Centre for Wellbeing in Public Policy

Wellbeing Event12 September 2016

Jan Gilbertson: CRESR, Sheffield Hallam UniversityAngela Tod: School of Nursing and Midwifery, University of Sheffield

Overview

• Background• Projects:

• Angela: Keeping warm in Later Life project (KWILLT) and Warm Well Families (WWF)• Jan: Evaluations of household warm homes/energy efficiency initiatives

• What we have done • What evaluation/ methodological challenges we were trying to overcome • Why we did it that way

• What are the challenges for the future?• Networking: FPRN and European Network

Who we are and what we have done

• Angela

• Jan

• Linking health and housing in a systematic / rigorous way

• Home heating / health behaviour

• Health impact of household energy efficiency interventions

Examples

• In-depth qualitative research:• Keeping Warm In Later Life project (KWILLT)• Warm Well Families

• Mixed methods evaluations:• Warm Front Evaluation• Evaluation of the Warm Homes Service• Evaluation of the Warm at Home Programme

What evaluation challenges did we want to overcome?• Qualitative:

• Didn’t just want to describe behaviour – we wanted to understand it?

• Wanted to generate findings a range of people could relate to and respond to: public, practice, policy.

• Wanted to challenge assumptions from research, policy and practice.

• Evaluations:• Pressure on voluntary sector for

evidence/economic arguments to support commissioned e.g. Home Improvement Agencies, Citizens Advice

• Methodological limitations because of funding time pressures:

• Funding linked to policy/politics• Absence of an obvious control group, ability to

randomise, conduct before evaluations• Sample bias• Data collection bias

Fed into current policy agenda, examples include:Cold Weather Plan: Public Health EnglandFuel poverty: Hills review and Marmot ReviewNICE Guidance on excess winter deaths and illnessEnergy Policy/Green Deal

What is KWILLT?Keeping Warm In Later Life projecTNIHR Research for Patient Benefit Programme

The drivers were… • Health impact of cold• High levels of fuel poverty• Costs to the NHS• Low uptake of energy efficiency interventions• Cold Weather Plan• DH Public Health Outcomes Framework (EWD/FP)

Keeping Warm In Later Life project (KWILLT)

Aim: To understand the influences and decisions of vulnerable older people in relation to keeping warm in winter – at home.

MethodologyQualitative methods

• 50 older people (aged 55-95), face to face in depth interviews,

• Temperature/humidity measurements

• 25 health and social care staff, face to face in depth interviews

• Six focus groups with older people and frontline/strategic staff (n=42)

• Consultation event

• Framework analysis

• Thematic framework

Apply Social Marketing PrinciplesUsing research findings – develop ‘insight’

Break down the target audience into the different types of people – ‘a segmentation model’

• What are the drivers to their behaviour• What are their thoughts, fears, perceptions• What are their barriers to change

Turning insight into action…

• Develop propositions or interventions for each segment

• Considering incentives and barriers (Competition/exchange) for each segment

• Develop the marketing mix i.e. “mix” of different interventions that will change behaviour

• Develop the tools and resources

KWILLT Findings: Themes Situation or context

factorsAttitudinal drivers of behaviour Barriers to positive behaviour

Money

Age

Social connections

Housing type and tenure

Health

Making ends meeto Competing prioritieso Prideo Struggling

I can manageo Thrifto Hardiness and Stoicism

Its my businesso Mistrusto Pride and Privacy

I'm frightenedo Personal safety/vulnerability

I'll stay as I amo Like routineo Fear and mis-trust

Awarenesso Knowledgeo Informationo Experience

Technologyo Heatingo Informationo Banking

Disjointed systemso Fragmentation or serviceso Local differenceso Lack of referral systems

Visibilityo Fuelo Moneyo Information

KWILLT Findings: the segmentation model

Segmentation group Description

Isolated and not wanting to cause a bother

Low income and fuel poor, over 55, socially isolated and frightened, lacks information and understanding about keeping warm, private rented housing, long term mental health problems (depressions/anxiety)

Getting by cautiously Low income household and fuel poor, over 65, some social connections but not well informed about keeping warm, privately owned house, live with a partner with chronic health problems

Dependent and poorly informed Low income household and fuel poor, over 55, limited social connections with strong cultural ties, poorly informed about keeping warm, privately owned housing, poor health and mobility and very dependent on close family.

