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Family health and health services utilisation in Belmont, Western Australia: a community case study

Family health and health services utilisation in Belmont, Western Australia: a community case study Nancy Hudson-Rodd and Salma Al Khudairi Centrefor Development Studies, Edith Cowan University, Perth Raele n e Roydhouse Department o Psychiatry, University o Western Australia, Perth f f Abstract: This case study was designed to examine the self-defined health needs of families in one urban Western Australian community. We conducted 157 family interviews to examine the relationship between family sociodemographic variables and patterns of use of health services, which included senlces used within the previous 12 months, and what the family needed and wanted from these services. Questions covered perceptions of health, family health concerns and the role of the family health guardian. Quantitative analysis included frequencies, cross-tabulations, chi-squared tests and multiple regression analysis. Open-ended responses were categorised and analysed for common themes. Approximately 80 per cent of participants had used one or more health services during the previous 12 months and, despite 35.9 per cent of families having at least one family member with a long-standing illness, disability or infirmity, most (82.1 per cent) considered the family healthy. The correlational analysis revealed several associations. Predictably, younger persons reported higher health ratings and older persons had more health concerns. Larger families reported better perceived levels of health. Higher utilisation rates were recorded for families with children, who tended to use the general practitioner for general care and medication, whereas one-parent families used hospital and specialist care more often, and 98.7 per cent reported satisfaction with services. What they needed and wanted from their health service providers was ‘full disclosure’ and ‘not being talked down to’, and for specialists especially to be approachable and impart information simply and honestly. (Aust N Z JPublic Health 1998; 22: 107-14) HE ‘current trend toward decentralisation of health planning and service delivery is consistent with the primary health care principle of community self-determination. However, despite the rhetoric of the ‘new public health’, professional assumptions about community health needs continue to dominate funding and administrative decisions aboiut health care. Despite considerable progress in building a research basis for informed health planning and equitable resource allocation, there remains little information on locally defined health issues and patterns of service use. Such research is costly, labour-intensive and not considered generalisable in terms of the prevailing models, which demand statistical, rather than informational significance. It is, however, essential that any community health research portfolio includes a series of snapshots of Australian communities, to ensure that, in the true spirit of Alma Ata, public health professionals continue to ‘think globally’, but ‘act locally’. The community case study or snapshot is an essential buildin,g block of the type of informed health Correspondence to Professor Anne McMurray, School of Nursing, GrifYith University, PMB 50, Gold Coast Mail Centre, Qld 9726. Fax (07) 5594 8526. Email: a.mcmurray@gu.edu.au planning identified in the current national goals and targets statement’ and is consonant with the mandate of the Ottawa Charter for Health Promotion to reorient health roles from paternalism to enabling and mediating healthy choices by people themselves.‘+ Another area that has so far been neglected in mainstream public health research is that which focuses on the family, particularly in examining variation in families’ perceptions of health and how health is supported within changing family struct u r e ~It~ widely accepted that a person’s concept . is of being healthy is socially constructed within the cultural system of the family and social group.”1° As the primary agent of socialisation of health care attitudes and behaviour, a family’s conception of ‘health’ may differ considerably from medical or morbidity-related definitions.’.” Perceptions of family health and patterns of health services use should therefore be examined carefully, particularly in light of the growing body of international health services research suggesting that self-assessment of health status is one of the best predictors of use of health care services.’”-” Toward this end, the current study was devised to examine health and health services use in an urban Western Australian community from the perspective of the families who live there. VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 The study The study began 12 months before data collection, with formation of a community reference and planning group. Included were lay and professional members of the community who met to discuss what type of information would assist health planners and service providers to best meet the health needs of the people of Belmont. An interview, rather than a questionnaire survey was selected as the method of choice to secure greater depth of information, particularly from the family perspective. The interview guide was developed and refined following a series of pilot interviews conducted with seven families who were recruited by a local general practitioner. After the pilot interviews, minor modifications to the guide were made. Ethical approval for the study was granted by the Edith Cowan University Committee for the Conduct of Ethical Research. The sample The sample consisted of 157 families, with one family member being interviewed in the home. Participants were recruited through a door-to-door request, following promotion of the study via newspaper, local radio and poster advertisements. Members of the city council, the community reference group and community health nurses practising in child and community clinics, school health, adclescent health and aged care settings also assisted in promoting the study. One member of the research team provided intensive interviewing skills training to volunteer third-year nursing students from Edith Cowan University, who conducted the interviews. Each interviewer was assigned to an area (a group of streets) so that participants could be recruited from throughout the community. The interviewers were compensated on the basis of the number of completed interviews ($25 per interview) to encourage them to return to homes in their allocated streets at various hours of the day and on weekends and thus recruit working families. One sampling issue that is always problematic is that of defining the family.'B-20 After investigating a range of approaches, we decided to use the household, a strategy that excludes some family members (for example, a visiting parent), but allows ease of analysis. Another sampling issue related to selection of an arbitrary measure of family stage. We chose the age of the head of the household to indicate developmental stage: that is, whether the family was a young, middle-stage, or older family, again to simplify the analysis. The sample was small, yet representative of the ethnic mix, proportion of migrants, socioeconomic status and family type of Belmont and, to a slightly lesser extent, Perth.21 Method For each family participating, the interviewers introduced the purpose of the study and gained a signed consent from the family member who had agreed to provide information on family variables and patterns of use. Family variables included family composition, developmental stage, socioeconomic status, residency or migration history and religion. Patterns of use included relative frequency of use of a range of serviceswithin the previous 12 months, identification of what the family needed or wanted from these services, and health concerns. In addition, respondents were asked to describe their perceptions of the meaning of health, to what extent they believed the family was healthy, and who they believed assumed the role of family health guardian. For each of these areas, open-ended comments were encouraged to supplement the information recorded in the various categories of the interview guide. The household interview