Beat the Heat: don't forget your drink – a brief public education program
Tracey Oakman, Public Health Unit, Greater Southern Area Health Service, PO Box 3095. Albury NSW 2640. Fax: (02) 6080 8999; e-mail: email@example.com
Background: The Beat the Heat: don't forget your drink program was initiated to enable the general public to recognise and manage heat stress. It was accompanied by a telephone survey to assess program reach and knowledge and behaviours of the general public in managing heat stress.
Methods: The program was implemented in the Riverina-Murray region of New South Wales, in the summer of 2008/09, through radio and television sound bytes, newspaper announcements, distribution of posters and brochures, and public talks. Computer Assisted Telephone Interviews were conducted with 328 randomly selected participants from across the region.
Results: Sixty-three per cent of participants reported hearing heat health warnings and 53% changed their heat management strategies, although only 25% recalled the program slogan. On average, participants self-rated their understanding of managing heat health at 7.9 on a 10 point scale. More than 75% of participants said they would recognise the symptoms of heat stress. Most reported exposure to heat and health information from television, radio and newspapers rather than from posters, brochures and talks. Those at greatest risk included people who worked or exercised outdoors, men and those taking medication.
Conclusions: Television, radio and newspapers were successful media for the program. Knowledge and responses of the general public to heat risks were well developed, with several exceptions – people taking medications, or working or playing sports outdoors, as well as tourists and men. These exceptions should be targeted in future programs.
Mass communication campaigns have been shown to constitute an effective way to modify health behaviours of the public.1 In the Riverina-Murray region of New South Wales (NSW), recognition of the increased morbidity associated with high temperatures and the increasing air temperatures resulting from climate change indicated an urgent need for the community to recognise the health risks associated with heat and understand how to mitigate these risks. A mass communication program was developed by the Greater Southern Area Health Service (GSAHS) Population Health unit to meet this need. This report describes the background and design of that program and the results of a telephone survey conducted in conjunction with the program.
The Riverina-Murray region has a dry, semi-arid climate, characterised by hot summers and cool winters. Evidence is increasing that climate is changing and that the warming occurring across all continents is more than minor climate variability.2–5 During the summer of 2008/09, the Australian Bureau of Meteorology reported that the average daily minimum temperature for the regional centre of Wagga Wagga exceeded the long-term average minimum for previous summers by almost 1ºC. In addition, the average daily maximum temperature exceeded the long-term average maximum for previous summers by nearly 2ºC, with a record maximum of 45.2ºC recorded in February 2009. Days were hotter and nights cooled less than was typical in summers of previous years, indicating a dual source of heat stress.
Data from the Public Health Real-Time Emergency Department Surveillance System (PHREDSS), Centre for Epidemiology and Research, NSW Department of Health, showed that, in the summer of 2008/09, numbers of Emergency Department (ED) presentations associated with a range of heat effects, including heat stroke, sunstroke, heat syncope and heat exhaustion, increased by 65% compared with the average numbers across the previous four summers. February, the hottest month in that summer, accounted for just over half these presentations, of which most were by means of ambulance transfer. Most patients presenting in February were categorised as Triage 3 – potentially unstable and requiring medical treatment within 30 minutes. One patient was admitted to the Critical Care Unit, and the other patients were categorised as Triage 4–5, indicating less severe presentations. These effects of the heat on ED presentation rates are somewhat higher than the 4% to 8% increases in ambulance transports and hospital admissions reported previously6 during heatwaves (maximum temperature 35ºC or more on three consecutive days), in metropolitan Adelaide.
The human body maintains a normal temperature around 37ºC and can adjust to a rise of 1–2ºC, but reaches a crisis point at 40.5ºC.7,8 High core body temperature is central to heat stress and affects the functioning of the motor centres, causing human systems to break down and leading, in the worst cases, to death. Many factors affect heat stress, including individual ability to maintain hydration and electrolyte balance and acclimatise.9 Population groups particularly vulnerable to heat stress include children,10,11 the elderly, disabled and ill,12–17 pregnant women,18,19 people who are obese20,21 and people who work or exercise outdoors in summer. Illness heightens the effects of hot weather on the human body and this combination generates a burden for health services. It is estimated that for every death attributed directly to heat, 10 occur due to aggravation of a pre-existing illness through dehydration or hyperthermia.14
The general public must understand the full range of heat stress symptoms and their severity if they are to manage these risks. Heat stress is dehydrating and rehydration is essential to maintain wellness. In average temperatures, adults lose about 2.5 litres of water daily through normal bodily processes. The body loses more in hot weather or prolonged exercise22 and requires extra fluids to replenish those lost, with the amount tailored to age, activity level and diet.23 The general population and the carers of vulnerable people need to be well-educated in these respects.
