may experience an increase in cardiovascular mortality (62).

Gypsy, Roma and Traveller populations

Evidence on risks among Gypsy, Roma and Traveller communities is very limited. There is a small body of qualitative work suggesting that these populations are at greater risk of health effects from heat and cold exposure because of living and outdoor working conditions (63, 64), but quantitative data measuring the extent of this effect is not currently available.

Summary of analysis

This section has shown that some evidence exists for inequalities in health risks arising from adverse weather hazards. However, the strength of the evidence varies considerably and evidence is absent altogether for some groups (for example, many inclusion health groups) known to be at greater risk than the general population for many health conditions. Finally, risks do not apply across all of the population groups identified at the top of this report and vary in important ways depending on the adverse weather hazard being considered.

Overall:

• socioeconomic status is a source of risk for all groups: those people living in deprivation are at greater risk from all of the major adverse weather hazards
• there is good evidence that people with certain long-term conditions are at greater risk from extreme heat and cold – especially those with cardiovascular, respiratory and kidney disease
• there is also evidence of elevated risk among young children, older adults, pregnant women from both cold and heat exposure
• older adults and people living with disabilities are at greater risk during the acute phase of flooding because they may find it more difficult to move to places of safety
• evidence on inclusion health groups is limited: people sleeping rough are at greater risk than the general population from heat and cold exposure, but there is insufficient data from England to assess risks for those in contact with the criminal justice system although international evidence is indicative of increased risk from heat

This review identified no evidence to suggest elevated risk from any of the adverse weather hazards because of someone’s marital status, religion or belief, or sexual orientation.

Finally, although there is a tendency in the published evidence to consider individual categories of risk (for example, age, gender, socio-economic), in reality many people experience multiple, overlapping vulnerabilities. How these vulnerabilities overlap varies from person to person and community to community. While there are very few studies that consider people living with multiple vulnerabilities, risks for these individuals and communities are likely to be significantly greater than for those who fall into a single risk group.

Consultation, engagement and involvement under the AWHP

One mechanism for supporting equity in processes and outcomes from the plan is through robust processes of consultation and engagement through its development and implementation. This section of the review details the organisations and sectors consulted during the development of the AWHP and associated guidance aimed at identified at-risk groups and summarises some of the wider engagement activities carried out around the plan. The reviewing and updating of materials under the AWHP is intended to be an iterative process and UKHSA will continue to consider ways of broadening the scope of consultation in the coming years to help improve the scientific robustness, usability and relevance of the tools that we produce.

Consultation

The Extreme Events and Health Protection Team has consulted broadly on all aspects of AWHP development, to help ensure relevance of messaging to as broad a set of audiences as possible. The AWHP was shared with key interlocking government departments (such as the MoJ, MoD, Cabinet Office and DHSC), as well as delivery partners in Health and Social Care (that is, NHS England, Local Government Association and Association of Directors of Public Health) during development, and comments have been sought on its effectiveness. This is in addition to the standing group of attendees that join the quarterly AWHP Steering Group that helped shape the plan. This early engagement has helped to support the effective implementation of the plan and ensure that the plan meets its objectives and is meaningful for the organisations using it.

Appendix B outlines key stakeholders consulted during guidance development for heat, cold and flooding.

Engagement and involvement

This section instead sets out a series of case studies demonstrating best and promising practice examples of engagement and involvement to support the plan, many of them involving research work carried out by UKHSA teams.

Case study: Extreme heat focus groups with older adults

The UKHSA Behavioural Science and Insights Unit conducted focus groups with 50 adults aged over 65 years to explore public attitudes towards extreme heat in response to the 2022 heatwave and to inform recommendations for updating messages communicating risks and protective behaviours for heatwaves, which were embedded into the “Beat the heat” guidance in the AWHP after further consultation with UKHSA Extreme Events, Communications Teams, and NHS consultants.

