BATH-OUT

Housing adaptations are important prevention interventions for older adults who have difficulties with daily living activities. They are believed to prevent further deterioration in physical function and the need for other health and social care services. Bathing is a particularly important activity for older adults as it may be rapidly followed by difficulties in other daily living activities.

People may be eligible for help with major adaptations to support bathing – such as removing the bath and replacement with a level access shower – from social care and housing services provided by their local authority council.

However, there are long waiting times and waiting times vary across the country.

There is no robust evidence of the effect of bathing adaptations on health and social care outcomes. There is no robust evidence of cost effectiveness. Our study aimed to investigate these issues, in addition to the impact of waiting times on outcomes.

• Aims

  Our primary objective was to determine the effectiveness and cost effectiveness of major adaptations to bathing facilities versus no adaptations. Our secondary objectives were to explore the impact of waiting times for bathing adaptations on outcomes and to explore the factors associated with the implementation of adaptations.

• Methods

  We carried out a randomised controlled trial, with embedded economic and process evaluations, in which 296 older adults referred to local authority housing adaptations services were randomised to receive an expedited bathing adaptation compared to routine wait. We interviewed trial participants, and we interviewed and surveyed social care and housing professionals.

  The research team was a collaboration between the Universities of Newcastle, York, Northumbria, and Nottingham plus Nottingham City Council and Foundations. A range of local authorities took part in the study.

• Findings

  • Participants had, on average, a physical wellbeing score that was 2.5 points higher (95% CI 0.8 to 4.2, p = 0.003) after their adaptation than those who had not had their adaptation, which was a statistically significant finding. This was measured using the SF-36 Physical Component Summary score between groups at follow-up one. The difference between the groups (PCS score) reduced at the later follow up points was not statistically significant.
  • All other outcomes favoured the expedited intervention group, and were statistically significant at follow up one, including: mental wellbeing, social care related quality of life, fear of falling, independence in daily activities and bathing, perceived difficulty in bathing and number of falls. In terms of differences between the groups at later time points for these secondary outcomes the picture was mixed across the range of outcomes.
  • Across the whole trial period, the intervention arm (expedited adaptation) had lower health and social care resource use and a statistically significant increase in Quality Adjusted Life Years (QALYS).
  • Attrition was higher than expected and worse in the control group; thus, our findings should be interpreted with some caution. Sensitivity analyses indicated that participants with worse quality of life at baseline in the control group were more likely to drop out of the study and were not included in the subsequent follow-ups.
  • Findings from our process evaluation suggested that participants were engaged in a cycle of disruption, exploration and adoption of various strategies and techniques prior to entering the trial. The bathing adaptations were part of this ongoing strategy.
  • Responses to our survey of social care and housing professionals revealed key challenges in delivering trials and expedited housing adaptations and ways in which the findings may be used in practice – with a majority seeing the potential for Randomised Controlled Trials to have an impact on services.

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  Bath-Out 2 results demonstrate and confirm what many older citizens have known for years. The sooner a level access shower is installed following the decline in health, strength or movement of the older person, the more independence they maintain, the better they feel both psychologically and physically and the lower the costs to the local Council for minor adaptations and care agency support which otherwise would need providing in the interim. The sooner the level access shower is in situ the less degeneration of the older person’s health is likely to happen.

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  A level access shower room is generally standardised in what is being provided and so is the parameter of costs involved. Therefore, there is no reason why more areas across the country should delay putting in place this major adaptation as soon as the need is identified by an occupational therapist.

  All councils in England receive money for disabled facilities grants to be used by their population from central government, therefore wait times from identification of need through to finished inspection of the adaptation should be completed within a reasonable timeframe and ideally as soon as is practicable.

  Major adaptations to bathing facilities led to improvements in all outcomes four weeks after the installation of the adaptations. The primary outcome was physical well being at four weeks; the difference between the groups reduced at later the follow up points. The longer term effect of the adaptations on the secondary outcomes over the trial was mixed.

