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UBC Theses and Dissertations

The impact of a preventive health care program for older people on health status, knowledge and costs Pickard, Lynette Elizabeth 1979

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THE  IMPACT OF A PREVENTIVE HEALTH CARE PROGRAM  FOR OLDER PEOPLE ON HEALTH STATUS, KNOWLEDGE AND COSTS  by  9 1 LYNETTE ELIZABETH PICKARD N a t i o n a l Diploma i n O c c u p a t i o n a l Therapy P r e t o r i a C o l l e g e o f O c c u p a t i o n a l Therapy, South A f r i c a , 1967 B.Sc. ( O c c u p a t i o n a l Therapy) U n i v e r s i t y o f Western O n t a r i o , 1975  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  in THE FACULTY OF GRADUATE STUDIES (Department of A d u l t  We accept  Education)  t h i s t h e s i s as conforming  to the r e q u i r e d s t a n d a r d  THE UNIVERSITY OF BRITISH COLUMBIA September  Q  1979  L y n e t t e E l i z a b e t h P i c k a r d , 1979  In p r e s e n t i n g t h i s  thesis in partial  an a d v a n c e d d e g r e e a t the L i b r a r y I further for  shall  the U n i v e r s i t y  make i t  agree that  freely  this  thesis for  It  Department of  f i n a n c i a l gain shall  Adutt  &d^.c#Jio«  The U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , Canada V6T 1W5  BP  75-51  1 E  I agree  r e f e r e n c e and copying of  this  that  not  copying or  for  that  study. thesis  by t h e Head o f my D e p a r t m e n t  i s understood  permission.  the requirements  B r i t i s h Columbia,  extensive  s c h o l a r l y p u r p o s e s may be g r a n t e d  written  DE-6  of  available for  permission for  by h i s r e p r e s e n t a t i v e s . of  f u l f i l m e n t of  or  publication  be a l l o w e d w i t h o u t  my  ABSTRACT  The who  purpose of t h i s study was  received preventive nursing  s i z e d h e a l t h promotion (through  to t e s t the c l a i m t h a t s e n i o r  citizens  s e r v i c e s which were a c c e s s i b l e and h e a l t h education,  d e t e c t i o n of d i s e a s e ) would have s i g n i f i c a n t l y  c o u n s e l l i n g and  emphaearly  lower h e a l t h c o s t s and  f i c a n t l y g r e a t e r h e a l t h s t a t u s , knowledge and b e h a v i o u r than those r e c e i v e d n u r s i n g s e r v i c e s which were l e s s a c c e s s i b l e and emphasis on h e a l t h Residents End  study.  who  less  promotion.  of two  of Vancouver  placed  apartment complexes f o r s e n i o r c i t i z e n s i n the West  (Nicholson  and  Sunset Towers) were p a r t i c i p a n t s i n t h i s  The main d i f f e r e n c e s between the n u r s i n g programs i n these  two  complexes are the i n c r e a s e d a c c e s s i b i l i t y of the nurses i n N i c h o l s o n and  signi-  the g r e a t e r amount of h e a l t h e d u c a t i o n  and  Towers  c o u n s e l l i n g which i s done  there. A sample of i n d i v i d u a l s from each complex was interviewing.  randomly s e l e c t e d f o r  Data c o l l e c t e d from r e s i d e n t s i n a s t r u c t u r e d  interview  measured h e a l t h knowledge, h e a l t h b e h a v i o u r , h e a l t h s t a t u s and i d e n t i f i e d i n the l i t e r a t u r e as r e l a t e d to h e a l t h knowledge and status.  The M e d i c a l  on number and  S e r v i c e s P l a n of B.C.  c o s t of h e a l t h s e r v i c e s and  i n the study over an e i g h t month p e r i o d .  and  variables health  Pharmacare s u p p l i e d  c o s t of m e d i c a t i o n  data  for individuals  Data were computer analyzed  using  the U n i v e r s i t y of B r i t i s h Columbia's v e r s i o n of SPSS. Results  of the study i n d i c a t e d t h a t average h e a l t h c o s t s were not  s i g n i f i c a n t l y lower i n the b u i l d i n g i n which p r e v e n t i v e n u r s i n g  services  - i i i-  were a v a i l a b l e .  P o s s i b l e reasons f o r t h i s unexpected f i n d i n g a r e t h a t  Home Care n u r s i n g s e r v i c e s a r e c o s t l y , Home Care n u r s i n g s e r v i c e s l e a d s c o s t s , t h a t the a b i l i t y by  the aging  prevention  process  that increased  to i n c r e a s e d u t i l i z a t i o n and i n c r e a s e d  to b r i n g about improvement i n h e a l t h i s l i m i t e d  and t h a t we may have u n r e a l i s t i c  expectations of  programs.  Residents  of N i c h o l s o n  Towers (who r e c e i v e d p r e v e n t i v e  were found t o have s i g n i f i c a n t l y  account f o r the s i g n i f i c a n t l y complex.  The s o c i a l  and low content  significant  f u n c t i o n than  nursing s e r v i c e s ) .  Towers has a s i g n i f i c a n t l y  s m a l l e r percentage o f r e s i d e n t s e l i g i b l e f o r Long Term Care.  bility  services)  f o r Long Term Care accounts f o r a l a r g e percentage of v a r i a n c e  i n p h y s i c a l f u n c t i o n and N i c h o l s o n  this  nursing  g r e a t e r p h y s i c a l and s o c i a l  those i n Sunset Towers (who d i d not r e c e i v e p r e v e n t i v e Eligibility  a c c e s s i b i l i t y of  (34% v s . 39%) This  greater p h y s i c a l function of residents i n  f u n c t i o n s c a l e evidenced low ( . 4 3 )  and convergent v a l i d i t y .  Findings  alpha  Findings  relia-  r e g a r d i n g the  d i f f e r e n c e s between t h e complexes i n terms of s o c i a l  are t h e r e f o r e  could  function  tenuous. regarding health education  i n both complexes support the  c o n c l u s i o n t h a t t h e r e c o u l d be g r e a t e r use of group methods and techniques of i n s t r u c t i o n . efficiency  This i s l i k e l y  of health  education.  to i n c r e a s e both t h e e f f e c t i v e n e s s and  — iv -  TABLE OF CONTENTS  ABSTRACT  i i  LIST OF TABLES  v i i  LIST OF FIGURES  viii  ACKNOWLEDGMENTS  ix  Chapter I.  II.  INTRODUCTION  1  THE EROBLEM  1  Changing Emphases i n the Health Care System Expenditures on H e a l t h o f O l d e r People A l t e r n a t e Forms o f H e a l t h Care D e l i v e r y f o r O l d e r People E f f e c t i v e n e s s and C o s t - B e n e f i t P o t e n t i a l o f V a r i o u s Health S t r a t e g i e s Summary o f Problem PURPOSE OF THE STUDY  1 4  REVIEW OF LITERATURE PREVENTIVE HEALTH CARE HEALTH EDUCATION Research and Theory From R e l a t e d F i e l d s Germane to H e a l t h E d u c a t i o n Cultural studies Sociological studies Social-psychological studies Multidisciplinary studies Studies on diffusion of innovations Adult education studies Participation studies Methods, Techniques and Devices i n H e a l t h E d u c a t i o n . E f f e c t i v e n e s s and C o s t - B e n e f i t P o t e n t i a l of H e a l t h Education EASE AND QUALITY OF CONTACT WITH HEALTH PROFESSIONALS .. MEASUREMENT OF HEALTH C l a s s i f i c a t i o n of H e a l t h Status I n d i c e s M o r t a l i t y Based I n d i c e s M o r b i d i t y Based I n d i c e s U n i f i e d M o r t a l i t y / M o r b i d i t y Indices SUMMARY OF LITERATURE REVIEW IMPLICATIONS FOR RESEARCH  6 9 12 14 16 16 20 21 22 22 24 25 25 26 27 28 29 32 35 36 36 36 38 40 41  -  V -  Chapter III.  METHODOLOGY  43  SETTING OF STUDY PURPOSE OF STUDY HYPOTHESES DIFFERENCES BETWEEN NURSING SERVICES Accessibility Health Education C o u n s e l l i n g ,. SAMPLING DATA COLLECTION Introduction Data from Home Care Nurses Data from M e d i c a l S e r v i c e s P l a n and Pharmacare ... Data from R e s i d e n t s  Health knowledge Sources of health Health behaviours Perceived benefit Variables related health status, Health status  57 57 58 58  information of nurses to health  knowledge and  Development o f the H e a l t h Knowledge S c a l e A d a p t a t i o n of the P h y s i c a l F u n c t i o n S c a l e A d a p t a t i o n o f the Emotional F u n c t i o n S c a l e A d a p t a t i o n of the S o c i a l F u n c t i o n S c a l e RELATIONSHIPS INVESTIGATED IN THE STUDY ANALYSIS OF DATA IV.  43 44 44 46 47 48 50 50 52 52 55 56 56  RESULTS INTRODUCTION SCALES DEVELOPED FOR THE STUDY R e l i a b i l i t i e s o f H e a l t h F u n c t i o n and H e a l t h Knowledge S c a l e s V a l i d i t i e s o f H e a l t h Function:;and. Health! Knowledge Scales TESTS OF HYPOTHESES DIFFERENCES BETWEEN APARTMENT COMPLEXES N u r s i n g Programs B i o g r a p h i c a l Data B e n e f i t s of Programs Number of H e a l t h R e l a t e d V i s i t s Average Costs of H e a l t h S e r v i c e s Sources of H e a l t h I n f o r m a t i o n S e t t i n g i n which H e a l t h I n f o r m a t i o n i s Learned ... H e a l t h Behaviour PREDICTORS OF PHYSICAL, EMOTIONAL AND SOCIAL FUNCTION PREDICTORS OF HEALTH COSTS AND NUMBERS OF HEALTH RELATED VISITS .  58 59 59 61 62 64 65 65 68 68 68 69 72 75 78 78 79 79 80 80 81 83 83 84 87  - vi-  Chapter DIFFERENCES BETWEEN RESIDENTS RECEIVING DIFFERENT LEVELS OF NURSING SERVICE V.  SUMMARY, DISCUSSION OF RESULTS, RECOMMENDATIONS AND CONCLUSIONS SUMMARY OF STUDY IMPLICATIONS OF FINDINGS I m p l i c a t i o n s of F i n d i n g s on Costs o f H e a l t h Care ,. I m p l i c a t i o n s o f F i n d i n g s on H e a l t h Status I m p l i c a t i o n s of F i n d i n g s on H e a l t h E d u c a t i o n Program P l a n n i n g f o r H e a l t h E d u c a t i o n i n Dense Residential Settings RECOMMENDATIONS CONCLUSION  94  96 96 103 103 107 109 110 117 119  REFERENCES  122  APPENDIX  129  - vii -  LIST OF TABLES  1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.  Canada-Wide I n c r e a s e i n Numbers of Persons Aged 65 and Over Canada-Wide P r o j e c t i o n s of Numbers of Persons Aged 65 and Over T o p i c s Examined i n L i t e r a t u r e Review Comparison of Expected Costs and B e n e f i t s of N u r s i n g Programs.. H e a l t h Comparisons of Two R e s i d e n t i a l Groups V a r i a b l e s Measured and Method of Measurement H e a l t h Knowledge Questions C o r r e l a t i o n C o e f f i c i e n t s f o r I n d i v i d u a l Items w i t h H e a l t h Scales C o r r e l a t i o n s Among H e a l t h F u n c t i o n and H e a l t h Knowledge S c a l e s . A n a l y s i s of V a r i a n c e Between Complexes and Between L e v e l s of N u r s i n g S e r v i c e A n a l y s i s of V a r i a n c e of Sources of H e a l t h I n f o r m a t i o n V a r i a n c e i n P h y s i c a l , Emotional and S o c i a l F u n c t i o n Accounted f o r by B i o g r a p h i c a l and H e a l t h Status V a r i a b l e s V a r i a n c e i n H e a l t h Care C o s t s Accounted f o r by B i o g r a p h i c a l and H e a l t h S t a t u s V a r i a b l e s P r e d i c t i o n C o e f f i c i e n t s (Beta) f o r H e a l t h Costs f o r 16 Variables P r e d i c t i o n C o e f f i c i e n t s (Beta) f o r Numbers of H e a l t h R e l a t e d V i s i t s f o r 16 V a r i a b l e s Most E f f e c t i v e Methods and Techniques f o r A c q u i r i n g and A p p l y i n g Knowledge and S k i l l s  4 5 16 51 53 54 60 63 74 77 82 85 89 90 91 114  - viii  -  LIST OF FIGURES  1.  2.  P o l i c y Implications f o r Health Strategies C l a s s i f i e d A c c o r d i n g to E f f e c t i v e n e s s and C o s t - B e n e f i t Potential R e l a t i o n s h i p s I n v e s t i g a t e d i n the Study  10 66  ACKNOWLEDGEMENTS  Many, people a s s i s t e d w i t h t h i s study and P a r t i c i p a n t s i n t h i s study were 124 Towers i n the West End of Vancouver.  I wish  to thank them a l l .  r e s i d e n t s of N i c h o l s o n and  Without  Sunset  t h e i r w i l l i n g n e s s to be  i n t e r v i e w e d , the study would not have been p o s s i b l e .  Dr. L a r r y Chambers,  of MacMaster U n i v e r s i t y , p r o v i d e d v a l u a b l e i n f o r m a t i o n on the h e a l t h s t a t u s q u e s t i o n n a i r e used  i n t h i s study.  Home Care n u r s e s , gave me of  Yvonne L e e - R e i l l y and Ruth McDonald,  a g r e a t d e a l of a s s i s t a n c e w i t h p r a c t i c a l a s p e c t s  c o n d u c t i n g the s t u d y . Anne-Marie L a f l e u r , o f the B.C.  statistical  Housing Management Commission,  i n f o r m a t i o n on r e s i d e n t s of the two  Parker, of the B.C.  complexes.  Mrs.  compiled  Joanne  M e d i c a l S e r v i c e s Commission, compiled d a t a on c o s t s  of h e a l t h s e r v i c e s ;  and Mr.  Pat T i d b a l l ,  of Pharmacare, p r o v i d e d d a t a on  c o s t s of m e d i c a t i o n . Dr. Annette  S t a r k and Dr. Dale R u s n e l l , members of my  thesis  a s s i s t e d w i t h the d e s i g n of the study and c r i t i c a l l y reviewed d r a f t s of the t h e s i s .  Dr. John C o l l i n s , my  the study w i t h wisdom and f o r e s i g h t .  committee,  the v a r i o u s  r e s e a r c h s u p e r v i s o r , guided  H i s e x p e r t i s e i n r e s e a r c h methodology,  s t a t i s t i c s , computing and instrument d e s i g n were i n v a l u a b l e i n the study. He responded  to my  need, a t times, f o r support and encouragement;  and h i s  warmth, u n d e r s t a n d i n g , p a t i e n c e and humour h e l p e d make the task an e n j o y a b l e one. M a r i l y n E r n e s t assured me a b l e to w r i t e a t h e s i s ;  a t the b e g i n n i n g o f 1977  t h a t I would be  and my mother and f a t h e r p r o v i d e d s u p p o r t  encouragement from a l o n g d i s t a n c e away.  and  - 1 -  CHAPTER 1  INTRODUCTION THE PROBLEM The purpose who received emphasized early and  preventive health  detection  services  (through would  greater  health  nursing  on health  was to test  nursing  of disease)  who received emphasis  study  promotion  significantly  those less  of this  the claim  which  health  services  which  senior  were accessible  education,  have- significantly status,  that  and  counselling lower  knowledge  and  health  and behaviour  were less  citizens  accessible  costs than  and  placed  promotion.  Changing Emphases i n the H e a l t h  Care System  Changes i n knowledge o f the epidemiology o f d i s e a s e , i n the i n c i d e n c e of i n f e c t i o u s d i s e a s e s , i n s o c i a l and e n v i r o n m e n t a l c o n d i t i o n s , i n p u b l i c h e a l t h p r a c t i c e s and i n p u b l i c o p i n i o n have r e s u l t e d i n changing emphases i n the h e a l t h care system.  Health education  aimed a t m o d i f y i n g  presumed to be d e l e t e r i o u s t o h e a l t h and thereby  improving  behaviours  health, i s  receiving increasing attention. R i s i n g standards diseases  o f l i v i n g and i n c r e a s e d c o n t r o l over i n f e c t i o u s  s i n c e the b e g i n n i n g  of t h i s century  i n f a t a l i t y from i n f e c t i o u s d i s e a s e s the p r e v a l e n c e  have r e s u l t e d i n r e d u c t i o n s  throughout the w o r l d .  o f c h r o n i c d i s e a s e has i n c r e a s e d .  problems a r e s e l f - i n f l i c t e d  o r s o c i a l l y induced.  In c o n t r a s t ,  Many modern h e a l t h During  1971, the f i v e  major f a c t o r s r e s p o n s i b l e f o r reduced l i f e expectancy o f Canadians were motor v e h i c l e a c c i d e n t s , i s c h a e m i c  heart  disease, a l l other  accidents,  - 2 -  r e s p i r a t o r y d i s e a s e and l u n g cancer, and s u i c i d e .  These accounted f o r  213,000, 193,000, 179,000, 140,000 and 69,000 y e a r s r e s p e c t i v e l y t h a t were l o s t from a l i f e  expectance o f seventy  years  (which f o r Canada's p o p u l a t i o n  of 23 m i l l i o n r e p r e s e n t s 1.6 b i l l i o n man y e a r s ) A v a s t amount o f money i s spent been prevented.  (Lalonde,  t r e a t i n g d i s e a s e s which s h o u l d have  M i l l i o n s of d o l l a r s a r e spent  a n n u a l l y t r e a t i n g people  have been i n motor v e h i c l e a c c i d e n t s , who have ischaemic lung cancer.  1974).  h e a r t d i s e a s e and  A v e r y s m a l l p r o p o r t i o n of the h e a l t h budget i s a l l o c a t e d t o  r e s e a r c h and programs aimed a t e l i m i n a t i n g the causes o f these and  diseases.  However, t h i s s i t u a t i o n i s changing;  Governments have s t a r t e d a l l o c a t i n g g r e a t e r r e s o u r c e s and  who  disabilities  F e d e r a l and P r o v i n c i a l toward such r e s e a r c h  programs. The World H e a l t h O r g a n i z a t i o n s t a t e s that "Health i s a s t a t e o f  complete p h y s i c a l , mental and s o c i a l w e l l b e i n g and n o t merely t h e absence of d i s e a s e and i n f i r m i t y . "  (World  H e a l t h O r g a n i z a t i o n , 1958, p.459).  The  World H e a l t h O r g a n i z a t i o n i n t e n d s f a c t o r s which c o n t r i b u t e t o h e a l t h t o be viewed v e r y b r o a d l y .  When examined from the p e r s p e c t i v e of t h i s  d e f i n i t i o n , h e a l t h care systems seem inadequate  and i n e f f e c t i v e .  Medical  s e r v i c e s c o n s t i t u t e o n l y one o f the many f a c t o r s which c o n t r i b u t e t o health.  At any one time m e d i c a l  f i v e p e r cent of the p o p u l a t i o n  and n u r s i n g s e r v i c e s a r e r e q u i r e d by only (McPhee, 1977).  In s p i t e o f these  h e a l t h care systems have emphasized h o s p i t a l s , acute illness.  care and treatment of  S e r v i c e s have been t e c h n o l o g i c a l l y o r i e n t e d , o f f e r i n g  solutions to s p e c i f i c  facts,  specific  problems.  