strategy was readily accepted by most families, who welcomed the opportunity to have their say about health care; this may have been assisted by the community-wide promotion and cooperation by the city council and local health care professionals. However, one cause for concern was the large number who did not respond to questions about family income and religion, both of which have been reported as controversial and p r ~ b l e m a t i c . ~ ~ ~ ' ~ of the high rate of nonreBecause sponses (45 per cent for income, 35 per cent for religion), we have refrained from drawing conclusions based on these variables. Another concern about the sample was the high number of unemployed people, despite a third of these being older families (over the age of 60). This may be related to the sampling strategy in that the unemployed are more often available for interview. Interview questions began with a profile of family demographic characteristics, and identified family type, stage and income. Respondents were then asked about the following: Health: what health means to them, to what extent they considered the family healthy, and whether any family members had any activity-limiting, long-standing illness, disability or infirmity. It was our expectation that families with chronic illness or disability would see the family as less healthy than those with little experience of illness. If this hypothesis was confirmed it might indicate a need to promote support services for carers. Family health guardian: who usually sees to it that family members are healthy, and whether the role tended to be demanding and/or satisfying. We foresaw a need to examine whether the rhetoric of changing gender roles in the familyz4 matched was by a shift in caregiver responsibilities. If this was the case, there would be a need to review support or respite services tailored to male or female caregivers. Health treatment and services: knowledge of available health services; which (from a list) the family had used in the past 12 months; reasons for use, what they wanted or needed from each, ease of access, and what types of things they treated at home rather than in the health system. We were interested in knowing how familiar people were with existing services and in identifymg any unmet needs as well as preference for home care and/or nontraditional services or therapies. Health concerns: whether they had any concerns about their own or their family members' health and wellbeing; concerns about the environment NO. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 vot. 22 F FAMILY HEALTH IN BELMONT or health and safety in their community, and whether they believed the family's financial status influenced their health. We were interested in knowing whether families would identify environment and safety concerns under the rubric of 'health'. We also hypothesised that within a Medicare environment, a typical family would not see financial status as an important influence on health. At the conclusion of this last section of the interview, participants were asked for any further comments about family health issues, health services or any general topic. who identified themselves as blended families, and only one family identified itself as extended. Data anatpsis The data were recorded on the interview guide, which had been designed for both categorised information and open-ended responses. Quantitative data were analysed using the SPSS for Windows PC (Release 16.0, 1993) computer package. The categorised data were entered as recorded, and integer values were assigned to general categories for the open-ended responses for data entry. Initial analysis consisted of the generation of frequency tables for all variables, followed by cross-tabulations. Some comparisoms were made with the Australian Bureau of Statistics (ABS) census data of 1991 to ensure that the sample was representative of the Belmont community." 'Where possible, demographic data were grouped in accordance with the ABS publication, and percentages were compared. Using Pearson's correlation analysis, we examined the degree of association between the demographic data and the health practices of families. Chisquared analysis was used to determine whether differences between categorical family variables (income, religion, chronic illness) were statistically significant at the 0.05 level. Multiple regression analysis was used to determine which demographic factors represented significant influences on these health practices, with significance set at the 0.05 level. Resdts Family comjjosition Families with children constituted 72.6 per cent of the sample, with 94.3 per cent of families having four or fewer family members. Two-person families made up 31.8 per cent of respondents, and 27.4 per cent were single-member families, which is only slightly difl'erent from the wider Belmont community, in which 37 per cent live in two-person families and 21.2 per cent in single-member families." Fourand three-person families made up 19.1 per cent and 15.9 per cent of the sample, respectively. Developmental stage The family's developmental stage was operationalised as the age of the head of the household. Most were adult (37.6 per cent aged 30 to 50) or mature (28 per cent aged 51 to 64). Young families (under 29 years) represented 15.9 per cent of the sample, and only 18.5 per cent of participants were over the age of 65. This represents a slightly higher proportion of 30- to 50-year-olds than the rest of the community (26 per cent) but an equivalent number of older persons (18.5 per cent).2' Socioeconomic status Employment. Only 53.2 per cent of first family members in this sample were in full-time employment, 5.8 per cent were part-time workers, and 38.1 per cent of families had two members employed. Of the 41 per cent unemployed, 31 per cent were aged 60 or over. Part-time tertiary students made up 0.6 per cent of the sample. Income. Of those who chose to reveal this information, proportionally fewer (24 per cent) were in the lower income bracket ($20 000) than in the larger community (37 per cent).21Of the remainder 19.7 per cent were on government pensions, 25.5 per cent were in the $30 000 to $39 000 bracket, 18.7 per cent in the $40 000 to $69 000 bracket, and 11.7 per cent had an income over $70 000. When asked whether their family's financial status influenced health, most replied no. Of the 17.2 per cent who replied affirmatively, most identified cost and access to private health insurance, with five families reporting the need for increased government assistance for affordable private health insurance. Residency o migration r In this sample, 71.6 per cent of families were Australian-born, one of which was Aboriginal, compared with 66 per cent and 1.8 per cent, respectively, in the Belmont community.?' The remaining 49 families had migrated between six months and 55 years before from a range of countries, the most common being the United Kingdom (9 per cent). English was read and spoken by 98.1 per cent, similar to the national figure of 86 per cent.' Religion Of the 55 per cent identifylng religious affiliation, 22.3 per cent were Roman Catholic and 20.4 per cent Anglican. Of these, 1.9 per cent reported that religion influenced the health of their family, all of whom were Catholics who mentioned birth control. Health The most frequently identified meaning of health was 'not sick/feeling good' (78.3 per cent), 17.2 per cent equated good health with good nutrition or exercise, and 2.5 per cent defined health as 'professionals helping you'. When asked whether they felt VOL. Family type Half of the sample lived in two-parent families (49 per cent) which is similar to the 45 per cent in the Belmont community." One-parent families made up 19.1 per cent of the sample, which again is similar to the rest of the community (18 per cent).