The first aim of this report is to describe the program developed by the GSAHS Population Health unit. The second aim is to report the results of a telephone survey conducted to assess the program's reach and the knowledge and actions of the general public in managing health in the heat, so that recommendations for future, similar, programs can be made.
The Beat the Heat: don't forget your drink program was designed as a mass communication campaign that would achieve the public education and behaviours required to manage heat and heat stress. The program targeted the population of the Riverina-Murray region in NSW and its primary goal was to raise awareness of the dangers of heat stress, the value of prevention, and the need to recognise symptoms and manage heat stress. The program was implemented by the GSAHS, in collaboration with Charles Sturt University, and ran from mid-December 2008 to April 2009, under funding from the NSW Department of Environment and Climate Change. Time and financial constraints determined that the program focus should be on the larger populated areas of the Riverina-Murray, including Albury, Wagga Wagga and Griffith. The program involved three stages: planning, implementation and process evaluation.
The planning stage involved a literature review, development of key messages to be communicated, development of educational material and design of evaluation tools. A poster and three brochures targeting the general public, the elderly, carers and people engaged in outdoor work or exercise were designed and pilot-tested by a small focus group. Fact sheets on heat-related illness and heat stroke were developed in conjunction with NSW Health and made available on the NSW Health web site. Key messages were also developed for television, radio and newspapers, and included:
- • Recommended daily intake of water is 1,500–2,000 mL for an adult.
- • Half of that recommended daily intake will be in your food.
- • In hot weather, increase the amount of water taken, especially if exercising.
- • Recognise the symptoms of heat stress and treat them at once.
- • If possible, work, exercise and travel during cooler parts of the day.
- • Take special care of children, the elderly and those who are disabled in hot weather.
- • Wear light, loose clothes in summer.
- • Eat cool foods and high-water foods as part of a summer diet.
The program was designed principally as an education program, because the motivation, opportunity and ability of the general public to respond to the key messages24 were all considered to pre-exist. This made education the best tactic for achieving the Program's goals, rather than marketing or law.24 However, it could be argued that the education strategy complemented existing laws regarding occupational health and safety and duty of care, and that the immediate benefits to be gained by the general public from responding to the program messages were sufficiently substantial and desirable to create a total strategy that simulated social marketing.24
The implementation stage of the program commenced in early December 2008, and the program launch was attended by the media. Presentations in the form of brief information sessions and sound bytes were prepared and delivered by radio and television, and newspaper articles in the form of unpaid community announcements were similarly developed and delivered. Critical to the implementation of the program was media interest in promoting the risks associated with the heat. Prime News Wagga Wagga committed to reporting information messages with the nightly weather news when temperatures exceeded 36ºC. Radio stations played portions of interviews on heat and health throughout the summer. Media interest peaked during sustained hot days over summer. No paid advertisements were employed in the program. Presentations were given to seniors groups and the printed poster and pamphlets were delivered to a range of groups and organisations, including child care centres, shire councils, hospitals, health centres, clubs, and others, throughout the target region. A number of large outdoor events held over the summer were also targeted.
A process evaluation completed the final stage, and was focused particularly on assessing reach achieved by the program, while at the same time gathering valuable information on the current knowledge and behaviours of the public in relation to management of health in the heat. Ethics approval for the evaluation was given by the Human Research Ethics Committee of GSAHS.
The primary evaluation tool was a survey, which was carried out in the Riverina-Murray region, based on postcode of residence of participants, between 3 March and 19 March 2009. The survey was conducted on behalf of GSAHS by the Hunter Valley Research Foundation, via structured Computer Assisted Telephone Interviews (CATI) and using household telephone numbers randomly selected from the electronic White Pages directory. A person over the age of 18 years was randomly chosen from each willing household to participate in the survey, using a randomly generated number based on the number of eligible adults in the home. The interviews sought information on what heat messages had been heard over summer, the participant's knowledge and behaviours in heat health and heat stress management and some personal demographics. Carers of the elderly or disabled and people with children were asked to describe the heat management strategies they used.
