Inequalities in overcrowding [February 2022]: environmental health inequalities: fact sheet series

Environmental health inequalities Context This fact sheet series documents the magnitude of environmental health inequalities within countries in the WHO European Region. Environmental health inequalities relate to socioeconomic, sociodemographic or spatial differences in exposure to environmental health risk factors and to differences in health status caused by environmental conditions. The overcrowding fact sheet provides available data on the unequal distribution of living space within countries in the Region, updating earlier assessments. An overview of environmental health inequalities covered by the fact sheets and earlier assessments is available at: www.euro.who.int/en/EHinequalities February 2022 Fact sheet series Inequalities in overcrowding Key messages Prevalence of overcrowding is higher among central and south- eastern European countries than among western European countries. Low-income households are more often affected by overcrowding than the general population; the highest prevalence of overcrowding is often observed among the poorest households living in cities. Relative inequalities by poverty level, household type and income quintile are largest in western European countries. Both prevalence of overcrowding and absolute inequalities by poverty level and household type have decreased in central European countries in recent years. Overcrowding is linked to Sustainable Development Goals 3, 10 and 11, and supports the identification of national challenges to “leave no one behind”. Indicator data The data source for this fact sheet is the European Union Statistics on Income and Living Conditions (EU-SILC) (2019 data), based on self-reported data from households on their housing and social situation (2). EU-SILC defines overcrowding as relating to a household that does not have at its disposal a minimum number of rooms in relation to the number, age and gender of household members (3). Environmental health inequalities: fact sheet series Inequalities in overcrowding Defining inequalities Environmental health inequalities are the differences in environmental health conditions between population groups. They can be quantified as absolute and relative inequalities. Absolute inequalities are quantified by differences in the prevalence of a risk factor or disease between population groups (e.g. between poor and rich households). Relative inequalities, in contrast, are quantified as ratios between population groups. To provide an accurate assessment, absolute and relative inequalities are equally important. The data in this fact sheet thus aim (when possible) to provide information on both measures. Further information on defining and assessing environmental health inequalities is available from WHO’s Environmental health inequalities resource package (1). Methodological notes Box 1. Inequality stratifications Household type This fact sheet differentiates between single-parent households and the general population. Income The population is divided into income quintiles, each covering a fifth of the total population. Place of residence The population is divided into three groups of urbanization (cities, towns and suburbs, and rural areas). Poverty Households are divided into those living at or above and those living below the poverty threshold of 60% of the national median equivalized income. To provide an overview and compare inequality conditions by geopolitical subregion, countries were grouped into four subregions to provide population-weighted subregional averages (Table 1). Countries with available data are shown in bold. Subregion Coverage Countries included Euro 1 (21 countries) All countries belonging to the European Union (EU) before May 2004 and western European countries at comparable developmental level EU countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden Non-EU countries: Andorra, Iceland, Monaco, Norway, San Marino, Switzerland, United Kingdom Euro 2 (13 countries) All countries joining the EU after May 2004 Bulgaria, Croatia, Cyprus, Czechia, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Romania, Slovakia, Slovenia Euro 3 (12 countries) All countries belonging to the Commonwealth of Independent States, and Georgia and Ukraine Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan Euro 4 (7 countries) All countries that are part of the South-eastern Europe Health Network, and Turkey Albania, Bosnia and Herzegovina, Israel, Montenegro, Serbia, North Macedonia, Turkey Inequality stratifications To show inequalities within countries, prevalence data can be compared between population subgroups, stratified by: • socioeconomic determinants (e.g. income, poverty, education or employment); • sociodemographic determinants (e.g. age, gender, ethnicity or household type); or • spatial determinants (e.g. place of residence). Most data in this fact sheet rely on a comparison of prevalence of overcrowding: the proportion of people or households in a population with exposure to an overcrowded dwelling at a given time. Box 1 shows the inequality stratifications used in this fact sheet. Indicator Overcrowding Description Population living in an overcrowded dwelling Source and variable code EU-SILC: ilc_lvho05a,b,d Table 1. European subregions used for the assessment Note: The EU-SILC data used for the indicator do not cover Euro 3 countries. 