The focus groups helped to test an updated behavioural-science informed message toolkit. Some key examples of how our findings have informed relevant sections are as follows:

• framing the health risks linked to certain behaviours during hot weather, for example, alcohol consumption and exercising, as fact-based information emphasising people’s control in taking action to increase self-efficacy
• incorporating advice that is specific to high-risk groups – for example, for older people, emphasising the need for appropriate head protection where there is thinning hair or balding
• using positive framing that highlights behavioural adaptations to mitigate heat risks, rather than a focus on restricting certain risk behaviours entirely (for example, exercising and alcohol consumption), as this may be unrealistic and can lead to disengagement - possible suggestions in this context included exercising in the early morning or alternating alcohol with water or alcohol-free alternatives
• providing clear signposting to local support services and resources so that high risk groups (and those supporting them) know how to access help
• explaining why recommended behaviours are important, including the physiological basis of heat risks, and clearly stating the specific steps that individuals can take to reduce the consequences of extreme heat
• providing novel and thought-provoking information (for example, heat mortality rates) that illustrate the severity of heat-risks to increase awareness and risk perception
• providing specific and clear guidance on how to perform protective behaviours correctly, for example by reinforcing correct (and often misconceived) behaviour of closing curtains and windows with sun exposure and a with a higher outside temperature

Guidance materials were updated using some of the above recommendations to improve perception of risk to health from heat in at-risk groups and to increase uptake of endorsed protective actions included in the AWHP.

Case study: Focus groups with older adults to elicit experiences of the 2022 heatwave

UKHSA conducted focus groups with older adults (24 individuals over 65 years of age) and in-depth interviews (10 with those living with health conditions that suppress their immune systems) to understand perceptions and impact of summer of 2022, which was the hottest on record, among those likely to be at greatest risk from heat. The study aimed to explore perceptions of older adults’ perceived health risks, and coping strategies.

Most participants, including some individuals with health comorbidities linked to a higher heat strain, perceived themselves to be moderately at risk or not at risk at all. This level of risk perception was rationalised by participants by comparing themselves to other at-risk groups who participants perceived to be at a higher risk than themselves (for example, individuals aged 85 years and over, or babies), and believing that risks were mitigated by performing well-established and effective coping strategies.

Participants who were more at risk (that is, individuals with single or multiple comorbidities) perceived themselves to be at risk; however, they primarily acknowledged the potential for acute illness and did not recognise the potential of increased mortality risk. Other factors associated with risk perception identified by focus group attendees included:

• location - urban areas and the south of England were thought to be more exposed to heat)
• people living alone were thought to be at greater risk due to lack of access to support from other household members
• participants who felt worried about the increasing trend of heatwaves in the future perceived a higher sense of risk

Common behaviours that people reported adopting to cope in the heat were:

• using fans or water sprays and eating ice lollies to stay cool
• ensuring sufficient water intake
• eating lighter and smaller meals more often
• ensuring protection from the sun by applying extra sun cream and wearing hats or caps and light clothing
• avoiding going out in hottest parts of the day
• changing daytime routines by leaving the house only early or late in the day

Individuals perceived closing curtains and windows as helpful, however this behaviour needed more explaining as it was not clear for everyone as to the circumstances under which this behaviour should be undertaken (for example, depending on the orientation of the window and the outdoor temperature in comparison to indoors). Furthermore, while some participants with pre-existing health co-morbidities prepared a few days to a week prior to a heatwave, most participants carried out little to no planning in anticipation of the heatwaves.

Insights from the focus groups were used to update the relevant guidance on supporting at-risk people before and during hot weather for social care managers, staff, and carers for summer 2023.

Case Study: Protecting people sleeping rough from extreme heat Greater London Authority and UKHSA collaboration

People who are sleeping rough are at higher risk of poor health outcomes during periods of hot weather due to higher rates of exposure, increased susceptibility, and decreased ability to adapt. The summer of 2022 saw temperature records broken in England and identified the need for much greater adaptation to heat for homeless people. 