Just about managing Can pay for home heating but values thrift , over 70, some social connections but is private and trusts few people so is poorly informed about keeping warm, social housing, physical health problems and sensory impairment

Lonely and out of touch Financially secure but lives in a cold home, over 70, widowed, and socially isolated, poorly informed about keeping warm, privately owned house, physically well but bereaved.

Proud and wants to be self-sufficient

Low income but not fuel poor, over 70, regular but superficial social connections, poorly informed but values stoicism and hardiness and think they don’t need any help, social housing, good health, minor ailments.

The Pen Portraits – bringing the findings to life!

Lonely, Pearle

Proud, Fred

Dependent, Meena

Getting by, Bob and Joan

Just about managing, Enid

Isolated, Pat

http://kwillt.org/index.php/pen-portraits

Ben and Joan• Mid 60s,Low income, now

retired• Ben has chronic ill health• Joan is his carer

• Children nearby but Ben and Joan don’t like to be a bother

• Some social contact• Live in an old mid-terrace

(Right to buy)• Central heating system old,

not serviced and use supplementary heating

• Pay for fuel by direct debit but don’t understand how they work

Reflections

• Complex Picture• Behaviour is often not logical - People don't always do what you

think they will do• Findings challenge assumptions: policy and practice• Strategies and solutions:

• Partnership working• Networking• Recognising, identifying people at risk• Assessing and referring people in need• Neighbourhoods and communities• Government: (Department of Health (2011)

Assumptions• People aren’t cold these days• Its only the really old who are effected• Only people who are fuel poor are cold• Other people are tackling the problems• Family will help• People know that there are health impacts of being cold• People are aware of what healthy room temperatures

are

Assumptions cont..

• People know how to use technology – heating and banking• Vulnerable people read and act on information from

organisations such as energy companies, banks and Government bodies

• People will access interventions to help e.g. Social fuel tariffs and affordable warmth interventions e.g. Green Deal

• Vulnerable people will engage with processes to obtain help

• Interventions don’t have adverse consequences

Dissemination

• Pen portraits• Policy: NICE Guidance, Cold Weather Plan, Health and Wellbeing

Board Plans etc.• E-learning• Communication tools: Winter warmth England• Chap books

Dissemination Links

• WWF pen portraits and trade off model:http://www.shu.ac.uk/research/hsc/sites/shu.ac.uk/files/4567_1415RMBC%20BR%20About.pdf

• Winter Warmth England: http://www.winterwarmthengland.co.uk/

• KWILLT e-learning materials: http://teaching.shu.ac.uk/hwb/AHP_resources/kwillt_resource/index.htm

• Book of Damphttp://www.shu.ac.uk/research/hsc/sites/shu.ac.uk/files/The%20Book%20of%20Damp.pdf

An Evaluation of the FILT SSE Warm at Home Programme

• The primary purpose: to evaluate the Programme in terms of its impacts on housing conditions, health and wellbeing of beneficiary households.

• Approach is based on our experience of undertaking similar evaluations.

• Mixed methods approach to measure the impact:• a 'before and after' QOL survey of WAH beneficiaries - administered by HIAs and including

questions on housing conditions and satisfaction; thermal comfort, household finances and fuel bill affordability, self-reported health and wellbeing and health service use.

• Management Information data - linking relevant monitoring data to the QOL survey data as appropriate.

• Qualitative interviews (telephone and face to face) undertaken by the CRESR research team with HIAs and WAH beneficiaries.

Energy efficiency improvements, stress, and pathways to positive health outcomesGilbertson J, Grimsley M, Green G. Psychosocial routes from housing investment to health: Evidence from England's home energy efficiency scheme. Energy Policy 2012; Adapted in Liddell C, Guiney C (2015) Living in a cold and damp home: frameworks for understanding impacts on mental well-being Public Health I 29 (2015)

Key characteristics of WAH beneficiary households

• 72 per cent of all participants were aged over 60. Over 20 per cent were aged 80+ • Low income: more than 90 per cent had annual income below the nation median

household income of £31,000.• Majority were owner occupiers in older (pre-1970) terraced or semi-detached properties.• Exhibit many of the characteristics of energy poverty: many struggle to meet the costs of

heating their home.• In much poorer health and have far lower well-being than the general population.

• "As well as the ME I have asthma, hypertension, arthritis, all of which are effected by cold. You are recommended to stay in a nice sort of regular heated home, so that was a massive issue for me".