Costs o f h e a l t h care i n Canada have e s c a l a t e d i n r e c e n t y e a r s . c o s t s now comprise a s u b s t a n t i a l p r o p o r t i o n of the Gross N a t i o n a l and  of personal expenditures.  In 1973 t o t a l h e a l t h e x p e n d i t u r e s  Health  Product absorbed  - 3 -  6.9  per cent of the Gross N a t i o n a l Product.  average percentage 11 per cent greatest  i n c r e a s e i n t o t a l h e a l t h e x p e n d i t u r e s was  (National Health-Expenditures  Expenditures  dollars  1973,  the  approximately  i n Canada, 1975).  By f a r the  on i n s t i t u t i o n a l care i n 1973  amounted to  (52 per cent of t o t a l h e a l t h e x p e n d i t u r e s ) .  on General and A l l i e d f o r 3.2  and  (and most r a p i d l y r i s i n g ) c o s t s are those a s s o c i a t e d w i t h o p e r a t i n g  hospitals. billion  Between 1970  billion  Expenditures  S p e c i a l h o s p i t a l s (acute care f a c i l i t i e s )  of t h i s 4.3  b i l l i o n dollars  4.3  (Rombout, 1975).  accounted  Costs  related  to p h y s i c i a n s ' s e r v i c e s c o n s t i t u t e the second l a r g e s t element i n c o s t s (Robertson,  1973).  The number of h e a l t h problems which are s e l f - i n f l i c t e d induced,  or  i n c r e a s e d p r e v a l e n c e of c h r o n i c d i s e a s e s and e s c a l a t i o n of h e a l t h  care c o s t s , have l e d to government r e c o g n i t i o n t h a t a l e s s approach to h e a l t h care i s e s s e n t i a l .  expensive  F e d e r a l and P r o v i n c i a l Governments  have r e a l i z e d t h a t t h e r e should be an emphasis on promoting and h e a l t h r a t h e r than on treatment e d u c a t i o n aimed at changing thereby  socially  improving  of d i s e a s e and  behaviours  disability.  which are harmful  h e a l t h , i s consequently  maintaining  Health  to h e a l t h and  receiving increasing attention.  Demographic changes, i n p a r t i c u l a r the i n c r e a s i n g p r o p o r t i o n of e l d e r l y people education.  i n the p o p u l a t i o n , have l e d to new  S o c i a l changes have a l s o had  I n c r e a s i n g complexity first  implications f o r health education.  s o p h i s t i c a t i o n of m e d i c a l p r a c t i c e d u r i n g  h a l f of t h i s c e n t u r y l e d to i n c r e a s e d dependence on  i n t e r v e n t i o n and and  and  areas of f o c u s f o r h e a l t h  decreased  responsibility.  less subservient. i n f l i c t e d has  the  medical  emphasis on i n d i v i d u a l h e a l t h care management  In r e c e n t y e a r s , however, consumers have become f a r The  g r e a t e r awareness t h a t many h e a l t h problems are  l e d to the r e a l i z a t i o n t h a t h e a l t h i s l a r g e l y an  self-  individual  responsibility.  Individual r e s p o n s i b i l i t y f o r health implies  h e a l t h f u l behaviours;  and hence h e a l t h e d u c a t i o n .  An emphasis on promoting e d u c a t i o n has  learning  and m a i n t a i n i n g h e a l t h through h e a l t h  r e s u l t e d from s o c i a l , environmental and demographic  changes,  and changes i n the epidemiology o f d i s e a s e , i n p u b l i c h e a l t h p r a c t i c e s in public opinion. people;  and  Health education i s i n c r e a s i n g l y d i r e c t e d at healthy  p a r t i c u l a r l y a t p o p u l a t i o n s whose socio-demographic  b e h a v i o u r a l c h a r a c t e r i s t i c s suggest t h a t they a r e a t r i s k  and  ( R i c h a r d s , 1975).  E x p e n d i t u r e s on H e a l t h of O l d e r People A l a r g e p r o p o r t i o n of h e a l t h s e r v i c e s i s consumed by o l d e r p e o p l e . Many of these s e r v i c e s are the most expensive of the government f i n a n c e d s e r v i c e s , e.g. h o s p i t a l c a r e . c a l c u l a t e d by combining data.  H o s p i t a l i z a t i o n u t i l i z a t i o n r a t e s are  General H o s p i t a l morbidity data with p o p u l a t i o n  H o s p i t a l i z a t i o n u t i l i z a t i o n r a t e s are expressed i n the form of  " p a t i e n t days per person per y e a r " . whole, an average of 1.9  In 1971,  days per person was  For people aged 65 and over, the average was people aged 75 and over i t was  12.4  f o r the p o p u l a t i o n as a spent i n h o s p i t a l t h a t y e a r . 8.3  days per person;  days per p e r s o n .  In 1971  35 per cent  of a l l p a t i e n t days i n G e n e r a l and A l l i e d S p e c i a l h o s p i t a l s was by people aged 65 and over; of the p o p u l a t i o n (Rombout, S i n c e the 1961  census  y e t t h i s group  for  comprised o n l y 8.1  required per cent  1975). t h e r e has been a s u b s t a n t i a l i n c r e a s e i n the  number of people aged 65 and over i n the p o p u l a t i o n .  Only O n t a r i o  and Quebec have h i g h e r a c t u a l numbers of e l d e r l y people i n the p o p u l a t i o n than B r i t i s h Columbia.  In 1971  the p r o p o r t i o n s of e l d e r l y  people were h i g h e r i n t h r e e o t h e r p r o v i n c e s than i n B r i t i s h b u t a c c o r d i n g to S t a t i s t i c s Canada p r o j e c t i o n s , the  Columbia;  proportion  - 5 -  of e l d e r l y people i n B r i t i s h Columbia w i l l equal in  the Canadian  proportion  1986.  TABLE 1 CANADA WIDE INCREASE IN THE NUMBERS OF PERSONS AGED 65 AND OVER  1,086,400 1,744,410 2,002,345  1961 1971 1976  SOURCES:  The  P o p u l a t i o n Age P o p u l a t i o n Age  c h i e f l y to h i g h b i r t h and  7.7 8.1 8.7  Groups. Groups.  increase i n population  and  1971 1976  i n l i f e expectancy i s a t t r i b u t a b l e  (which a f f e c t s younger age  for  and  proportion  supporting  ago,  to advances i n h e a l t h c a r e .  i n c r e a s i n g p r o p o r t i o n of e l d e r l y p e o p l e . a decreasing  Census of Canada. Census of Canada.  immigration r a t e s some years  socio-economic c o n d i t i o n s and the b i r t h r a t e  Percentage of population  Persons 65 and over  Year  to improved The  decline in  groups) p a r t l y accounts f o r the I f low  fertility  rates  continue,  of working people w i l l be r e s p o n s i b l e f o r c a r i n g  these i n c r e a s i n g numbers of o l d e r people  (Weaver, et a l . ,  1975). Although the r a t e of i n c r e a s e i n the e l d e r l y p o p u l a t i o n to d e c l i n e a f t e r 1986, century.  In 1986,  almost f i f t y  per  t o t a l increases w i l l continue  until  than i n  on the h e a l t h of o l d e r p e o p l e .  h o s p i t a l i z a t i o n and  of  over w i l l  the be  1971.  I n c r e a s i n g numbers of o l d e r people w i l l n e c e s s i t a t e expenditure  the end  the number of people aged s i x t y - f i v e and  cent h i g h e r  i s expected  d i s t r i b u t i o n of d i s e a s e  I f 1971  increased  patterns  continue,  42.5  of  per cent  of a l l  - 6 -  p a t i e n t days w i l l be u t i l i z e d by the e l d e r l y i n 2001.  The major causes of  h o s p i t a l i z a t i o n f o r the e l d e r l y a r e o f a c h r o n i c n a t u r e .  Acute c a r e  f a c i l i t i e s a r e thus not the most e f f e c t i v e way o f meeting h e a l t h of t h i s age group. health  Older people would a l s o p r o b a b l y p r e f e r t o r e c e i v e  s e r v i c e s a t home (Rombout, 1975).  people, t h e i r d i s p r o p o r t i o n a t e  c o n d i t i o n s , make i t i m p e r a t i v e  Increasing  numbers o f e l d e r l y  consumption o f the most expensive forms o f  h e a l t h s e r v i c e s and t h e i r need f o r h e a l t h  eliminated  c a r e needs  services r e l a t e d to chronic  t h a t unnecessary i n s t i t u t i o n a l care be  and a l t e r n a t e forms o f h e a l t h  c a r e d e l i v e r y be  explored.  TABLE 2 CANADA WIDE PROJECTIONS OF NUMBERS OF PERSONS AGED 65 AND OVER  Year  1986 1990 2001  SOURCE:  Percentage o f population  Persons 65 and over 2,600,000 3,000,000 3,300,000  9.8 11.4 11.6  P r o j e c t i o n s f o r Canada and the P r o v i n c e s , S t a t i s t i c s Canada, 1976.  1976-2001  A l t e r n a t e Forms o f H e a l t h Care D e l i v e r y f o r Older People Approximately 85 per cent o f i n d i v i d u a l s over 65 a r e a b l e i n d e p e n d e n t l y without s p e c i a l s o c i a l or h e a l t h r e q u i r e some type of h e a l t h  services;  services or s o c i a l services  to l i v e  10 p e r cent (such as Home  Care, home-makers or Meals-on-Wheels) i n o r d e r t o remain i n the community; 5 per cent a r e i n s t i t u t i o n a l i z e d  (McDonell, 1972).  s e r v i c e s f o r the e l d e r l y have p r o v i d e d care.  Community  health  an a l t e r n a t i v e t o expensive h o s p i t a l  These s e r v i c e s have, however, been c h i e f l y c u s t o d i a l or c u r a t i v e  - 7 -  oriented.  They have f o c u s e d v e r y l i t t l e  has been g i v e n t o the promotion  on p r e v e n t i o n .  Little  attention  and maintenance o f the h e a l t h of those who  are l i v i n g i n d e p e n d e n t l y and who do not r e q u i r e s p e c i a l h e a l t h s e r v i c e s . However, promotion  o f h e a l t h i n o l d e r people i n v o l v e s more than  of acute and c h r o n i c d i s e a s e s . decreased mental  P r e v e n t i n g a c c i d e n t s , poor  treatment  nutrition,  and p h y s i c a l a c t i v i t y and f e e l i n g s o f i s o l a t i o n a r e a l l  important a s p e c t s of h e a l t h  promotion.  H e a l t h e d u c a t i o n i s o f c e n t r a l importance maintenance o f h e a l t h of o l d e r p e o p l e .  i n the promotion and  O l d e r people may have a c q u i r e d l e s s  h e a l t h i n f o r m a t i o n from the media than young p e o p l e , may be more h e s i t a n t to ask q u e s t i o n s and may b e l i e v e more " o l d wives t a l e s " 1975).  (Weaver, e t a l . ,  E d u c a t i o n r e g a r d i n g n u t r i t i o n , m e d i c a t i o n s , a c c i d e n t s and c o n t r o l  of c h r o n i c d i s e a s e s (such as d i a b e t e s and h y p e r t e n s i o n ) i s p a r t i c u l a r l y important. S t u d i e s o f m e d i c a t i o n use by the e l d e r l y have r e v e a l e d t h a t they knowledge i n c e r t a i n areas.  Drug nomenclature  n a t u r e o f drug s i d e e f f e c t s , how drugs  and r a t i o n a l e f o r use, the  should be a d m i n i s t e r e d i n o r d e r t o  be e f f e c t i v e , proper dosage regimens and hazards a s s o c i a t e d w i t h and l e n d i n g m e d i c a t i o n s , a r e a l l areas whose importance recognized  lack  borrowing  i s not f u l l y  ( P l a n t , 1977).  A study o f the n u t r i t i o n a l p r a c t i c e s o f the e l d e r l y found l a c k of knowledge t o be the b a s i c problem  i n those w i t h poor n u t r i t i o n a l  (Cambridgeshire, D i a b e t i c Dept., 1966).  D i a b e t e s , h y p e r t e n s i o n and  coronary h e a r t d i s e a s e a r e p r e v a l e n t among the aged. illnesses, diet  i s an important  practices  In a l l o f these  f a c t o r i n the promotion  and maintenance o f  health.  A c c i d e n t s a r e a major cause o f i n j u r y and death among  elderly  people.  Home s a f e t y e d u c a t i o n programs have been shown t o improve the  - 8 -  p r a c t i c e of home s a f e t y and  to decrease  the numbers of a c c i d e n t s  (Steckler,  1973). Gradual d e t e r i o r a t i o n accompanies the aging p r o c e s s ;  86 per cent of  e l d e r l y people have c h r o n i c d i s e a s e s which r e q u i r e augmented maintenance s k i l l s .  With d i s e a s e s such as d i a b e t e s and  self-  coronary h e a r t  d i s e a s e , knowledge of v a r i o u s a s p e c t s of the d i s e a s e can reduce t i o n s and promote h e a l t h .  complica-  In order to manage d i a b e t e s e f f e c t i v e l y ,  d i a b e t i c person r e q u i r e s good u n d e r s t a n d i n g  of the d i s e a s e , the  the  technique  of i n s u l i n i n j e c t i o n , u r i n e t e s t i n g , p r e v e n t i o n of k e t o a c i d o s i s , p r e v e n t i o n and management of hypoglycemia  and d i e t  (Stone, 1961;  Beaser,  H o s p i t a l i z a t i o n r a t e s and acute c o m p l i c a t i o n s have been found significantly  (from more than 500  year to l e s s than 100  admissions  1956). to  decrease  f o r d i a b e t i c k e t o a c i d o s i s per  per year over a seven year p e r i o d ) when e d u c a t i o n i s  p a r t of a comprehensive improvement i n the c l i n i c a l management of d i a b e t e s (Graber, et a l , 1977). E a r l y d e t e c t i o n of h e a l t h problems i s another aspect of p r e v e n t i o n which i s e s p e c i a l l y important  i n o l d e r people.  S e l f - r e p o r t i n g of  by the e l d e r l y t o the d o c t o r i s an u n s a t i s f a c t o r y way at an e a r l y s t a g e .  illness  of d e t e c t i n g i l l n e s s  At a c e n t r e e s t a b l i s h e d f o r examining  people who  are  over 55 and had no c o m p l a i n t s , many people were found by h e a l t h p e r s o n n e l to be i n need of s e r v i c e s they were not r e c e i v i n g .  Older people  tend not  to r e p o r t i l l n e s s e s to t h e i r d o c t o r s or not t o r e p o r t to d o c t o r s u n t i l l a t e stage i n the i l l n e s s . (Anderson,  The  reason f o r t h i s may  be d e n i a l of  illness  1976), or c o n f u s i o n of symptoms a t t r i b u t e d to the aging  w i t h symptoms of d i s e a s e ( W i l l i a m s o n , 1966). demonstrated t h a t when an o l d person was he d i d i n f o r m the d o c t o r ;  process  W i l l i a m s o n et a l . (1964)  c e r t a i n t h a t a d i s e a s e was  the d o c t o r was,  a  present,  however, o f t e n not c o n s u l t e d f o r  - 9 c o n d i t i o n s such as anaemia.  E f f e c t i v e n e s s and of V a r i o u s H e a l t h Preventive  s t r a t e g i e s are aimed a t r e d u c i n g  promoting h e a l t h . preventive  Cost-Benefit P o t e n t i a l Strategies  Recent i n c r e a s e d  s t r a t e g i e s has  r e s u l t e d i n the development of some i n n o v a t i v e and  e a r l y d e t e c t i o n of  disease.  would a n t i c i p a t e such programs to be more e f f e c t i v e at promoting  maintaining  h e a l t h and  reducing  c o s t s than those which are p u r e l y  However, h e a l t h s t r a t e g i e s vary payoff  i n c o s t - b e n e f i t terms.  limited.  b e n e f i t terms w i l l be  populations  cost-benefit potential.  payoff  f o r Health  Cost-Benefit  Strategies  first  i n cost-  Classified  P o t e n t i a l , Green (1978)  to t h e i r known e f f e c t i v e n e s s  He p l a c e s s t r a t e g i e s i n t o one  payoff  low,  e f f e c t i v e n e s s of methods and  payoff  are h i g h .  In  S t r a t e g i e s where e f f e c t i v e -  are i n quadrant IV. p o t e n t i a l payoff  and  of f o u r p o l i c y  to recommended investment of r e s o u r c e s ) .  quadrant I e f f e c t i v e n e s s and ness i s h i g h , but  d i r e c t e d i n the  are  greatest.  to E f f e c t i v e n e s s and  (according  be  where impact and  c l a s s i f i e s health strategies according  categories  curative.  Resources a v a i l a b l e f o r h e a l t h programs  In F i g u r e 1, P o l i c y I m p l i c a t i o n s According  and  i n terms of e f f e c t i v e n e s s and p o t e n t i a l  I t i s thus e s s e n t i a l t h a t r e s o u r c e s  i n s t a n c e at problems and  and  awareness of the importance of  programs which emphasize h e a l t h e d u c a t i o n One  c o s t s of h e a l t h c a r e  In quadrant I I I  are h i g h .  Examples of  s t r a t e g i e s i n t h i s quadrant i n c l u d e those aimed at smoking c e s s a t i o n , c o n t r o l of o b e s i t y and  education  of people w i t h  regimens are complex, p a i n f u l or long-term). importance of e v a l u a t i v e r e s e a r c h  chronic conditions  Green (1978) s t r e s s e s  on methods of h e a l t h e d u c a t i o n ,  improve e f f e c t i v e n e s s of s t r a t e g i e s i n t h i s  (where  quadrant.  to  the  - 10  -  FIGURE 1 POLICY IMPLICATIONS FOR HEALTH STRATEGIES CLASSIFIED ACCORDING TO EFFECTIVENESS AND COST-BENEFIT POTENTIAL  EFFECTIVENESS High Examples:  Examples:  Kidney d i a l y s i s , most s u r g e r y , mass s c r e e n i n g or h e a l t h e d u c a t i o n f o r r a r e or t r i v i a l conditions.  Family p l a n n i n g , immunization p r e n a t a l c a r e , c e r v i c a l and b r e a s t cancer s c r e e n i n g , genetic screening, defensive d r i v e r t r a i n i n g , swimming instruction, self-care e d u c a t i o n f o r s e l e c t e d groups.  Policy:  Policy:  Support f o r a p p l i e d r e s e a r c h to improve c o s t - e f f e c t i v e n e s s of methods, or f i n d new methods.  Government support to u n i v e r s a l coverage of programs  Low  IV. III.  assure  I.  High  II.  POTENTIAL PAYOFF  Examples:  Examples:  Lung s u r g e r y , organ t r a n s p l a n t s , i n s t r u c t i o n on h e a r t r e s u s c i t a t i o n , long-term c a r e .  Smoking c e s s a t i o n , o b e s i t y c o n t r o l , seat b e l t usage, long-term regimens to c o n t r o l r i s k factors, genetic counseling, school health education, preventive dental e d u c a t i o n , beofeedback.  