As part of the AWHP, UKHSA aimed to develop bespoke guidance for those with responsibility for sleeping rough. Similarly, the Greater London Authority (GLA) aimed to update an emergency protocol to be used by rough sleeping leads in London local authorities using parallels with the more well-established winter Severe Weather Emergency Protocol (SWEP).

A cross-agency steering group bringing together both decision makers and agencies driving implementation in this area was formed to identify critical issues, potential actions and areas requiring further development. To ensure timely delivery of guidance, existing networks across agencies were used to inform guidance production. This included attending and aligning with specific work led by the GLA on the development of SWEP, attendance at national homelessness conferences and presentation and discussion of evolving guidance at webinars. The guidance was further shared for feedback from agency partners to ensure alignment and practical application.

UKHSA guidance was published in May 2023. It was presented at a Homeless Link Webinar and VCSEP Summer Preparedness Webinars to over 500 attendees. It was also presented at a webinar hosted by Transformation Partners. 

Homelessness SWEP guidance was approved by the ‘Life Off the Streets’ core group and published and implemented in June 2023 due to Yellow Heat Health Alerts being active for the London region. Other regions have contacted the GLA to adopt or adapt the protocol. 

This case study is an excellent example of different public health teams co-developing resources, co-developing and working in parallel to produce mutually reinforcing products and services.  Areas for further development will be addressed in the coming year and inform future iterations of targeted guidance for this population.

Case study: Extreme heat focus groups with care providers

UKHSA conducted focus groups with 29 health and social care providers working in a range of care settings with at-risk adults and 4 social care sector stakeholders to explore attitudes towards heatwaves and how care providers experienced the summer of 2022, which was the hottest on record (65).

In the focus groups, the perceptions of health and social care professionals (HCPs) (residential care home and domiciliary workers caring for people with learning difficulties, older adults, and end of life care) of the utility of ‘Heatwave Plan for England’ and heat-health alerts during summer 2022 were assessed.

The focus groups provided insights for optimising dissemination and content of heatwave guidance. The key recommendations for updating guidance materials to provide targeted advice for HCPs included:

• the need to specify actionable guidance for caring for individuals with different conditions during hot weather which provide clear and practical actions that HCPs can adopt
• to provide specific advice for different care settings (for example, home-carers vs residential home carers), to include advice on how to look after the mental health of patients and healthcare workers
• to clearly specify risk factors and behaviours to facilitate identification of different types of heat-related illness among care workers

Insights from the focus groups were used to update the relevant guidance on supporting at-risk people before and during hot weather for social care managers, staff, and carers and included development of action cards for providers and commissioners of social care to accompany heat-health alerts as well as poster versions of the action cards to improve accessibility for care workers. In addition, an e-Learning for Health module was developed to increase the awareness of carers to the health threats posed by high temperatures and the simple actions they can take to protect themselves and those they care for from these risks.

Case study: insights from domiciliary care on managing extreme cold

UKHSA conducted qualitative research with 29 CQC-registered domiciliary care providers, four stakeholder representatives and five adults in receipt of domiciliary care in summer 2023. This work aimed to understand the experiences of domiciliary care providers and those they cared for during the winter, preparedness and planning by these providers for cold weather, and reactions to an action card for frontline workers published alongside the final iteration of the Cold Weather Plan for England.

This work showed that while awareness of cold weather risk was generally good, planning for cold weather by domiciliary care providers was not always formalised and there could be significant challenges in delivering care when weather conditions were bad enough to disrupt transport and other logistical arrangements. Social isolation and poor mental health were identified as problems for staff and service users alike, as were challenges in terms of energy affordability for households.