A total of 328 interviews were completed, representing a response rate of 68.9% of eligible contacts, when calculated in a manner consistent with the recommendations of the American Association of Public Opinion Research (http://www.aapor.org). The high response rate reflects the utilisation of a stringent call-back methodology and probable name recognition by using ‘Greater Southern Area Health Service’ in the call introduction. The responses were weighted using information from the 2006 Census of Population Housing25 to ensure that the sample was representative of the age and sex distribution of the population in the target region. The responses were also weighted to reflect the number of adults in the household, ensuring that the opinions of people living in larger households were given the same weight as the opinions of those living in small households. At a confidence level of 95%, a sample size of 300 ensured a statistical accuracy of ± 5.8% or better for estimates of proportions of the underlying population that would be associated with specific responses.
The CATI survey provided the following demographics: 49% male and 51% female participants, with age categories ranging from 18 to 65+ years. Almost all had some secondary schooling and 65% held a higher level qualification, ranging from a level one certificate to a postgraduate degree. Employment was categorised as: full-time paid 41%, part-time paid 23%, retired 19%, home duties 7%, pension (not age) 5%, student 3% and looking for employment 2%.
Results from the CATI survey indicated that 63% of respondents had heard or seen heat health warnings during the summer. Television (74% of this group), radio (42%) and newspapers (15%) provided their main sources of information. Among a number of heat management strategies, the most strongly heard messages reported by those respondents who had heard the health warnings during the summer related to maintaining hydration (52%), avoiding the heat (27%), and the use of protective clothing (21%). The Program slogan, ‘Beat the Heat’, was recalled by 25% of the total sample, with television, radio and newspapers providing their main sources. In all areas of the survey, more women than men heard the messages, made changes to their activities in summer and encouraged others to modify their leisure activities. Almost 54% of participants stated that they had changed their summer behaviour, although the nature of those changes was not specifically surveyed. Of the remaining 46% who indicated they did not change their behaviour, 96% of these respondents said they always acted responsibly in the heat. They self-rated their understanding of the heat health risks at 7.9 on a 10 point scale, slightly higher than their self-rating for a year previous.
Participant awareness of heat management strategies was high, and responses to questions about specific strategies are provided in Table 1. A notable exception to the generally high level of participant awareness of heat management strategies was that only 10% of participants on medication asked their doctor if there were any adverse effects related to taking their prescribed medication in hot weather.
Table 1. Participant responses to CATI question “What do you do in hot weather to stay healthy or make sure others stay healthy? Do you…..” (prompted question).
|Put ceiling fans or air conditioning on||96.1||3.6||0.2|| |
|Drink extra cool water||94.0||6.0|| || |
|Close blinds on windows through the day||93.2||5.9||0.6||0.3|
|Stay inside as much as possible||90.1||9.9|| || |
|Reduce outdoor activities levels||89.5||9.4||1.1|| |
|Wear a hat when outside||87.3||12.4||0.3|| |
|Stay in air-conditioned buildings as much as possible||85.6||13.2||1.2|| |
|Avoid going outside between 11 am and 3 pm||77.2||20.9||1.9|| |
|Wear sunscreen when outside||72.5||26.3||1.2|| |
|Make young children drink more frequently||64.5||2.6||32.9|| |
|Make sure vulnerable persons living alone are checked on twice daily||28.8||10.8||60.2||0.1|
|Wet clothes when exercising outside in the heat||27.6||47.3||25.0|| |
|Ask your doctors if medication you may be taking affects you in the heat||10.0||58.0||32.0|| |
Almost half the participants stated that they were taking prescribed medication, 27% were overweight and 23% had high blood pressure. The participants cited lesser numbers of other problems: 18% smoked, 8% had a heart condition, 4% had a mental health problem, 2% had kidney problems, 1% had an alcohol problem and just over 1% admitted to taking non-prescription drugs. Most participants (78% of the sample) said they recognised symptoms and treatment of heat stress, and 20% indicated they had suffered from the effects of heat themselves this summer. Reported symptoms included physical and behavioural changes and illnesses, although only two participants had sought medical treatment. Participants claimed their water consumption increased by up to 50% during summer.
Management of their children's health by 64 participants (21%) appeared careful and appropriate. Generally, they kept children indoors and involved in quiet activities during the heat of the day, gave high levels of fluids, and devised water activities to amuse and cool the youngsters. Changes in their routine from previous years were largely related to the long hot summer, but were also ascribed to having a new baby, children being a year older, or moving to a better insulated or air-conditioned house.