*' Other families consisted of 29.9 per cent singles, couples or friends sharing with no children. There were none AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 Table 1: Correlation coefficients for family variables with use of health services during the previous 12 months, Belmont, Western Australia, 1994 Services used Occupational Nursing health r P r P 0.212 0,008 0.032 0.692 Family variables Age General practitioner Specialist Hospital r P School Preventive Alternative NO. members 4.115 0.151 -0.010 0.897 0.088 0.275 -0.077 0.339 0.107 0.184 0.287 <0.001 -0.085 Type Marital status -0.167 <0.001 4,093 -0.039 -0.003 -0.028 -0.130 Years in Australia Years in Belmonf -0.140 -0.093 their family was healthy, 90.4 per cent stated that they were ‘healthy’, ‘very healthy’ or had ‘above average health’. In 35.9 per cent of families, at least one family member had a long-standing illness, disability or infirmity. Of these, 82.1 per cent still considered the family ‘healthy’ or ‘very healthy’, although 69.6 per cent of this group had limited activity, most being mobility problems related to arthritis. The most frequently reported illnesses were respiratory illnesses (30.4 per cent), arthritis (16.1 per cent), cardiac disorders (12.5 per cent), muscular dystrophy, gynaecological problems (9.1 per cent each) and diabetes (8.9 per cent). Many claiming no illness, disability or infirmity commented that the family included at least one person who suffered from asthma controlled by medication. Family health <guardian The family health guardian was identified as the female or wife of the family in 59.2 per cent of cases, the male or husband in 19.1 per cent of families, and both parents in 7.6 per cent of families. Others reported that members take responsibility for themselves (13.4 per cent), or rely on a son or daughter (0.6 per cent). In this sample, 78.3 per cent felt that the health guardian role was not demanding, and responses from this group were relatively genderbalanced, with 26.6 per cent from males and 25.8 per cent from females. The role was identified as ‘satisfjmg’ or ‘somewhat satisfying' by 91 per cent (88 per cent of male health guardians and 93 per cent of females). A correlational analysis of health rating and the number of individual health services used in the previous 12 months in relation to family variables was conducted using Pearson’s coefficient with a twotailed significance. Chi-squared analysis of health rating according to income, religion and chronic illness revealed few significant results, possibly because of the sample size and the number of categories. Similarly, the correlational analysis (in conjunction with relative frequencies) of health ratings, health guardian, health concerns and overall utilisation rates showed few highly significant relationships. However, some associations were apparent. The most notable of these was related to age, as expected. The data revealed only a slight-to-moderate positive correlation between age and health rating, suggesting that the younger the person, the higher the health rating. Similar associations were found between age and having health concerns (with older people reporting slightly more concerns), and between age and having used a health service in the past twelve months (with younger persons more likely to have done so). A minimal correlation between family number and health rating suggested a possible association between larger families and a better perceived level of health. However, this association may also be linked to age, in that it is primarily the elderly (single, or with their partners) who are not in the best of health. Not surprisingly, there was a slight-to-moderate positive correlation between families having a family member with an illness or disability and health rating. This suggests that the more painful or debilitating the disease, the poorer the health rating; however, 82.1 per cent of these families still considered the family ‘healthy’ or ‘very healthy’. Availability of health services Eighty per cent of study participants had used at least one health service during the previous 12 months. The most frequently identified health services identified by respondents were general practitioners (29.9 per cent), medical centres (25.8 per cent), dentists (14.3 per cent) and community health services (10.7 per cent). A two-tailed test of significance was again employed to examine the relationships between family variables and use of services. Most proved to have only minor significance; however, the analysis suggested several associations, which are presented in Table 1. Despite the lack of highly positive correlational data, there were some apparent associations VOL. AUSTRALIAN AND N W ZEALAND JOURNAL OF PUBLIC HEALTH 1998 E 22 NO. 1 FAMILY HEALTH IN BEMONT between family type and the number of services used in the previous 12 months, in that families with children hadl slightly higher utilisation rates (Table 2). These families also showed a propensity to use the general practitioner for general care and medication, respectively, and the trend was for one-parent families to use hospital and specialist care more often. Analysis of use of services in respect to family composition again yielded few significant relationships; however, predictably, the data suggested a greater likelihood of using school health services with larger numbers of family members. Regression analysis revealed that the number of years in Belmont was a significant predictor of having used no health services (a= 0.01). One could conclude from this that families living in the community for a shorter period would have less knowledge of available services. What people needed or wanted from health sewaces Most people stated that they neither needed nor wanted anything from their health services, which is congruent with the high rates of satisfaction with existing services. The most frequently stated needs, according to the service provided, were as follows: general practitioner: personalised care (30.6 per cent); medication (28.7 per cent) specialist: quality care (11.5 per cent); testing (8.9 per cent) hospitals: good service (14.0 p e ~ cent); general care (8.3 per cent) nurses: information, home care, good care (4.5 per cent each) occupational health: treatment (8.9 per cent); information (3.8 per cent) school health: check-ups (5.7 per cent); information (2.5 per cent) preventive services: immunisation (7.6 per cent); information and reminders (4.5 per cent each) alternatnve services: massage and chiropractic (1.9 per cent each). Most families (98.7 per cent) felt they were able to obtain access to services when they needed to. When asked what types of things they treated at home, 75.2 per cent identified minor ailments, while 16.6 per cent stated ‘nothing’, and 3.2 per cent ‘everything’. What they needed or wanted from the health services was slated in the open-ended comments as primarily ‘full disclosure’, ‘not being talked down to’, and for specialists especially, for them to be approachable and impart information simply and honestly. Health concerns Health-related concerns were identified by 26.8 per cent of participants. Most these were stated as general healthL-related worries (19 per cent), and the remainder were primarily concerns about increased incapacitation and not knowing where to turn (7.6 per cent). N o significant correlations were found between having concerns and sociodemographic variables; however, the largest group reporting general health concerns were pensioners (20 per cent), followed by those in the largest income bracket (11 Table 2: Frequency of family use of health services over previous 12 months, Belmont, Western Australia, 1994 (n = 126) Service General practitioner General care Medication Prevention (Pap test) Not stated Specialist Specialist treatment Gynaecological Dental Allergies Screening Pathology Hospital General care Surgery Maternity Fractures Psychology Nursing services Community nurse Child health Equipment Psychiatric nurse Occupational health Physiotherapy Equipment Occupational therapy Social worker General School health General Testing Dental Psychologist Preventive services Mammogram lmmunisation Diabetic screening Pap smear Pathology X-ray Unstated Alternative services Herbalist Chiropractor Acupuncturist All of the above Other services Optician Dietitian Reason for service per cent). Those most worried about their health, primarily related to incapacitation, were those with respiratory disease (30 per cent) and cardiac conditions (12.5 per cent). The environment was a concern for 36.3 per cent; this included pollution (21.7 per cent), noise (12.1 per cent) and graffiti (1.3 per cent). Community health and safety was identified as a concern by 38.9 per cent, predominantly in regard to increasing