Key recommendations for guidance improvement included:

• better signposting to sources of financial and other support during the winter months
• clearer advice on actions that people working in different roles in social care should take

Insights from this work have contributed to revisions to cold weather guidance. These include a much more extensive set of links to sources of financial support during the winter months, and links to advice on home improvements and energy efficiency measures. They also include changes to the structure of guidance documents and action cards to make clearer which actions are intended to apply to which professional groups.

Addressing negative impacts of adverse weather: actions in the AWHP to address health risks, and remaining gaps

UKHSA has a core role in tackling health inequalities, working alongside the Office for Health Improvement and Disparities (OHID) and other government departments to advise on the impacts of deprivation on health and wellbeing. The AHWP and its supporting products set out actions to address inequalities in health risk and outcomes following adverse weather exposure. This section outlines these actions and also considers the extent to which they may contribute to exacerbating inequalities in risk described above, considering both:

• the nature of the recommendations
• what is known about how different population groups access, understand and act on public health advice

Finally, it considers what additional steps might be needed to help address health equity through the AWHP. Material below focuses only on those groups for which evidence of variations in health risks have been identified above. Later sections of the review consider how evidence on risks for other groups might be strengthened.

Socioeconomic deprivation

Because socioeconomic deprivation is a cross-cutting factor that affects people of differing backgrounds, actions to address increased risks from adverse weather exposure are captured in both general guidance (for the public and for professionals), in dedicated guidance for at-risk groups, for example people who are homeless and sleeping rough, and elsewhere.

Cold weather guidance under the AWHP supports preparedness and response for those living in conditions of socioeconomic deprivation. General population guidance provides signposting to sources of financial and other support in improving home energy efficiency, improving heating or managing energy bills and to additional support for those living on low incomes. It also explicitly recognises increased risk among those who are socially isolated. Signposting to sources of support is reinforced in guidance and action cards for professionals, which also includes advice to identify individuals and families in the community at greater risk from cold weather exposure to help support winter preparedness and response. The Extreme Events team have also produced a toolkit to support local stakeholders wishing to set up warm spaces during the winter (often targeted at those having difficulty heating their own homes) in light of the existing evidence. Separate UKHSA guidance recognises links between cold, damp and mould in housing and provides advice on how to manage this for private and social landlords.

Guidance for frontline responders on flooding highlights the importance of building community resilience as one strategy for improving preparedness among socioeconomically deprived communities, and signposts to providers of affordable insurance for those most at risk. Guidance for the public signposts to various forms of support, including financial, which may be available to those affected by flooding, depending on their circumstances.

People with long-term health conditions

Heat and cold impact assessments underpinning the Weather-Health Alerting system explicitly recognise variations in risk for people with certain long-term health conditions, and that people living with these conditions are likely to see negative health impacts at more moderate temperatures than those who are otherwise fit and will.

Guidance on addressing heat risks and cold risks for healthcare professionals and for social care professionals under the AWHP:

• sets out in more detail risks for those with cardiovascular disease, respiratory disease, diabetes and other long-term health conditions
• makes recommendations for action including considering extra care needs, and considerations for those taking certain medications (for example, diuretics) during hot weather

UKHSA’s general population advice also includes tips on reducing risk from heat exposure and cold exposure that will be relevant to those with underlying health conditions, as well as considerations for those with respiratory conditions during drought.

However, existing guidance and other supporting tools do not include tailored messages for those with specific underlying health conditions. This is partly because of limitations to our knowledge and understanding of the extent of these risks and what is driving them. For example, we do not yet have a clear picture of the mechanisms by which thunderstorms contribute to increased risks in those with asthma. In other areas, however, there is stronger evidence to inform action: medication risks in hot weather is one such example.

Protected characteristics

Age

Heat and cold impact assessments underpinning the Weather-Health Alerting system explicitly recognise greater risk from heat and cold exposure among those aged 65 and over and among children, and that negative health impacts are likely to be seen in these individuals at more moderate temperatures than others.