Management of the frail or elderly by 27 participants (9%) was similarly well thought out. Carers encouraged their charges to engage in indoor activities during the heat of the day and to wear loose, light clothing, and ensured they used an air-conditioner or electric fan. They maintained hydration, checked their well being often and assisted them with showers and housework. Changes in respondent routines from previous years related mostly to the cared-for person being older (including being less active, now alone, or requiring more vigilance), to the hotter summer this year, and to improvements in home insulation or installing air-conditioning.
Participants were asked if there had been a time over summer when they had been unable to afford the cost of keeping cool. Although 94% answered in the negative, the costs of keeping cool had been a problem for 19 participants. Twelve of those unable to afford the cost of keeping cool were in the 18–29 age group.
Data from the Bureau of Meteorology was consistent with previous research findings indicating an ongoing pattern of globally rising minimum temperatures, and a consequent reduction in the hours of night time relief from the heat.2–4 This data and the PHREDSS data together suggested that, in the Riverina-Murray region during the summer of 2008/09, the general population was at increased risk of heat stress unless they developed measures to cope with the weather.
The majority of participants believed that they were coping sensibly with the heat, although some reported heat stress problems during the summer and many of those taking medication appeared unaware of the advisability of discussing possible impacts of taking their medication in summer, with their doctors. Carers of the elderly, disabled and children appeared well-informed and alert to heat-related risks. Women, perhaps due to socialisation into care-taking roles, reported more care in managing health risks in hot weather than men.
The program did not use paid advertising but the majority of participants, both those who recalled the Beat the heat: don't forget your drink slogan (25% of all participants surveyed) and those who heard heat messages but did not recall the program slogan, learnt their heat management messages from television, radio and newspapers. These items, presented as a community service, appear more effective in their reach and retention than the other forms of publicity employed. It is quite possible that heat health warnings issued by Victoria and NSW Health, in response to the protracted hot weather and the disastrous Victorian bushfires, combined with the Beat the Heat educational material to provided complementary reinforcement. In this program, many of the television messages were promulgated alongside weather reports indicating high temperatures, further exploiting this strategy.
It is highly likely that many more than the 25% who recalled the program slogan were reached by the program's key messages even if they did not recall its slogan, and this is supported by the increased awareness participants believed they possessed in the summer of 2008/09 compared to that they possessed in the previous summer, and the fact that many of their reported actions to manage health in the heat reflected the program's key messages. In any case, with no paid advertising, the reach of the program to at least 25% of the population is a good result, though, future programs may be able to improve on this reach with the goal to further reduce hospital presentations for heat-related illness, particularly in those at higher risk (e.g. those taking medications).
Limitations of the study
The survey participants were randomly chosen from landline numbers, excluding people whose only telephone is a mobile phone and those without a home phone. Only participants who spoke English were selected as participants, eliminating anyone not competent in the language.
It was a requirement that the participant be a resident of the Riverina-Murray region, a criterion that eliminated visitors to the region. Visitors’ ability to cope with hot weather requires consideration for a number of reasons. Tourism is a major source of income to the Riverina-Murray and tourist awareness of heat stress and heat management strategies is unknown. It is possible that overseas tourists, in particular, might put their health in danger through ignorance. It is also possible that they will manage better, stay longer and recommend the area to other people if care is taken to help them cope and acclimatise. Tourist bureaus, tourist accommodation managers (motels, hotels, bed and breakfasts) and tourism venues should be invited to join with public health agencies in educating tourists on heat management strategies.
The program lacked a baseline because it had not previously been conducted and this limited the conclusions that could be drawn regarding program impacts and outcomes.
It is clear from climactic and ED data, combined with information from this study regarding groups at higher risk, that public health education on heat stress management needs to be ongoing. It appears that heat and health management programs should continue at least until the general population takes preventive measures as a matter of course – particularly those at higher risk in the heat. These include people with an existing medical problem, tourists, men in general, people who work long hours outdoors in summer and those who play sport in summer. The health-related issues among the participants were numerous, suggesting that the general public needs to discuss management of prescribed medication with a general practitioner prior to summer and that future heat and health management programs need to be actively supported by doctors, pharmacists, nurses and allied health professionals. It appears that the low-cost media strategies employed in the program, involving unpaid television, radio and newspaper announcements paired, where possible, with weather reports, are effective means of reaching the general public, including those at higher risk.
We thank Associate Professor Julia Coyle and Dr Dianne Boxall for their advice on research design, the NSW Department of Environment and Climate Change for funding the program, and the research support provided by the Centre for Inland Health at Charles Sturt University and the Hunter Valley Research Foundation.