Art & science | research
Barriers to keeping warm in later life Angela Tod and colleagues discuss why some older people may be at risk of cold-related harm and illness, and how nurses can improve their access to necessary aid and care Correspondence [email protected]
Abstract
Angela Tod is professor, Centre for Health and Social Care Research, Sheffield Hallam University Adelaide Lusambili was a researcher at NHS Rotherham at the time of writing. She is now research fellow, academic unit of elderly care and rehabilitation, Bradford Institute for Health Research Jo Cooke is programme manager, Collaboration for Leadership in Applied Health Research and Care for South Yorkshire Catherine Homer is researcher, Sheffield Hallam University Jo Abbott is consultant in public health, Rotherham Metropolitan Borough Council Amanda Stocks is director AJ Stocks Ltd Kath McDaid is National Energy Action project development co-ordinator Date of submission January 3 2013 Date of acceptance January 30 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Aim To identify factors influencing older people’s ability to keep warm and well in winter. Method This qualitative study used in-depth individual interviews with older people (n=50) and health and social care staff (n=25), alongside six focus groups with 43 participants and a consultation event. Temperatures were measured in the homes of the older people interviewed. Framework analysis techniques were used. Findings The data indicated a lack of awareness among participants of the importance to a person’s health of keeping warm. A summary of findings related to the themes of awareness, money, mindset and machinery COLD WEATHER can present a major threat to health, especially for people with existing vulnerability. Some older people are particularly at risk if they have multiple healthcare needs. This article provides a summary of the Keeping Warm in Later Life (KWILLT) project, a qualitative research study funded by the National Institute for Health Research through its Research for Patient Benefit Programme. KWILLT aimed to explore factors influencing older people’s ability to keep warm and well in winter. The main intent of this article is to reflect on the implications of the findings for nursing practice.
Background and literature Every year in England, there are approximately 24,000 deaths attributable to the effects of cold weather (Department of Health (DH) 2012a, 2012b), mostly among older people. However, cold weather also has a number of negative effects on health and wellbeing. The Marmot Review Team (MRT) (2011) summarised the effects that cold homes can have on people’s health: there is an established strong relationship between cold temperatures and cardiovascular diseases including heart attack
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is presented here, with reflections on their relevance to nursing in terms of identifying older people at risk of the negative health effects of cold, their assessment and support. Conclusion The study revealed a number of ways older people are vulnerable to cold at home. Timely interventions from nurses in various sectors could help avoid cold-related harm. Keywords Cold-related harm, cold weather, fuel poverty, keeping warm in winter, public health and stroke, increased blood pressure, respiratory illness, and mental health problems. Cold homes also increase levels of minor illnesses, such as colds and flu, and worsen underlying chronic conditions, such as arthritis and rheumatism. In addition to ill health, being cold increases the risk of accidents in the home as well as of slips and falls outside the home (DH 2012a, 2012b). To avoid these effects the World Health Organization (WHO) recommends that living rooms should be maintained at 21°C and bedrooms at 18°C (MRT 2011). The DH has recognised concerns about the link between cold temperatures and health. In 2011, it launched its first cold weather plan for England (DH 2011a), alongside a document showing the need for the plan (DH 2011b). The plan was relaunched in 2012 with supporting documentation and action cards for different staff groups (DH 2012a, 2012b, 2012c, Public Health England (PHE) 2013). The plan recommends steps and actions to reduce the health risks of cold weather, and calls for systematic partnership planning and action by the NHS, local authorities, social care, the voluntary sector, individuals and communities. Identifying those who are at risk and reducing risk are important parts of NURSING OLDER PEOPLE
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the plan. Nurses could be important in realising the health benefits of the plan.
Fuel poverty and health In 2010, there were 4.6 million homes in fuel poverty in England. Those in fuel poverty are more at risk of cold-related death or illness (MRT 2011). A household is in fuel poverty if more than 10 per cent of household income is required to keep rooms at the WHO’s recommended safe temperatures. The government has recently set out a new definition, where a household is said to be in fuel poverty if (Hills 2012, Department of Energy & Climate Change 2013): ■■ They have required fuel costs that are above the national median level. ■■ They would be left with a residual income below the official poverty line if they spent that amount. However, the 10 per cent definition has been in place for many years, since the formative work by Boardman (1991, 2010). Fuel poverty is dependent on three factors: the cost of fuel, household income and energy efficiency of the property (MRT 2011). This means that being fuel poor is different from being poor, although fuel poverty rates and excess winter deaths are higher in areas of deprivation. Someone can live on a modest income in an energy-efficient home and not be fuel poor. Likewise, a person living in a large, under-occupied, energy-inefficient property may be in fuel poverty, despite a healthy income. Health professionals should remember this when considering who may be at risk of being cold. The effect that being fuel poor can have on health is reflected in the public health outcomes framework, where addressing fuel poverty is an objective (DH 2012d). In recent years, policy interventions to address fuel poverty have focused on increasing the energy efficiency of properties through initiatives such as Warm Front, which has now been replaced by the Green Deal; increasing income to pay for fuel through schemes such as the winter fuel allowance; and reducing fuel costs through social energy tariffs and the warm home discount scheme. However, there is concern that those most at risk, such as older people, do not always access available help (Liddell and Morris 2010, Stockton and Campbell 2011). Some older people are especially at risk of fuel poverty, including those who rely on a pension or ‘flat income’ and are therefore unable to absorb fuel price increases, and those who have higher fuel bills because they are housebound as a result of illness or infirmity. Under-occupancy can be a major contributor to energy inefficiency and the ability to keep a home warm, so people who live alone in a house that was once home to NURSING OLDER PEOPLE
a larger family are also at risk. Those living in rented property are also more likely to be fuel poor than those living in homes they own – in 2011, 19 per cent of households in the private rented sector were fuel poor (MRT 2011).
Older people and cold Being cold can cause a range of health problems but with age comes increased vulnerability. Worfolk (1997) gave many reasons for this and, while that article is old, little has been written since that improves or updates the explanation, revealing an interesting gap in the literature and evidence base about cold and health. The physiological systems responsible for thermoregulation are complex. However, as the body ages, the efficiency of this finely tuned mechanism decreases. Heat generation is reduced due to a decline in metabolism and muscle activity. Heat loss increases as thinner skin impairs the body’s natural insulation. The body also struggles to maintain body temperature as effectively in the cold. Autonomic nervous system impairment may compromise vasoconstriction on exposure to cold. Medication for chronic health problems can exacerbate an older person’s susceptibility to the cold. Compensatory responses may also be affected if a person is cold and ill – activity and warm food and drink can help to protect against the cold, but the ability to do or consume these can be impaired by age and infirmity (Worfolk 1997). Hypothermia is usually thought of as severe – that is, when a person’s body temperature drops below 35°C. However, hypothermia at any stage could be dangerous for older people, especially for those with multiple health problems. An important point made by Worfolk (1997) is that, because of impaired physiological response, an older person can be cold in an environment that is comfortable for a busy, active younger person. Healthcare professionals such as nurses may therefore visit older patients at home and not notice that patients are cold. Despite this complex picture, little has been written about nursing responses to older patients’ vulnerability to the negative health effects of cold, and there is little evidence to explain why older people may end up being cold. KWILLT aimed to address that gap in the evidence.