The AWHP and its supporting documents help to address increased risk among young children and older adults in the following ways:

• information aimed at the general public (Beat the Heat and Keeping warm and well: staying safe in cold weather) provides practical guidance that implicitly and explicitly includes advice targeted towards both the youngest and oldest populations
• there is dedicated guidance for those working with children in educational and early years settings to help reduce risks from exposure to adverse hot weather and cold weather respectively, as well as recommendations on actions to protect children during flood recovery (spanning water hazards, mental health needs and other areas)
• UKHSA’s general population advice on identifying and managing risks from cold exposure includes an advice leaflet for those aged over 65, produced jointly with Age UK and NHS England. This leaflet covers health risks, simple measures to keep warm at home and in the community, but also advice on – for example – financial support available for older adults during the winter months
• there is dedicated guidance on reducing risks from heat exposure and cold for professionals working in adult social care settings under the AWHP, where a focus of the recommendations is on those addressed to older adults (aged over 65) - messages in these documents are segmented according to the social care provider setting, in recognition of differences in the kinds of vulnerability between – for example – older adults living at home and those in living in nursing home settings

These actions prioritise the role of guidance in mobilising action to reduce risk, but we know that the extent to which this occurs varies by age. Older people often believe that increasing age is not associated with increasing vulnerability to extreme heat and cold. Particularly at-risk groups (often isolated individuals with little or no support network which is more common in older age groups) are also often reluctant to seek help (66). The AWHP Supporting Evidence Document also documents research work indicating that household income, educational level and home ownership status may influence perceptions of risk from cold exposure among older adults.

However, our understanding of drivers of risk perception across population groups remains limited. Further work is needed to understand which communication approaches can best support improved risk perception across all age groups, and how to mobilise action accordingly. In addition, where at-risk groups are highlighted, groups are often approached as homogenous (for example, all people aged over 65) with little detail on those most at risk or subgroups that would require targeted or priority responses (for example, older people living alone or with dementia or those from different cultural or ethnic backgrounds). Future iterations of the AWHP will need to build more detailed understanding of variations in risk between individuals of a similar age group, to help inform guidance.

Disability

AWHP materials address some forms of disability directly: for example, advice on keeping warm during cold weather, recognises that simple stretching can help maintain warmth for all, including wheelchair users. Guidance for heat similarly recommends closer monitoring of those with reduced mobility by health and social care professionals during hot weather, because people may find it harder to move away from hot environments.

However, guidance and action card recommendations do not offer dedicated advice beyond this for those living with disabilities, and there is a need to improve accessibility of AWHP materials for many groups. Work to produce easy read versions of guidance is ongoing, and for those who are deaf and use British Sign Language (BSL) as a first language, we are also producing BSL versions of AWHP materials to support access to information on adverse weather risks, to help increase mobilisation to action among people living with disabilities, with an aim to publish in spring 2024.

Pregnancy

UKHSA’s general population advice includes tips on managing heat exposure at home and in the community that will be of relevance to other demographic groups identified as at-risk (including pregnant women). This also applies to general population guidance for cold weather.

While there is an emerging literature now documenting elevated risks arising from heat and cold exposure in pregnancy, there is a need both to strengthen the evidence base informing an assessment of these risks, and of actions to reduce these, for pregnant women specifically. Future iterations of the AWHP may explore the development of guidance supporting professionals working with pregnant women, subject to findings from ongoing work to strengthen the evidence base on this topic.

Ethnicity

While existing guidance and other supporting documents under the AWHP recognise increased risks for those from ethnic minority groups, there is a lack of clear evidence setting out how this risk occurs.

AWHP materials – including guidance – are currently published only in English. However, Census data from 2021 show that, for around 9% of the population, English was not their first language; around 1.5% of the population could not speak English well, and 0.3% spoke no English at all (67). There is a need to strengthen the accessibility of messaging adverse weather risks and actions to address these, to help address some of the structural barriers affecting preparedness and response for these populations. AWHP materials are currently being translated into 11 languages (to match those most commonly spoken in the UK) to help improve accessibility.  