2 Overcrowding is defined as a condition in which the number of occupants (in relation to their age and gender) exceeds the capacity of the dwelling space available – measured as rooms, bedrooms or floor area – resulting in adverse physical and mental health outcomes (4). Living in overcrowded housing is recognized in the EU as the main characteristic of severe housing deprivation (5). Overcrowding is known to have health consequences: it can affect quality of life and well-being and increase stress levels, sleep disorders and mental health issues (4). The risk of infectious disease transmission also increases among people in overcrowded housing. Children are recognized to be more vulnerable to overcrowding, as it can increase the risk of injury as well as infections such as tuberculosis and meningitis (6). The prevalence of overcrowding varied widely between European subregions and countries in 2019, ranging from 3.2% in Ireland to 28.7% in Greece in the Euro 1 subregion; from 2.2% in Cyprus to 45.8% in Romania in the Euro 2 subregion; and from 40.7% in Turkey to 63.0% in Montenegro in the Euro 4 subregion (Fig. 1). Furthermore, prevalence of overcrowding differed by socioeconomic, sociodemographic and spatial aspects. This fact sheet provides an overview of the status of inequalities by poverty, household type and income, and of the interaction between socioeconomic and spatial inequalities. Status of inequalities in overcrowding Introduction and health relevance Fig. 1. Prevalence of overcrowding among the general population (2019) Note: [a] latest available data for Iceland and United Kingdom from 2018. Source: Eurostat EU-SILC public access database (7) (latest update 1 July 2021). Environmental health inequalities: fact sheet series Inequalities in overcrowding 3 Environmental health inequalities: fact sheet series A consistent pattern of social disadvantage can be seen: households below the relative poverty level reported overcrowding more often than those above it in 2019. This applies in all countries except Latvia, where the prevalence of overcrowding was slightly higher among households above the relative poverty level (42.7% versus 40.4%) (Fig. 2). The Euro 4 subregion had the highest prevalence of and the highest absolute inequalities in overcrowding: 65.7% of households below the relative poverty level and 35.5% of those above it lived in overcrowded conditions. Montenegro had the highest national prevalence in this subregion: 75.1% of households below the relative poverty level and 59.0% of households above it had too little living space. The largest absolute national inequalities in overcrowding by relative poverty level were in Turkey (33.0 percentage points), Sweden (30.5 percentage points) and Slovakia (25.8 percentage points). Relative inequalities were largest in the Euro 1 subregion, with an average ratio of 2.5:1. Norway had the largest relative inequality: households below the relative poverty level were almost seven times more often affected by overcrowding than those above it. Latvia had the smallest relative inequality, at 0.9:1, but prevalence of overcrowding was very high for households both above and below the relative poverty level. Inequalities by poverty Fig. 2. Prevalence of overcrowding by relative poverty level (2019) Note: [a] latest available data for Iceland and United Kingdom from 2018. Source: Eurostat EU-SILC public access database (7) (latest update 1 July 2021). Inequalities in overcrowding 4 Between 2010 and 2019, the prevalence of overcrowding increased slightly in the Euro 1 subregion for those both above and below the relative poverty level. Almost a quarter of households in relative poverty were affected in 2019 (Fig. 3). Overcrowding decreased strongly in the Euro 2 subregion between 2010 and 2019. The largest reduction was observed among households below the relative poverty level, where prevalence of overcrowding fell from 59.5% in 2010 to 43.0% in 2019. Absolute inequalities increased from 13.1 to 14.5 percentage points in the Euro 1 subregion and decreased from 18.1 to 11.3 percentage points in the Euro 2 subregion. Relative inequalities were larger within the Euro 1 than the Euro 2 subregion but showed little change over the period. In the Euro 1 subregion, relative inequality decreased from 2.6:1 in 2010 to 2.5:1 in 2019, while in the Euro 2 subregion the ratio was 1.4:1 in both 2010 and 2019. Time trend of inequalities by poverty Fig. 3. Time trend of prevalence of overcrowding by relative poverty level (2010–2019) Notes: no Euro 4 data available; Euro 1 figures for 2019 exclude Iceland and United Kingdom due to lack of data. Source: Eurostat EU-SILC public access database (7) (latest update 1 July 2021). Environmental health inequalities: fact sheet series Inequalities in overcrowding 5 National prevalence of overcrowding among single- parent households showed wide differences in 2019, ranging from 4.1% in Malta to 86.9% in Serbia (Fig. 4). Single-parent households were more often affected by overcrowding than the general population in all countries except Turkey and Albania. Absolute inequalities between single-parent households and all households were largest in the Euro 2 subregion (17.8 percentage points), where the greatest differences were seen in Poland (25.8 percentage points) and Bulgaria (25.6 percentage points). Across all countries, Serbia had the largest absolute inequality, with a difference of 33.6 percentage points between single-parent households and the general population. The largest relative inequalities were seen in the Euro 1 subregion: 11 countries had inequality ratios of 2.0:1 or