Aim The overall aim of KWILLT was to examine the knowledge, beliefs and values of older people about keeping warm at home. The project aimed to identify factors influencing their ability to keep warm and well in winter and barriers to accessing help in keeping warm. December 2013 | Volume 25 | Number 10 23
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Art & science | research Method
Box 2 Staff sample (n=25)
The study was conducted in Rotherham, an area in the south Yorkshire coalfields in the north of England. In-depth, semi-structured interviews were conducted with 50 older people over the age of 55 years and 25 health and social care professionals. The older people were interviewed in the winter months of 2009/2010 and 2010/11. Participants were recruited through social and community groups. Local government and healthcare services’ data on housing, excess winter deaths, older people’s falls, and respiratory and cardiovascular disease were reviewed to help identify areas with vulnerable older adults. Older people’s day care centres, community organisations for vulnerable people and churches were contacted to identify and recruit participants. Snowball sampling was also used. In this way, vulnerable, socially isolated participants were included. The sample included a range of people in terms of age, gender and living circumstances. Box 1 provides demographic details of the older people who participated. Further details of the methods and findings from the older participants are published elsewhere (Tod et al 2012). Semi-structured interviews were guided by schedules devised by the research team. The interview schedules included issues relating to the type and nature of housing, heating patterns, heating methods, mode of payment, heating systems, values and beliefs. A professional translator was hired to assist the study researcher with interviews for the minority ethnic focus group. Most of the interviews were audio-recorded and field notes were taken. The week before the interviews were conducted, temperature and relative humidity recorders were placed in the rooms in which participants spent most of their days and nights, to explore whether their views and perceptions of warmth matched actual room temperatures. Findings from the temperature measurements are not presented here. Box 1 Older people’s demographic data (n=50) Age (years)
Ethnicity
Gender
55-69
14
65+
36
Black and minority ethnic
19
English
31
Female
36
Male
10
Couples 24 December 2013 | Volume 25 | Number 10
4
Voluntary sector organisations
5
Health and social care practitioners
12
Local authority
3
Social housing organisations
5
Total
25
Health and social care professionals were purposively recruited to ensure there was a range of participants from different organisations, including the voluntary sector, local authority and social housing. Healthcare practitioners included nurses, occupational therapists, domiciliary care workers and GPs working with older people. In-depth interviews were conducted at professionals’ workplaces. Box 2 shows a summary of the health and social care participants in the study. Qualitative data from the initial interviews were transcribed and entered into the qualitative software package NVivo 8. Using framework analysis methods, data were analysed thematically, coded and continuously reviewed by the research team (Ritchie and Spencer 1994, Ritchie and Lewis 2003). The research team discussed the emerging findings from data collection in the first winter. These findings were used to guide the older people’s interviews in the second winter and focus group discussions. For example, issues concerning social connections, heating technology and behaviour regarding heating emerged in the initial analysis and were explored in detail in the second sample of interviews. Emerging findings from the interviews were tested in six focus groups with a total of 43 participants. The first three focus groups were conducted with older people considered vulnerable either because they attended older people’s day care centres or participated in a community support group. The first two focus group discussions for older people were diverse in terms of age, gender and educational level. The third group consisted of minority ethnic women with shared cultural values. All interviews were conducted at older people’s community centres. Three focus groups were also conducted with staff working at strategic and policy levels, which included financial inclusion organisations, local government representatives from the study area, and community allied health professionals. Table 1 summarises the focus groups’ genders. In the final stage, findings were discussed at a consultation event, with more than 110 representatives from local, regional and NURSING OLDER PEOPLE
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national NHS, local authority and voluntary sector organisations, including lay representatives. Ethical considerations Ethical approval for this study was granted by the Leeds East NHS research ethics committee. All participants were assured of confidentiality, and information deemed to compromise anonymity was removed from interview transcripts and quotes. With the consent of interviewees, interviews were audio-recorded. Informed consent was gained from focus group participants.
Findings KWILLT generated in-depth insight into the complex range of interrelating factors that can influence an older person’s ability to keep warm at home. A more detailed account of the findings is available elsewhere (Tod et al 2012) and on the KWILLT website (kwillt.org). This article presents a summary of findings related to four themes: awareness, money, mindset and machinery. Awareness The older people interviewed revealed a lack of awareness about the link between health and heating (Tod et al 2012). They also displayed a lack of knowledge about safe temperatures and talked about a preference for cold rather than hot rooms: ■■ ‘I can’t get into a warm bed. It has to be cold for me to get into’ (woman, 59, private rented accommodation, chronic mental and physical health problems). ■■ ‘I’ve never been spoilt, and I’m not bothered about being right warm’ (woman, 84, social housing, ill health and deaf). ■■ ‘I don’t like it too hot, I don’t like it too cold... not too warm, that’s unhealthy, isn’t it?’ (woman, 76, detached privately owned house, deaf). Table 1 Code
Focus group gender demographic data Men
Women
Total
FGOP1
3
7
10
FGOP2
0
8
8
FGOP3
1
5
6
FGS1
4
4
8
FGS2
3
2
5
FGS3
1
5
6
FGOP=focus group for older people FGS=focus group for strategic staff groups
NURSING OLDER PEOPLE
Examples were given where people thought a hot room was bad for them: ■■ ‘We do get that from patients, it needs to be off at night, you’re breeding germs, that’s why everybody has so many colds and they’re always at the doctor’s. We were never at the doctor’s’ (staff participant, domiciliary care provider). Others viewed heating as a luxury rather than a necessity and so did not prioritise being warm and paying for heating: ■■ ‘I think older people see heating as a luxury. I don’t think they see it has any bearing on their health. I think they think they can get by without it a lot of the time or just very little’ (staff participant, financial advice worker). ■■ ‘My dad’s nearly 70, just an example. He won’t have his heating on, will not, and it’s freezing in his house; he’ll put more jumpers on. He believes that that’s unhealthy, having heat on; he’ll have jumpers on’ (staff participant, home carer). While expressing concern that older people should not be cold, staff also exhibited a lack of knowledge of safe temperatures and how to use heating technology in the home: ■■ ‘I don’t think people actually associate heat or warmth with health at all. I mean I have to say, as a health visitor and a nurse, for goodness knows how many years, it’s only when affordable warmth became sort of being promoted that I really linked the two. So, you know, even as a health professional I haven’t really given it a great deal of thought’ (staff participant, public health, nursing background). ■■ ‘But I don’t think they know how to work these new heating systems. I don’t actually; I leave it to my husband’ (staff participant, community nurse). Other areas where older people and staff displayed lack of knowledge included where to get help how to change tariffs and, for staff, how to identify if someone was at risk: ■■ ‘I’ve changed and I ended up with a big bill because they don’t always come out and read your meter and things… and then another company tells you they’re going to be cheaper and save you loads of money, and you change over and you end up with a big bill. You know, I don’t understand them so the elderly certainly won’t’ (staff participant, community nurse). Money It was clear that, for some, lack of money was a barrier to heating their home. Where household income was short, there was a tendency to turn off or turn down and be careful about heating. For some, fear of a big bill combined with past hardship got in the way of maintaining a warm home, even if their income was sufficient to keep the home warm. December 2013 | Volume 25 | Number 10 25