• "’I mean this house is so cold and with us being that old – you get cold and then you get miserable. If we hadn’t had it, I don’t know what we would have done. I’ve been in hospital a few times with pneumonia and I have had to have oxygen for quite a while now, so I don’t know what would have happened."

Improvements in the conditions of people's homes

• There was a reduction in the proportion of households reporting problems with condensation, damp, mould and draughts once the work had been completed.

• Satisfaction with the standard of people's homes also increased considerably.

• There was an increase in the proportion of households reporting 'comfortable' home temperatures once the work had been completed.

• "I’m not cold anymore, and I know I can keep the house warm, a lot warmer than with just the fire on. And I can go to bed and I am warm, and when I get up in the morning I am warm. Everything has been wonderful, to have it done."

• "It’s a lot warmer. I can open the doors between the kitchen and the living room it lets in more light. You don’t ever feel cold in there in the winter time. I walk round a bit more, I use the house more."

Home environment

• Levels of satisfaction with the home environment

• Problems within the home

57

34

48

3241

27

70

37

Baseline Followup

Baseline Followup

Baseline Followup

Baseline Followup

Condensation Damp Mould Draft

Perc

enta

ge o

r res

pond

ents

Problems within the home

5970

37

73

49

71 6677

Baseline Followup

Baseline Followup

Baseline Followup

Baseline Followup

Standard of housing Indoor temperature Humidity indoors Freshness of airindoors

Perc

enta

ge o

r res

pond

ents

Satisfaction with the home environment

Thermal comfort and energy finance

12

36

45

473

5

Baseline Follow-up

Perc

enta

ge o

r res

pond

ents

Comfortably warm Comfortable Comfortably cool

64

37

74

51

77

51

Baseline Followup

Baseline Followup

Baseline Followup

Find it difficult to managefuel bills

Worry about not havingenough money to pay

energy bills

Heat the home less thanneeded because of the cost

of heating

Perc

enta

ge o

r res

pond

ents

Ability to manage finances

Energy Finance

• There were reductions in the proportion of households reporting that they:• find it difficult to manage fuel bills• worry about not having enough money to pay energy bills• heat the home less than needed because of the cost of heating

• "The living room only had an open fire, and since the radiator has been put in its made a big difference, its lovely and snug, obviously it has made the room warmer and we are in the house a lot of the time because of health problems like this arthritis, so it's more economical (than the open fire) and it’s got a thermostat on."

• "Recently my bills have been reduced, so I can only assume, I realise that the boiler was very old, it was 19-20 years old, so I realise it was quite inefficient, but I think that just goes to show really what a difference an efficient boiler can make."

Improvements in health and wellbeing• There was a reduction in the proportion of respondents

reporting poor health once the work had been completed.• There was a reduction in the proportion of respondents

reporting low well-being once the work had been completed.• However, the proportion of respondents reporting poor health

and low well-being was still considerably higher than in the general population.

• "I had terrible trouble with breathing problems and that was the main thing; since we got the work done I seem to be quite fit and well … it was very depressing sitting in the cold, definitely improved my life – the house is lovely and warm and I really feel a lot better with it."

• "It was absolutely massive, in terms of how it affected both my stress levels, and obviously my day to day comfort and living experience."

• "It also makes the house more welcoming. I’ve taken on this lodger three months ago, and it seems to working out okay."

4942

5

39

24

5

3124

9

Baseline Followup

Generalpopulation

Baseline Followup

Generalpopulation

Baseline Followup

Generalpopulation

Very bad or bad health Very low well-being Find it difficult to managefinancially

Perc

enta

ge o

r res

pond

ents

Health and well-being

Reflections

• Timing – before and after measurement• Seasonal pressures• Control group• Vulnerability of client group (burden and disruption)• Standardising data collection

• Training • Support• Bias

• Pro’s and con’s in involving services (HIAs) in data collection

Next steps

• In depth analysis of the factors associated with change- was change more/less likely for households with different characteristics; - what is the relationship between change and intervention type and cost?

• Understanding the economic benefits of the changes identified

• Report due Oct 2016

Mrs KL

• (See hand out) • Example of extreme and complex nature of clients' vulnerability • Benefits and impacts

- immediate impact on their life in terms of comfort, wellbeing, warmth, safety, hygiene and nutrition.

- increased control of home environment - reduced stress and improved peace of mind - improved social relations - preventing further harm and illness