more, meaning that single-parent households were at least twice as likely to experience overcrowding as the general population. In the Euro 4 subregion, a relative disadvantage of single-parent households versus the general population was only seen in North Macedonia (ratio of 1.1:1), Montenegro (1.2:1) and Serbia (1.6:1). In contrast, single-parent households were less often affected by overcrowding than the general population in Turkey (ratio of 0.8:1) and Albania (0.9:1). Inequalities by household type Fig. 4. Prevalence of overcrowding among single-parent households versus the general population (2019) Environmental health inequalities: fact sheet series Note: [a] latest available data for Iceland and United Kingdom from 2018. Source: Eurostat EU-SILC public access database (7) (latest update 1 July 2021). Inequalities in overcrowding 6 Time series data for 2010–19 show that the prevalence of overcrowding fell sharply among both single-parent households and all households in the Euro 2 subregion. The larger fall was among single- parent households, where prevalence of overcrowding decreased from 68.2% in 2010 to 51.5% in 2019 (Fig. 5). In the Euro 1 subregion, in contrast, prevalence of overcrowding increased slightly for both single- parent households (from 18.3% to 19.6%) and all households (from 10.3% to 11.7%). Absolute inequalities decreased from 23.7 to 17.8 percentage points in the Euro 2 subregion and from 8.1 to 7.9 percentage points in the Euro 1 subregion in this period. Relative inequalities changed little between 2010 and 2019. In the Euro 1 subregion, relative inequality between single-parent households and all households fell slightly from 1.8:1 to 1.7:1, and in the Euro 2 subregion, the inequality ratio was 1.5:1 for both 2010 and 2019. Time trend of inequalities by household type Fig. 5. Time trend of prevalence of overcrowding by household type (2010–2019) Notes: no Euro 4 figures due to lack of data; Euro 1 figures for 2019 exclude Iceland and United Kingdom due to lack of data. Source: Eurostat EU-SILC public access database (7) (latest update 1 July 2021). Environmental health inequalities: fact sheet series Inequalities in overcrowding 7 Inequalities by income Overall, a trend of increasing prevalence of overcrowding with decreasing income was clear in 2019. This can be observed for almost all countries, although at different prevalence levels (Fig. 6). Across all countries except Lithuania and Latvia, households with the lowest incomes were most often affected by overcrowding. In many countries, the lowest income quintile was by far the most deprived population group – sometimes at least twice as often affected as quintile 2 (e.g. in Norway, France or Denmark). Absolute inequalities between the lowest and the highest income quintile were especially large in Turkey (52.3 percentage points), Sweden (35.2 percentage points) and Greece (32.1 percentage points). The Euro 1 subregion had the highest relative inequalities between the lowest and highest income quintiles, with an average ratio of 4.7:1. Within the Euro 1 subregion, relative inequality ratios ranged widely from 2.2:1 in Italy to 26.1:1 in Switzerland. The small ratio in Italy is mainly due to higher prevalence of overcrowding across almost all income groups, in comparison to the other Euro 1 countries. Conversely, in Switzerland, the high inequality ratio results from the very low prevalence of overcrowding in the highest income quintile (0.5%) versus the lowest (13.6%). Within the Euro 2 and 4 subregions, the highest relative inequalities were found in Cyprus (ratio of 14.0:1) and Turkey (4.4:1). Fig. 6. Prevalence of overcrowding by income quintile (2019) Environmental health inequalities: fact sheet series Note: [a] latest available data for Iceland and United Kingdom from 2018. Source: Eurostat EU-SILC production database: unpublished data (latest update 1 July 2021). Inequalities in overcrowding 8 Interaction between socioeconomic and spatial inequalities The poorest households living in cities were those most often affected by overcrowding in almost all countries in the WHO European Region in 2019, while the richest households living in rural areas were often those least affected (Fig. 7). Across all urbanization levels, prevalence of overcrowding was higher among the poorest income quintile. In some countries, the richest households showed a low-prevalence cluster markedly distinguished from the high-prevalence cluster for the poorest households, as in Italy, Sweden and Poland. Inequalities by urbanization level were larger among the poorest income quintiles in the Euro 1 subregion. In the Euro 2 and Euro 4 subregions, in contrast, inequalities by urbanization level were larger among the richest income quintiles. Serbia had the largest absolute inequality, with an overcrowding prevalence of 74.6% for households with the lowest incomes in cities and 25.1% for households with the highest incomes in rural areas. The smallest absolute inequalities were seen in the Netherlands (prevalence ranging from 0.6% to 12.9%) and the United Kingdom (from 0.2% to 12.2%). The highest relative inequalities were found in the Euro 1 subregion. Switzerland (94.2:1), Norway (83.1:1) and the United Kingdom (71.9:1) had the highest ratios, as a result of very low prevalence among households with the highest incomes in towns (0.2–0.4%) versus households with the lowest incomes in cities (12.2–30.7%). Albania had the lowest relative inequality (1.5:1), but this was due to very high prevalence of