rates of crime (29.3 per cent). AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 VOL. 22 NO. 1 F McMURRAY flA t Older people stated that they worried about a degraded environment being a heritage for their grandchildren. Those who elaborated on specific facets of environmental concern cited ‘too many cars’, or ‘plane noise’, as Belmont is close to the airport. At the conclusion of interviews, people were invited to make comment on any health-related matter. Some stated that they live happily in Belmont (13.4 per cent), while others reinforced the statement that all family members were healthy (12.1 per cent). Several others mentioned issues ranging from the need for more information to the fact that they would like a healthier lifestyle. Most comments about health services (from 42.7 per cent of the sample) were positive; however, the need for more or better services was identified by 11.7 per cent of families, and 2.5 per cent expressed a need for low-cost or free private health care for low-income families. Discussion Health and healthiness in Belmont The way people described ‘health’ was not remarkable in the context of other s t u d i e ~ ;however, the ~~~*~ large proportion declaring their health status as ‘healthy’ or ‘very healthy’ was notable, particularly when a third of the families had a family member with limiting, long-standing illness or disability. This may have reflected their satisfaction with their quality of life and lifestyle, as was found in one Canadian study.12 The Canadian research found that people’s views of healthiness reflected a sense of wellbeing, linked to a psychological state. They concluded that people tend to describe ‘being healthy’ in terms of their ability to maintain their preferred quality of life.“ Our findings revealed few comments about psychological state, but this may have been incorporated in descriptions of ‘feeling good’. A recent review of the literature on personal definitions of health revealed that some people identifji mobility, some identify activity and some, interactions with others.” In some cases, ideas about health are dependent on age,z6psychological f a ~ t o r s , ~sex,31 ’-~~ socioeconomic status,31and ~ u l t u r e . ~ ’ our study, In no significant correlations were found between definitions of health and any of the sociodemographic factors, but it was interesting that both younger and older age groups were equally represented in the 17 per cent of families who identified nutrition and exercise as part of being healthy. This suggests that strategies currently aimed at the young may be as effective in reinforcing existing health beliefs among older people. It was also interesting that a third of families identified the environment as a health concern. Belmont is an established, inner-urban city within metropolitan Perth, which offers, in addition to a wide range of sporting and recreational facilities, a broad range of community health and social services.” However, most people still use private, rather than public transportation, creating considerable air pollution, and Belmont’s close proximity to the airport and rising crime rates2’are also experienced by these peo112 ple as threats to family health. This indicates a need for greater intersectoral collaboration in health promotion campaigns, integrating community services, local council issues (transportation, environment, policing), and those of the wider community with health department programs. Although it was not statistically significant, a relationship was found between family size and perceived level of health, but this may have been a reflection of marital status rather than the number of family members. We found only a modest association between marital status and health rating but this adds weight to the notion that married people tend to report perceptions of better health than singles, although previous research has drawn mixed conclusions.33 Comments on the link between financial resources and health indicated that we should have asked people whether they were privately insured, and this is a limitation of the study. The findings suggest that the cost of such insurance is beyond most families’ financial means. From the modest but positive association between age and health rating, it would appear that younger people enjoy better health; this was borne out in the analysis of health concerns, where a greater number of health concerns and higher rates of service use (with the exception of occupational and school health services) were reported by older people. For households in which the head of the household was aged 65 or over, respondents had used at least one health service in the previous 12 months, which supports prior findings of disproportionate use patterns by the elderly.34 Health guardian That a fifth of males considered themselves the family health guardian, and a large proportion of families considered looking after the family’s health a joint responsibility seems illustrative of the trend toward shared caregiving in young families of the 1990s.35,36 other notable finding was the relative The gender-balanced reporting of both the demands and satisfaction of the role of health guardian. This indicates a need for health promotion materials (brochures, posters, pamphlets) that depict a better gender balance than currently. Although women continue to be overrepresented as family caregivers for the elderly,37 findings indicate that things are the changing. Respite services, which have to date attempted to attract female caregivers, may need to make a special effort to ensure access for males. Patterns o use o health services f f Approximately 80 per cent of families had used one or more health services during the previous 12 months, and it appeared that most were familiar with existing services and were satisfied customers. People in extended or other relationships were more likely to have used a health service in the past 12 months than those living alone, but this may have been related to having children, particularly with the finding that one- and two-parent families represented 71 per cent of all visits to general practitioners. This indicates a need for further research on VOL. AUSTRALIAN AND N W ZEALAND JOURNAL O PUBLIC HEALTH 1998 E F 22 NO. 1 FAMILY HEALTH IN BELMONT single dwellers, in that they may have unmet needs that are not revealed in surveys of service use. There is also a need to investigate the differences between two-parent and one-parent families’ use of the emergency department and general practitioners when their children need medical care. Another issue for further research is related to the immunisation debate. We found a disproportionate use of immunisation services between one- and two-parent families, with two-parent families reporting more use of immunisa tion services. Further research with a larger sample size may shed some light on whether this is a typical pattern or an artefact of the sample. Comments on what was needed from health care providers were similar to those in other studies. Lloyd et al. found that bedside manners and caring attitudes were most i m p ~ r t a n t ; ’other Australian ~ studies reveal that what people need most is better health i n f o r m a t i ~ n Our participants generally .~~~ were familiar with services, but their comments focused om communication style. They wanted ‘full disclosure’ and ‘to not be talked down to’, especially by specialists. This issue has been identified in studies of differing perceptions of doctors and patients with the conclusion that medical practitioners must recognise communication problems as a serious threat to desired This supports a need for greater awareness of the problem among the medical community and in those preparing curricula for medical s t ~ d e n t s . ~ ~ . ~ ~ planning and, therefore, efficient distribution of resources.5o Acknowledgments The authors would like to acknowledge the Public and Community Health Unit, East Metropolitan Health Area, Health Department of Western Australia, for providing the financial assistance for the research, and members of the Belmont community, especially Dr Pradeep Jayasuriya and the Belmont City Council for their assistance in promoting the study. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Family health and health services utilisation in Belmont, Western Australia: a community case study