Inclusion health groups

People in contact with the justice system

Responsibility for the health needs of those in contact with the justice system lies with the Ministry of Justice and HM Prison and Probation Service (HMPPS). While UKHSA do not provide dedicated guidance for adverse weather conditions in these settings we have provided input to HMPPS guidance on cold and heat for custodial settings.

People homeless and sleeping rough

There is dedicated guidance under the AWHP for those working with people who are homeless and sleeping rough to help reduce their risks from adverse heat exposure and cold exposure respectively. This guidance addresses those with responsibilities for people sleeping rough in England, and – for cold weather – should be seen as complementary to local Severe Weather Emergency Protocols (SWEP) that set out actions to be taken during instances of severe or prolonged cold. Although thresholds for SWEP activation vary from area to area, the Weather-Health Alerting system is intended to help inform decision-making on activation by issuing alerts when higher-order impacts on health are expected.

However, this guidance is based on a narrow definition of homelessness, focusing solely on those sleeping rough currently. Future iterations will consider wider definitions of homelessness (including, for example, “sofa-surfing”) and the utility of additional recommendations for these groups.

Cross-cutting considerations: health literacy, digital access and risk perception

The AWHP relies on the use of online guidance materials published in English, but we know that different people access and use health information in different ways. These variations may reduce the likelihood of uptake of key recommendations among some groups – noting that, for example:

• literacy levels are variable across the population: the 2011 Skills for Life Survey for England found that 1 in 6 of the population had very low literacy levels (68) and analysis of health literacy suggests this is generally lower among men and older adults (69)
• digital exclusion is a significant challenge for some groups: people living with a disability or a long-term health condition are less likely to use online services than others, and those living in low-income households are more likely to have access only to smartphones which may impede access to some forms of online content (70)

Evidence in the section on consultation, engagement and involvement also underscores variations in the ways in which health risks from adverse weather hazards are understood by different groups – including the extent to which different people understand them as threats to their health at all. There is now a large literature documenting gaps between the objective risks that some population groups face from different types of health threat, how they actually perceive these risks and why people may perceive themselves to be personally at lower risk even if this does not align with reality (71, 72). Future developments of AWHP products will need to take this into account.   

In addition, while core public health advice to reduce health risks from adverse weather will likely be consistent to a large degree, the ways in which these messages are communicated, interpreted and actioned may be specific to different population groups and localities. There are natural limits to the extent to which nationally produced guidance can reflect this. Co-development of tailored public health materials with voluntary and community sector organisations and groups will therefore be essential in ensuring that key messages are understood by different groups, and actionable by them. Some recommendations of the review below are specifically addressed to this.

Summary assessment of the AWHP against Equality Act 2010 requirements

Eliminating unlawful discrimination, harassment and victimisation

Material presented above outlines a series of groups for which there is established evidence of increased risk following adverse weather events. It is also makes clear that evidence on effects for many groups remains limited and there is work to be done to better understand the level of risk linked to different adverse weather hazards.

Available evidence does not suggest that the AWHP is contributing to unlawful discrimination, harassment or victimisation through its recommendations for action (for example, in guidance and action cards) in response to these hazards. However, as with all public health guidance, UKHSA needs constantly to consider how its advice is communicated to the general public and the extent to which it supports mobilisation to action. We will continue to strengthen our work with local stakeholders, voluntary and community organisations and others to ensure that the reach of UKHSA guidance is maximised, and that it supports people to take the necessary actions to maintain their health and wellbeing.  

UKHSA publishes guidance and other materials on GOV.UK in accordance with government accessibility requirements. However, these are generic requirements and there are important opportunities to improve the accessibility and comprehensibility of guidance and other materials specific to adverse weather. As noted above, UKHSA has already begun to amend the content and presentation of our public health guidance (for example, for older people) to ensure greater accessibility and usability. The recommendations and action-planning section below outlines further steps we are taking to address this.  