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Art & science | research The winter fuel allowance was a real benefit and relieved financial strain and pressure. However, for some, regardless of whether they had money, their default behaviour was to be careful, under-heat the home, only heat one room, and use extra layers and hot water bottles to keep warm: ■■ ‘They’re quite scared when they get big bills, although they might have money in the bank... And I said why don’t you spend some of this and get, you know, get your house warmed up and get, and perhaps if they’re living in a bit of a neglected state they might need new settees, new carpet. Why have you got all this money sat in the bank and you’re living like you are? They can’t always answer you, you know, “Well it’s always been there, I’ve always had to save for that, there might be one day when I might need it.” Well now’s the time, this is that one day. Yeah and it’s trying to get them to draw the money out, it’s such a stumbling block for them to go and draw the money out and spend it’ (staff participant, financial advice worker). A past life of financial austerity left its mark on many participants and meant they found it difficult to spend money on their own comfort at home: ■■ ‘I was trained to be frugal; it was part of my upbringing. You didn’t have a lot so you were careful with what you did have. And with the costs rising now, I’m certainly not extravagant with the heating, I’m very wary’ (woman, 76, detached privately owned house, deaf). ■■ ‘It’s because they’ve lived such a frugal life through the wars and beyond. They’ve had to be so tight with their money and so frugal that to spend an excessive – what they consider an excessive – amount of money now is quite vulgar to them and it’s just not in their mindset. Their mindset is to spend as little as possible and get by with as little as possible, and that’s what they’ve been doing all their life. So now that they’ve got the money, it doesn’t register that they can afford it; they just don’t think they’re supposed to do it. They don’t think they’re supposed to spend. So to be living in a warm, cosy house with the heating on, it’d be frightening to them in some respects because they’d be thinking they’d be spending money they shouldn’t be spending’ (staff participant, financial advice worker). This financial caution was heightened when people wanted to leave what little they had to their families and did not want to spend it on themselves: ■■ ‘They seem to want to save it for family don’t they?’ (staff participant, community allied health professional). 26 December 2013 | Volume 25 | Number 10
Mindset The data illustrated the behaviour of many participants was driven by past experiences and values that had built up over time. There were many examples of why older people were not able to follow advice about heating, as it clashed with their existing values and beliefs. More frequent examples of this related to thrift, frugality, hardiness and stoicism. Regarding thrift, some people were naturally cautious about spending money on fuel, regardless of whether they had the money to pay for it. At times, this was underpinned by the importance placed on being careful with money, not just fear of a big bill and being debt averse. However, where frugality was accompanied by regard for being hardy and putting on a brave face, there was an increased tendency to be careful with heating: ■■ ‘I mean, growing up there would have been ice on the inside of the bedroom windows quite regularly because it would be really, really cold in the bedrooms in winter. So, I don’t know, you are influenced to think a little bit, in our generation, you tend to think they’re a bit nannied. Talk about a nanny state, you know, but they’re so coddled with everything and that it shouldn’t really be much of a hardship to be cold occasionally… No, I wouldn’t say it’s, I wouldn’t see it as a life-threatening issue to have been without the heating for a month because yes you’re probably quite right we grew up without any’ (woman, 58, privately owned bungalow, in good health). ■■ ‘They’re very hardy. And sometimes they think they’re being extravagant if they’re warm because they might have come from a background where they’ve always struggled, their family have struggled, it’s a luxury to be warm, and sometimes they’re just in that mental frame of mind where it’s a luxury, you know’ (staff participant, domiciliary care provider). Another factor that prevented people accessing help, such as better fuel tariffs or energy efficiency schemes, was a preference for routine and dislike of change. Even though it meant life was uncomfortable, the thought of change and disruption could not be brooked: ■■ ‘I don’t think I would change, no. I wouldn’t like the hassle, no, because nothing’s straightforward’ (woman, 82, private housing, in good health). ■■ ‘She pays cash. She thinks that she doesn’t trust them; they might charge more with direct debit’ (woman interviewed through interpreter, 55, privately owned terraced house, heart disease and diabetes). ■■ ‘They’re frightened about any changes. They don’t like changes, they like their routine, they’re frightened… The elderly will say “I’ve not got to my NURSING OLDER PEOPLE
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age to be told what to do. Yes, I know what’s good for me, I haven’t got to this age by not knowing what’s good for me and it’s never killed me before”’ (staff participant, domiciliary care provider). Finally, in terms of mindset, mistrust had a large role to play. This was particularly directed towards energy companies. Many schemes for cheaper tariffs or energy efficiency were administered through energy companies and there was a universal tendency among older participants to disbelieve what was on offer. This was sometimes reinforced by a bad experience of their own or that of friends and neighbours if they had tried an initiative: ■■ ‘There is a lack of trust because of what it’s like giving something with one hand and taking it away with the other, you know, you might change from one service provider to the one that seems to be providing the best value for money, only to find that six months later it’s swapped again, you know. So I do think people are, I do feel quite confused’ (staff participant, public health, nursing background). ■■ ‘Some of them are not what they’re supposed to be – they’re scams, because you get it cheaper for one year and then it’s dearer than the one you left’ (woman, 77, social housing, chronic health problems). Machinery A common experience for older participants was to be challenged by the technology involved with keeping warm. Often this would be heating technology, such as boilers, programmers and thermostats: ■■ ‘I find that they’re built by somebody who knows how to use digital technology, and the sort of way they work isn’t conducive to easily changing any of the parameters really, you know. But I do know how to use mine, but my wife wouldn’t know. My wife wouldn’t be able to use them if I wasn’t here’ (man, 63, privately owned terraced house, carer for wife with Alzheimer’s and cancer). ■■ ‘I don’t actually have to touch the boiler… I can’t actually set it, it is set, and like when the clocks change I’ve a friend that sets the timer for me; he changes the clock’ (woman, 76, council flat, asthma). However, the difficulties did not just lie with heating, but also technology related to banking, payment for fuel or information over the internet: ■■ ‘They’ll not do direct debits a lot of them, they don’t know how to do it; they like to physically go and pay a bill. So I would say the majority of the pensioners that I see do use the post office. Apart from the ones that have been brought up to date by family members and have got direct debits set up for them’ (staff participant, financial advice worker). NURSING OLDER PEOPLE
Discussion The main limitation of KWILLT was that it was a single-site study, which could limit the extent to which findings are transferable to other populations. However, this approach did facilitate the generation of in-depth understanding of the sample. Attempts were made to ensure a broad sample in terms of income, housing type and tenure, health and age. This diversity increases the potential to apply the findings to other populations. This summary of KWILLT findings has provided some indication of how complex it is for people, as they get older, to make and implement decisions about heating homes. For many health professionals, it may seem strange that people do not put on their heating, especially when they are cold and apparently able to afford to do so. However, as indicated, there may be a range of influences that mean people, with the best of intentions, decide to heat their homes insufficiently. Factors identified include difficulty in keeping up to date with health advice, especially if it is on the internet; pre-existing values and beliefs that clash with public advice campaigns; fear of change; difficulty operating technology; and perception of risk. The range of influences and how they appear in different individuals is difficult to present in the context of a short article or report. For that reason, the KWILLT team developed a series of six pen portraits. These were not real people but constructed using the thematic framework and data generated from participants’ views and experiences. The portraits represent people with different characteristics and who are at risk of being cold for different reasons. They can be accessed on the KWILLT website (kwillt.org).
Implications for practice The cold weather plan (DH 2012a, PHE 2013) makes clear that there are easy and quick actions that can be taken in terms of preparing for cold weather, being alert and ready if cold weather is anticipated, and responding if cold weather arrives. Systems and resources should be in place before the winter months. Actions that nurses can be actively engaged in fall into three main areas, briefly considered here in the light of KWILLT findings. Identifying those at risk KWILLT indicates that a large number of people are at risk of being cold at home in winter. Some older people will be at risk of harm from the cold at a temperature acceptable to younger adults. It is important for health professionals like nurses to set the bar low when thinking about who is at risk – it is not December 2013 | Volume 25 | Number 10 27
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Art & science | research just the very old, very poor or those in the worst housing. Someone can be relatively young – say, 55 to 60 years old – but have chronic, complex health problems and live in an energy-inefficient, rented property that would put them at risk from the cold. People who are old and well, and live in energy-efficient homes of a decent standard are still at risk from the cold if they have no idea how to heat their homes or are naturally frugal and hardy. It will also be necessary to review medications to see who is at increased risk of cold as a side effect of the medication they are taking.