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Copyright © 1998 Wiley Subscription Services, Inc., A Wiley Company
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Abstract

Nancy Hudson-Rodd and Salma Al Khudairi Centrefor Development Studies, Edith Cowan University, Perth Raele n e Roydhouse Department o Psychiatry, University o Western Australia, Perth f f Abstract: This case study was designed to examine the self-defined health needs of families in one urban Western Australian community. We conducted 157 family interviews to examine the relationship between family sociodemographic variables and patterns of use of health services, which included senlces used within the previous 12 months, and what the family needed and wanted from these services. Questions covered perceptions of health, family health concerns and the role of the family health guardian. Quantitative analysis included frequencies, cross-tabulations, chi-squared tests and multiple regression analysis. Open-ended responses were categorised and analysed for common themes. Approximately 80 per cent of participants had used one or more health services during the previous 12 months and, despite 35.9 per cent of families having at least one family member with a long-standing illness, disability or infirmity, most (82.1 per cent) considered the family healthy. The correlational analysis revealed several associations. Predictably, younger persons reported higher health ratings and older persons had more health concerns. Larger families reported better perceived levels of health. Higher utilisation rates were recorded for families with children, who tended to use the general practitioner for general care and medication, whereas one-parent families used hospital and specialist care more often, and 98.7 per cent reported satisfaction with services. What they needed and wanted from their health service providers was ‘full disclosure’ and ‘not being talked down to’, and for specialists especially to be approachable and impart information simply and honestly. (Aust N Z JPublic Health 1998; 22: 107-14) HE ‘current trend toward decentralisation of health planning and service delivery is consistent with the primary health care principle of community self-determination. However, despite the rhetoric of the ‘new public health’, professional assumptions about community health needs continue to dominate funding and administrative decisions aboiut health care. Despite considerable progress in building a research basis for informed health planning and equitable resource allocation, there remains little information on locally defined health issues and patterns of service use. Such research is costly, labour-intensive and not considered generalisable in terms of the prevailing models, which demand statistical, rather than informational significance. It is, however, essential that any community health research portfolio includes a series of snapshots of Australian communities, to ensure that, in the true spirit of Alma Ata, public health professionals continue to ‘think globally’, but ‘act locally’. The community case study or snapshot is an essential buildin,g block of the type of informed health Correspondence to Professor Anne McMurray, School of Nursing, GrifYith University, PMB 50, Gold Coast Mail Centre, Qld 9726. Fax (07) 5594 8526. Email: a.mcmurray@gu.edu.au planning identified in the current national goals and targets statement’ and is consonant with the mandate of the Ottawa Charter for Health Promotion to reorient health roles from paternalism to enabling and mediating healthy choices by people themselves.‘+ Another area that has so far been neglected in mainstream public health research is that which focuses on the family, particularly in examining variation in families’ perceptions of health and how health is supported within changing family struct u r e ~It~ widely accepted that a person’s concept . is of being healthy is socially constructed within the cultural system of the family and social group.”1° As the primary agent of socialisation of health care attitudes and behaviour, a family’s conception of ‘health’ may differ considerably from medical or morbidity-related definitions.’.” Perceptions of family health and patterns of health services use should therefore be examined carefully, particularly in light of the growing body of international health services research suggesting that self-assessment of health status is one of the best predictors of use of health care services.’”-” Toward this end, the current study was devised to examine health and health services use in an urban Western Australian community from the perspective of the families who live there. VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 The study The study began 12 months before data collection, with formation of a community reference and planning group. Included were lay and professional members of the community who met to discuss what type of information would assist health planners and service providers to best meet the health needs of the people of Belmont. An interview, rather than a questionnaire survey was selected as the method of choice to secure greater depth of information, particularly from the family perspective. The interview guide was developed and refined following a series of pilot interviews conducted with seven families who were recruited by a local general practitioner. After the pilot interviews, minor modifications to the guide were made. Ethical approval for the study was granted by the Edith Cowan University Committee for the Conduct of Ethical Research. The sample The sample consisted of 157 families, with one family member being interviewed in the home. Participants were recruited through a door-to-door request, following promotion of the study via newspaper, local radio and poster advertisements. Members of the city council, the community reference group and community health nurses practising in child and community clinics, school health, adclescent health and aged care settings also assisted in promoting the study. One member of the research team provided intensive interviewing skills training to volunteer third-year nursing students from Edith Cowan University, who conducted the interviews. Each interviewer was assigned to an area (a group of streets) so that participants could be recruited from throughout the community. The interviewers were compensated on the basis of the number of completed interviews ($25 per interview) to encourage them to return to homes in their allocated streets at various hours of the day and on weekends and thus recruit working families. One sampling issue that is always problematic is that of defining the family.'B-20 After investigating a range of approaches, we decided to use the household, a strategy that excludes some family members (for example, a visiting parent), but allows ease of analysis. Another sampling issue related to selection of an arbitrary measure of family stage. We chose the age of the head of the household to indicate developmental stage: that is, whether the family was a young, middle-stage, or older family, again to simplify the analysis. The sample was small, yet representative of the ethnic mix, proportion of migrants, socioeconomic status and family type of Belmont and, to a slightly lesser extent, Perth.21 Method For each family participating, the interviewers introduced the purpose of the study and gained a signed consent from the family member who had agreed to provide information on family variables and patterns of use. Family variables included family composition, developmental stage, socioeconomic status, residency or migration history and religion. Patterns of use included relative frequency of use of a range of serviceswithin the previous 12 months, identification of what the family needed or wanted from these services, and health concerns. In addition, respondents were asked to describe their perceptions of the meaning of health, to what extent they believed the family was healthy, and who they believed assumed the role of family health guardian. For each of these areas, open-ended comments were encouraged to supplement the information recorded in the various categories of the interview guide. The household interview strategy was