overcrowding across all income quintiles and urbanization levels (48.7–71.7%). Fig. 7. Prevalence of overcrowding by income quintile and urbanization level (2019) Notes: [a] latest available data for Iceland and United Kingdom from 2018; Belgium, Ireland, Malta, Cyprus, Turkey and Montenegro excluded due to limited or no data on income quintiles and urbanization levels. Source: Eurostat EU-SILC production database: unpublished data (latest update 1 July 2021). Environmental health inequalities: fact sheet series Inequalities in overcrowding 9 Prevalence of overcrowding varies widely within countries with available data but represents a concern in most countries. The average prevalence of overcrowding was higher in the Euro 2 and Euro 4 subregions than the Euro 1 subregion. Within all subregions and countries, however, prevalence differed by poverty, household type, income and urbanization level, with possible adverse health effects for the most disadvantaged population groups. A clear trend is visible – across all subregions and almost all countries – that the poorest households were most often affected by overcrowding. In most countries, the poorest households living in cities reported the highest prevalence of overcrowding compared to all other population groups. In the Euro 2 subregion, prevalence of overcrowding fell between 2010 and 2019, also leading to a reduction in absolute inequalities by poverty level and household type. In the Euro 1 subregion, in contrast, prevalence of overcrowding increased slightly, and absolute inequalities by poverty level also rose during the period. Conclusions and suggested mitigation actions References 1. Environmental health inequalities resource package: a tool for understanding and reducing inequalities in environmental risk. Copenhagen: WHO Regional Office for Europe; 2019 (https://apps.who.int/iris/handle/10665/346223, accessed 16 December 2021). 2. Income and living conditions – overview [website]. Luxembourg: Eurostat; 2021 (https://ec.europa.eu/eurostat/web/income-and-living- conditions/overview, accessed 4 November 2021). 3. Glossary: overcrowding rate [website]. Luxembourg: Eurostat; 2021 (https://ec.europa.eu/eurostat/statistics- explained/index.php?title=Glossary:Overcrowding_rate, accessed 4 November 2021). 4. WHO housing and health guidelines. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/276001, accessed 26 October 2021). 5. Ahrendt D, Dubois H, Jungblut JM, Roys M, Nicol S, Ormandy D et al. Inadequate housing in Europe: costs and consequences. Luxembourg: Publications Office of the European Union; 2016 (https://www.eurofound.europa.eu/publications/report/2 016/quality-of-life-social-policies/inadequate-housing-in- europe-costs-and-consequences, accessed 26 October 2021). 6. Housing and the health of young children. London: National Children’s Bureau; 2016 (https://www.ncb.org.uk/resources/all- resources/filter/wellbeing-mental-health/housing-and- health-young-children, accessed 26 October 2021). 7. Eurostat database [online database]. Luxembourg: Eurostat; 2021 (https://ec.europa.eu/eurostat/web/main/data/database, accessed 4 November 2021). Further reading on the subject is available at: https://www.uni-bremen.de/en/who-collaborating- centre-for-environmental-health-inequalities Suggested mitigation actions are: • ensuring that all new residential buildings, and the existing housing stock when renovated, provide a minimum proportion of dwellings for large households; • providing targeted financial support to the most vulnerable groups (including low-income and single-parent households) to facilitate access to dwellings of appropriate size; • encouraging public housing programmes that provide dwellings with an adequate number of rooms to reduce overcrowding, especially among low-income households and other vulnerable groups. Environmental health inequalities: fact sheet series Inequalities in overcrowding 10 Environmental health inequalities Fact sheet series WHO European Centre for Environment and Health Platz der Vereinten Nationen 1 D-53113 Bonn, Germany Tel.: +49 228 815 0400 Fax: +49 228 815 0440 E-mail: euroeceh@who.int Website: www.euro.who.int Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves Member States © World Health Organization 2022. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license. Suggested citation: Inequalities in overcrowding [February 2022]. Environmental health inequalities: fact sheet series. Copenhagen: WHO Regional Office for Europe; 2022. WHO/EURO:2022-4871-44634-63333 This fact sheet was produced by the WHO Collaborating Centre for Environmental Health Inequalities https://www.uni-bremen.de/en/who-collaborating-centre- for-environmental-health-inequalities/about-who-cc The full overview of environmental health inequalities covered by the fact sheets can be viewed at www.euro.who.int/en/EHinequalities Layout and design: Imre Sebestyén/Unit Graphics Acknowledgments The WHO Regional Office for Europe would like to thank the following contributors: Authors Gabriele Bolte, Gesa Czwikla, Stefanie Dreger, Pia Hasselder and Birgit Reineke (WHO Collaborating Centre for Environmental Health Inequalities) for data compilation, analysis and content development Matthias Braubach and Sinaia Netanyahu (WHO European Centre for Environment and Health) for conceptual design, data compilation and technical editing This fact sheet was produced with the financial support of the German Federal Ministry for the Environment, Nature Conservation, Nuclear Safety and Consumer Protection.