Box 3 Questions to identify people at risk of cold-related harm
Signposting When vulnerability is identified in clinical consultations, at-risk clients and patients should be directed to appropriate help, such as home insulation schemes, benefits advice and advice about fuel payment.
(Department of Health 2012a, Public Health England 2013)
Risk reduction Intervening and taking action to reduce risk or provide support is important. Examples include ensuring the vulnerable have flu vaccinations and providing information about home heating in a form that is acceptable and accessible. These actions appear straightforward. However, for them to work, systems, resources and partnerships should be in place. Appropriate tools also need to be in place so that health staff can quickly and efficiently identify people at risk. There are two approaches listed in the cold weather plan. The first is to identify people at risk of cold-related harm by asking three simple questions (Box 3). The second is the Kirklees NHS Predictive Risk Toolkit (DH 2012b, PHE 2013), which can be used in GP practices to target the most vulnerable people.
1. Is your whole house warm in winter? This question helps to identify how people are heating their home and if they are limiting heating to certain rooms. 2. Can you afford to heat your home to a comfortable level? This question helps to identify whether occupants are meeting ‘minimum’ recommended temperatures all the time. 3. Can you afford to pay your fuel bills? This question will flag whether someone has sufficient income to spend on the fuel they need for warmth and comfort.
Resources and planning are especially required when it comes to signposting and referral. Some voluntary agencies will accept referrals of this nature, including some local Age UK services, home improvement agencies and schemes, financial inclusion organisations and Citizens Advice. Fire and rescue services will often provide home safety checks to those at risk of cold. Before the winter, nurses working with vulnerable populations should identify whom to direct patients to and quick and easy systems should be put in place to achieve this. In some areas, there are partnership referral schemes, such as the south Yorkshire Hot Spots scheme. Nurses can identify, refer and support vulnerable older people to keep warm. As the largest and most diverse healthcare workforce, nurses are in an ideal position to identify people who are vulnerable to cold weather and who may struggle to keep warm and therefore well. Nurses in hospital, primary care or community settings, as well as those in managerial
Box 4 Keeping Warm in Later Life projecT (KWILLT) educational tools Pen portraits Six pen portraits describing how vulnerable older people are at risk of being cold for different reasons. Available electronically and in hard copy to any organisation or group of staff working with older, vulnerable people, people in fuel poverty or in the implementation of the cold weather plan (kwillt.org). The pen portraits aim to help relevant organisations and individuals to: ■■ Find and recognise people who are at risk. ■■ Understand the complex reasons why older people are cold. ■■ Support the design and delivery of acceptable and accessible services. ■■ Identify strategies to overcome barriers. 28 December 2013 | Volume 25 | Number 10
■■ Promote strategies to support self-management to keep warm. Winter Warmth The Winter Warmth England website (www. winterwarmthengland.co.uk) provides information, statistics and communication resources to help relevant organisations and staff ensure that vulnerable people stay safe, well and warm during the winter. Learning resources DVDs/videos: three of the pen portraits have been used to make educational films. They aim to help staff and students at any level to engage with the experiences of vulnerable older people and understand why they may be
cold at home. They are available on the Winter Warmth England website: winterwarmthengland.co.uk E-learning materials: all six pen portraits form the basis of a free, structured e-learning resource on the KWILLT website (kwillt. org). They can be used in different ways, for example: ■■ By individuals for their own reflection and learning. ■■ By organisations to provide workforce training. ■■ As additional materials to existing workforce training and development. ■■ By educational organisations and universities to build into curricula. NURSING OLDER PEOPLE
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and strategic roles, can all aid identification of those at risk, their assessment and referral. To date, attention has focused on those in the community, and the cold weather plan action cards target community and primary care teams (DH 2012c, PHE 2013). District nurses can identify and signpost those at risk as they visit older patients in their homes. However, practice nurses are also in a position to help. They are often responsible for the management of chronic diseases and may be responsible for regular review of those with underlying conditions that would predispose them to cold-related harm, such as cardiovascular, respiratory or diabetic disease. Additional identification, assessment and action must be realistic in terms of time and workload. A strong management lead is required to ensure the systems are in place for rapid assessment – for example, by using the three questions outlined in Box 3 and signposting/referral using local processes planned before the winter. Referral systems need to be rapid, responsive and provide feedback to the referring health professional to engage staff. Staff working in hospital settings can also identify those at risk. The possibility that older patients may have conditions that have been brought on or exacerbated by cold should be considered. Again, systems need to be in place so that those admitted with recurrent respiratory disease and other cold-related illnesses are identified. It is also necessary to build processes into planning discharges. Self-report can be unreliable as patients may want to be seen as coping and living in warm homes; they also may not recognise they are cold. Even if a social worker or allied health professional visits the patient at home, it is difficult to assess how cold the home will be after the patient has returned to it, as the home will not have been heated during the hospital stay. A referral for a home safety check a few days post-discharge could detect any problems.
A final point relates to training. For the above actions to be undertaken and staff to be engaged, training in risk, assessment and referral is required. The cold weather plan recommends integrating training about cold and heating behaviour into existing provisions, such as Making Every Contact Count, which was developed in the Yorkshire and Humber region to train frontline staff in health-related, behavioural change interventions (DH 2012a, PHE 2013). KWILLT findings indicate that staff may lack the information, insight or awareness to identify if someone is at risk or who to refer to if there is concern. The cold weather plan requires that all staff are made aware of the plan and how to recognise dangers and risks (DH 2012a, PHE 2013). To help with this, KWILLT findings have been used to develop the Winter Warmth England website (www. winterwarmthengland.co.uk). Funded by the DH Warm Homes Healthy People fund, it provides up-todate, consistent messages for staff and the public on affordable warmth and cold protection. In addition, there are DVDs/videos and e-learning materials based on the pen portraits, which can be used as training materials by individual practitioners, in organisational training and education curricula. A summary of KWILLT educational tools is in Box 4.
Conclusion This article provides evidence and insight to explain why some older people may be at risk of coldrelated harm and illness. Implications of the KWILLT findings for nursing practice have been summarised. Nurses are in a prime position to identify those at risk and improve access to necessary support and care. However, they require training and resources and the managerial support for effective referral mechanisms, patient pathways and systems to be in place. Educational outputs from KWILLT may help to achieve this.
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Conflict of interest This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) programme (grant reference number PB-PG-0408-16041) and supported by the Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health Acknowledgement We acknowledge the time and generosity of the KWILLT participants and extend our heartfelt thanks
References Boardman B (1991) Fuel Poverty: From Cold Homes to Affordable Warmth. Belhaven Press, London.
Department of Health (2012a) Cold Weather Plan for England 2012: Protecting Health and Reducing Harm From Severe Cold. DH, London.
Liddell C, Morris C (2010) Fuel poverty and human health: a review of recent evidence. Energy Policy. 38, 6, 2987-2997.
Boardman B (2010) Fixing Fuel Poverty: Challenges and Solutions. Earthscan, Abingdon.
Department of Health (2012b) Cold Weather Plan for England 2012: Supporting the Case. DH, London.
Marmot Review Team (2011) The Health Impacts of Cold Homes and Fuel Poverty. tinyurl.com/d8jw32t (Last accessed: October 22 2013.)
Department of Energy and Climate Change (2013) Fuel Poverty Statistics. tinyurl.com/ ppn5lgh (Last accessed: October 22 2013.) Department of Health (2011a) Cold Weather Plan for England: Protecting Health and Reducing Harm from Severe Cold. DH, London. Department of Health (2011b) Cold Weather Plan for England: Making the Case: Why Cold Weather Planning is Essential to Health and Well-being. DH, London.