readily accepted by most families, who welcomed the opportunity to have their say about health care; this may have been assisted by the community-wide promotion and cooperation by the city council and local health care professionals. However, one cause for concern was the large number who did not respond to questions about family income and religion, both of which have been reported as controversial and p r ~ b l e m a t i c . ~ ~ ~ ' ~ of the high rate of nonreBecause sponses (45 per cent for income, 35 per cent for religion), we have refrained from drawing conclusions based on these variables. Another concern about the sample was the high number of unemployed people, despite a third of these being older families (over the age of 60). This may be related to the sampling strategy in that the unemployed are more often available for interview. Interview questions began with a profile of family demographic characteristics, and identified family type, stage and income. Respondents were then asked about the following: Health: what health means to them, to what extent they considered the family healthy, and whether any family members had any activity-limiting, long-standing illness, disability or infirmity. It was our expectation that families with chronic illness or disability would see the family as less healthy than those with little experience of illness. If this hypothesis was confirmed it might indicate a need to promote support services for carers. Family health guardian: who usually sees to it that family members are healthy, and whether the role tended to be demanding and/or satisfying. We foresaw a need to examine whether the rhetoric of changing gender roles in the familyz4 matched was by a shift in caregiver responsibilities. If this was the case, there would be a need to review support or respite services tailored to male or female caregivers. Health treatment and services: knowledge of available health services; which (from a list) the family had used in the past 12 months; reasons for use, what they wanted or needed from each, ease of access, and what types of things they treated at home rather than in the health system. We were interested in knowing how familiar people were with existing services and in identifymg any unmet needs as well as preference for home care and/or nontraditional services or therapies. Health concerns: whether they had any concerns about their own or their family members' health and wellbeing; concerns about the environment NO. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 vot. 22 F FAMILY HEALTH IN BELMONT or health and safety in their community, and whether they believed the family's financial status influenced their health. We were interested in knowing whether families would identify environment and safety concerns under the rubric of 'health'. We also hypothesised that within a Medicare environment, a typical family would not see financial status as an important influence on health. At the conclusion of this last section of the interview, participants were asked for any further comments about family health issues, health services or any general topic. who identified themselves as blended families, and only one family identified itself as extended. Data anatpsis The data were recorded on the interview guide, which had been designed for both categorised information and open-ended responses. Quantitative data were analysed using the SPSS for Windows PC (Release 16.0, 1993) computer package. The categorised data were entered as recorded, and integer values were assigned to general categories for the open-ended responses for data entry. Initial analysis consisted of the generation of frequency tables for all variables, followed by cross-tabulations. Some comparisoms were made with the Australian Bureau of Statistics (ABS) census data of 1991 to ensure that the sample was representative of the Belmont community." 'Where possible, demographic data were grouped in accordance with the ABS publication, and percentages were compared. Using Pearson's correlation analysis, we examined the degree of association between the demographic data and the health practices of families. Chisquared analysis was used to determine whether differences between categorical family variables (income, religion, chronic illness) were statistically significant at the 0.05 level. Multiple regression analysis was used to determine which demographic factors represented significant influences on these health practices, with significance set at the 0.05 level. Resdts Family comjjosition Families with children constituted 72.6 per cent of the sample, with 94.3 per cent of families having four or fewer family members. Two-person families made up 31.8 per cent of respondents, and 27.4 per cent were single-member families, which is only slightly difl'erent from the wider Belmont community, in which 37 per cent live in two-person families and 21.2 per cent in single-member families." Fourand three-person families made up 19.1 per cent and 15.9 per cent of the sample, respectively. Developmental stage The family's developmental stage was operationalised as the age of the head of the household. Most were adult (37.6 per cent aged 30 to 50) or mature (28 per cent aged 51 to 64). Young families (under 29 years) represented 15.9 per cent of the sample, and only 18.5 per cent of participants were over the age of 65. This represents a slightly higher proportion of 30- to 50-year-olds than the rest of the community (26 per cent) but an equivalent number of older persons (18.5 per cent).2' Socioeconomic status Employment. Only 53.2 per cent of first family members in this sample were in full-time employment, 5.8 per cent were part-time workers, and 38.1 per cent of families had two members employed. Of the 41 per cent unemployed, 31 per cent were aged 60 or over. Part-time tertiary students made up 0.6 per cent of the sample. Income. Of those who chose to reveal this information, proportionally fewer (24 per cent) were in the lower income bracket ($20 000) than in the larger community (37 per cent).21Of the remainder 19.7 per cent were on government pensions, 25.5 per cent were in the $30 000 to $39 000 bracket, 18.7 per cent in the $40 000 to $69 000 bracket, and 11.7 per cent had an income over $70 000. When asked whether their family's financial status influenced health, most replied no. Of the 17.2 per cent who replied affirmatively, most identified cost and access to private health insurance, with five families reporting the need for increased government assistance for affordable private health insurance. Residency o migration r In this sample, 71.6 per cent of families were Australian-born, one of which was Aboriginal, compared with 66 per cent and 1.8 per cent, respectively, in the Belmont community.?' The remaining 49 families had migrated between six months and 55 years before from a range of countries, the most common being the United Kingdom (9 per cent). English was read and spoken by 98.1 per cent, similar to the national figure of 86 per cent.' Religion Of the 55 per cent identifylng religious affiliation, 22.3 per cent were Roman Catholic and 20.4 per cent Anglican. Of these, 1.9 per cent reported that religion influenced the health of their family, all of whom were Catholics who mentioned birth control. Health The most frequently identified meaning of health was 'not sick/feeling good' (78.3 per cent), 17.2 per cent equated good health with good nutrition or exercise, and 2.5 per cent defined health as 'professionals helping you'. When asked whether they felt VOL. Family type Half of the sample lived in two-parent families (49 per cent) which is similar to the 45 per cent in the Belmont community." One-parent families made up 19.1 per cent of the sample, which again is similar to the rest of the community (18 per cent).