Policy:  Policy:  S h i f t r e s e a r c h r e s o u r c e s to quadrant I I and program r e s o u r c e s to quadrant I.  Support f o r i n n o v a t i v e demonstration programs and e v a l u a t i v e r e s e a r c h on new methods. Low  Source: Green  (1978)  - 11 -  When viewed i n terms of the major f a c t o r s r e s p o n s i b l e f o r reduced  life  expectancy of Canadians, i t becomes c l e a r t h a t h e a l t h problems i n quadrant I I r e q u i r e much r e s e a r c h reducing  emphasis.  d i s a b i l i t i e s and  deaths from motor v e h i c l e a c c i d e n t s .  c e s s a t i o n , o b e s i t y c o n t r o l and prevention  of ischaemic  heart  importance i n the p r e v e n t i o n cancer.  Seat b e l t usage i s important i n Smoking  e x e r c i s e are important i n the treatment disease.  and  and  Smoking c e s s a t i o n i s of p i v o t a l  treatment of r e s p i r a t o r y d i s e a s e  and  lung  Adherence to long-term regimens i s important i n the treatment  people w i t h Preventive  chronic conditions  (such as ischaemic  disease).  s t r a t e g i e s r e l a t e d to the major f a c t o r s r e s p o n s i b l e f o r reduced  l i f e expectancy r e q u i r e v o l u n t a r y education.  heart  of  changes i n b e h a v i o u r ;  and  However, the e f f e c t i v e n e s s of h e a l t h e d u c a t i o n  i s low both because t h e r e are b a r r i e r s to b e h a v i o u r a l g r e a t e r knowledge r e g a r d i n g  how  hence h e a l t h  i n these areas  change and  to b r i n g about b e h a v i o u r a l  because  change i s  required. Research r e g a r d i n g methods of h e a l t h e d u c a t i o n t h i s way  can e f f e c t i v e n e s s be  improved.  e f f e c t i v e n e s s of h e a l t h e d u c a t i o n . may  be a f f e c t e d by  is essential.  Numerous f a c t o r s i n f l u e n c e  Responses to h e a l t h e d u c a t i o n  c u l t u r a l influences, s o c i a l pressures,  f a c t o r s , i n d i v i d u a l needs and method of i n s t r u c t i o n . to i d e n t i f y which f a c t o r s might account f o r success education  Only i n  programs  socio-demographic  I t i s thus important  or f a i l u r e of h e a l t h  programs.  Some i n n o v a t i v e programs (which have developed i n response to increased  emphasis on p r e v e n t i o n )  are c h a r a c t e r i z e d by  a c c e s s i b i l i t y of h e a l t h p r o f e s s i o n a l s . opportunities f o r health education, and  reassurance.  One  Increased  increased  accessibility  e a r l y d e t e c t i o n of d i s e a s e ,  would a n t i c i p a t e ease and  creates counselling  q u a l i t y of c o n t a c t  with  - 12 -  h e a l t h p r o f e s s i o n a l s t o be important i n promotion o f h e a l t h and p r e v e n t i o n of i l l n e s s . Increased  Empirical studies regarding  a c c e s s i b i l i t y of health professionals i s c o s t l y .  e s s e n t i a l t h a t programs w i t h benefit  a c c e s s i b i l i t y are scarce.  increased  I t i s therefore  a c c e s s i b i l i t y be assessed  i n cost-  terms.  Summary of Problem S o c i a l , e n v i r o n m e n t a l and demographic changes, and changes i n the incidence of i n f e c t i o u s diseases,  i n p u b l i c h e a l t h p r a c t i c e s and p u b l i c  o p i n i o n have r e s u l t e d i n an emphasis on promoting and m a i n t a i n i n g and  a new emphasis on and approach t o h e a l t h e d u c a t i o n .  Costs o f h e a l t h  care i n Canada have e s c a l a t e d enormously i n r e c e n t y e a r s . h e a l t h problems a r e s e l f - i n f l i c t e d  or s o c i a l l y induced.  t r e a t i n g d i s e a s e s which c o u l d have been p r e v e n t e d .  and  education  Much money spent  t o r e s e a r c h and  s e l f - i n f l i c t e d and s o c i a l l y induced  promoting and m a i n t a i n i n g Health  Many modern  F e d e r a l and P r o v i n c i a l  Governments have s t a r t e d a l l o c a t i n g g r e a t e r r e s o u r c e s programs aimed a t r e d u c i n g  health,  diseases  health.  which i s aimed at changing b e h a v i o u r s presumed t o be  harmful to h e a l t h , i s r e c e i v i n g i n c r e a s i n g a t t e n t i o n . the t a r g e t s o f many h e a l t h e d u c a t i o n demographic and b e h a v i o u r a l  programs.  Healthy people a r e  Populations  whose s o c i o -  c h a r a c t e r i s t i c s suggest t h a t they a r e at r i s k  are r e c e i v i n g s p e c i a l a t t e n t i o n .  The e l d e r l y c o n s t i t u t e one such  population. The  i n c r e a s i n g p r o p o r t i o n of e l d e r l y people i n the p o p u l a t i o n and  t h e i r d i s p r o p o r t i o n a t e consumption o f the most expensive forms o f h e a l t h s e r v i c e , make i m p e r a t i v e  the development o f a l t e r n a t e forms o f h e a l t h  d e l i v e r y f o r t h i s age group. chronic diseases.  Health  care  E i g h t y - s i x p e r cent o f e l d e r l y people have  education  r e g a r d i n g management o f d i s e a s e and  - 13  -  h e a l t h b e h a v i o u r reduces h o s p i t a l i z a t i o n r a t e s and  promotes h e a l t h .  Early  d e t e c t i o n of h e a l t h problems i s an important f a c t o r i n the promotion of h e a l t h of o l d e r p e o p l e . c r i s i s and  prevention  Ease of access  to e m o t i o n a l support  of s o c i a l i s o l a t i o n , a l s o promote h e a l t h .  forms of h e a l t h care d e l i v e r y f o r o l d e r people should community based  i n times of  therefore  Alternate be  ( r a t h e r than i n s t i t u t i o n a l l y based), a c c e s s i b l e , and  emphasize promotion and maintenance of h e a l t h through h e a l t h e d u c a t i o n e a r l y d e t e c t i o n of Preventive  disease.  s t r a t e g i e s are aimed at r e d u c i n g  promoting h e a l t h .  c o s t s of h e a l t h care  and  increased  awareness of the importance of p r e v e n t i v e  e a r l y d e t e c t i o n of d i s e a s e have developed i n response to strategies.  a n t i c i p a t e such programs to be more e f f e c t i v e at promoting and reducing  orientation. and  payoff  i s low  Health  maintaining  s t r a t e g i e s v a r y , however, i n terms of e f f e c t i v e n e s s  s t r a t e g i e s can be  classified  according  to t h e i r known e f f e c t i v e -  S t r a t e g i e s where e f f e c t i v e n e s s of methods  p o t e n t i a l p a y o f f h i g h , i n c l u d e those aimed at smoking c e s s a t i o n ,  o b e s i t y c o n t r o l and  education  of people w i t h  regimens are complex, p a i n f u l or long-term). major f a c t o r s r e s p o n s i b l e f o r reduced l i f e require voluntary  changes of b e h a v i o u r .  r e s e a r c h which w i l l l e a d to i n c r e a s e d education  would  c o s t s than those which are p u r e l y c u r a t i v e i n  cost-benefit potential.  and  One  i n c o s t - b e n e f i t terms.  Health ness and  and  Some i n n o v a t i v e programs which emphasize h e a l t h  education  h e a l t h and  and  strategies.  chronic conditions  (where  These are areas r e l a t e d to  expectancy of Canadians.  They  There i s a need f o r e v a l u a t i v e  e f f e c t i v e n e s s of these h e a l t h  - 14 -  PURPOSE OF THE STUDY T h i s study i n v e s t i g a t e s two f a c t o r s presumed t o be important i n promoting h e a l t h o f a d u l t s  (and e l d e r l y people i n p a r t i c u l a r ) .  f a c t o r s are h e a l t h education professionals.  and ease and q u a l i t y of c o n t a c t w i t h  The study e x p l o r e s  ness o f h e a l t h e d u c a t i o n .  These health  f a c t o r s which i n f l u e n c e the e f f e c t i v e -  I t i d e n t i f i e s t h e combination o f f a c t o r s most  l i k e l y t o be e f f e c t i v e i n b r i n g i n g about improvements i n h e a l t h b e h a v i o u r and  concomitant improvements i n h e a l t h s t a t u s .  I t i d e n t i f i e s those  aspects  of a c c e s s i b i l i t y and q u a l i t y o f c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s which appear t o be most important i n promotion of h e a l t h o f o l d e r Community based h e a l t h programs f o r o l d e r people v a r y which they emphasize h e a l t h e d u c a t i o n health professionals. education  citizens. i n t h e extent t o  and ease and q u a l i t y o f c o n t a c t  with  One would a n t i c i p a t e programs which emphasize h e a l t h  and ease and q u a l i t y o f contact w i t h h e a l t h p r o f e s s i o n a l s t o be  e f f e c t i v e i n maintaining  h e a l t h and r e d u c i n g  health costs.  S i m i l a r l y , one  would expect programs which a r e c h i e f l y c u r a t i v e o r i e n t e d , and do n o t emphasize the above f a c t o r s , to be l e s s e f f e c t i v e i n m a i n t a i n i n g reducing  health  Health  h e a l t h and  costs.  education,  c o u n s e l l i n g and a c c e s s i b i l i t y o f nurses a r e  emphasized i n a p r e v e n t i v e  Home Care n u r s i n g program i n a p a r t i c u l a r  housing complex f o r s e n i o r c i t i z e n s i n t h e West End o f Vancouver. A l l o t h e r Home Care n u r s i n g programs f o r s e n i o r c i t i z e n s i n B r i t i s h are c h i e f l y treatment o r i e n t e d . the p r e v e n t i v e  Columbia  A study was designed t o determine whether  program was a s s o c i a t e d w i t h  g r e a t e r h e a l t h knowledge, h e a l t h  s t a t u s and lower h e a l t h c o s t s than a s i m i l a r , but c u r a t i v e o r i e n t e d program. The  study i s s i g n i f i c a n t because i t c o n t r i b u t e s t o knowledge o f  r e l a t i o n s h i p s between h e a l t h e d u c a t i o n  and a c c e s s i b i l i t y o f h e a l t h  - 15 -  p r o f e s s i o n a l s and the f o l l o w i n g : status way  and h e a l t h  costs.  Findings  h e a l t h knowledge, h e a l t h b e h a v i o u r , of the study have i m p l i c a t i o n s  health  f o r the  i n which h e a l t h e d u c a t i o n i s conducted i n dense r e s i d e n t i a l s e t t i n g s ,  f o r the r e t r a i n i n g o f h e a l t h facilities  p r o f e s s i o n a l s , f o r the r e s t r u c t u r i n g of  f o r the e l d e r l y and f o r the d i r e c t i o n of f u t u r e government p o l i c y  on p r e v e n t i v e  programs s i m i l a r t o those i n v e s t i g a t e d  i n t h i s study.  - 16  -  CHAPTER I I  REVIEW OF  LITERATURE  T h i s review of l i t e r a t u r e p r o v i d e s investigated.  an overview of the a r e a  I t examines r e l a t i o n s h i p s between h e a l t h e d u c a t i o n ,  q u a l i t y of c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s and page 17,  being ease  h e a l t h promotion.  and  Table  3,  summarizes the review of l i t e r a t u r e by t o p i c .  Preventive  h e a l t h care i s d e f i n e d and  p r e v e n t i v e h e a l t h care d e l i n e a t e d . of h e a l t h e d u c a t i o n  may  which have r e l e v a n c e techniques  and  are reviewed.  be  the h e a l t h e d u c a t i o n  aspect  F a c t o r s to which the success  a t t r i b u t e d are i d e n t i f i e d .  f o r h e a l t h education  or  Research and  are p r e s e n t e d .  of h e a l t h e d u c a t i o n  r e l a t e d to e f f e c t i v e n e s s and  are e x p l o r e d .  failure theory  Methods,  d e v i c e s which have been proven e f f e c t i v e i n h e a l t h Issues  of  education  cost-benefit potential  L i t e r a t u r e on the r o l e of ease  and  q u a l i t y of c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s i n h e a l t h promotion i s reviewed. The  u l t i m a t e g o a l of p r e v e n t i v e  ment of h e a l t h .  h e a l t h care i s maintenance and  Determining the e f f e c t i v e n e s s of a program i n  improve-  maintaining  or improving h e a l t h , r e q u i r e s the i d e n t i f i c a t i o n of the v a r i o u s a s p e c t s good h e a l t h and  i n d i c e s f o r measuring each.  l i t e r a t u r e review focuses  The  f i n a l s e c t i o n of  on measurement of h e a l t h  the  status.  PREVENTIVE HEALTH CARE The  shift  i n the causes of m o r b i d i t y  p r o p o r t i o n of people l i v i n g l o n g e r  and  l i v e s and  m o r t a l i t y , the increased  increased  c o s t s of h e a l t h  of  - 17 -  TABLE 3 TOPICS EXAMINED IN LITERATURE REVIEW  R e l a t i o n s h i p s Between H e a l t h E d u c a t i o n , Ease and Q u a l i t y of Contact and H e a l t h Promotion P r e v e n t i v e H e a l t h Care Importance o f p r e v e n t i v e h e a l t h care Operational d e f i n i t i o n of preventive  medicine  H e a l t h e d u c a t i o n component o f p r e v e n t i v e h e a l t h care Health Education D e f i n i t i o n of h e a l t h education C u l t u r a l f a c t o r s c e n t r a l to health education  S o c i o l o g i c a l f a c t o r s c e n t r a l to health education  Psychological f a c t o r s c e n t r a l to health education  M u l t i - d i s c i p l i n a r y approach t o h e a l t h education Models which e x p l a i n h e a l t h  behaviour  D i f f u s i o n of innovations C h a r a c t e r i s t i c s of the a d u l t l e a r n e r P a r t i c i p a t i o n and dropout from h e a l t h e d u c a t i o n programs  Author  Lalonde, M. Kulak, L . L . and Chisholm, D.M. Green,  L.W.  Green, L.W. P a u l , B.D. W e l l i n , E. A d e n i y i , J .D. Samora, J . et a l , B i c e , I.W. and White, K.L. McKinlay, J.B Anderson, J.G Rosenstock, I M. Koos, E.L. Wadsworth, M.E. Green, L.W. Keyes, L . L . Suchman, E.A. S t r a u s , R. B a t i s t e l l a , R.M B e r n s t e i n , D.A. Keyes, L . L . Gibson, G. McKinlay, J.B. R i c h a r d s , N.D. Mechanic, D. Z o l a , I.K. B a r i c , L. Suchman, E.A. Becker, M.H. Haefner, D.P. et a l . R i c h a r d s , N.D Rogers, E.M. Green, L.W. Knowles, M.S. R i c h a r d s , N.D Ward, A.W.  - 18 TABLE 3 - CONTINUED R e l a t i o n s h i p s Between H e a l t h E d u c a t i o n , Ease and Q u a l i t y o f Contact and H e a l t h Promotion Methods, techniques  East  and d e v i c e s  E f f e c t i v e n e s s and c o s t - b e n e f i t p o t e n t i a l of h e a l t h e d u c a t i o n and Q u a l i t y of Contact w i t h H e a l t h P r o f e s s i o n a l s  Author Verner, C. and D i c k i n s o n , G. Young, M.A.C. Knowles, M.S. Lewin, K. Kaplan, A. McKeachie, W.J. R i c h a r d s , N.D. Green, L.W. Becker, M.H. and Green, L.B. Green, L.W. Cochran, D.L. Becker, M.H. and Green, L.B. M u l l e n , P.F. Busse, E.W. and P f e i f f e r , E. Anderson, W.F. B e l l i n , S. and Hardt, R. Kay, D.W.K. e t a l . Robertson, H.R. Palmore, E.  Measurement o f H e a l t h M o r t a l i t y based i n d i c e s M o r b i d i t y based i n d i c e s  Unified mortality/morbidity  indices  I n d i c e s measuring s o c i a l , emotional and physical health separately  Moriyama, I.M. B a l i n s k y , W. and Berger, R. G a r f i e l d , S.R. Brodman, K.E.A. e t a l . Martin, J . J . et a l . K i s c h , A.E. e t a l . Hennes, J.D. Abramson, J.H. Friedsam, H. and M a r t i n , H. Heyman, D. and J e f f e r s , F. Maddox, G. Suchman, E.A. T i s s u e , T. Rosow, I . and B r e s l a n , N. B a l i n s k y , W. and Berger, R. M i l l e r , J.E. Chiang, C L . Lawton, M.P. e t a l . D a v i e s , D.F. S a c k e t t , D.L. and Chambers, L.W. Chambers, L.W. and Segovia, J .  - 19 -  c a r e , a r e some o f t h e f a c t o r s which have g i v e n r i s e t o the i n c r e a s e d emphasis on p r e v e n t i o n as a s t r a t e g y o f h e a l t h c a r e .  The Lalonde  Report  (Lalonde, 1974) proposed the H e a l t h F i e l d Concept as a c o n c e p t u a l framework for  h e a l t h care.  The H e a l t h F i e l d Concept i s comprised  elements a f f e c t i n g an i n d i v i d u a l ' s h e a l t h : care o r g a n i z a t i o n and human b i o l o g y . environment and l i f e  life  o f f o u r broad  s t y l e , environment, h e a l t h  E f f o r t s i n the c a t e g o r i e s o f  s t y l e have the g r e a t e s t p o t e n t i a l f o r r e d u c i n g  m o r t a l i t y and m o r b i d i t y and t h e i r r e l a t e d monetary and s o c i a l c o s t s . P r e v e n t i v e medicine factors.  i s concerned  with l i f e  s t y l e and  An o p e r a t i o n a l d e f i n i t i o n o f p r e v e n t i v e medicine  d i s e a s e as h a v i n g  environmental envisions  four stages:  1.  P r e - d i s e a s e stage: emphasis on r i s k f a c t o r s which make a person more o r l e s s s u s c e p t i b l e t o d e v e l o p i n g a c e r t a i n i l l n e s s . A c t i v i t i e s designed t o reduce r i s k f a c t o r s and prevent the development o f d i s e a s e a r e c a l l e d primary p r e v e n t i o n .  2.  Pre-symptomatic stage: a l t h o u g h the person has no symptoms, the d i s e a s e process has s t a r t e d and can be d e t e c t e d by s p e c i a l procedures. E a r l y secondary p r e v e n t i o n i n v o l v e s a c t i v i t i e s whose g o a l i s e a r l y d e t e c t i o n o f d i s e a s e and d i s a b i l i t y , f o l l o w e d by i n t e r v e n t i o n to cure the d i s e a s e or prevent p r o g r e s s i o n t o a more serious condition.  3.  