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Department of Health (2012c) Cold Weather Plan for England 2012: Action Cards for Cold Weather Alert Service: GPs and Primary Care Teams. tinyurl.com/paf2gfh (Last accessed: October 22 2013.) Department of Health (2012d) The Public Health Outcomes Framework for England, 2013-2016. DH, London. Hills J (2012) Getting the Measure of Fuel Poverty. Final Report of the Fuel Poverty Review. tinyurl. com/oxtsmk9 (Last accessed: October 22 2013.)
Public Health England (2013) Cold Weather Plan for England 2013: Protecting Health and Reducing Harm from Cold Weather. tinyurl.com/pcruoa4 (Last accessed: November 1 2013.) Ritchie J, Spencer L (1994) Qualitative data analysis for applied policy research. In Bryman A, Burgess R (Eds) Analyzing Qualitative Data. Routledge, Abingdon.
Ritchie J, Lewis J (Eds) (2003) Qualitative Research Practice: A Guide for Social Science Students and Researchers. Sage Publications, London. Stockton H, Campbell R (2011) Time to Reconsider UK Energy and Fuel Poverty Policies? Joseph Rowntree Foundation, York. Tod A, Lusambili A, Homer C et al (2012) Understanding factors influencing vulnerable older people keeping warm and well in winter: a qualitative study using social marketing techniques. BMJ Open. 2:e000922 doi:10.1136/ bmjopen-2012-000922 Worfolk J (1997) Keep frail elders warm! Geriatric Nursing. 18, 1, 7-11.
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Barriers to keeping warm in later life Angela Tod and colleagues discuss why some older people may be at risk of cold-related harm and illness, and how nurses can improve their access to necessary aid and care Correspondence [email protected]
Abstract
Angela Tod is professor, Centre for Health and Social Care Research, Sheffield Hallam University Adelaide Lusambili was a researcher at NHS Rotherham at the time of writing. She is now research fellow, academic unit of elderly care and rehabilitation, Bradford Institute for Health Research Jo Cooke is programme manager, Collaboration for Leadership in Applied Health Research and Care for South Yorkshire Catherine Homer is researcher, Sheffield Hallam University Jo Abbott is consultant in public health, Rotherham Metropolitan Borough Council Amanda Stocks is director AJ Stocks Ltd Kath McDaid is National Energy Action project development co-ordinator Date of submission January 3 2013 Date of acceptance January 30 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Aim To identify factors influencing older people’s ability to keep warm and well in winter. Method This qualitative study used in-depth individual interviews with older people (n=50) and health and social care staff (n=25), alongside six focus groups with 43 participants and a consultation event. Temperatures were measured in the homes of the older people interviewed. Framework analysis techniques were used. Findings The data indicated a lack of awareness among participants of the importance to a person’s health of keeping warm. A summary of findings related to the themes of awareness, money, mindset and machinery COLD WEATHER can present a major threat to health, especially for people with existing vulnerability. Some older people are particularly at risk if they have multiple healthcare needs. This article provides a summary of the Keeping Warm in Later Life (KWILLT) project, a qualitative research study funded by the National Institute for Health Research through its Research for Patient Benefit Programme. KWILLT aimed to explore factors influencing older people’s ability to keep warm and well in winter. The main intent of this article is to reflect on the implications of the findings for nursing practice.
Background and literature Every year in England, there are approximately 24,000 deaths attributable to the effects of cold weather (Department of Health (DH) 2012a, 2012b), mostly among older people. However, cold weather also has a number of negative effects on health and wellbeing. The Marmot Review Team (MRT) (2011) summarised the effects that cold homes can have on people’s health: there is an established strong relationship between cold temperatures and cardiovascular diseases including heart attack
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is presented here, with reflections on their relevance to nursing in terms of identifying older people at risk of the negative health effects of cold, their assessment and support. Conclusion The study revealed a number of ways older people are vulnerable to cold at home. Timely interventions from nurses in various sectors could help avoid cold-related harm. Keywords Cold-related harm, cold weather, fuel poverty, keeping warm in winter, public health and stroke, increased blood pressure, respiratory illness, and mental health problems. Cold homes also increase levels of minor illnesses, such as colds and flu, and worsen underlying chronic conditions, such as arthritis and rheumatism. In addition to ill health, being cold increases the risk of accidents in the home as well as of slips and falls outside the home (DH 2012a, 2012b). To avoid these effects the World Health Organization (WHO) recommends that living rooms should be maintained at 21°C and bedrooms at 18°C (MRT 2011). The DH has recognised concerns about the link between cold temperatures and health. In 2011, it launched its first cold weather plan for England (DH 2011a), alongside a document showing the need for the plan (DH 2011b). The plan was relaunched in 2012 with supporting documentation and action cards for different staff groups (DH 2012a, 2012b, 2012c, Public Health England (PHE) 2013). The plan recommends steps and actions to reduce the health risks of cold weather, and calls for systematic partnership planning and action by the NHS, local authorities, social care, the voluntary sector, individuals and communities. Identifying those who are at risk and reducing risk are important parts of NURSING OLDER PEOPLE
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the plan. Nurses could be important in realising the health benefits of the plan.
Fuel poverty and health In 2010, there were 4.6 million homes in fuel poverty in England. Those in fuel poverty are more at risk of cold-related death or illness (MRT 2011). A household is in fuel poverty if more than 10 per cent of household income is required to keep rooms at the WHO’s recommended safe temperatures. The government has recently set out a new definition, where a household is said to be in fuel poverty if (Hills 2012, Department of Energy & Climate Change 2013): ■■ They have required fuel costs that are above the national median level. ■■ They would be left with a residual income below the official poverty line if they spent that amount. However, the 10 per cent definition has been in place for many years, since the formative work by Boardman (1991, 2010). Fuel poverty is dependent on three factors: the cost of fuel, household income and energy efficiency of the property (MRT 2011). This means that being fuel poor is different from being poor, although fuel poverty rates and excess winter deaths are higher in areas of deprivation. Someone can live on a modest income in an energy-efficient home and not be fuel poor. Likewise, a person living in a large, under-occupied, energy-inefficient property may be in fuel poverty, despite a healthy income. Health professionals should remember this when considering who may be at risk of being cold. The effect that being fuel poor can have on health is reflected in the public health outcomes framework, where addressing fuel poverty is an objective (DH 2012d). In recent years, policy interventions to address fuel poverty have focused on increasing the energy efficiency of properties through initiatives such as Warm Front, which has now been replaced by the Green Deal; increasing income to pay for fuel through schemes such as the winter fuel allowance; and reducing fuel costs through social energy tariffs and the warm home discount scheme. However, there is concern that those most at risk, such as older people, do not always access available help (Liddell and Morris 2010, Stockton and Campbell 2011). Some older people are especially at risk of fuel poverty, including those who rely on a pension or ‘flat income’ and are therefore unable to absorb fuel price increases, and those who have higher fuel bills because they are housebound as a result of illness or infirmity. Under-occupancy can be a major contributor to energy inefficiency and the ability to keep a home warm, so people who live alone in a house that was once home to NURSING OLDER PEOPLE
a larger family are also at risk. Those living in rented property are also more likely to be fuel poor than those living in homes they own – in 2011, 19 per cent of households in the private rented sector were fuel poor (MRT 2011).