Advancing equality of opportunity

Much of the guidance under the AWHP outlined above is addressed to individuals or groups who are identified as at particular risk for different adverse weather hazards. While there is no evidence to suggest that implementing these actions will advance equality of opportunity in and of itself, it is likely to do so in some areas. For example, guidance for professionals working with children and young people in educational settings to address risks from heat and cold respectively, are designed to support preparedness and resilience of educational settings to adverse weather, and continuity in teaching delivery. These actions will help reduce the probability of adverse effects on educational attainment, emotional wellbeing and other outcomes given what is known about the impact that extreme cold and heat may have on these.

Fostering good relations between groups

Building community resilience to adverse weather events is one of the AWHP’s main goals. The plan outlines the important areas where the public sector, independent sector, voluntary sector, health and social care organisations and local communities can work together to maintain and improve integrated arrangements for planning and response to deliver the best outcomes possible during adverse weather. UKHSA recognises, however, that it is primarily at local level – from neighbourhoods and communities with Local Authorities providing essential support and infrastructure – that such community resilience is built and delivered (73).

The importance of community resilience in supporting preparedness for adverse weather events is recognised in products including UKHSA’s guidance for frontline responders on flooding and health. The central role of community groups and organisations in supporting preparedness and response to all adverse weather hazards is also recognised through action cards for cold and heat for voluntary and community sector partners through the AWHP.

Evidence gaps

The review has identified a number of areas where there is currently insufficient evidence to inform a robust assessment of risk for different populations. The extent of our understanding of what works in reducing risk for different groups is also variable. While it is beyond the scope of this review to put forward a comprehensive agenda for future research, indicative areas for further work include:

• risks and drivers of these risks for different adverse weather events for those with certain protected characteristics, for example, pregnant women
• risks and drivers of these risks for those with long-term health conditions, especially mental health conditions
• risks and evidence on interventions to reduce these risks for inclusion health groups for all adverse weather types. For example, there is a dearth of evidence from the UK considering risks among people in contact with the criminal justice system, and particularly those in prisons and other custodial settings – although evidence from the United States is indicative of increased risk from extreme heat, for example
• factors influencing perceived risk for different types of adverse weather event between population groups, and how these may be influenced
• factors influencing mobilisation to action for different types of adverse weather event between population groups, and how these may be influenced

Further detail on these and other topics can be found in the Supporting Evidence Document.

Review recommendations and action-planning for improvement

This section outlines cross-cutting areas for action identified through this Equity Review. Detailed actions for updates to each of the AWHP components (Weather-Health Alerts, evidence and guidance) will be outlined in an Annual Report for the plan which is due for publication in 2024. Recommendations below span those that are:

• short term (expected fulfilment within the next 6 months)
• medium term (within 1 to 2 years)
• long-term (within 3 to 5 years)

Research recommendations may be addressed directly through preparatory work for future AWHP updates, but principally through ongoing work with the National Institute for Health and Care Research (NIHR) Health Protection Research Unit in Environmental Change and Health, and other research grants. Further detail can be found in the Supporting Evidence Document.

Improving understanding of risk and identifying sources of resilience to adverse weather

Where at-risk groups are highlighted, groups are often approached as homogenous (for example, all aged over 65) with little detail on those with intersecting risks that would require targeted or priority responses (for example, older people living alone or with dementia or older people who are also from ethnic minorities). Doing so more clearly would enable us to identify those most at risk would allow for more targeted, effective, and responsive action across the health and care system. To address this, stronger evidence is needed to inform assessment of how risk varies across groups, including:

• further definition of groups at greatest risk to health from adverse weather exposure, accounting where possible for variations in risk even within groups (1 to 2 years)
• quantitative evaluation of mortality and morbidity risks for different adverse weather hazards – disaggregating by age, sex and the presence of certain long-term health conditions for example (3 to 5 years)
• exploration of potential sources of resilience among at-risk groups (for example a low income individual who is exposed to flood risk and cannot afford flood insurance but may nevertheless be resilient due to effective flood defences, an early warning system, and fast emergency service responses) (3 to 5 years)
• building evidence on risks for inclusion health groups to address data shortfalls identified in this review (3 to 5 years)

Improving communication and strengthening mobilisation to action

Besides known variations in risk between population groups this review has also identified variations in risk perception for adverse weather hazards between groups, and other factors that may reduce mobilisation to action.