Symptomatic s t a g e : symptoms o f i l l n e s s a r e e v i d e n t . d i r e c t e d at c u r i n g o r l i m i t i n g the d i s e a s e a r e termed secondary p r e v e n t i o n .  4.  C h r o n i c and R e h a b i l i t a t i v e s t a g e : not p o s s i b l e t o " c u r e " the disease. E f f o r t s aimed a t r e d u c i n g d i s a b i l i t y and promoting r e h a b i l i t a t i o n a r e termed t e r t i a r y p r e v e n t i o n (Kulak & Chisholm, 1974).  U n t i l v e r y r e c e n t l y our h e a l t h care system emphasized l a t e and  t e r t i a r y prevention.  The Lalonde  Efforts late  secondary  r e p o r t , however, proposes h e a l t h  promotion as one o f f i v e s t r a t e g i e s f o r f u t u r e a c t i o n .  The h e a l t h promotion  s t r a t e g y f o c u s e s l a r g e l y on primary  prevention  1974).  and e a r l y secondary  (Lalonde,  New o b j e c t i v e s o f the M i n i s t r y o f H e a l t h i n B r i t i s h Columbia i n c l u d e  the promotion o f programs o f a p r e v e n t i v e n a t u r e and t h e implementation  of  - 20 -  p u b l i c e d u c a t i o n programs ( M i n i s t r y o f H e a l t h ,  1979).  P r e v e n t i v e h e a l t h care encompasses a v a s t range o f a d m i n i s t r a t i v e , l e g a l , environmental  and e d u c a t i o n a l s t r a t e g i e s .  What d i s t i n g u i s h e s  e d u c a t i o n a l s t r a t e g i e s from the o t h e r t h r e e s t r a t e g i e s , i s t h a t e d u c a t i o n a l s t r a t e g i e s a r e designed  t o encourage v o l u n t a r y changes i n b e h a v i o u r .  Some  p r e v e n t i v e measures demand no i n d i v i d u a l a c t i o n , but many r e q u i r e b e h a v i o u r a l change and c o - o p e r a t i o n on the p a r t o f i n d i v i d u a l s .  It i s  p o s s i b l e t o l e g i s l a t e some o f the p r e v e n t i o n measures which r e q u i r e b e h a v i o u r a l change (e.g., seat b e l t usage). on v o l u n t a r y change.  Most measures depend, however,  Such b e h a v i o u r a l change presupposes adequate h e a l t h  education. The h e a l t h e d u c a t i o n t h r e e components.  aspect  o f p r e v e n t i v e h e a l t h programs c o n s i s t s o f  These components a r e (1) communications aimed at  i n f l u e n c i n g h e a l t h knowledge, a t t i t u d e s and behaviour;  (2) community  o r g a n i z a t i o n a c t i v i t i e s , aimed a t i n d u c i n g adjustment o f r e s o u r c e s t o i n c r e a s e a c c e s s i b i l i t y and a c c e p t a b i l i t y o f h e a l t h s e r v i c e s t o those who need them;  (3) s t a f f development a c t i v i t i e s  continuing education)  (such as i n - s e r v i c e and  aimed at i n f l u e n c i n g the way i n which p r o v i d e r s o f  h e a l t h care approach p a t i e n t s , c l i e n t s and the p u b l i c (Green, T h i s study i s l i m i t e d to examination education families.  o f t h a t aspect  1976).  of h e a l t h  concerned w i t h communications t o the p u b l i c , p a t i e n t s and L i t e r a t u r e r e l a t e d t o t h i s aspect  of health education i s  reviewed below.  HEALTH EDUCATION Education  i s the p r i n c i p a l t o o l o f those a s p e c t s o f p r e v e n t i v e h e a l t h  care which demand a c t i o n on the p a r t of the i n d i v i d u a l . i s d e f i n e d as "any combination  Health  education  of l e a r n i n g o p p o r t u n i t i e s designed t o  - 21 -  f a c i l i t a t e v o l u n t a r y a d a p t a t i o n s of behaviour m a i n t a i n h e a l t h " (Green, concern  1978,  p. 28).  which w i l l improve or  At the program l e v e l , the  i s to d e s i g n l e a r n i n g o p p o r t u n i t i e s i n such a way  the maintenance of h e a l t h most e f f i c i e n t l y .  facilitate  At the p o l i c y l e v e l , the main  i s s u e i s s e l e c t i o n of areas of h e a l t h behaviour, has  as to  chief  i n which b e h a v i o u r a l change  the g r e a t e s t p o t e n t i a l p a y o f f i n c o s t - b e n e f i t terms, both f o r  i n d i v i d u a l s and The  s o c i e t y (Green,  1978).  f i r s t p a r t of t h i s s e c t i o n i s concerned  health education.  The  w i t h methods and  d e s i g n of  purpose i s not to e v a l u a t e i n d i v i d u a l methods, but  to i d e n t i f y f a c t o r s to which success or f a i l u r e of h e a l t h e d u c a t i o n may attributed.  Research and  i s presented.  be  theory which has r e l e v a n c e f o r h e a l t h e d u c a t i o n  Methods, techniques  and  d e v i c e s which have been proven  e f f e c t i v e i n h e a l t h e d u c a t i o n are reviewed. f o c u s e s on e f f e c t i v e n e s s and  The  l a s t p a r t of t h i s s e c t i o n  c o s t - b e n e f i t p o t e n t i a l of h e a l t h e d u c a t i o n  strategies.  Research and Theory from R e l a t e d Germane to H e a l t h E d u c a t i o n  Fields  The major g o a l of h e a l t h e d u c a t i o n i s to modify behaviour d e l e t e r i o u s to h e a l t h and however, extremely guarantees  thereby  complex and  which may account  Human behaviour i s ,  the p o s s e s s i o n of h e a l t h knowledge i n no  changes i n b e h a v i o u r .  merely i m p a r t i n g i n f o r m a t i o n .  improve h e a l t h .  presumed  way  H e a l t h e d u c a t i o n i n v o l v e s f a r more than  C u l t u r a l , s o c i a l and p s y c h o l o g i c a l f a c t o r s  f a c i l i t a t e or impede b e h a v i o u r a l change, must be taken  when p l a n n i n g h e a l t h e d u c a t i o n programs.  into  S t u d i e s which have  r e l e v a n c e f o r h e a l t h e d u c a t i o n programs are reviewed  below.  - 22  Cultural  -  studies  H e a l t h e d u c a t i o n does not e x i s t  i n a vacuum.  P r e s s u r e s e x e r t e d by  groups to which an i n d i v i d u a l belongs are v e r y p o w e r f u l determinants behaviour. change.  These p r e s s u r e s must be c o n s i d e r e d when t r y i n g to b r i n g  Many programs f a i l  of about  t o r e c o g n i z e the r e l a t i o n s h i p between v a l u e s ,  b e l i e f s , b e h a v i o u r s and s o c i a l , c u l t u r a l and r e l i g i o u s systems.  There i s  overwhelming evidence of the n e c e s s i t y f o r s u c c e s s f u l programs to c o n s i d e r these f a c t o r s Wellin  ( P a u l , 1955).  (1958), f o r example, documents the f a i l u r e of e f f o r t s to  convince P e r u v i a n housewives of the n e c e s s i t y of b o i l i n g d r i n k i n g water. In two  y e a r s , a r e s i d e n t hygiene worker persuaded  to b o i l water.  Water b o i l i n g was,  associated with being s i c k . a t t r i b u t e d t o apathy, Adeniyi epidemic  The  o n l y e l e v e n housewives  however, not an i s o l a t e d a c t i o n .  s m a l l response  ignorance or  c o u l d thus not  was  be  stubbornness.  (1972) i l l u s t r a t e s the f a i l u r e of e f f o r t s to c o n t r o l a c h o l e r a  i n N i g e r i a , because t r a d i t i o n a l b e l i e f s were not c o n s i d e r e d .  people b e l i e v e d the epidemic  t o be the r e s u l t of anger  s a c r i f i c e s to appease the gods.  of gods;  Some  they made  A number of people b e l i e v e d c h o l e r a should  be t r e a t e d l i k e o t h e r d i s e a s e s w i t h symptoms of d i a r r h e a ; native  It  they  utilized  medicine.  Sociological  studies  Socio-demographic  and s o c i o l o g i c a l v a r i a b l e s have a l s o been shown to  a f f e c t an i n d i v i d u a l ' s d e c i s i o n t o seek h e a l t h care and adopt h e a l t h promoting  behaviours.  socio-economic  and  There  i s much evidence on the r e l a t i o n s h i p between  socio-demographic  f a c t o r s and knowledge of d i s e a s e  (Samora, 1961), use of h e a l t h s e r v i c e s Anderson, 1973), acceptance  ( B i c e , 1970;  McKinlay,  of p r e v e n t i v e h e a l t h s e r v i c e s  1972;  (Rosenstock,  1969;  -  23 -  Rosenstock, 1969a) and use of s e l f - m e d i c a t i o n s Many s t u d i e s have found d i f f e r i n g p e r c e p t i o n s services. reported  (Wadsworth, e t a l . , 1971). of symptoms and use of  Koos (1954) found t h a t persons of lower socio-economic themselves i l l  l e s s o f t e n , were l e s s l i k e l y  a c t u a l symptoms b u t r e p o r t e d economic s t a t u s .  less i l l n e s s  status  to seek c a r e , had more  than people of h i g h e r  socio-  A study by Green (1970a) found socio-economic  status  to be t h e most important p r e d i c t o r of a d o p t i o n  of p r e v e n t i v e  health  behaviour. Models of h e a l t h r e l a t e d b e h a v i o u r s have been formulated health actions.  Mechanic  (1968) l i s t s  the main f a c t o r s which  response t o i l l n e s s as symptoms, s a l i e n c e , p e r c e i v e d symptoms, i n t e r f e r e n c e w i t h  activities,  to e x p l a i n affect  s e r i o u s n e s s of  tolerance threshold, available  i n f o r m a t i o n and c u l t u r a l assumptions r e g a r d i n g  symptoms, d e n i a l  tendencies,  competing needs, a c c e s s i b i l i t y o f treatment and economic and p s y c h o l o g i c a l costs  involved. Zola  (1966) developed the n o t i o n of f i v e " t r i g g e r s " which may have  d i f f e r i n g degrees o f importance i n a f f e c t i n g an i n d i v i d u a l ' s d e c i s i o n to seek h e a l t h  care.  These n o n - p h y s i o l o g i c a l  o c c u r r e n c e of i n t e r p e r s o n a l c r i s i s perceived others; Baric  i n t e r f e r e n c e with perceived  t r i g g e r s a r e the f o l l o w i n g :  f o c u s i n g a t t e n t i o n on symptoms;  social activities;  i n t e r f e r e n c e w i t h work;  s o c i a l pressures  temporalizing  from  o f symptoms.  (1969) d e s c r i b e s a t - r i s k b e h a v i o u r i n terms o f the f o l l o w i n g phases:  a c q u i s i t i o n of i n f o r m a t i o n information;  about a h e a l t h t h r e a t ;  e x p l o r a t i o n of the s o c i a l environment r e g a r d i n g t h e  c r e d i b i l i t y of t h i s i n f o r m a t i o n , confirmation threat;  v a l i d a t i o n of this  and the p r e v e n t i v e  from h e a l t h p r o f e s s i o n a l s r e g a r d i n g  a c t i o n recommended;  the d i r e c t n e s s of the  acceptance or r e j e c t i o n of membership o f a h i g h - r i s k group.  This  - 24  formulation risk.  has  Points  implications  -  f o r h e a l t h e d u c a t i o n of p o p u l a t i o n s  of i n t e r v e n t i o n i n t h i s model need e x p l o r a t i o n  at  high  (Richards,  1975). Suchman (1969) notes t h a t h e a l t h e d u c a t o r s have been unable to the  l a c k of response of people i n low  h e a l t h campaigns.  He  the person belongs and considered.  The  been found to be  socio-economic groups to  Implications  the h e a l t h o r i e n t a t i o n s the person adheres t o ,  form of s o c i a l o r g a n i z a t i o n  s i g n i f i c a n t l y r e l a t e d to m e d i c a l o r i e n t a t i o n .  " p a r o c h i a l " groups a " p o p u l a r " h e a l t h  f o r h e a l t h e d u c a t i o n are  that  s c i e n t i f i c " groups would l i k e l y  Social-psychological  orientation.  b r i n g i n g about b e h a v i o u r a l  "cosmopolitan-  to programs which are r a t i o n a l .  a t t i t u d e s may  also influence  behavioural  1968;  Bernstein,  b e h a v i o u r i s complex.  t h e i r behaviour.  causal  b e h a v i o u r , have severe l i m i t a t i o n s i n  change (Suchman, 1964; 1969).  People may  h a v i n g changed t h e i r a t t i t u d e s . not  groups would  A t t i t u d e change s t r a t e g i e s , based on the assumption of a  r e l a t i o n s h i p between a t t i t u d e s and  and  "Cosmopoli-  studies  I n d i v i d u a l needs, b e l i e f s and  Batistella,  The  1961;  r e l a t i o n s h i p between a t t i t u d e s  acquire  They may  Straus,  new  b e h a v i o u r without  first  a l s o change t h e i r a t t i t u d e s  and  A t t i t u d e change s t r a t e g i e s have tended to i s o l a t e an  a t t i t u d e from o t h e r a t t i t u d e s , to i s o l a t e a t t i t u d e s from u n d e r l y i n g and  has  health  "parochial-popular"  respond best  be  to which a person belongs  respond w e l l to programs which u t i l i z e group a p p r o v a l ;  change.  preventive  suggests t h a t the s t r u c t u r e of s o c i a l groups to which  t a n " types of groups are more l i k e l y to have a " s c i e n t i f i c " o r i e n t a t i o n and  explain  p e r s o n a l i t y systems and  from s o c i o l o g i c a l and  S o c i a l norms, s o c i a l d i s t a n c e  and  value  situation variables.  s o c i a l perceptions  are  extremely  important i n t e r v e n i n g v a r i a b l e s between knowledge, a t t i t u d e s and  health  - 25  behaviour The  -  (Keyes, 1972). H e a l t h B e l i e f Model i s based on a number of r e s e a r c h s t u d i e s of  responses to p r e v e n t i v e programs.  I t attempts to e x p l a i n the behaviour  of  those who  v o l u n t a r i l y u t i l i z e preventive health services.  maintains  t h a t an i n d i v i d u a l w i l l engage i n p r e v e n t i v e h e a l t h behaviour i f  the f o l l o w i n g c o n d i t i o n s e x i s t :  T h i s model  he p e r c e i v e s h i m s e l f s u s c e p t i b l e to  the  i l l n e s s , he b e l i e v e s t h a t c o n t r a c t i n g i l l n e s s w i l l have s e r i o u s r e p e r c u s s i o n s f o r him,  he e s t i m a t e s  t h a t a p a r t i c u l a r course of a c t i o n w i l l  be b e n e f i c i a l ; he b e l i e v e s t h a t t h e r e are no b a r r i e r s  (financial,  p s y c h o l o g i c a l or p h y s i c a l ) i n v o l v e d i n the a c t i o n and he e x p e r i e n c e s to  t r i g g e r the a p p r o p r i a t e a c t i o n .  support  f o r the model (Becker,  Multidisciplinary  a  cue  I n i t i a l t e s t s of the model p r o v i d e  Haefner, et a l . , 1977).  studies  These c u l t u r a l i n f l u e n c e s , s o c i a l f o r c e s , socio-demographic f a c t o r s and  i n d i v i d u a l needs and p e r c e p t i o n s have a l l been used to e x p l a i n  d i f f e r i n g responses to e d u c a t i o n a l programs designed  to promote h e a l t h .  There have been v a r i o u s attempts to c o - o r d i n a t e these approaches 1972;  M c K i n l a y , 1972).  C o n s i d e r a t i o n of a l l these  s y n t h e s i s of data from s t u d i e s i n d i f f e r e n t  components  education  1968a) review  supports  Studies  of r e s e a r c h and  and  f i e l d s should allow b e t t e r  p l a n n i n g of h e a l t h e d u c a t i o n programs ( R i c h a r d s , 1975). 1967a; 1968;  (Gibson,  Young's (.1967;  s t u d i e s r e l a t e d to h e a l t h  t h i s view.  on d i f f u s i o n of  The work of Rogers the sequence of stages  innovations  (.1962) r e g a r d i n g a d o p t i o n i n the a d o p t i o n  i n t e r e s t , e v a l u a t i o n , t r i a l and  of new  adoption);  of i n n o v a t i o n s , i . e . ,  p r a c t i c e s (awareness,  and  the c a t e g o r i z a t i o n of  - 26 -  adopters as i n n o v a t o r s , laggards,  e a r l y adopters, e a r l y majority,  has been u t i l i z e d  i n health education  w i t h maximizing e f f e c t i v e n e s s of h e a l t h a t t e n t i o n to innovation new programs.  l a t e majority  (Green, 1975).  and  Concern  s e r v i c e s has r e s u l t e d i n i n c r e a s e d  and f a c t o r s which i n f l u e n c e acceptance and use o f  The e f f e c t i v e n e s s o f a program can be judged by the r a p i d i t y  w i t h which people accept and use the i d e a s . i n f l u e n c e d by the way i n which h e a l t h f o r m a l and i n f o r m a l  s o c i a l systems  information  (Richards,  people adopt a new p r a c t i c e i s i n i t i a l l y u n t i l the m a j o r i t y  E f f e c t i v e n e s s may w e l l be i s communicated  1975).  slow.  through  The r a t e a t which  The r a t e then  increases  o f p o t e n t i a l consumers has adopted the p r a c t i c e .  After  t h i s , the r a t e o f change i s slow, as an attempt i s made t o reach more r e s i s t a n t and s o c i a l l y  i s o l a t e d sub-groups o f the p o p u l a t i o n .  are most e f f e c t i v e a t a r o u s i n g of the a d o p t i o n p r o c e s s  Mass media  i n t e r e s t , and thus a t the awareness stage  (Rogers, 1962;  Green, 1975).  Interpersonal  techniques a r e more e f f e c t i v e a t l a t e r stages and a t e f f e c t i n g  behavioural  changes (Green, 1978).  Adult  education  Adult  h e a l t h e d u c a t i o n has u t i l i z e d  education.  the r e s e a r c h  In a d u l t e d u c a t i o n , the t e a c h i n g - l e a r n i n g  co-operative learning.  studies  e f f o r t between t e a c h e r and l e a r n e r ;  The a d u l t  p r o c e s s i s seen as a  each c o n t r i b u t e s t o  l e a r n e r i s seen as a person who i s s e l f d i r e c t e d , has  a wealth of e x p e r i e n c e t o c o n t r i b u t e  t o the l e a r n i n g s i t u a t i o n and whose  approach t o l e a r n i n g i s a problem o r i e n t e d implications  and t h e o r y o f a d u l t  one.  These c h a r a c t e r i s t i c s have  f o r the s t r u c t u r i n g o f the l e a r n i n g s i t u a t i o n (Knowles, 1970).  