Older people and cold Being cold can cause a range of health problems but with age comes increased vulnerability. Worfolk (1997) gave many reasons for this and, while that article is old, little has been written since that improves or updates the explanation, revealing an interesting gap in the literature and evidence base about cold and health. The physiological systems responsible for thermoregulation are complex. However, as the body ages, the efficiency of this finely tuned mechanism decreases. Heat generation is reduced due to a decline in metabolism and muscle activity. Heat loss increases as thinner skin impairs the body’s natural insulation. The body also struggles to maintain body temperature as effectively in the cold. Autonomic nervous system impairment may compromise vasoconstriction on exposure to cold. Medication for chronic health problems can exacerbate an older person’s susceptibility to the cold. Compensatory responses may also be affected if a person is cold and ill – activity and warm food and drink can help to protect against the cold, but the ability to do or consume these can be impaired by age and infirmity (Worfolk 1997). Hypothermia is usually thought of as severe – that is, when a person’s body temperature drops below 35°C. However, hypothermia at any stage could be dangerous for older people, especially for those with multiple health problems. An important point made by Worfolk (1997) is that, because of impaired physiological response, an older person can be cold in an environment that is comfortable for a busy, active younger person. Healthcare professionals such as nurses may therefore visit older patients at home and not notice that patients are cold. Despite this complex picture, little has been written about nursing responses to older patients’ vulnerability to the negative health effects of cold, and there is little evidence to explain why older people may end up being cold. KWILLT aimed to address that gap in the evidence.
Aim The overall aim of KWILLT was to examine the knowledge, beliefs and values of older people about keeping warm at home. The project aimed to identify factors influencing their ability to keep warm and well in winter and barriers to accessing help in keeping warm. December 2013 | Volume 25 | Number 10 23
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Art & science | research Method
Box 2 Staff sample (n=25)
The study was conducted in Rotherham, an area in the south Yorkshire coalfields in the north of England. In-depth, semi-structured interviews were conducted with 50 older people over the age of 55 years and 25 health and social care professionals. The older people were interviewed in the winter months of 2009/2010 and 2010/11. Participants were recruited through social and community groups. Local government and healthcare services’ data on housing, excess winter deaths, older people’s falls, and respiratory and cardiovascular disease were reviewed to help identify areas with vulnerable older adults. Older people’s day care centres, community organisations for vulnerable people and churches were contacted to identify and recruit participants. Snowball sampling was also used. In this way, vulnerable, socially isolated participants were included. The sample included a range of people in terms of age, gender and living circumstances. Box 1 provides demographic details of the older people who participated. Further details of the methods and findings from the older participants are published elsewhere (Tod et al 2012). Semi-structured interviews were guided by schedules devised by the research team. The interview schedules included issues relating to the type and nature of housing, heating patterns, heating methods, mode of payment, heating systems, values and beliefs. A professional translator was hired to assist the study researcher with interviews for the minority ethnic focus group. Most of the interviews were audio-recorded and field notes were taken. The week before the interviews were conducted, temperature and relative humidity recorders were placed in the rooms in which participants spent most of their days and nights, to explore whether their views and perceptions of warmth matched actual room temperatures. Findings from the temperature measurements are not presented here. Box 1 Older people’s demographic data (n=50) Age (years)
Ethnicity
Gender
55-69
14
65+
36
Black and minority ethnic
19
English
31
Female
36
Male
10
Couples 24 December 2013 | Volume 25 | Number 10
4
Voluntary sector organisations
5
Health and social care practitioners
12
Local authority
3
Social housing organisations
5
Total
25
Health and social care professionals were purposively recruited to ensure there was a range of participants from different organisations, including the voluntary sector, local authority and social housing. Healthcare practitioners included nurses, occupational therapists, domiciliary care workers and GPs working with older people. In-depth interviews were conducted at professionals’ workplaces. Box 2 shows a summary of the health and social care participants in the study. Qualitative data from the initial interviews were transcribed and entered into the qualitative software package NVivo 8. Using framework analysis methods, data were analysed thematically, coded and continuously reviewed by the research team (Ritchie and Spencer 1994, Ritchie and Lewis 2003). The research team discussed the emerging findings from data collection in the first winter. These findings were used to guide the older people’s interviews in the second winter and focus group discussions. For example, issues concerning social connections, heating technology and behaviour regarding heating emerged in the initial analysis and were explored in detail in the second sample of interviews. Emerging findings from the interviews were tested in six focus groups with a total of 43 participants. The first three focus groups were conducted with older people considered vulnerable either because they attended older people’s day care centres or participated in a community support group. The first two focus group discussions for older people were diverse in terms of age, gender and educational level. The third group consisted of minority ethnic women with shared cultural values. All interviews were conducted at older people’s community centres. Three focus groups were also conducted with staff working at strategic and policy levels, which included financial inclusion organisations, local government representatives from the study area, and community allied health professionals. Table 1 summarises the focus groups’ genders. In the final stage, findings were discussed at a consultation event, with more than 110 representatives from local, regional and NURSING OLDER PEOPLE
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national NHS, local authority and voluntary sector organisations, including lay representatives. Ethical considerations Ethical approval for this study was granted by the Leeds East NHS research ethics committee. All participants were assured of confidentiality, and information deemed to compromise anonymity was removed from interview transcripts and quotes. With the consent of interviewees, interviews were audio-recorded. Informed consent was gained from focus group participants.
Findings KWILLT generated in-depth insight into the complex range of interrelating factors that can influence an older person’s ability to keep warm at home. A more detailed account of the findings is available elsewhere (Tod et al 2012) and on the KWILLT website (kwillt.org). This article presents a summary of findings related to four themes: awareness, money, mindset and machinery. Awareness The older people interviewed revealed a lack of awareness about the link between health and heating (Tod et al 2012). They also displayed a lack of knowledge about safe temperatures and talked about a preference for cold rather than hot rooms: ■■ ‘I can’t get into a warm bed. It has to be cold for me to get into’ (woman, 59, private rented accommodation, chronic mental and physical health problems). ■■ ‘I’ve never been spoilt, and I’m not bothered about being right warm’ (woman, 84, social housing, ill health and deaf). ■■ ‘I don’t like it too hot, I don’t like it too cold... not too warm, that’s unhealthy, isn’t it?’ (woman, 76, detached privately owned house, deaf). Table 1 Code
Focus group gender demographic data Men
Women
Total
FGOP1
3
7
10
FGOP2
0
8
8
FGOP3
1
5
6
FGS1
4
4
8
FGS2
3
2
5
FGS3
1
5
6
FGOP=focus group for older people FGS=focus group for strategic staff groups
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Examples were given where people thought a hot room was bad for them: ■■ ‘We do get that from patients, it needs to be off at night, you’re breeding germs, that’s why everybody has so many colds and they’re always at the doctor’s. We were never at the doctor’s’ (staff participant, domiciliary care provider). Others viewed heating as a luxury rather than a necessity and so did not prioritise being warm and paying for heating: ■■ ‘I think older people see heating as a luxury. I don’t think they see it has any bearing on their health. I think they think they can get by without it a lot of the time or just very little’ (staff participant, financial advice worker). ■■ ‘My dad’s nearly 70, just an example. He won’t have his heating on, will not, and it’s freezing in his house; he’ll put more jumpers on. He believes that that’s unhealthy, having heat on; he’ll have jumpers on’ (staff participant, home carer). While expressing concern that older people should not be cold, staff also exhibited a lack of knowledge of safe temperatures and how to use heating technology in the home: ■■ ‘I don’t think people actually associate heat or warmth with health at all. I mean I have to say, as a health visitor and a nurse, for goodness knows how many years, it’s only when affordable warmth became sort of being promoted that I really linked the two. So, you know, even as a health professional I haven’t really given it a great deal of thought’ (staff participant, public health, nursing background). ■■ ‘But I don’t think they know how to work these new heating systems. I don’t actually; I leave it to my husband’ (staff participant, community nurse). Other areas where older people and staff displayed lack of knowledge included where to get help how to change tariffs and, for staff, how to identify if someone was at risk: ■■ ‘I’ve changed and I ended up with a big bill because they don’t always come out and read your meter and things… and then another company tells you they’re going to be cheaper and save you loads of money, and you change over and you end up with a big bill. You know, I don’t understand them so the elderly certainly won’t’ (staff participant, community nurse). Money It was clear that, for some, lack of money was a barrier to heating their home. Where household income was short, there was a tendency to turn off or turn down and be careful about heating. For some, fear of a big bill combined with past hardship got in the way of maintaining a warm home, even if their income was sufficient to keep the home warm. December 2013 | Volume 25 | Number 10 25