To help improve information accessibility, we will:

• develop easy read, BSL and other alternative accessible formats of online AWHP materials, including translated materials (within 6 months)
• simplify the language in AWHP guidance using plain English (for example, using Crystal Mark checks) (1 to 2 years)
• explore acceptable definitions of the risk groups that resonate with target groups (for example, older people who do not perceive of themselves in this way), to ensure they understand messages as personally relevant to them (1 to 2 years)

We will also carry out further research to:

• better understand risk perception among other at-risk groups, beyond older adults, and factors influencing people to act on perceived risks or preventing them from doing so (1 to 2 years)
• evaluate accessibility and uptake of messages from materials produced in hard copy, such as the Keep Warm Keep Well leaflet for older adults (1 to 2 years)
• explore the potential for adjustments to the UKHSA Weather-Health Alerting system to tailor alerts more explicitly to groups known to be at greatest risk (3 to 5 years)

Strengthening consultation, engagement and involvement for better health equity

The section on consultation, engagement and involvement outlines some of the ways in which UKHSA has engaged with AWHP stakeholders and with at-risk groups to help develop the plan and its supporting material. Working through AWHP governance arrangements we will continue to strengthen consultation, engagement and involvement especially from at-risk groups by:

• carrying out qualitative research to understand how and where messaging in guidance products can be better tailored to the needs of at-risk groups (for example, children or adults living with long-term conditions) to strengthen uptake (6 months and over the longer term)
• engaging with inclusion health groups through representatives from the voluntary and community sector and with people with lived experience (for example, Gypsy, Roma and Traveller communities) to co-produce culturally competent and responsive approaches (3 to 5 years)

Strengthening monitoring and evaluation of equity impacts

This review sets out how we are developing our understanding and actions to better address health inequities linked to adverse weather hazards. To strengthen our ability to understand how the plan is contributing to reducing health inequities, we will:

• ensure that our monitoring of adverse weather impacts on health through the AWHP uses robust, disaggregated data sources (where available) to enable identification of differential impacts between population groups (1 to 2 years and over the long-term)
• embed monitoring of public perceptions and behaviours in response to adverse weather in evaluation plans of the AWHP, for example, using large-scale surveys to assess performance of various heat-related behaviours during hot weather events, and/or qualitative research including interviews/ focus groups (1 to 2 years)
• develop and test metrics to monitor the impact of the AWHP on variations in outcomes between at-risk groups (3 to 5 years)

Monitoring and evaluation for improved health equity

The AWHP was published for the first time in April 2023. Progress is being monitored through a series of indicators outlined in the appendices of the plan and progress evaluated through a series of mid-term and annual reviews, as well as through discrete evaluation activities. The AWHP’s contribution to reducing health inequalities and improving health equity has been assessed, for the first time, in this review. Findings will contribute to the ongoing development of the AWHP Supporting Evidence Document and ultimately the implementation of the AWHP itself.

Evidence underpinning this review will be updated on a periodic basis, alongside planned updates to the AWHP supporting evidence document. Progress towards the outcomes identified in this equity review will be monitored through updates provided in AWHP Annual Reports and through monitoring and evaluation activities linked to the plan, but also through the development of equity metrics as outlined in the preceding section.

Appendices

Appendix A: Population groups by identifying source

Appendix B: Description of consultation activities for the AWHP for products aimed at known at-risk groups

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