Teaching t e c h n i q u e s v a r y i n terms o f a p p r o p r i a t e n e s s f o r d i f f e r e n t k i n d s o f l e a r n i n g outcomes; aptitudes.  and f o r l e a r n e r s with, d i f f e r e n t t r a i t s and  The l e c t u r e and the group d i s c u s s i o n a r e , f o r example,  equally  - 27 -  e f f e c t i v e at t r a n s m i t t i n g information; to the l e c t u r e i n changing behaviour h e a l t h education  s t u d i e s have found  i n changing behaviours  (Verner and D i c k i n s o n , 1967). group d i s c u s s i o n a powerful  such as i n c r e a s i n g v i s i t s  c l i n i c s f o r screening; improving  but the group d i s c u s s i o n i s s u p e r i o r  improving  compliance w i t h m e d i c a l  technique  to p h y s i c i a n s and t o  preventive health p r a c t i c e s ; regimens  Numerous  and  (Young, 1967).  A d u l t s have c e r t a i n c h a r a c t e r i s t i c s which govern the c h o i c e o f i n s t r u c t i o n a l technique.  They have a g r e a t d e a l o f e x p e r i e n c e ;  which a l l o w one t o tap t h i s e x p e r i e n c e  should be used.  techniques  A d u l t s have f i x e d  h a b i t s and thought p a t t e r n s which sometimes i n t e r f e r e w i t h l e a r n i n g and b e h a v i o u r a l change. and  Group d i s c u s s i o n s a r e more e f f e c t i v e i n i d e n t i f y i n g  a l t e r i n g these a t t i t u d e s than a r e techniques  there i s l i t t l e  learner participation  such as l e c t u r e s , where  (Knowles, 1970;  Lewin, 1953;  Kaplan, 1970). The more ego involvement t h a t takes p l a c e .  there i s , the g r e a t e r w i l l be the l e a r n i n g  The l i k e l i h o o d  o f ego-involvement i s g r e a t e r when the  l e a r n e r i s a c t i v e l y i n v o l v e d (e.g., i n a group d i s c u s s i o n ) , than when he i s a passive recipient  of information.  than p a s s i v e l e a r n i n g (Knowles, 1970;  A c t i v e l e a r n i n g i s more e f f i c i e n t McKeachie, 1969).  Techniques which  a l l o w and promote l e a r n e r p a r t i c i p a t i o n a r e more a p p r o p r i a t e f o r use w i t h a d u l t l e a r n e r s than techniques  Participation  which do n o t .  studies  S t u d i e s on p a r t i c i p a t i o n and drop out from e d u c a t i o n a l programs have contributed to greater understanding participation.  o f v a r i a b l e s which i n f l u e n c e  S t u d i e s o f n o n - p a r t i c i p a n t s and reasons  f o r f a i l u r e to  p a r t i c i p a t e i n p r e v e n t i v e programs have i d e n t i f i e d weaknesses o f e d u c a t i o n a l approaches and the need f o r d i f f e r e n t  educational strategies  - 28  ( R i c h a r d s , 1975).  -  A number of s t u d i e s c o n f i r m the v a l u e of t h i s  For example, Ward's (1971) study on reasons planning c l i n i c visit  or one  found  approach.  f o r drop out at a f a m i l y  t h a t b e h a v i o u r a l change cannot be e f f e c t e d by  exposure to a program;  a s u s t a i n e d , repeat v i s i t  one  program i s  important.  Methods, Techniques and Devices  i n Health  Numerous methods, techniques encourage people  Education  and d e v i c e s have been u t i l i z e d  to adopt h e a l t h y b e h a v i o u r s .  programmed i n s t r u c t i o n ) and groups, meetings and speeches, debates,  to  I n d i v i d u a l methods  group methods (e.g., the c l a s s , d i s c u s s i o n  forums) have been used.  Techniques such as  lectures,  p a n e l s , group d i s c u s s i o n s , buzz groups, seminars  r o l e p l a y i n g have been used.  Devices  utilized  The  and  include wallcharts, posters,  l e a f l e t s , e x h i b i t s , models, r a d i o , t e l e v i s i o n , f i l m s , s l i d e s and recorders  (e.g.,  tape  ( R i c h a r d s , 1975). l i t e r a t u r e abounds w i t h r e p o r t s r e g a r d i n g the e f f e c t s of v a r i o u s  techniques.  A f i n d i n g which c o n s i s t e n t l y emerges from comparison of h e a l t h  e d u c a t i o n programs w i t h p o s i t i v e v e r s u s n e g a t i v e r e s u l t s , i s t h a t  "the  d u r a b i l i t y of c o g n i t i v e and b e h a v i o u r a l changes are p r o p o r t i o n a l to  the  degree of a c t i v e r a t h e r than p a s s i v e p a r t i c i p a t i o n of the l e a r n e r "  (Green,  1978,  p. 34).  Another c o n s i s t e n t f i n d i n g i s t h a t the l i k e l i h o o d of a  h e a l t h education  program o b t a i n i n g p o s i t i v e r e s u l t s , i s d i r e c t l y r e l a t e d  the number of d i f f e r e n t e d u c a t i o n a l techniques i s seldom b e h a v i o u r a l change a f t e r one needed  used  contact;  (Green,  1978).  multiple contacts  There are  ( R i c h a r d s , 1975).  Even when the b e h a v i o u r a l o b j e c t i v e i s the same, d i f f e r e n t may  to  be r e q u i r e d f o r d i f f e r e n t p o p u l t a t i o n groups  techniques  ( R i c h a r d s , 1975).  Programs r e q u i r e d i f f e r i n g emphases i n order to achieve d i f f e r e n t  types  of  - 29  behaviour  change.  -  For example, i f i t i s important  p e r s i s t w i t h a p a r t i c u l a r h e a l t h behaviour  that  individuals  over long p e r i o d s of time,  the most e f f e c t i v e h e a l t h e d u c a t i o n methods are those t h a t p r o v i d e in  the c l i n i c  or home.  m e d i c a l regimens  T h i s has been found  then  support  i n s t u d i e s on compliance  with  (Becker and Green, 1975), and p e r s i s t e n c e w i t h d i e t  smoking c e s s a t i o n (Green,  1970).  I f the h e a l t h behaviour  should  and  be  repeated r e g u l a r l y , then h e a l t h e d u c a t i o n methods which g i v e cues at p a r t i c u l a r i n t e r v a l s are more e f f e c t i v e than s p o r a d i c or one-shot methods. I n t e n s i v e h e a l t h e d u c a t i o n methods, such as i n d i v i d u a l c o u n s e l l i n g and home v i s i t s ,  are most e f f e c t i v e when b e h a v i o u r a l g o a l s are complex  (Green,  1978). Some h e a l t h e d u c a t i o n programs have emphasized i n f o r m a t i o n g i v i n g , some a t t i t u d e change and of  o t h e r s b e h a v i o u r a l change.  The major o b j e c t i v e  h e a l t h e d u c a t i o n i s to b r i n g about b e h a v i o u r a l change.  p o s s e s s i o n of knowledge i n no way  guarantees  r e l a t i o n s h i p between knowledge and  b e h a v i o u r a l change;  attitudes i s unclear.  programs should t h e r e f o r e f o c u s on the t a r g e t behaviours determinants.  i n f l u e n c e behaviour.  an i n t e r a c t i o n between technique  whether one  Health and  Numerous c u l t u r a l f o r c e s , s o c i a l f a c t o r s and  needs i n t e r a c t and of  However, the  technique  and  technique  the  education  their individual  Effective instruction i s a result learners.  i s b e t t e r than another  The  i s s u e i s thus  not  but under what c o n d i t i o n s and  w i t h what p o p u l a t i o n s are c e r t a i n techniques b e t t e r than other? of  and  should be based on type of l e a r n i n g o b j e c t i v e and  Selection prior  assessment of the a t t i t u d e s , v a l u e s and b e l i e f s of the t a r g e t p o p u l a t i o n .  E f f e c t i v e n e s s and C o s t - B e n e f i t P o t e n t i a l of H e a l t h  Education  H e a l t h e d u c a t i o n e f f o r t s have v a r i e d g r e a t l y i n terms of s o p h i s t i c a t i o n , q u a l i t y , q u a n t i t y , e f f i c i e n c y and  effectiveness.  The  -  30  -  s e c t i o n below addresses i s s u e s of e f f e c t i v e n e s s and  payoff  in cost-benefit  terms. D e f i c i e n c i e s i n the e v a l u a t i o n of h e a l t h e d u c a t i o n assessment of the e f f e c t i v e n e s s of h e a l t h e d u c a t i o n . education, practice  though accepted (Green, 1977).  i n p r i n c i p l e , has  hindered  E v a l u a t i o n of h e a l t h  been r e l a t i v e l y n e g l e c t e d  P r i o r to the 1950's, e v a l u a t i o n c o n s i s t e d  of a d e s c r i p t i o n of the program and  the degree of e f f o r t  mid-1950's, e v a l u a t i o n by o b j e c t i v e s was evaluated  have  i n terms of the c r i t e r i o n of e f f e c t i v e n e s s .  improving the e f f i c i e n c y of h e a l t h programs has  grown.  chiefly  expended.  being u t i l i z e d ;  in  By  the  programs were  Concern I t has  regarding resulted in  i n c r e a s e d emphasis on e f f i c i e n c y i n terms of c o s t - b e n e f i t a n a l y s i s  and  q u a l i t y c o n t r o l (Cochran, 1964). Evaluations deficiencies.  of h e a l t h e d u c a t i o n  programs have e x h i b i t e d s e v e r a l  Most e v a l u a t i o n s have used p r i m i t i v e p r e - e x p e r i m e n t a l  quasi-experimental  designs  (Green, 1977).  The  b e h a v i o u r , however, demands a f a c t o r i a l d e s i g n of h e a l t h e d u c a t i o n  complexity  use  a n a l y s i s and have documented procedures i n i n s u f f i c i e n t  research  health  (Green, 1978).  programs have made i n s u f f i c i e n t  a l s o been i n s u f f i c i e n t  of  of  all. and  Evaluations  statistical  detail.  There  a t t e n t i o n to the cumulative b u i l d i n g of theory  has and  (Green, 1977).  S e v e r a l f a c t o r s pose problems f o r the e v a l u a t i o n of h e a l t h programs.  and  An  Health  education  approach t h a t works f o r some i n d i v i d u a l s does not work f o r education  has  some e f f e c t s which are immediate and  o t h e r s which develop more s l o w l y but  last  temporary,  f o r a longer p e r i o d .  This  poses problems f o r the t i m i n g of measurement of outcomes (Green, 1977). L i m i t a t i o n s of time or r e s o u r c e s range outcomes.  Health  education  have a l s o p r e c l u d e d  measurement of  longer  i s o f t e n p a r t of a more comprehensive  - 31  program e f f o r t making i t d i f f i c u l t education  to i s o l a t e the e f f e c t s of h e a l t h  (Green, 1978).  A review of r e s e a r c h the l i t e r a t u r e from 1961 1968a).  -  r e l a t e d to h e a l t h e d u c a t i o n - 1966  was  published  i n these s t u d i e s .  the s t u d i e s .  Many i n c l u d e d no  these s t u d i e s a c c o r d i n g  Inadequate designs evaluation.  t h e r e f o r e not p o s s i b l e to a s s e s s  Green (1976a;  1978)  1967a  objectives  were u t i l i z e d no  There has  health.  analyze review  It i s  e f f e c t i v e n e s s of h e a l t h  evaluative  research.  reviewed h e a l t h e d u c a t i o n  l i t e r a t u r e and  obtained  education  improvements i n s p e c i f i c h e a l t h b e h a v i o u r s or i n d i c e s of  By e x t r a p o l a t i n g from these c o n s i s t e n t r e l a t i o n s h i p s , he made  c o s t - b e n e f i t estimates education  i n many of  been no  evidence of c o n s i s t e n t r e l a t i o n s h i p s between p a r t i c u l a r h e a l t h s t r a g e g i e s and  1968;  are  attempt to  s i n c e that time.  the c u r r e n t  on the b a s i s of p u b l i s h e d  and  There was  to t h e i r e f f e c t i v e n e s s .  of the r e s e a r c h r e l a t e d to h e a l t h e d u c a t i o n  education  by Young (1967;  Numerous e d u c a t i o n a l methods, techniques  represented  p r a c t i c e covering  and  on the t r a d e o f f between investments i n h e a l t h  comparative investments i n t e r t i a r y h e a l t h c a r e .  c l a s s i f i e d m e d i c a l and e f f e c t i v e n e s s and  health education  p o t e n t i a l payoff  s t r a t e g i e s according  He  to t h e i r known  i n c o s t - b e n e f i t terms ( F i g u r e 1, page  10). Resources a v a i l a b l e f o r h e a l t h e d u c a t i o n  are l i m i t e d .  e s s e n t i a l t h a t , at the p o l i c y l e v e l , e d u c a t i o n a l r e s o u r c e s towards those problems and h e a l t h w i l l be g r e a t e s t .  populations The  be d i r e c t e d  where improvements i n the  p o l i c y analyst  r e l a t i v e need f o r improvement i n each problem r e l a t i v e p o t e n t i a l f o r improvement  I t i s thus  i s faced with  two  issues:  (potential payoff);  (effectiveness).  The  nation's  and  p r i o r i t y of a  p a r t i c u a l a r h e a l t h problem i n r e l a t i o n to other h e a l t h problems v a r i e s f o r  -  d i f f e r e n t populations.  -  32  I t i s t h e r e f o r e necessary  t o u t i l i z e a method f o r  a s s i g n i n g d i f f e r e n t p r i o r i t i e s t o the same h e a l t h problems i n v a r i o u s populations developed  (Green,  1978).  The Q index i s such a method.  f o r the U.S. I n d i a n H e a l t h S e r v i c e  T h i s index was  ( M i l l e r , 1970).  I t combines  the dimensions of p o t e n t i a l p a y o f f and e f f e c t i v e n e s s i n one index. On the b a s i s o f assessments of the most p r o d u c t i v e areas education  i n the U.S., Green  f o r health  (1978) made recommendations f o r p a r t i c u l a r  p o p u l a t i o n s and b e h a v i o u r a l g o a l s .  He recommends t h a t h e a l t h  r e s o u r c e s be d i r e c t e d " t o m a t e r n i t y  care, preventive c h i l d  education  care, adult  p r e v e n t i v e care and c h r o n i c i l l n e s s c a r e , i n t h a t order o f p r i o r i t y " (Green,  1978, p. 58).  resource a l l o c a t i o n .  There a r e 16 o t h e r recommendations r e g a r d i n g F o r example, "During  pregnancy, i n s t r u c t i o n  should  be o f f e r e d on n u t r i t i o n , f a m i l y p l a n n i n g , s e l f - c a r e , d e l i v e r y , and parenthood: father". Given render  up t o s i x hours o f group i n s t r u c t i o n each, f o r mother and  (Green,  1978, p. 5 8 ) .  the c u r r e n t s t a t e o f h e a l t h e d u c a t i o n ,  these p r i o r i t i e s  the maximum c o s t - b e n e f i t advantage t o s o c i e t y .  should  There i s a need  f o r r e s e a r c h and e v a l u a t i o n i n areas which a r e l e s s e f f e c t i v e but have h i g h payoff  (e.g. d i e t therapy,  hypertension  and d i a b e t e s )  o b e s i t y c o n t r o l , l o n g term management o f (Green,  1978).  EASE AND QUALITY OF CONTACT WITH HEALTH PROFESSIONALS One would a n t i c i p a t e access supportive value;  t o sympathetic  care t o have p r e v e n t i v e ,  t h a t people w i l l do w e l l i f they a r e sure they can get  h e l p and a d v i c e when they need i t .  I t i s reasonable  of t h i s c o n t a c t  ( i . e . concern w i t h e m o t i o n a l ,  to be important  i n promoting h e a l t h .  t o expect  the q u a l i t y  s o c i a l and p h y s i c a l h e a l t h )  It i s d i f f i c u l t  t o support  these  - 33 -  p r o p o s i t i o n s w i t h hard f a c t s .  The l i t e r a t u r e on a c c e s s i b i l i t y  compares  u t i l i z a t i o n o f m e d i c a l s e r v i c e s b e f o r e and a f t e r t h e i n t r o d u c t i o n o f medical a i d ; aid.  o r u t i l i z a t i o n p a t t e r n s o f people w i t h and without  medical  E m p i r i c a l s t u d i e s on the r o l e of support and r e a s s u r a n c e i n h e a l t h  promotion  are scarce.  S t u d i e s on compliance  however, i n d i c a t e t h e importance  w i t h m e d i c a l regimens do,  of the d o c t o r - p a t i e n t r e l a t i o n s h i p  (Becker and Green, 1975; M u l l e n , 1973). There  i s c o n s i d e r a b l e evidence t h a t numerous s t r e s s e s a s s o c i a t e d w i t h  o l d age ( i . e . l o s s o f income, i s o l a t i o n , l o s s o f s o c i a l r o l e , bereavement, loss of cognitive functioning) result i l l n e s s among e l d e r l y p e o p l e . to sympathetic  i n h i g h e r r a t e s o f severe  Measures which reduce  stress  mental  (such as a c c e s s  c a r e , and p r e v e n t i o n o f i s o l a t i o n ) can be expected t o  prevent o r reduce mental  illness  (Palmore,  1973).  Work w i t h o l d e r c i t i z e n s at t h e R u t h e r g l e n C o n s u l t a t i v e H e a l t h Centre i n S c o t l a n d a l s o supports the p r o p o s i t i o n s r e g a r d i n g ease and q u a l i t y o f contact.  The primary causes o f e m o t i o n a l d i s t u r b a n c e s ( a n x i e t y and  d e p r e s s i o n ) i n e l d e r l y people a r e p h y s i c a l d i s e a s e and an adverse environment  (which i n c l u d e s l i v i n g alone  (Anderson,  1976)).  Elderly  people  have more p h y s i c a l d i s e a s e s and c h r o n i c c o n d i t i o n s than younger people (Palmore,  1973).  Many of them l i v e a l o n e .  Physical i l l  h e a l t h i s a source  of a n x i e t y and d e p r e s s i o n , and may cause emotional d i s t u r b a n c e s .  There i s  an a s s o c i a t i o n between d i s a b i l i t y and i l l n e s s and h i g h e r r a t e s o f mental illness  ( B e l l i n and H a r t , 1958; Kay e t a l . , 1964).  A study w i t h o l d e r  people found emotional d i s t u r b a n c e s i n 13 p e r cent o f h e a l t h y men and 18 per cent o f h e a l t h y women;  but i n 31 p e r cent o f men and 38 p e r cent o f  women who had some p h y s i c a l d i s e a s e .  