Summary of findings on public knowledge and behaviour

Most adults at-risk of heat-related morbidity or mortality, did not feel that heatwaves posed a health risk to themselves, but were more likely to identify a risk in others, especially those with greater physical or cognitive needs. The majority of participants aged 75+ and those with a LLSI did not consider themselves to be at risk, while only half (50%) of those in bad health said they were at risk. Similar or higher proportions expressed positive views about hot weather (‘I love hot weather’). This is important as an individual’s attitude to risk shapes their behaviour during hot weather. These findings are in accordance with results from previous studies (Abrahamson et al., 2009, Wolf et al., 2010, van Loenhout et al., 2016, Bassil and Cole, 2010).

The general public appears to be generally aware of the effectiveness of protective behaviours: two-thirds or more recognised the effectiveness of staying out of the sun 11am-3pm, drinking cool fluids, covering skin with clothing, limiting physical activity and opening windows at night. Other protective behaviours were recognised as effective by less than half of adults (keeping curtains closed on exposed windows during the day; avoiding alcohol; using an electric fan and keeping exposed windows closed during the day). The results were similar for the three vulnerable groups (aside from a few differences in detail).

All regions in England were issued a level 3 heat-health alert for a short period (17th to 21st) in June 2017. Half (51%) of the adults in our survey reported that they had heard hot weather-related publicity/advice during that heatwave. Among those who had heard the advice, 43% reported changing their behaviour as a result of the publicity (which means about one in five of the adult population reported changing their behaviour). However, hearing the publicity/advice was not associated with participants’ perceptions of the effectiveness of protective behaviours. Among our vulnerable groups, participants aged 75+ were more likely to hear the publicity (64%), those aged 18-74 in bad health were less likely to (only 38% heard it), and adults with a LLSI were similar to the average (52%).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 5.16 Percent experiencing 1 or more hot weather-related symptoms in summer 2017, by whether hot weather is risk to own health

Strongly agree Agree Neither Disagree Strongly disagree

1+ symptoms No symptoms

Protective behaviours taken by half or more of adults included drinking cool fluids (87%), opening windows at night (87%), staying in the shade (61%), limiting physical activity (56%), avoiding alcohol (51%), covering the skin with clothing (51%), and closing curtains in direct sunlight (48%). Using a fan (39%) and closing windows in the direct sunlight (35%) were least commonly taken. Eight of these actions were asked about in a survey following the summer 2013 heatwave, and the proportion of adults taking these actions in 2017 was higher for most of them (Public Health England, 2016 see Figure 6).

Adults aged 75+ were more likely than average to take most of these actions, aside from drinking cool fluids, using an electric fan or opening windows at night.

Similarly, in the focus groups, age-related risk tended not to be perceived by many older participants as related to thermoregulation, and therefore they were less likely to take extra hydrating or other ‘indoor’ protective actions, such as using fans or opening windows at night. This should be seen in relation to a recent study which demonstrated that older people were less likely to be aware that they were

‘overheating’ and therefore to take appropriate thermoregulating actions (Waldock et al., 2018).

Overall, just under 2% of adults sought professional health advice during the June heatwave, as did about 3% of our vulnerable groups.

As shown by previous studies (Lefevre et al., 2015, Abrahamson and Raine, 2009, Wolf et al., 2010, Ibrahim et al., 2012, Kalkstein and Sheridan, 2007, Semenza et al., 2008), the likelihood of taking protective actions was associated with an individual’s perception of risk, such that participants who viewed hot weather as a risk to their own health were much more likely to take these actions than those who did not share this view. Taking the actions was even more strongly associated with an individual’s perception of the effectiveness of the action. Younger adults (18-44) were also more likely than adults aged 45+ to underestimate the health risk of hot weather and to have positive views overall about hot weather, which helps explain why they were less likely to take protective actions.