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Art & science | research The winter fuel allowance was a real benefit and relieved financial strain and pressure. However, for some, regardless of whether they had money, their default behaviour was to be careful, under-heat the home, only heat one room, and use extra layers and hot water bottles to keep warm: ■■ ‘They’re quite scared when they get big bills, although they might have money in the bank... And I said why don’t you spend some of this and get, you know, get your house warmed up and get, and perhaps if they’re living in a bit of a neglected state they might need new settees, new carpet. Why have you got all this money sat in the bank and you’re living like you are? They can’t always answer you, you know, “Well it’s always been there, I’ve always had to save for that, there might be one day when I might need it.” Well now’s the time, this is that one day. Yeah and it’s trying to get them to draw the money out, it’s such a stumbling block for them to go and draw the money out and spend it’ (staff participant, financial advice worker). A past life of financial austerity left its mark on many participants and meant they found it difficult to spend money on their own comfort at home: ■■ ‘I was trained to be frugal; it was part of my upbringing. You didn’t have a lot so you were careful with what you did have. And with the costs rising now, I’m certainly not extravagant with the heating, I’m very wary’ (woman, 76, detached privately owned house, deaf). ■■ ‘It’s because they’ve lived such a frugal life through the wars and beyond. They’ve had to be so tight with their money and so frugal that to spend an excessive – what they consider an excessive – amount of money now is quite vulgar to them and it’s just not in their mindset. Their mindset is to spend as little as possible and get by with as little as possible, and that’s what they’ve been doing all their life. So now that they’ve got the money, it doesn’t register that they can afford it; they just don’t think they’re supposed to do it. They don’t think they’re supposed to spend. So to be living in a warm, cosy house with the heating on, it’d be frightening to them in some respects because they’d be thinking they’d be spending money they shouldn’t be spending’ (staff participant, financial advice worker). This financial caution was heightened when people wanted to leave what little they had to their families and did not want to spend it on themselves: ■■ ‘They seem to want to save it for family don’t they?’ (staff participant, community allied health professional). 26 December 2013 | Volume 25 | Number 10
Mindset The data illustrated the behaviour of many participants was driven by past experiences and values that had built up over time. There were many examples of why older people were not able to follow advice about heating, as it clashed with their existing values and beliefs. More frequent examples of this related to thrift, frugality, hardiness and stoicism. Regarding thrift, some people were naturally cautious about spending money on fuel, regardless of whether they had the money to pay for it. At times, this was underpinned by the importance placed on being careful with money, not just fear of a big bill and being debt averse. However, where frugality was accompanied by regard for being hardy and putting on a brave face, there was an increased tendency to be careful with heating: ■■ ‘I mean, growing up there would have been ice on the inside of the bedroom windows quite regularly because it would be really, really cold in the bedrooms in winter. So, I don’t know, you are influenced to think a little bit, in our generation, you tend to think they’re a bit nannied. Talk about a nanny state, you know, but they’re so coddled with everything and that it shouldn’t really be much of a hardship to be cold occasionally… No, I wouldn’t say it’s, I wouldn’t see it as a life-threatening issue to have been without the heating for a month because yes you’re probably quite right we grew up without any’ (woman, 58, privately owned bungalow, in good health). ■■ ‘They’re very hardy. And sometimes they think they’re being extravagant if they’re warm because they might have come from a background where they’ve always struggled, their family have struggled, it’s a luxury to be warm, and sometimes they’re just in that mental frame of mind where it’s a luxury, you know’ (staff participant, domiciliary care provider). Another factor that prevented people accessing help, such as better fuel tariffs or energy efficiency schemes, was a preference for routine and dislike of change. Even though it meant life was uncomfortable, the thought of change and disruption could not be brooked: ■■ ‘I don’t think I would change, no. I wouldn’t like the hassle, no, because nothing’s straightforward’ (woman, 82, private housing, in good health). ■■ ‘She pays cash. She thinks that she doesn’t trust them; they might charge more with direct debit’ (woman interviewed through interpreter, 55, privately owned terraced house, heart disease and diabetes). ■■ ‘They’re frightened about any changes. They don’t like changes, they like their routine, they’re frightened… The elderly will say “I’ve not got to my NURSING OLDER PEOPLE
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age to be told what to do. Yes, I know what’s good for me, I haven’t got to this age by not knowing what’s good for me and it’s never killed me before”’ (staff participant, domiciliary care provider). Finally, in terms of mindset, mistrust had a large role to play. This was particularly directed towards energy companies. Many schemes for cheaper tariffs or energy efficiency were administered through energy companies and there was a universal tendency among older participants to disbelieve what was on offer. This was sometimes reinforced by a bad experience of their own or that of friends and neighbours if they had tried an initiative: ■■ ‘There is a lack of trust because of what it’s like giving something with one hand and taking it away with the other, you know, you might change from one service provider to the one that seems to be providing the best value for money, only to find that six months later it’s swapped again, you know. So I do think people are, I do feel quite confused’ (staff participant, public health, nursing background). ■■ ‘Some of them are not what they’re supposed to be – they’re scams, because you get it cheaper for one year and then it’s dearer than the one you left’ (woman, 77, social housing, chronic health problems). Machinery A common experience for older participants was to be challenged by the technology involved with keeping warm. Often this would be heating technology, such as boilers, programmers and thermostats: ■■ ‘I find that they’re built by somebody who knows how to use digital technology, and the sort of way they work isn’t conducive to easily changing any of the parameters really, you know. But I do know how to use mine, but my wife wouldn’t know. My wife wouldn’t be able to use them if I wasn’t here’ (man, 63, privately owned terraced house, carer for wife with Alzheimer’s and cancer). ■■ ‘I don’t actually have to touch the boiler… I can’t actually set it, it is set, and like when the clocks change I’ve a friend that sets the timer for me; he changes the clock’ (woman, 76, council flat, asthma). However, the difficulties did not just lie with heating, but also technology related to banking, payment for fuel or information over the internet: ■■ ‘They’ll not do direct debits a lot of them, they don’t know how to do it; they like to physically go and pay a bill. So I would say the majority of the pensioners that I see do use the post office. Apart from the ones that have been brought up to date by family members and have got direct debits set up for them’ (staff participant, financial advice worker). NURSING OLDER PEOPLE
Discussion The main limitation of KWILLT was that it was a single-site study, which could limit the extent to which findings are transferable to other populations. However, this approach did facilitate the generation of in-depth understanding of the sample. Attempts were made to ensure a broad sample in terms of income, housing type and tenure, health and age. This diversity increases the potential to apply the findings to other populations. This summary of KWILLT findings has provided some indication of how complex it is for people, as they get older, to make and implement decisions about heating homes. For many health professionals, it may seem strange that people do not put on their heating, especially when they are cold and apparently able to afford to do so. However, as indicated, there may be a range of influences that mean people, with the best of intentions, decide to heat their homes insufficiently. Factors identified include difficulty in keeping up to date with health advice, especially if it is on the internet; pre-existing values and beliefs that clash with public advice campaigns; fear of change; difficulty operating technology; and perception of risk. The range of influences and how they appear in different individuals is difficult to present in the context of a short article or report. For that reason, the KWILLT team developed a series of six pen portraits. These were not real people but constructed using the thematic framework and data generated from participants’ views and experiences. The portraits represent people with different characteristics and who are at risk of being cold for different reasons. They can be accessed on the KWILLT website (kwillt.org).