E x p e r i e n c e a t the R u t h e r g l e n  Consul-  t a t i v e H e a l t h Centre i n d i c a t e s t h a t the most important method o f p r e v e n t i n g  - 34 -  mental i l l n e s s  i n older people, i s reassurance regarding p h y s i c a l h e a l t h ;  r e a s s u r a n c e based on a thorough p h y s i c a l examination  (Anderson,  1976).  S o c i a l i s o l a t i o n i n c r e a s e s the l i k e l i h o o d of admission to a mental h o s p i t a l , p a r t i c u l a r l y among people over 65. 65 who  Two-thirds o f people over  are i n mental h o s p i t a l s a r e s i n g l e , widowed or d i v o r c e d .  Work a t  the R u t h e r g l e n C o n s u l t a t i v e H e a l t h Centre i n d i c a t e s t h a t home v i s i t i n g t r a i n e d p e r s o n n e l improves  mental h e a l t h and p r e v e n t s  P r o v i d i n g c o u n s e l l i n g and support to those who emotional h e a l t h  (Anderson,  by  loneliness.  need i t ,  promotes s o c i a l  and  1976).  R e s u l t s of i n t r o d u c t i o n of p r e v e n t i v e h e a l t h s e r v i c e s i n i n d u s t r y , p r o v i d e f u r t h e r support f o r the p r o p o s i t i o n s r e g a r d i n g ease and q u a l i t y of contact.  Medical s t a f f  i n B e l l Canada, which has 40,000 employees, spent  an i n c r e a s i n g percentage of t h e i r time on p r e v e n t i v e s e r v i c e s e d u c a t i o n , c o u n s e l l i n g and assessment) between 1947 treatment of i l l n e s s and i n j u r i e s accounted visits;  and i n 1974,  changes,  work because i n 1948,  than f o r treatment.  were the f o l l o w i n g :  per cent i n 1970  each u n i t of p a y r o l l , dropped  In  1947,  In 1974  t h e r e were more  C o i n c i d e n t w i t h these  (1) the percentage of employees away from  of i l l n e s s each day dropped  to 2.2  and 1974.  f o r 70 per cent of employee  f o r 40 per cent of v i s i t s .  v i s i t s f o r h e a l t h promotion  (health  and  s i g n i f i c a n t l y from 3.2  per cent  (2) s i c k n e s s d i s a b i l i t y payments f o r  from $17.50 i n 1945  to $7.50 i n 1970.  A  c a u s a l link.between i n c r e a s e d a t t e n t i o n to h e a l t h e d u c a t i o n , c o u n s e l l i n g and assessment  and the above r e s u l t s cannot be e s t a b l i s h e d .  The r e s u l t s  suggest, however, t h a t ease and q u a l i t y of c o n t a c t between a person  and  the p r o v i d e r s of h e a l t h s e r v i c e s are important f a c t o r s i n the promotion health  (Robertson,  1973).  do  of  - 35 -  MEASUREMENT OF HEALTH Preventive health.  h e a l t h care  In order  maintaining  i s aimed at maintenance and improvement o f  t o determine the e f f e c t i v e n e s s of a program i n  o r improving h e a l t h , one needs t o i d e n t i f y t h e v a r i o u s  components good h e a l t h and i n d i c e s f o r measuring these.  The development o f  a h e a l t h index r e q u i r e s d e f i n i t i o n s o f h e a l t h t h a t can be t r a n s l a t e d i n t o o p e r a t i o n a l terms. Health  Many d e f i n i t i o n s o f h e a l t h , i n c l u d i n g t h a t o f t h e World  Organization,  a r e u n s a t i s f a c t o r y f o r measurement purposes because  they do n o t s p e c i f y c r i t e r i a f o r determining (Sheldon, 1968). multi-dimensional;  where h e a l t h begins or ends  One problem i n o p e r a t i o n a l i z i n g h e a l t h i s t h a t h e a l t h i s another, i s t h a t o f measuring t h e v a l u e  judgements  which draw the l i n e between h e a l t h and i l l n e s s . Development of a h e a l t h index i n v o l v e s i d e n t i f y i n g t h e dimensions o r . components o f h e a l t h and a s s i g n i n g weights t o each component. components a r e c o n s i d e r e d  t o be " i n d i c a t o r s " .  These  An index i s a d e r i v e d  measure which combines s e v e r a l i n d i c a t o r s ( L e r n e r , 1973).  According to  Hennes, a l t h o u g h numerous h e a l t h i n d i c e s have been developed "there  remains  today no widespread agreement on what t o measure or how t o measure, t o a s s e s s , h e a l t h i n t h e community" (1973, p. 1268).  Other o b s t a c l e s  development of i n s t r u m e n t s t o measure h e a l t h a r e s t a t i s t i c a l v a l i d i t y and s e n s i t i v i t y / a p p l i c a b i l i t y instruments, An  to the  reliability,  ( B a l i n s k y and Berger, 1975).  Most  f o r example, have o n l y s u p e r f i c i a l v a l i d a t i o n (Hennes, 1972).  index o f h e a l t h should  possess c e r t a i n c h a r a c t e r i s t s :  I t should be meaningful and u n d e r s t a n d a b l e , s e n s i t i v e , c l e a r , j u s t i f i a b l e and reasonable i n i t s assumptions. I t should be composed of c l e a r l y d e f i n e d components, c o n s i s t o f independent p a r t s ( I . e . , independent c o n t r i b u t i o n s t o t o t a l v a r i a n c e ) and i t should use data t h a t i s a v a i l a b l e or o b t a i n a b l e (Moriyama, 1968, p. 593).  - 36 C l a s s i f i c a t i o n of H e a l t h Health  Status  -  Indices  s t a t u s i n d i c e s can be  classified  as:  m o r t a l i t y based,  based or u n i f i e d m o r t a l i t y / m o r b i d i t y based i n d i c e s ( B a l i n s k y and  morbidity  Berger,  1975).  M o r t a l i t y Based  Indices  M o r t a l i t y based i n d i c e s are the t r a d i t i o n a l method of measuring h e a l t h . They u t i l i z e d a t a on age/sex a d j u s t e d  life  expectancies.  Underlying  this  method of measuring h e a l t h i s the assumption t h a t t h e r e i s a c l e a r r e l a t i o n s h i p between the m o r t a l i t y index and h e a l t h . and  increased  fatality  c o n t r o l over i n f e c t i o u s d i s e a s e s  from d i s e a s e .  increased.  The  prevalence  living  resulted i n reduction i n  of c h r o n i c d i s e a s e s ,  however,  M o r t a l i t y r a t e s consequently became i n s e n s i t i v e to c e r t a i n p a r t s  of the h e a l t h spectrum. data  R i s i n g standards of  A t t e n t i o n was  then d i r e c t e d to m o r b i d i t y  based  (Moriyama, 1968).  Morbidity  Based  Indices  "A m o r b i d i t y of w e l l n e s s Morbidity  index i s a measure of the p r e v a l e n c e  i n a given population"  ( B a l i n s k y and  of i l l n e s s or degree  Berger, 1975,  p.  286).  i n d i c e s are d e r i v e d from a number of v a r i a b l e s which are l e s s  e a s i l y d e f i n e d and measured than those comprising A morbidity  based index can,  p o t e n t i a l l y , be  of h e a l t h than a m o r t a l i t y index; but  the m o r t a l i t y  index.  a more s e n s i t i v e measurement  attempts at i s o l a t i n g and  v a r i a b l e s have encountered problems of ambiguity  ( B a l i n s k y and  defining Berger,  1975). V a r i a b l e s such as d i s a b i l i t y , have been used i n m o r b i d i t y  dysfunction,  indices.  t h r e e c a t e g o r i e s : c l i n i c a l evidence, laboratory tests;  a c t i v i t y and  These v a r i a b l e s can be such as symptoms and  s u b j e c t i v e evidence,  such as how  discomfort grouped i n t o  r e s u l t s of  the person f e e l s ;  and  - 37 behavioural  evidence,  such as absenteeism  ( B a l i n s k y and Berger, 1975).  Examples o f h e a l t h i n d i c e s which a r e fundamentally c l i n i c a l a r e the Kaiser-Permanente P a t i e n t Inventory C o r n e l l Medical  Questionnaire  (Garfield,  1970), the  Index (Brodman, e t a l . , 1949), the Mayo C l i n i c  Questionnaire  ( M a r t i n , e t a l . , 1969), and the K i s c h , e t a l . proxy measure ( K i s c h , e t a l . , 1969).  The C o r n e l l M e d i c a l  Index has been the most e x t e n s i v e l y  questionnaire  (Hennes, 1972).  196 q u e s t i o n s  t o which the i n d i v i d u a l answers yes o r no.  contains  questions  Berger, 1975).  I t i s s e l f - a d m i n i s t e r e d and c o n s i s t s of  on the presence of symptoms  e t c . ) , and q u e s t i o n s  utilized  on d e p r e s s i o n ,  anxiety  This  index  (respiratory, digestive,  and t e n s i o n  ( B a l i n s k y and  Abramson (1966) reviewed the v a l i d i t y o f the CMI and  found the t o t a l number o f p o s i t i v e responses to be a u s e f u l i n d i c a t o r of emotional h e a l t h .  The degree of emotional d i s t u r b a n c e  p o s i t i v e l y correlated with valuable  the t o t a l s c o r e .  i n d i c a t o r of general h e a l t h s t a t u s .  r e l a t e to p h y s i c a l h e a l t h o r to s p e c i f i c The  i n a group i s  T o t a l s c o r e on the CMI i s a The CMI does, however, not  diseases.  K i s c h , e t a l . proxy measure c o n t a i n s  four questions  regarding  days of h o s p i t a l i z a t i o n , drug usage, acute c o n d i t i o n s and c h r o n i c  conditions.  T h i s s e l f - a d m i n i s t e r e d q u e s t i o n n a i r e was p a r t i a l l y v a l i d a t e d a g a i n s t physician evaluations  ( K i s c h , e t a l . , 1969).  S e l f - a s s e s s m e n t s o f h e a l t h may r a i s e q u e s t i o n s these judgements. and  about the v a l i d i t y o f  There i s , however, a h i g h c o r r e l a t i o n  o b j e c t i v e assessments of the h e a l t h o f o l d e r p e o p l e .  between s u b j e c t i v e L e v e l s o f agreement  between s e l f - r a t i n g s and r a t i n g s of p h y s i c i a n s have been found to be approximately s e v e n t y - f i v e per cent and  (Friedsam  and M a r t i n ,  J e f f e r s , 1963; Maddox, 1962; Suchman, e t a l . , 1958).  1963; Heyman There i s a  tendency f o r people over seventy to g i v e themselves b e t t e r h e a l t h r a t i n g s than those under seventy  (Busse, 1966; Suchman, e t a l . , 1958).  Self-ratings  -  a r e s u b j e c t i v e responses;  38  they r e f l e c t  -  the i n d i v i d u a l ' s p e r c e p t i o n of h i s  c o n d i t i o n to a g r e a t e r e x t e n t than they r e f l e c t r e c e i p t of m e d i c a l care  ( T i s s u e , 1972).  i n c i d e n c e of d i s e a s e o r  The v a l u e of s e l f - r a t e d h e a l t h  should not, however, be d i s c o u n t e d ; a person's  f u n c t i o n a l c a p a c i t y may be  a f f e c t e d f a r more by h i s p e r c e p t i o n of h i s h e a l t h than by h i s  technical  m e d i c a l c o n d i t i o n (Rosow and B r e s l a n , 1966).  U n i f i e d Mortality/Morbidity Indices The  H e a l t h Problem Index (Q)  developed  S e r v i c e , the mathematical model developed  f o r the U.S. I n d i a n H e a l t h  by Chiang,  the index developed by  the North E a s t Ohio R e g i o n a l M e d i c a l Program and the u t i l i t y by Torrance,  combine m o r t a l i t y and m o r b i d i t y d a t a .  Index, age and sex a d j u s t e d s t a t i s t i c s  In the H e a l t h Problem  c o n s t i t u t e the m o r t a l i t y component.  Data oh h o s p i t a l days, d i s e a s e days and o u t p a t i e n t v i s i t s , ty component.  form the m o r b i d i -  A f i g u r e d e s c r i b i n g degree o f d i s a b i l i t y i s o b t a i n e d by  w e i g h t i n g m o r b i d i t y days.  There i s , however, no measure o f d i s a b i l i t y  as l i m i t a t i o n on a c t i v i t y l e v e l Miller  index proposed  ( B a l i n s k y and Berger,  19 75).  such  A c c o r d i n g to  (1970) there i s a c l o s e c o r r e l a t i o n between the Q v a l u e and r a t i n g s  based on p r o f e s s i o n a l judgements. Mathematical Chiang  models have been used i n the development of h e a l t h i n d i c e s .  (1965) combined measures of the frequency  of i l l n e s s ,  of i l l n e s s and m o r t a l i t y to produce a h e a l t h index.  the d u r a t i o n  A weakness of the  model i s i t s inadequacy i n d e f i n i n g l e v e l s of h e a l t h / i l l n e s s .  In h i s  index,  one day of u n h e a l t h i n e s s c o u l d be the r e s u l t of a c o l d o r v i r a l pneumonia ( B a l i n s k y and Berger,  1975).  Lawton, e t a l . (1967) used f a c t o r a n a l y s i s , another o r i e n t e d procedure,  i n d e v e l o p i n g a h e a l t h index.  mathematically  They attempted t o  i d e n t i f y a common s t r u c t u r e o r s e v e r a l common s t r u c t u r e s among t h i r t y  d i f f e r e n t indices of health  (e.g., number o f s i g n s l i s t e d by p h y s i c i a n ,  f u n c t i o n a l d i s a b i l i t y on a s i x p o i n t r a t i n g s c a l e , worry over h e a l t h on a four point r a t i n g s c a l e ) . 66.5  F o r males the f a c t o r s o l u t i o n accounted f o r  p e r cent of the t o t a l v a r i a n c e ;  f o r females i t accounted f o r 50.9  per c e n t .  Common f a c t o r s thus accounted f o r a r e l a t i v e l y  variance.  Lawton and h i s a s s o c i a t e s conclude t h a t  low amount of  the f a c t o r s t r u c t u r e o f i n d i c e s of h e a l t h i s q u i t e complex and we hope that t h i s study and o t h e r s w i l l put to r e s t the i d e a t h a t there i s a s i n g l e concept of h e a l t h which may e v e n t u a l l y be reduced t o an o p e r a t i o n a l d e f i n i t i o n (Lawton, et a l . , 1967, p. 340). E x i s t i n g i n d i c e s of m o r t a l i t y and m o r b i d i t y  assess  impact of changes  i n l i f e s t y l e , environment or h e a l t h care o r g a n i z a t i o n (Lalonde,  1974).  They tend,  too,  inadequately  to be i n s e n s i t i v e to changes i n s o c i a l ,  emotional and p h y s i c a l w e l l b e i n g as i d e n t i f i e d by the World Organization  (1958).  Increased  emphasis on p r e v e n t i o n  opposed to d i s e a s e ) has i n c r e a s e d  Health  and h e a l t h (as  the need f o r an index which measures  s o c i a l , emotional and p h y s i c a l h e a l t h  (Chambers and Segovia, 1978) .  S e v e r a l f e a t u r e s of h e a l t h can be i d e n t i f i e d :  freedom from symptoms,  p h y s i c a l h e a l t h , p h y s i c a l f u n c t i o n , s o c i a l and emotional h e a l t h . feature consists of q u a l i t a t i v e l y d i f f e r i n g f a c e t s ; qualitatively, distinct. one h e a l t h index (Davies, Sackett,  each f e a t u r e i s thus  They can t h e r e f o r e not be added o r combined i n t o 1975).  Chambers, e t a l . (1977) developed an instrument which  produces s e p a r a t e  i n d i c e s of s o c i a l ,  e m o t i o n a l and p h y s i c a l f u n c t i o n .  i s comprehensive and g e n e r a l l y a p p l i c a b l e .  I n i t i a l evaluations  instrument i n d i c a t e that i t possesses b i o l o g i c a l and c l i n i c a l I t i s , however, expensive to a d m i n i s t e r interviews.  Each  The r e l i a b i l i t y  of the  validity.  s i n c e i t i s designed f o r home  o f the index has y e t to be  It  assessed.  - 40 SUMMARY OF LITERATURE REVIEW Education  forms a v i t a l p a r t of those aspects  of p r e v e n t i v e  health  care which demand v o l u n t a r y b e h a v i o u r change on the p a r t of the i n d i v i d u a l . Health  education  can, b u t does not n e c e s s a r i l y , r e s u l t i n changes i n  b e h a v i o u r and improvement i n h e a l t h s t a t u s .  Numerous c u l t u r a l , s o c i a l and  i n d i v i d u a l f a c t o r s i n f l u e n c e the e f f e c t i v e n e s s of h e a l t h According  to the l i t e r a t u r e a person w i l l probably  education. engage i n the  advocated h e a l t h f u l b e h a v i o u r i f he c o n s i d e r s he may c o n t r a c t the i l l n e s s and  t h a t t h i s i l l n e s s w i l l have s e r i o u s r e s u l t s , i f he t h i n k s a c e r t a i n  course of a c t i o n w i l l be b e n e f i c i a l ,  i f t h e r e a r e no f i n a n c i a l o r psycho-  l o g i c a l b a r r i e r s and i f a cue t r i g g e r s some a c t i o n on h i s p a r t . there i s l i k e l y  to be b e h a v i o u r a l  the t a r g e t p o p u l a t i o n  change i f c u l t u r a l and s o c i a l f o r c e s i n  (such as how people change b e h a v i o u r s and b a r r i e r s to  change) have been taken i n t o account i n the p l a n n i n g several educational  Also,  techniques  i n the l e a r n i n g process forcement h e l p s m a i n t a i n  of the program, i f  a r e used, i f the p e r s o n i s a c t i v e l y  and there a r e m u l t i p l e c o n t a c t s . this behavioural  involved  Periodic rein-  change.  E m p i r i c a l s t u d i e s on the r o l e of ease and q u a l i t y of c o n t a c t  with  h e a l t h p r o f e s s i o n a l s i n promoting h e a l t h of i n d i v i d u a l s , a r e s c a r c e . A v a i l a b l e l i t e r a t u r e suggests t h a t these a r e important f a c t o r s i n h e a l t h promotion. those w i t h  Populations  a t r i s k of d e v e l o p i n g  emotional d i s t u r b a n c e a r e  p h y s i c a l d i s e a s e and those who l i v e a l o n e .  physical disease  The i n c i d e n c e o f  i n c r e a s e s a t the age o f 70 (Anderson, 1976).  older c i t i z e n s l i v e alone.  Numerous  One would thus a n t i c i p a t e t h a t h e a l t h  care  f o r o l d e r c i t i z e n s which i s a c c e s s i b l e , i n c l u d e s r e g u l a r home v i s i t s , provides  reassurance regarding  p h y s i c a l h e a l t h and has a h o l i s t i c  to i n d i v i d u a l h e a l t h , w i l l promote s o c i a l ,  approach  e m o t i o n a l and p h y s i c a l h e a l t h .  