We asked participants aged 65+ and those under 65 with a LLSI whether they were contacted by anyone during the heatwave to check how they were. The vast majority were not (75%) and only 6% were contacted by a health professional (a GP/

doctor, nurse or local authority social services). The vast majority of contacts were by neighbours/family/friends (21%). Nearly half of those aged 75+ were contacted (44.7%), but again it was mainly by neighbours/family/friends (38%). Some focus group participants felt that it was not appropriate for them to be targeted as potentially vulnerable by health and social care services, as recommended in the HWP, as this was not considered a good use of ‘scant’ resources.

Over half (53%) of all adults reported experiencing one or more hot weather-related health symptoms during the 2017 summer. This was higher among those aged 18-64 with a LLSI (63%) or in bad health (68%), but was lower among those aged 75+ (32%). The latter is explained by this group being more cautious in hot weather, especially in relation to the sun. In the focus groups, some participants felt they were more at risk of becoming burnt by the sun or getting skin cancer due to their age and ‘thinning skin’, echoing findings by Wolf and colleagues (Wolf et al., 2010), and felt this risk had increased due to climate change; this meant they were more likely to stay indoors or in the shade during the hotter parts of the day, and to use sun protection such as hats and lotion when out during the day. The likelihood of

reporting symptoms, in fact, was inversely related to age. Similar results have been previously reported elsewhere, e.g. by Khare et al. (2015) in a survey following the 2013 heatwave in the UK. While younger adults are less at risk than older adults, not only are they less likely to take many of the actions that would protect them from the heat, they are also more likely to take risky actions during periods of hot weather (e.g.

increased physical activity, sunbathing and alcohol consumption).

The most common symptoms reported were headaches (26%), irritability (22%), dehydration/intense thirst (20%) and sunburn (18%). The health symptoms were not generally severe enough to require medical treatment, as only 1.4% of all adults reported contacting the NHS as a result of hot weather. The proportion of those aged 75+ contacting the NHS, however, was higher at 6.7%. There was a strong association with participant’s health in general, with those in bad health much more likely to report many of these symptoms.

5.8 Limitations

The survey of the general public is based on self-reported behaviour. Thus we cannot be entirely sure whether the statements made reflect actual attitudes or past behaviours, particularly those relating to the most recent heatwave which was relatively short-lived and did not involve excessive heat. Although the data were weighted to take into account non-response among various sub-groups of the population, we cannot be certain that all bias is eliminated. Also, the survey included only residents living in private households, so some individuals who may be particularly vulnerable to hot weather have been excluded (e.g. the homeless).

The Heatwave Plan for England (HWP) aims to protect health and reduce harm from heatwaves and severe hot weather. Its main intervention is a heat-health alert system that local authorities, which have formal responsibility for public health, in partnership with the agencies (such as the local NHS) that together form Local Resilience Forums, are required to establish and maintain. Through this system, commissioners of

health and social care services alert service providers, such as hospitals, community services and care homes, of a heatwave being imminent once a regionally defined temperature threshold is breached.

The evaluation addressed the following three questions:

1. Has the introduction of the HWP in 2004 had any effect in terms of reducing morbidity and mortality?

2. To what extent, if any, has the HWP informed local decisions on management of heat-related health risk and response?

3. Is the general population aware of the risks of heat and overheating buildings, do they change their behaviour in hot weather and as a result of hearing heat alerts/

advice, and do they take any actions to prevent potential negative effects of hot weather (e.g. adapt their homes)?

The evaluation was a mixed method study, comprising three components, to examine the contribution of the HWP to protecting the health of the population during hot weather. To this end, we conducted:

1. A time-series analysis of daily mortality and emergency hospital admissions data in England to establish the relationships between high ambient temperatures and health outcomes.

2. Longitudinal case studies in five areas in England looking at the local implementation of the HWP.

3. A national survey of nursing staff in hospital, community and care home settings on their awareness of the HWP and actions taken during heat-health alerts

4. A survey and focus groups of members of the general public, to explore the extent to which adults are aware of the risks from hot weather to their health and whether they protect themselves by following the advice set out in the HWP.