*' Other families consisted of 29.9 per cent singles, couples or friends sharing with no children. There were none AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 Table 1: Correlation coefficients for family variables with use of health services during the previous 12 months, Belmont, Western Australia, 1994 Services used Occupational Nursing health r P r P 0.212 0,008 0.032 0.692 Family variables Age General practitioner Specialist Hospital r P School Preventive Alternative NO. members 4.115 0.151 -0.010 0.897 0.088 0.275 -0.077 0.339 0.107 0.184 0.287 <0.001 -0.085 Type Marital status -0.167 <0.001 4,093 -0.039 -0.003 -0.028 -0.130 Years in Australia Years in Belmonf -0.140 -0.093 their family was healthy, 90.4 per cent stated that they were ‘healthy’, ‘very healthy’ or had ‘above average health’. In 35.9 per cent of families, at least one family member had a long-standing illness, disability or infirmity. Of these, 82.1 per cent still considered the family ‘healthy’ or ‘very healthy’, although 69.6 per cent of this group had limited activity, most being mobility problems related to arthritis. The most frequently reported illnesses were respiratory illnesses (30.4 per cent), arthritis (16.1 per cent), cardiac disorders (12.5 per cent), muscular dystrophy, gynaecological problems (9.1 per cent each) and diabetes (8.9 per cent). Many claiming no illness, disability or infirmity commented that the family included at least one person who suffered from asthma controlled by medication. Family health <guardian The family health guardian was identified as the female or wife of the family in 59.2 per cent of cases, the male or husband in 19.1 per cent of families, and both parents in 7.6 per cent of families. Others reported that members take responsibility for themselves (13.4 per cent), or rely on a son or daughter (0.6 per cent). In this sample, 78.3 per cent felt that the health guardian role was not demanding, and responses from this group were relatively genderbalanced, with 26.6 per cent from males and 25.8 per cent from females. The role was identified as ‘satisfjmg’ or ‘somewhat satisfying' by 91 per cent (88 per cent of male health guardians and 93 per cent of females). A correlational analysis of health rating and the number of individual health services used in the previous 12 months in relation to family variables was conducted using Pearson’s coefficient with a twotailed significance. Chi-squared analysis of health rating according to income, religion and chronic illness revealed few significant results, possibly because of the sample size and the number of categories. Similarly, the correlational analysis (in conjunction with relative frequencies) of health ratings, health guardian, health concerns and overall utilisation rates showed few highly significant relationships. However, some associations were apparent. The most notable of these was related to age, as expected. The data revealed only a slight-to-moderate positive correlation between age and health rating, suggesting that the younger the person, the higher the health rating. Similar associations were found between age and having health concerns (with older people reporting slightly more concerns), and between age and having used a health service in the past twelve months (with younger persons more likely to have done so). A minimal correlation between family number and health rating suggested a possible association between larger families and a better perceived level of health. However, this association may also be linked to age, in that it is primarily the elderly (single, or with their partners) who are not in the best of health. Not surprisingly, there was a slight-to-moderate positive correlation between families having a family member with an illness or disability and health rating. This suggests that the more painful or debilitating the disease, the poorer the health rating; however, 82.1 per cent of these families still considered the family ‘healthy’ or ‘very healthy’. Availability of health services Eighty per cent of study participants had used at least one health service during the previous 12 months. The most frequently identified health services identified by respondents were general practitioners (29.9 per cent), medical centres (25.8 per cent), dentists (14.3 per cent) and community health services (10.7 per cent). A two-tailed test of significance was again employed to examine the relationships between family variables and use of services. Most proved to have only minor significance; however, the analysis suggested several associations, which are presented in Table 1. Despite the lack of highly positive correlational data, there were some apparent associations VOL. AUSTRALIAN AND N W ZEALAND JOURNAL OF PUBLIC HEALTH 1998 E 22 NO. 1 FAMILY HEALTH IN BEMONT between family type and the number of services used in the previous 12 months, in that families with children hadl slightly higher utilisation rates (Table 2). These families also showed a propensity to use the general practitioner for general care and medication, respectively, and the trend was for one-parent families to use hospital and specialist care more often. Analysis of use of services in respect to family composition again yielded few significant relationships; however, predictably, the data suggested a greater likelihood of using school health services with larger numbers of family members. Regression analysis revealed that the number of years in Belmont was a significant predictor of having used no health services (a= 0.01). One could conclude from this that families living in the community for a shorter period would have less knowledge of available services. What people needed or wanted from health sewaces Most people stated that they neither needed nor wanted anything from their health services, which is congruent with the high rates of satisfaction with existing services. The most frequently stated needs, according to the service provided, were as follows: general practitioner: personalised care (30.6 per cent); medication (28.7 per cent) specialist: quality care (11.5 per cent); testing (8.9 per cent) hospitals: good service (14.0 p e ~ cent); general care (8.3 per cent) nurses: information, home care, good care (4.5 per cent each) occupational health: treatment (8.9 per cent); information (3.8 per cent) school health: check-ups (5.7 per cent); information (2.5 per cent) preventive services: immunisation (7.6 per cent); information and reminders (4.5 per cent each) alternatnve services: massage and chiropractic (1.9 per cent each). Most families (98.7 per cent) felt they were able to obtain access to services when they needed to. When asked what types of things they treated at home, 75.2 per cent identified minor ailments, while 16.6 per cent stated ‘nothing’, and 3.2 per cent ‘everything’. What they needed or wanted from the health services was slated in the open-ended comments as primarily ‘full disclosure’, ‘not being talked down to’, and for specialists especially, for them to be approachable and impart information simply and honestly. Health concerns Health-related concerns were identified by 26.8 per cent of participants. Most these were stated as general healthL-related worries (19 per cent), and the remainder were primarily concerns about increased incapacitation and not knowing where to turn (7.6 per cent). N o significant correlations were found between having concerns and sociodemographic variables; however, the largest group reporting general health concerns were pensioners (20 per cent), followed by those in the largest income bracket (11 Table 2: Frequency of family use of health services over previous 12 months, Belmont, Western Australia, 1994 (n = 126) Service General practitioner General care Medication Prevention (Pap test) Not stated Specialist Specialist treatment Gynaecological Dental Allergies Screening Pathology Hospital General care Surgery Maternity Fractures Psychology Nursing services Community nurse Child health Equipment Psychiatric nurse Occupational health Physiotherapy Equipment Occupational therapy Social worker General School health General Testing Dental Psychologist Preventive services Mammogram lmmunisation Diabetic screening Pap smear Pathology X-ray Unstated Alternative services Herbalist Chiropractor Acupuncturist All of the above Other services Optician Dietitian Reason for service per cent). Those most worried about their health, primarily related to incapacitation, were those with respiratory disease (30 per cent) and cardiac conditions (12.5 per cent). The environment was a concern for 36.3 per cent; this included pollution (21.7 per cent), noise (12.1 per cent) and graffiti (1.3 per cent). Community health and safety was identified as a concern by 38.9 per cent, predominantly in regard to increasing rates of crime (29.3 per cent). AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 VOL. 22 NO. 1 F McMURRAY flA t Older people stated that they worried about a degraded environment being a heritage for their grandchildren. Those who elaborated on specific facets of environmental concern cited ‘too many cars’, or ‘plane noise’, as Belmont is close to the airport. At the conclusion of interviews, people were invited to make comment on any health-related matter. Some stated that they live happily in Belmont (13.4 per cent), while others reinforced the statement that all family members were healthy (12.1 per cent). Several others mentioned issues ranging from the need for more information to the fact that they would like a healthier lifestyle. Most comments about health services (from 42.7 per cent of the sample) were positive; however, the need for more or better services was identified by 11.7 per cent of families, and 2.5 per cent expressed a need for low-cost or free private health care for low-income families. Discussion Health and healthiness in Belmont The way people described ‘health’ was not remarkable in the context of other s t u d i e ~ ;however, the ~~~*~ large proportion declaring their health status as ‘healthy’ or ‘very healthy’ was notable, particularly when a third of the families had a family member with limiting, long-standing illness or disability. This may have reflected their satisfaction with their quality of life and lifestyle, as was found in one Canadian study.12 The Canadian research found that people’s views of healthiness reflected a sense of wellbeing, linked to a psychological state. They concluded that people tend to describe ‘being healthy’ in terms of their ability to maintain their preferred quality of life.“ Our findings revealed few comments about psychological state, but this may have been incorporated in descriptions of ‘feeling good’. A recent review of the literature on personal definitions of health revealed that some people identifji mobility, some identify activity and some, interactions with others.” In some cases, ideas about health are dependent on age,z6psychological f a ~ t o r s , ~sex,31 ’-~~ socioeconomic status,31and ~ u l t u r e . ~ ’ our study, In no significant correlations were found between definitions of health and any of the sociodemographic factors, but it was interesting that both younger and older age groups were equally represented in the 17 per cent of families who identified nutrition and exercise as part of being healthy. This suggests that strategies currently aimed at the young may be as effective in reinforcing existing health beliefs among older people. It was also interesting that a third of families identified the environment as a health concern. Belmont is an established, inner-urban city within metropolitan Perth, which offers, in addition to a wide range of sporting and recreational facilities, a broad range of community health and social services.” However, most people still use private, rather than public transportation, creating considerable air pollution, and Belmont’s close proximity to the airport and rising crime rates2’are also experienced by these peo112 ple as threats to family health. This indicates a need for greater intersectoral collaboration in health promotion campaigns, integrating community services, local council issues (transportation, environment, policing), and those of the wider community with health department programs. Although it was not statistically significant, a relationship was found between family size and perceived level of health, but this may have been a reflection of marital status rather than the number of family members. We found only a modest association between marital status and health rating but this adds weight to the notion that married people tend to report perceptions of better health than singles, although previous research has drawn mixed conclusions.33 Comments on the link between financial resources and health indicated that we should have asked people whether they were privately insured, and this is a limitation of the study. The findings suggest that the cost of such insurance is beyond most families’ financial means. From the modest but positive association between age and health rating, it would appear that younger people enjoy better health; this was borne out in the analysis of health concerns, where a greater number of health concerns and higher rates of service use (with the exception of occupational and school health services) were reported by older people. For households in which the head of the household was aged 65 or over, respondents had used at least one health service in the previous 12 months, which supports prior findings of disproportionate use patterns by the elderly.34 Health guardian That a fifth of males considered themselves the family health guardian, and a large proportion of families considered looking after the family’s health a joint responsibility seems illustrative of the trend toward shared caregiving in young families of the 1990s.35,36 other notable finding was the relative The gender-balanced reporting of both the demands and satisfaction of the role of health guardian. This indicates a need for health promotion materials (brochures, posters, pamphlets) that depict a better gender balance than currently. Although women continue to be overrepresented as family caregivers for the elderly,37 findings indicate that things are the changing. Respite services, which have to date attempted to attract female caregivers, may need to make a special effort to ensure access for males. Patterns o use o health services f f Approximately 80 per cent of families had used one or more health services during the previous 12 months, and it appeared that most were familiar with existing services and were satisfied customers. People in extended or other relationships were more likely to have used a health service in the past 12 months than those living alone, but this may have been related to having children, particularly with the finding that one- and two-parent families represented 71 per cent of all visits to general practitioners. This indicates a need for further research on VOL. AUSTRALIAN AND N W ZEALAND JOURNAL O PUBLIC HEALTH 1998 E F 22 NO. 1 FAMILY HEALTH IN BELMONT single dwellers, in that they may have unmet needs that are not revealed in surveys of service use. There is also a need to investigate the differences between two-parent and one-parent families’ use of the emergency department and general practitioners when their children need medical care. Another issue for further research is related to the immunisation debate. We found a disproportionate use of immunisation services between one- and two-parent families, with two-parent families reporting more use of immunisa tion services. Further research with a larger sample size may shed some light on whether this is a typical pattern or an artefact of the sample. Comments on what was needed from health care providers were similar to those in other studies. Lloyd et al. found that bedside manners and caring attitudes were most i m p ~ r t a n t ; ’other Australian ~ studies reveal that what people need most is better health i n f o r m a t i ~ n Our participants generally .~~~ were familiar with services, but their comments focused om communication style. They wanted ‘full disclosure’ and ‘to not be talked down to’, especially by specialists. This issue has been identified in studies of differing perceptions of doctors and patients with the conclusion that medical practitioners must recognise communication problems as a serious threat to desired This supports a need for greater awareness of the problem among the medical community and in those preparing curricula for medical s t ~ d e n t s . ~ ~ . ~ ~ planning and, therefore, efficient distribution of resources.5o Acknowledgments The authors would like to acknowledge the Public and Community Health Unit, East Metropolitan Health Area, Health Department of Western Australia, for providing the financial assistance for the research, and members of the Belmont community, especially Dr Pradeep Jayasuriya and the Belmont City Council for their assistance in promoting the study.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Jan 1, 1998

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