Maintenance and improvement of h e a l t h a r e the u l t i m a t e g o a l s o f  - 41 preventive h e a l t h care.  -  Determining how  e f f e c t i v e l y a program has  t a i n e d or improved h e a l t h r e q u i r e s i d e n t i f y i n g good h e a l t h and and m o r b i d i t y health.  i n d i c e s f o r measuring each component.  emphasis on h e a l t h , the need has  index which measures h e a l t h  (as opposed to d i s e a s e ) .  e m o t i o n a l h e a l t h are q u a l i t a t i v e l y d i s t i n c t Sackett,  IMPLICATIONS FOR  and  physical  emerged f o r an Physical, social  should be  and  measured  separately.  RESEARCH  would expect programs which emphasize h e a l t h e d u c a t i o n  a c c e s s i b i l i t y and with  I n d i c e s of m o r t a l i t y  Chambers et a l . (1977) developed an instrument which  measures these three dimensions of h e a l t h  One  components of  are i n s e n s i t i v e to changes i n s o c i a l , e m o t i o n a l and  With the new  separately.  the v a r i o u s  main-  q u a l i t y of c o n t a c t w i t h h e a l t h p e r s o n n e l  g r e a t e r h e a l t h and  and  to be  associated  lower h e a l t h c o s t s than programs which do  not  emphasize these f a c t o r s . Gradual d e t e r i o r a t i o n accompanies the aging p r o c e s s ; people have c h r o n i c d i s e a s e s . I t can  Health  i s a major concern of o l d e r p e o p l e .  t h e r e f o r e be argued that most o l d e r people w i l l  which promote h e a l t h to be b e n e f i c i a l . that t h e r e i s l i k e l y  to be  The  a cue  provide  i f such a d v i c e  cultural factors;  change.  The  literature  t h a t maintenance of or improvement i n h e a l t h w i l l be  i n times of c r i s i s .  The  final  and  suggests  enhanced i f  that the h e a l t h p r o f e s s i o n a l i s a c c e s s i b l e and  emotional support  is  i f there  i f the person i s a c t i v e l y i n v o l v e d i n l e a r n i n g  i s r e i n f o r c e d f o r e f f o r t s at b e h a v i o u r a l  the o l d e r person f e e l s  suggests  to t r i g g e r a c t i o n (e.g. i n the form of  based on assessment of i n d i v i d u a l , s o c i a l and  further,  actions  review of l i t e r a t u r e  encouragement from a h e a l t h p r o f e s s i o n a l ) ;  are m u l t i p l e c o n t a c t s ;  consider  improvement i n or maintenance of h e a l t h i f  the e l d e r l y person experiences a d v i c e and  and most e l d e r l y  t e s t , of  will  course,  - 42 i s whether r e s u l t a n t improvement i n or maintenance of h e a l t h i s r e f l e c t e d i n reduced h e a l t h  costs.  - 43 -  CHAPTER I I I  METHODOLOGY  T h i s chapter o u t l i n e s the methodology o f the study. s e t t i n g of the study and i d e n t i f i e s d e s c r i b e s sampling procedures d e s c r i b e s measuring  i t s purpose.  I t d e s c r i b e s the  I t s t a t e s the hypotheses,  and o u t l i n e s data c o l l e c t i o n p r o c e d u r e s .  instruments u t i l i z e d  It  i n the study and the way i n which  d a t a were a n a l y z e d .  SETTING OF STUDY N i c h o l s o n and Sunset Towers a r e B r i t i s h Columbia s e n i o r c i t i z e n s i n the West End o f Vancouver.  housing complexes f o r  The B r i t i s h Columbia  Housing  Management Commission p r o v i d e s sound, a f f o r d a b l e accommodation f o r low to moderate income c i t i z e n s who cannot private sector. out the p r o v i n c e .  f i n d s u i t a b l e accommodation i n the  There a r e 8,400 r e n t a l u n i t s i n 48 m u n i c i p a l i t i e s  through-  C r i t e r i a f o r admission to these d w e l l i n g s a r e a minimum  age of 65 and p h y s i c a l independence on the p a r t of the r e s i d e n t s . N i c h o l s o n Towers i s a s i n g l e complex w i t h 240 r e s i d e n t s . c o n s i s t s of two complexes residents.  Sunset  Towers  ( B u i l d i n g s A and B), each w i t h approximately 240  The t h r e e complexes a r e almost  i d e n t i c a l i n construction, with  c l o s e p r o x i m i t y to s t o r e s and access to p u b l i c t r a n s p o r t a t i o n . male to female r e s i d e n t s i n each complex i s 1:3. i n N i c h o l s o n Towers i s 78.76 and i n Sunset  The r a t i o o f  The mean age of r e s i d e n t s  Towers, 74.64.  Since 1974 s e n i o r c i t i z e n s i n these two complexes have r e c e i v e d d i f f e r e n t n u r s i n g programs, both o f which a r e p r o v i d e d by Home Care. Care i s funded by the P r o v i n c e of B.C. and i s a d m i n i s t e r e d through  Home  the C i t y  - 44 of Vancouver H e a l t h Department. and  Home Care i n c l u d e s a number of s e r v i c e s  programs which a s s i s t i n d i v i d u a l s to m a i n t a i n  independence a t home. hospitals;  maximal f u n c t i o n and  These s e r v i c e s a l l o w e a r l y d i s c h a r g e  from acute  they a l s o prevent h o s p i t a l i z a t i o n .  P r o v i s i o n of Home Care n u r s i n g s e r v i c e s to r e s i d e n t s of Sunset Towers i s a t the request and  of a physician.  a r e s i m i l a r to those p r o v i d e d  Conversely,  S e r v i c e s are mostly treatment  oriented,  i n other p a r t s o f the c i t y and p r o v i n c e .  the n u r s i n g program i n N i c h o l s o n  Towers i s an attempt to f i n d  an a l t e r n a t e way of d e l i v e r i n g h e a l t h c a r e to o l d e r p e o p l e .  This a l t e r n a t e  program has f o u r g o a l s : i n t e r v e n t i o n a t an e a r l y stage o f unwellness problems become severe; health habits; disease;  promotion of h e a l t h through e d u c a t i o n  before  about good  promotion o f h e a l t h and independence through e d u c a t i o n  monitoring  of chronic diseases  i n order  to m a i n t a i n  about  a stable  l e v e l of f u n c t i o n i n g .  PURPOSE OF STUDY The  study d e s c r i b e d below t e s t e d the c l a i m that h e a l t h knowledge,  h e a l t h b e h a v i o u r and h e a l t h s t a t u s of s e n i o r c i t i z e n s who r e c e i v e d nursing (through  s e r v i c e s which were a c c e s s i b l e and emphasized h e a l t h health education,  preventive  promotion  c o u n s e l l i n g and e a r l y d e t e c t i o n of d i s e a s e ) ,  would be s i g n i f i c a n t l y g r e a t e r and h e a l t h c o s t s s i g n i f i c a n t l y lower than those who r e c e i v e d n u r s i n g  s e r v i c e s which were l e s s a c c e s s i b l e and p l a c e d  l e s s emphasis on h e a l t h promotion.  HYPOTHESES The  n u r s i n g program a t N i c h o l s o n  Towers i n c o r p o r a t e s many o f the  f a c t o r s i d e n t i f i e d i n the l i t e r a t u r e as important and e f f e c t i v e i n promoting h e a l t h and r e d u c i n g incorporates  health costs.  The n u r s i n g program i n Sunset Towers  fewer of these f a c t o r s .  The main d i f f e r e n c e s between, the  - 45  -  programs are the i n c r e a s e d a c c e s s i b i l i t y of the nurses i n N i c h o l s o n and  the g r e a t e r amount of h e a l t h e d u c a t i o n  and  Towers  c o u n s e l l i n g which i s done  there. Research f i n d i n g s r e l a t e d to h e a l t h e d u c a t i o n c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s , l e a d one  and  ease and  q u a l i t y of  to expect c e r t a i n outcomes.  One  would a n t i c i p a t e the g r e a t e r amount of h e a l t h e d u c a t i o n  and  increased  a c c e s s i b i l i t y of nurses i n N i c h o l s o n  and  counselling  Towers to accomplish  c e r t a i n t h i n g s : prevent the development of c e r t a i n h e a l t h problems; i n t e r v e n t i o n at an e a r l y stage of unwellness; knowledge and  r e s u l t i n increased  allow health  improved h e a l t h b e h a v i o u r s and h e a l t h s t a t u s .  Hypothesis 1: H e a l t h knowledge, health.. b e h a v i o u r and h e a l t h of s e n i o r c i t i z e n s i n N i c h o l s o n  Towers w i l l be  status  s i g n i f i c a n t l y greater  than  t h a t of s e n i o r c i t i z e n s i n Sunset Towers. One  would expect that as a r e s u l t o f ^ i n c r e a s e d a c c e s s i b i l i t y of nurses  i n Nicholson  Towers, h o s p i t a l i z a t i o n of some r e s i d e n t s i s prevented  (because the problem i s d e a l t w i t h b e f o r e necessary p h y s i c i a n v i s i t s by  the n u r s e ) .  are prevented  i t becomes a c r i s i s ) and  (because the problem i s d e a l t w i t h  Because s e n i o r c i t i z e n s i n N i c h o l s o n  r e g u l a r b a s i s , nurses are a b l e to monitor m e d i c a t i o n example, a b l e necessary by t i o n with  the p h y s i c i a n ) .  zations, physician v i s i t s  One  use.  and  to be  average h e a l t h  Hypothesis 2: Over an e i g h t month p e r i o d , related v i s i t s  made by  include v i s i t s  hospitali-  r e f l e c t e d i n reduced costs.  the average number of h e a l t h  or to r e s i d e n t s of N i c h o l s o n  be s i g n i f i c a n t l y lower i n N i c h o l s o n  than  (in consulta-  would a n t i c i p a t e reduced number of use  a  They a r e , f o r  of a c e r t a i n m e d i c a t i o n  and m e d i c a t i o n  number of h e a l t h r e l a t e d v i s i t s  visits  Towers are seen on  to prevent r e s i d e n t s from t a k i n g m e d i c a t i o n s l o n g e r advising discontinuance  un-  and  Sunset Towers w i l l  than i n Sunset Towers.  to g e n e r a l p r a c t i t i o n e r s , s p e c i a l i s t s ,  Health  related  paramedical  - 46 personnel  ( p h y s i o t h e r a p i s t s , p o d i a t r i s t s and c h i r o p r a c t o r s ) ,  laboratories,  h o s p i t a l s and n u r s e s . Hypothesis 3: Over an e i g h t month p e r i o d , average c o s t s of a l l h e a l t h s e r v i c e s p r o v i d e d to r e s i d e n t s of N i c h o l s o n and Sunset Towers w i l l significantly  lower i n N i c h o l s o n than i n Sunset Towers.  s e r v i c e s i n c l u d e c o s t s of v i s i t s  be  Costs of h e a l t h  to g e n e r a l p r a c t i t i o n e r s ,  specialists,  paramedical p e r s o n n e l , l a b o r a t o r i e s , h o s p i t a l s and c o s t s of p o s t - o p e r a t i v e visits  and m e d i c a t i o n .  Approximately  50 r e s i d e n t s i n each b u i l d i n g are e l i g i b l e f o r admission  to Long Term Care i n s t i t u t i o n s  ( M i n i s t r y o f H e a l t h , 1978).  T h i s means  t h a t they r e q u i r e a s s i s t a n c e w i t h c e r t a i n a s p e c t s of housekeeping ( i . e . c l e a n i n g , cooking and s h o p p i n g ) .  The c o s t of c a r i n g f o r someone i n a Long  Term Care i n s t i t u t i o n i s s i g n i f i c a n t l y h i g h e r than the c o s t of a d a i l y or weekly v i s i t by a Home Care n u r s e . accessibility  One would expect the i n c r e a s e d  of nurses i n N i c h o l s o n Towers to a l l o w a l a r g e r number of such  i n d i v i d u a l s to remain i n the complex (and not be admitted to a Long Term Care  institution). Hypothesis 4: Of those r e s i d e n t s e l i g i b l e f o r Long Term Care, a  significantly  g r e a t e r percentage i n N i c h o l s o n than i n Sunset Towers, w i l l  •consider t h a t they are a b l e to c o n t i n u e l i v i n g i n the apartment  because  nurses are a c c e s s i b l e .  DIFFERENCES BETWEEN NURSING SERVICES The main d i f f e r e n c e s between the n u r s i n g s e r v i c e s a t N i c h o l s o n Towers and Sunset Towers are the i n c r e a s e d a c c e s s i b i l i t y  of the nurses i n N i c h o l -  son Towers and the g r e a t e r amount of h e a l t h e d u c a t i o n and which i s done t h e r e .  counselling  - 47 Accessibility The bility  r e s i d e n t s o f both N i c h o l s o n and Sunset Towers have h i g h  to h e a l t h care s e r v i c e s .  accessi-  Both a r e covered by the M e d i c a l S e r v i c e s  P l a n of B r i t i s h Columbia and a r e e l i g i b l e f o r a f r e e p r e s c r i p t i o n program.  Residents  drug  o f both complexes have t h e i r own f a m i l y d o c t o r s .  When r e s i d e n t s o f Sunset Towers r e q u i r e Home Care n u r s i n g s e r v i c e s , a doctor requests t h i s s e r v i c e ,  the Home Care nurse  comes to the b u i l d i n g ,  p r o v i d e s the s e r v i c e and then l e a v e s the b u i l d i n g . charged  The r e s i d e n t i s d i s -  from the s e r v i c e as soon as p o s s i b l e , because t h e r e i s a d m i n i s t r a -  t i v e p r e s s u r e to see r e s i d e n t s no l o n g e r than a b s o l u t e l y n e c e s s a r y .  Nurse  turnover may occur as o f t e n as every s i x months, which reduces c o n t i n u i t y . At N i c h o l s o n Towers, two nurses  are o f f i c e d  s i x hours a day t h e r e , f i v e days a week.  i n the b u i l d i n g and spend  Nurses would d i s c o n t i n u e s e e i n g a  h y p e r t e n s i v e r e s i d e n t i n Sunset Towers a f t e r two o r three months.  In  N i c h o l s o n Towers the nurses would c o n t i n u e to see him on a r e g u l a r b a s i s to monitor  h i s h e a l t h and to educate him r e g a r d i n g f a c t o r s r e l a t e d  t e n s i o n , thereby p r e v e n t i n g f u t u r e problems. o f t e n , thus  t h e r e i s more c o n t i n u i t y .  o f f i c e , by telephone,  The nurses  The nurses  o r i n the hallway  to hyper-  are replaced less  can be c o n t a c t e d a t the  and a r e thus p e r c e i v e d as h i g h l y  accessible. According  to the nurses  i n N i c h o l s o n Towers, the g r e a t e r a c c e s s i b i l i t y  of the nurses  s h o u l d produce the f o l l o w i n g e f f e c t s .  secure;  those who a r e seen r e g u l a r l y by the nurses, and those who a r e  not.  both  The r e s i d e n t s f i n d comfort  f e e l more  i n knowing t h a t , s h o u l d h e a l t h problems  a r i s e , t h e r e a r e knowledgeable people problems.  Residents  i n the b u i l d i n g  The nurses a r e a b l e to prevent  to d e a l w i t h  such  c e r t a i n problems from d e v e l o p i n g .  They may, f o r example, be requested by one r e s i d e n t to check on another resident.  The nurses  e i t h e r a t t e n d to the problem themselves o r recommend  - 48 a visit  to a doctor.  The nurses a r e a b l e to s c r e e n h e a l t h problems of the  r e s i d e n t s , thereby p r e v e n t i n g unnecessary v i s i t s  to the d o c t o r , or  f a c i l i t a t i n g e a r l y treatment of the c o n d i t i o n by a d v i s i n g an immediate appointment  w i t h the d o c t o r .  acute c o n d i t i o n  The nurses a r e a b l e to v i s i t  someone w i t h an  (e.g., i n f e c t i o n ) as o f t e n as t h r e e times a day.  would not be p o s s i b l e i n Sunset Towers. nursing services;  This  There i s h i g h e r u t i l i z a t i o n o f  f o r example, i n t e r v e n t i o n to prevent problems and  s c r e e n i n g o f problems as mentioned. Some r e s i d e n t s approach problems.  the nurses f o r r e a s s u r a n c e r e g a r d i n g h e a l t h  T h i s cannot be viewed  as unnecessary  contact.  The r e a s s u r a n c e  may take o n l y two minutes, but i t s p s y c h o l o g i c a l v a l u e to the r e s i d e n t may be immeasurable. death.  There a r e many f e a r s r e l a t e d  to aging and approaching  A n y t h i n g t h a t h e l p s a l l a y these f e a r s c o n t r i b u t e s to e m o t i o n a l  h e a l t h and may d i f f u s e to s o c i a l and p h y s i c a l h e a l t h . One  advantage  of the c o n t i n u i t y of the nurses i n N i c h o l s o n Towers, i s  t h a t the nurses get to know the r e s i d e n t s v e r y w e l l , a r e f a m i l i a r w i t h  their  unique d i f f i c u l t i e s and e x a c t l y what was d e a l t w i t h i n the most r e c e n t visit.  Remembering unique p e r s o n a l i n f o r m a t i o n about a r e s i d e n t t r a n s m i t s  to him a f e e l i n g o f genuine  concern about him.  The nurses a r e a b l e to  r e i n f o r c e r e l e v a n t b e h a v i o u r s and ask p e r t i n e n t q u e s t i o n s . e a s i l y done when i n f o r m a t i o n r e g a r d i n g the l a s t v i s i t  This i s less  i s t r a n s m i t t e d from  one nurse to the next i n the form of p r o g r e s s n o t e s , which i s o f t e n the case i n Sunset  Towers.  Health Education The second d i f f e r e n c e between the two apartment  complexes i s that  r e s i d e n t s i n N i c h o l s o n Towers r e c e i v e a f a r g r e a t e r amount of h e a l t h t i o n than do those i n Sunset Towers.  educa-  In r e c e n t months, h e a l t h i n f o r m a t i o n  - 49 has been posted on the b u l l e t i n Towers.  board  H e a l t h e d u c a t i o n i s , however, done c h i e f l y on an i n d i v i d u a l b a s i s .  I n d i v i d u a l needs a r e thus c o n s i d e r e d . problems r e g u l a r l y . resident, with The nurse  listens  There i s a c o n t i n u a l d i a l o g u e between the nurse and  to what the r e s i d e n t says and responds to the l i f e s t y l e How much c o n t a c t does he have w i t h o t h e r people?  o f t e n does he g e t out o f the b u i l d i n g ? it?  