Implications for practice The cold weather plan (DH 2012a, PHE 2013) makes clear that there are easy and quick actions that can be taken in terms of preparing for cold weather, being alert and ready if cold weather is anticipated, and responding if cold weather arrives. Systems and resources should be in place before the winter months. Actions that nurses can be actively engaged in fall into three main areas, briefly considered here in the light of KWILLT findings. Identifying those at risk KWILLT indicates that a large number of people are at risk of being cold at home in winter. Some older people will be at risk of harm from the cold at a temperature acceptable to younger adults. It is important for health professionals like nurses to set the bar low when thinking about who is at risk – it is not December 2013 | Volume 25 | Number 10 27
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Art & science | research just the very old, very poor or those in the worst housing. Someone can be relatively young – say, 55 to 60 years old – but have chronic, complex health problems and live in an energy-inefficient, rented property that would put them at risk from the cold. People who are old and well, and live in energy-efficient homes of a decent standard are still at risk from the cold if they have no idea how to heat their homes or are naturally frugal and hardy. It will also be necessary to review medications to see who is at increased risk of cold as a side effect of the medication they are taking.
Box 3 Questions to identify people at risk of cold-related harm
Signposting When vulnerability is identified in clinical consultations, at-risk clients and patients should be directed to appropriate help, such as home insulation schemes, benefits advice and advice about fuel payment.
(Department of Health 2012a, Public Health England 2013)
Risk reduction Intervening and taking action to reduce risk or provide support is important. Examples include ensuring the vulnerable have flu vaccinations and providing information about home heating in a form that is acceptable and accessible. These actions appear straightforward. However, for them to work, systems, resources and partnerships should be in place. Appropriate tools also need to be in place so that health staff can quickly and efficiently identify people at risk. There are two approaches listed in the cold weather plan. The first is to identify people at risk of cold-related harm by asking three simple questions (Box 3). The second is the Kirklees NHS Predictive Risk Toolkit (DH 2012b, PHE 2013), which can be used in GP practices to target the most vulnerable people.
1. Is your whole house warm in winter? This question helps to identify how people are heating their home and if they are limiting heating to certain rooms. 2. Can you afford to heat your home to a comfortable level? This question helps to identify whether occupants are meeting ‘minimum’ recommended temperatures all the time. 3. Can you afford to pay your fuel bills? This question will flag whether someone has sufficient income to spend on the fuel they need for warmth and comfort.
Resources and planning are especially required when it comes to signposting and referral. Some voluntary agencies will accept referrals of this nature, including some local Age UK services, home improvement agencies and schemes, financial inclusion organisations and Citizens Advice. Fire and rescue services will often provide home safety checks to those at risk of cold. Before the winter, nurses working with vulnerable populations should identify whom to direct patients to and quick and easy systems should be put in place to achieve this. In some areas, there are partnership referral schemes, such as the south Yorkshire Hot Spots scheme. Nurses can identify, refer and support vulnerable older people to keep warm. As the largest and most diverse healthcare workforce, nurses are in an ideal position to identify people who are vulnerable to cold weather and who may struggle to keep warm and therefore well. Nurses in hospital, primary care or community settings, as well as those in managerial
Box 4 Keeping Warm in Later Life projecT (KWILLT) educational tools Pen portraits Six pen portraits describing how vulnerable older people are at risk of being cold for different reasons. Available electronically and in hard copy to any organisation or group of staff working with older, vulnerable people, people in fuel poverty or in the implementation of the cold weather plan (kwillt.org). The pen portraits aim to help relevant organisations and individuals to: ■■ Find and recognise people who are at risk. ■■ Understand the complex reasons why older people are cold. ■■ Support the design and delivery of acceptable and accessible services. ■■ Identify strategies to overcome barriers. 28 December 2013 | Volume 25 | Number 10
■■ Promote strategies to support self-management to keep warm. Winter Warmth The Winter Warmth England website (www. winterwarmthengland.co.uk) provides information, statistics and communication resources to help relevant organisations and staff ensure that vulnerable people stay safe, well and warm during the winter. Learning resources DVDs/videos: three of the pen portraits have been used to make educational films. They aim to help staff and students at any level to engage with the experiences of vulnerable older people and understand why they may be
cold at home. They are available on the Winter Warmth England website: winterwarmthengland.co.uk E-learning materials: all six pen portraits form the basis of a free, structured e-learning resource on the KWILLT website (kwillt. org). They can be used in different ways, for example: ■■ By individuals for their own reflection and learning. ■■ By organisations to provide workforce training. ■■ As additional materials to existing workforce training and development. ■■ By educational organisations and universities to build into curricula. NURSING OLDER PEOPLE
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and strategic roles, can all aid identification of those at risk, their assessment and referral. To date, attention has focused on those in the community, and the cold weather plan action cards target community and primary care teams (DH 2012c, PHE 2013). District nurses can identify and signpost those at risk as they visit older patients in their homes. However, practice nurses are also in a position to help. They are often responsible for the management of chronic diseases and may be responsible for regular review of those with underlying conditions that would predispose them to cold-related harm, such as cardiovascular, respiratory or diabetic disease. Additional identification, assessment and action must be realistic in terms of time and workload. A strong management lead is required to ensure the systems are in place for rapid assessment – for example, by using the three questions outlined in Box 3 and signposting/referral using local processes planned before the winter. Referral systems need to be rapid, responsive and provide feedback to the referring health professional to engage staff. Staff working in hospital settings can also identify those at risk. The possibility that older patients may have conditions that have been brought on or exacerbated by cold should be considered. Again, systems need to be in place so that those admitted with recurrent respiratory disease and other cold-related illnesses are identified. It is also necessary to build processes into planning discharges. Self-report can be unreliable as patients may want to be seen as coping and living in warm homes; they also may not recognise they are cold. Even if a social worker or allied health professional visits the patient at home, it is difficult to assess how cold the home will be after the patient has returned to it, as the home will not have been heated during the hospital stay. A referral for a home safety check a few days post-discharge could detect any problems.
A final point relates to training. For the above actions to be undertaken and staff to be engaged, training in risk, assessment and referral is required. The cold weather plan recommends integrating training about cold and heating behaviour into existing provisions, such as Making Every Contact Count, which was developed in the Yorkshire and Humber region to train frontline staff in health-related, behavioural change interventions (DH 2012a, PHE 2013). KWILLT findings indicate that staff may lack the information, insight or awareness to identify if someone is at risk or who to refer to if there is concern. The cold weather plan requires that all staff are made aware of the plan and how to recognise dangers and risks (DH 2012a, PHE 2013). To help with this, KWILLT findings have been used to develop the Winter Warmth England website (www. winterwarmthengland.co.uk). Funded by the DH Warm Homes Healthy People fund, it provides up-todate, consistent messages for staff and the public on affordable warmth and cold protection. In addition, there are DVDs/videos and e-learning materials based on the pen portraits, which can be used as training materials by individual practitioners, in organisational training and education curricula. A summary of KWILLT educational tools is in Box 4.
Conclusion This article provides evidence and insight to explain why some older people may be at risk of coldrelated harm and illness. Implications of the KWILLT findings for nursing practice have been summarised. Nurses are in a prime position to identify those at risk and improve access to necessary support and care. However, they require training and resources and the managerial support for effective referral mechanisms, patient pathways and systems to be in place. Educational outputs from KWILLT may help to achieve this.
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Conflict of interest This article presents independent research commissioned by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) programme (grant reference number PB-PG-0408-16041) and supported by the Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health Acknowledgement We acknowledge the time and generosity of the KWILLT participants and extend our heartfelt thanks
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