  The expedited intervention arm had lower resource use and improved quality of life over the course of the trial. There was evidence of ‘resource shifting’ during the follow-up period with higher secondary care costs and formal care costs in the control group.

  Our findings should be interpreted with some caution due to the high attrition rate, particularly in the control group. We carried out a range of sensitivity analyses on the effectiveness and cost effectiveness results which did not change the findings. However, we are limited in the extent to which we can mitigate the difference in follow up rates between the groups and this remains a limitation.

   

   

• Publications

  • Whitehead, J., Belshaw, S., Brady, S. et al. Bathing Adaptations in the Homes of Older Adults (BATH-OUT-2): study protocol for a randomised controlled trial, economic evaluation and process evaluation. Trials 25, 75 (2024). https://doi.org/10.1186/s13063-023-07677-3
  • McAnuff, , Rapley, T., Rooney, L. and Whitehead, P., 2024. Navigating uncharted territory with a borrowed map: lessons from setting up the BATH-OUT-2 randomised controlled trial in adult social care and housing services in English local authorities. Trials, 25(1), p.215. https://doi.org/10.1186/s13063-024-08073-1

• Research team

  In addition to the co-applicants listed above, the following people were part of the BATH-OUT research team

  • Samantha Brady, Research Fellow/Trial Manager, York Trials Unit, University of York
  • Elizabeth Coleman, Statistician, York Trials Unit, University of York
  • Laura Doherty, Trial Coordinator, York Trials Unit, University of York
  • Maisie Martland, Trial Coordinator, York Trials Unit, University of York
  • Jennifer McAnuff, Research Fellow, Northumbria University
  • Andrew McCarthy, Assistant Professor, Northumbria University
  • Melanie Narayanasamy, Research Assistant, University of Nottingham Dr Craig Newman, Research Associate, Newcastle University
  • Leigh Rooney, Research Associate, Newcastle University
  • Laura Sheard, Senior Research Fellow, York Trials Unit, University of York

• Bathing adaptations in the homes of older adults – The BATH-OUT trial

  The Care Act 2014 placed a statutory duty on local authorities to provide services that prevent deterioration and minimise the use of other services. Housing adaptations have been identified as one of the top ten prevention services for older adults, with bathing facilities being the most requested. Such adaptations may increase health and wellbeing for older adults and carers. However, many local authorities have lengthy waiting times which may increase costs, reduce effectiveness, and reduce the preventative effect. Furthermore, there is no robust evidence of the effect of these adaptations on: health, wellbeing and functional ability.

  This research tested whether it is feasible to conduct a randomised controlled trial (RCT) of bathing adaptations for older adults and their carers. Participants were randomised to receive immediate adaptations or routine waiting list. Outcomes were assessed at 3 and 6 months: health and social care related quality of life, functional ability, and use of services. This allowed  us to examine the effect of the adaptations and whether waiting times lead to worse outcomes. Qualitative interviews with users and carers supplemented the findings. The ultimate aim of this study was to inform the design of a powered RCT.

• Publications

  Whitehead PJ, Golding-Day MR. The lived experience of bathing adaptations in the homes of older adults and their carers (BATH-OUT): A qualitative interview study. Health Soc Care Community. 2019; 27: 1534–1543. https://doi.org/10.1111/hsc.12824

   

  Whitehead, P.J., Golding-Day, M.R., Belshaw, S. et al. Bathing adaptations in the homes of older adults (BATH-OUT): results of a feasibility randomised controlled trial (RCT). BMC Public Health 18, 1293 (2018). https://doi.org/10.1186/s12889-018-6200-4

   

  Whitehead PJ, James M, Belshaw S, et al Bathing adaptations in the homes of older adults (BATH-OUT): protocol for a feasibility randomised controlled trial (RCT) BMJ Open 2016;6:e013448. doi: 10.1136/bmjopen-2016-013448