Nurses see r e s i d e n t s w i t h h e a l t h  the r e s i d e n t b e i n g a c t i v e l y i n v o l v e d i n the l e a r n i n g p r o c e s s .  of the r e s i d e n t .  prepare  i n the main lobby a t N i c h o l s o n  The nurse educates  How  What does he e a t and how does he  the r e s i d e n t r e g a r d i n g the management of  h i s p a r t i c u l a r h e a l t h problems, and a l s o r e g a r d i n g f a c t o r s  (such as d i e t ,  p h y s i c a l e x e r c i s e and s o c i a l c o n t a c t ) which a r e known to be p a r t i c u l a r l y important  i n promoting the h e a l t h of e l d e r l y  Because the nurses  people.  i n N i c h o l s o n Towers see t h e r e s i d e n t s r e g u l a r l y ,  they a r e a b l e to r e i n f o r c e the e d u c a t i o n a t r e g u l a r i n t e r v a l s , changes i n b e h a v i o u r  monitor  and h e a l t h s t a t u s and g i v e support and r e i n f o r c e m e n t  f o r e f f o r t s a t b e h a v i o u r a l change.  The a c c e s s i b i l i t y o f the nurses  r e s i d e n t s to c o n t a c t them r e g a r d i n g h e a l t h q u e s t i o n s . c o n s t i t u t e " t e a c h a b l e moments"; l e a r n makes him p a r t i c u l a r l y  Such c o n t a c t s  moments when the person's  r e c e p t i v e to e d u c a t i o n  In Sunset Towers, the Home Care nurses  r e a d i n e s s to  (Knowles, 1970).  p r o v i d e h e a l t h e d u c a t i o n on an  i n d i v i d u a l b a s i s to r e s i d e n t s whom they v i s i t .  The percentage  of r e s i d e n t s  r e c e i v i n g Home Care n u r s i n g s e r v i c e s a t any one time i s much lower Towers (4 p e r cent) than i n N i c h o l s o n Towers (31 p e r c e n t ) . e d u c a t i o n thus occurs here  allows  than i n N i c h o l s o n Towers.  i n Sunset  Less h e a l t h  I n a d d i t i o n , i n Sunset  Towers t h e r e i s l e s s c o n t i n u i t y of n u r s e s , l e s s a c c e s s i b i l i t y and t h e r e a r e fewer c o n t a c t s w i t h each r e s i d e n t .  There a r e thus fewer o p p o r t u n i t i e s t o  r e i n f o r c e e d u c a t i o n a l p o i n t s , to r e i n f o r c e e f f o r t s a t b e h a v i o u r a l change and to use t e a c h a b l e moments.  - 50 Counselling The t h i r d d i f f e r e n c e between the two apartment  complexes,  i s the  g r e a t e r amount of c o u n s e l l i n g which o c c u r s i n N i c h o l s o n Towers.  Home Care  nurses i n both complexes spend f a r l e s s time c o u n s e l l i n g than e d u c a t i n g ; c o u n s e l l i n g does thus not c o n s t i t u t e a major p a r t of t h e i r j o b s .  Counsel-  l i n g c a n be d i s t i n g u i s h e d from h e a l t h e d u c a t i o n i n t h a t i t i s s u p p o r t i v e and t h e r a p e u t i c , and not aimed a t v o l u n t a r y changes i n h e a l t h b e h a v i o u r (Green,  1978).  Nurses at  i n N i c h o l s o n Towers p r o v i d e r e s i d e n t s w i t h emotional support  times when t h i s i s needed;  (e.g., when t h e r e i s a disagreement w i t h  r e l a t i v e s , o r when a spouse d i e s ) . and a c c e s s i b i l i t y of n u r s e s . fewer r e s i d e n t s a r e seen;  I n Sunset Towers t h e r e i s l e s s  continuity  There a r e fewer c o n t a c t s w i t h each p e r s o n and  thus t h e r e i s l e s s  counselling.  D i f f e r e n c e s between the n u r s i n g programs and expected c o s t s and b e n e f i t s o f programs a r e summarized i n T a b l e 4, page 51.  SAMPLING At  t h e time of the study  (August-September,  1978), of the 240 r e s i -  dents i n N i c h o l s o n Towers, 75 (31 p e r cent) were b e i n g seen by the nurses on a r e g u l a r b a s i s ;  47 a d d i t i o n a l i n d i v i d u a l s  (19 p e r c e n t ) had been seen  by the nurses a t some time d u r i n g the p r e c e d i n g two y e a r s , b u t not i n the month p r e c e d i n g the study; nursing services. 10  118 r e s i d e n t s  (50 p e r cent) had never  received  Of the 244 r e s i d e n t s i n Sunset Towers ( B u i l d i n g A ) ,  (4 p e r c e n t ) were b e i n g seen by a nurse from Home Care: 45 i n d i v i d u a l s  (19 p e r c e n t ) had r e c e i v e d Home Care n u r s i n g s e r v i c e s a t some time i n t h e p r e c e d i n g two y e a r s , b u t not i n the p r e c e d i n g month;  186 i n d i v i d u a l s (77  per cent) had never r e c e i v e d n u r s i n g s e r v i c e s . To ensure t h a t i n d i v i d u a l s who were r e c e i v i n g n u r s i n g s e r v i c e s a t the  - 51 -  TABLE 4. COMPARISON OF EXPECTED COSTS AND BENEFITS OF NURSING PROGRAMS  Nursing  Variable  Programs  D i f f e r e n c e s between n u r s i n g programs A c c e s s i b i l i t y of nurses  N i c h o l s o n Towers  ^  Sunset Towers  Amount of h e a l t h e d u c a t i o n which occurs  N i c h o l s o n Towers  ^>  Sunset Towers  Amount o f c o u n s e l l i n g which  N i c h o l s o n Towers  Sunset Towers  N i c h o l s o n Towers  Sunset Towers  Cost o f p h y s i c i a n v i s i t s  N i c h o l s o n Towers  Sunset Towers  Cost o f h o s p i t a l i z a t i o n  N i c h o l s o n Towers  Sunset Towers  Cost of m e d i c a t i o n s  N i c h o l s o n Towers  Sunset Towers  Number of p h y s i c i a n v i s i t s  N i c h o l s o n Towers  Sunset Towers  Number o f days o f h o s p i t a l i z a t i o n  Nicholson  Towers  Sunset Towers  Number o f p r e s c r i b e d m e d i c a t i o n s per person  N i c h o l s o n Towers  Sunset Towers  Number of i n d i v i d u a l s e l i g i b l e f o r Long Term Care who c o n s i d e r they are a b l e t o c o n t i n u e l i v i n g i n apartment because nurses a r e accessible  N i c h o l s o n Towers  Sunset Towers  H e a l t h knowledge of i n d i v i d u a l s  Nicholson  Towers  Sunset Towers  Health behaviour of i n d i v i d u a l s  N i c h o l s o n Towers  Sunset Towers  P h y s i c a l f u n c t i o n of i n d i v i d u a l s  N i c h o l s o n Towers  Sunset  Emotional f u n c t i o n o f i n d i v i d u a l s  N i c h o l s o n Towers  Sunset Towers  S o c i a l f u n c t i o n of i n d i v i d u a l s  N i c h o l s o n Towers  Sunset Towers  F e e l i n g s o f s e c u r i t y and b e n e f i t from presence o f n u r s e s  N i c h o l s o n Towers  Sunset Towers  occurs  Expected c o s t s Cost o f n u r s e s '  visits  Expected b e n e f i t s  Towers  - 52 time of the study were adequately  and those who had r e c e i v e d n u r s i n g s e r v i c e s i n the p a s t ,  represented,  a sample of i n d i v i d u a l s i n each complex was  randomly s e l e c t e d from each of three c a t e g o r i e s .  The c a t e g o r i e s were the  f o l l o w i n g : i n d i v i d u a l s r e c e i v i n g n u r s i n g s e r v i c e s a t the time of the study; i n d i v i d u a l s who had r e c e i v e d n u r s i n g s e r v i c e s i n the two year p e r i o d p r e ceding  the study but not i n the month p r e c e d i n g  the study;  individuals  who had never r e c e i v e d n u r s i n g s e r v i c e s . So t h a t s i m i l a r p r o p o r t i o n s of i n d i v i d u a l s i n each of the t h r e e c a t e g o r i e s i n N i c h o l s o n and Sunset Towers were i n t e r v i e w e d , o n l y  individuals  i n N i c h o l s o n Towers and i n d i v i d u a l s i n B u i l d i n g A of Sunset Towers (and not  those  i n B u i l d i n g B) were i n t e r v i e w e d .  exception.  There was, however, one s m a l l  A s m a l l number of r e s i d e n t s (ten) i n B u i l d i n g A of Sunset  Towers was r e c e i v i n g n u r s i n g s e r v i c e s a t the time of the study.  The t h r e e  i n d i v i d u a l s i n B u i l d i n g B of Sunset Towers who were r e c e i v i n g n u r s i n g s e r v i c e s , were thus  i n c l u d e d i n the study.  Since t h e r e was no known  d i f f e r e n c e s between i n d i v i d u a l s i n B u i l d i n g s A and B of Sunset Towers, i n c l u s i o n of these i n d i v i d u a l s was not expected of the study  i n any way.  to i n f l u e n c e the outcome  Sample and p o p u l a t i o n s i z e s are shown i n Table 5.  DATA COLLECTION Introduction A summary of v a r i a b l e s measured and method of measurement i s p r e s e n t e d i n T a b l e 6.  Measurements f a l l  i n t o f o u r c a t e g o r i e s : b i o g r a p h i c a l data,  d i f f e r e n c e s between n u r s i n g programs, c o s t s and expected n u r s i n g programs. nursing charts;  b e n e f i t s of  Data were c o l l e c t e d from three s o u r c e s : nurses  Medical  S e r v i c e s P l a n of B.C. and Pharmacare;  and  and  r e s i d e n t s i n the sample themselves. The  f o l l o w i n g data were c o l l e c t e d from Home Care nurses  i n each  - 53 -  TABLE 5 HEALTH COMPARISONS OF TWO RESIDENTIAL  Nicholson Sample Size  Towers  Population Size  GROUPS  Sunset Towers Sample Size  Population Size  Receiving nursing s e r v i c e s a t time o f study  30  75  13  13  Received n u r s i n g s e r v i c e s i n two year period preceding study b u t n o t i n month p r e c e d i n g study  15  47  17  45  Never r e c e i v e d nursing services  20  118  29  186  Total  65  240  59  244  - 54 TABLE 6 VARIABLES MEASURED AND METHOD OF MEASUREMENT  Variable  D i f f e r e n c e s Between Nursing Programs Accessibility Health education  Counselling  Biographical Information Sex Age Marital status Years of s c h o o l i n g Socio-economic status Number of l i f e change u n i t s Number of m e d i c a l conditions Eligibility for Long Term Care Number and Costs o f Health Related V i s i t s Number of v i s i t s t o : GP, s p e c i a l i s t s , paramedical personnel, laboratories, hospitals Number o f v i s i t s t o nurses Costs i n d o l l a r s o f v i s i t s to hospitals GPs, s p e c i a l i s t s , paramedical personnel, laboratories, postoperative v i s i t s Cost o f n u r s i n g visits Cost o f m e d i c a t i o n Expected B e n e f i t s H e a l t h knowledge H e a l t h behaviours Physical function Emotional f u n c t i o n Social function Residents e l i g i b l e f o r Long Term Care who c o n s i d e r they can continue l i v i n g i n a complex because nurses a r e accessible Feeling of security from presence of nurses  Measurement o f V a r i a b l e  Source o f Data  Questions r e how e a s i l y nurses can be contacted. Mean number o f hours spent by nurses w i t h r e s i d e n t s per month, m u l t i p l i e d by percentage of time spent e d u c a t i n g . Question r e whether r e s i d e n t has ever t a l k e d t o the nurse when w o r r i e d about a p e r s o n a l or f a m i l y problem.  Residents Nurses  Item completed by i n t e r v i e w e r . Question r e . age. Question r e . m a r i t a l s t a t u s . Question r e . years o f s c h o o l i n g . B l i s h e n O c c u p a t i o n a l Rating S c a l e .  Residents Residents Residents Residents Residents  S o c i a l Readjustment S c a l e (Holmes & Rahe).  Residents  Questions on presence or absence of particular conditions.  Residents  Residents  Nurses  Medical Services Plan of B.C.  Nursing charts Medical Services P l a n of B.C.  $20.  per v i s i t .  Home Care Pharmacare  Questions based on i n f o r m a t i o n taught by nurses i n N i c h o l s o n Towers. Questions r e . h e a l t h behaviours. Physical function scale. Emotional f u n c a t i o n s c a l e . Social function scale. Question t o r e s i d e n t s e l i g i b l e f o r l o n g term care r e whether they c o u l d continue l i v i n g i n complex i f nurses were not a c c e s s i b l e .  Question r e . presence o f nurses i s a s s o c i a t e d with g r e a t e r f e e l i n g s of s e c u r i t y  Residents Residents Residents Residents Residents Residents  Residents  - 55 b u i l d i n g : amount o f h e a l t h e d u c a t i o n month;  which occurs  which i n d i v i d u a l s were e l i g i b l e  Home Care n u r s i n g v i s i t s  i n each complex; per  f o r Long Term Care;  number of  t o i n d i v i d u a l s i n the sample f o r the p e r i o d  January 1 to August 31, 1978. The M e d i c a l  S e r v i c e s P l a n o f B.C. and Pharma-  care s u p p l i e d data on number and c o s t of a l l h e a l t h s e r v i c e s and c o s t of medication  f o r r e s i d e n t s i n the sample f o r the time p e r i o d January 1 to  August 31, 1978. Data c o l l e c t e d from r e s i d e n t s i n a s t r u c t u r e d i n t e r v i e w measured h e a l t h knowledge; haviours;  health status;  sources of h e a l t h i n f o r m a t i o n ; p e r c e i v e d b e n e f i t of nurses;  (Appendix)" health be-  and v a r i a b l e s  i d e n t i f i e d i n the l i t e r a t u r e as r e l a t e d to h e a l t h knowledge and h e a l t h status.  Health  knowledge was measured by q u e s t i o n s  taught to r e s i d e n t s by nurses i n N i c h o l s o n  Towers.  based on i n f o r m a t i o n Health  s t a t u s was  measured u s i n g adapted v e r s i o n s of s c a l e s o f p h y s i c a l , emotional and s o c i a l f u n c t i o n developed by S a c k e t t ,  Chambers e t a l . (Chambers & Segovia, 1978).  V a r i a b l e s r e l a t e d to h e a l t h s t a t u s and h e a l t h c o s t s measured i n t h i s were sex,  age, years  of s c h o o l i n g , socio-economic s t a t u s , number o f  m e d i c a l c o n d i t i o n s and number o f l i f e Occupational  Rating  study  change u n i t s .  Blishen's  (1967)  S c a l e was used to measure socio-economic s t a t u s .  The  S o c i a l Re-adjustment S c a l e developed by Holmes & Rahe (1967) was used to measure l i f e  changes.  Data c o l l e c t i o n from each of the above sources i s d i s c u s s e d in  i n detail  the f o l l o w i n g s e c t i o n .  Data from Home Care Nurses Amount o f h e a l t h e d u c a t i o n which occurs (1) by determining in  i n each complex was measured  the mean number o f hours spent by nurses w i t h  residents  each b u i l d i n g p e r month and (2) by a s k i n g nurses i n each b u i l d i n g to  - 56 estimate  what percentage o f t h e i r time i s spent e d u c a t i n g .  Multiplication  of these f i g u r e s produced the approximate number of hours spent on h e a l t h education  i n each b u i l d i n g p e r month.  Information  r e g a r d i n g which  v i d u a l s were e l i g i b l e f o r Long Term Care was a l s o o b t a i n e d as were the number o f n u r s i n g v i s i t s  indi-  from the n u r s e s ,  to each i n d i v i d u a l f o r the time  p e r i o d January 1 - August 31, 1978. The Home Care O f f i c e p r o v i d e d  informa-  t i o n t h a t each v i s i t by a Home Care nurse c o s t s a p p r o x i m a t e l y $20.  Data from M e d i c a l The M e d i c a l  S e r v i c e s P l a n and Pharmacare S e r v i c e s P l a n o f B r i t i s h Columbia s u p p l i e d d a t a on numbers  and  c o s t s of v i s i t s  and  l a b o r a t o r i e s f o r the time p e r i o d January 1 - August 31, 1978. Data on  c o s t of m e d i c a t i o n  Data from  to h o s p i t a l s , G.P.s, s p e c i a l i s t s , p a r a m e d i c a l  f o r the same time p e r i o d were o b t a i n e d  from Pharmacare.  Residents  Some i n f o r m a t i o n Therefore The  personnel  c o u l d be o b t a i n e d  only from r e s i d e n t s p e r s o n a l l y .  a q u e s t i o n n a i r e was designed s p e c i f i c a l l y  f o r t h i s purpose.  q u e s t i o n n a i r e was developed to determine h e a l t h knowledge, h e a l t h be-  haviours,  h e a l t h s t a t u s , p e r c e i v e d b e n e f i t of the nurses and v a r i a b l e s  known to be r e l a t e d to h e a l t h knowledge and h e a l t h The  status.  q u e s t i o n n a i r e was p r e t e s t e d on t e n r e s i d e n t s who were n o t p a r t of  the p o p u l a t i o n  ( i . e . r e s i d e n t s o f Sunset Towers, B u i l d i n g B).  C l a r i t y of  questions,  responses to q u e s t i o n s  assessed.  Adjustments i n the q u e s t i o n n a i r e were made a c c o r d i n g l y .  A sample s t r a t i f i e d  according  from each df the two b u i l d i n g s . of the study by l e t t e r .  and l e n g t h of i n t e r v i e w were thereby  to l e v e l of n u r s i n g  I n d i v i d u a l s i n the sample were n o t i f i e d  They were then c o n t a c t e d  t h e i r w i l l i n g n e s s to p a r t i c i p a t e i n the study; i n t e r v i e w were s e t .  s e r v i c e was drawn  by telephone  regarding  the date and time o f the  F o r each i n d i v i d u a l who r e f u s e d  to p a r t i c i p a t e i n the  - 57 study,  a replacement was  -  randomly drawn from the a p p r o p r i a t e sample.  i n d i v i d u a l s approached, 14 i n d i v i d u a l s r e f u s e d to p a r t i c i p a t e i n the The  number of people i n t e r v i e w e d was One  study.  124.  I n d i v i d u a l s were Interviewed  apartments i n a 40 minute s t r u c t u r e d s c h e d u l e . plexes were i n t e r v i e w e d  each day  to q u e s t i o n s were entered f e r r e d onto coding  ledge;  to c o n t r o l f o r e f f e c t s of time.  (Appendix) %'> was  of h e a l t h i n f o r m a t i o n ;  designed  Responses  subsequently  trans-  to measure h e a l t h know-  and v a r i a b l e s i d e n t i f i e d  s e c t i o n of the i n t e r v i e w schedule  I t was  and  h e a l t h behaviours;  as r e l a t e d to h e a l t h knowledge and h e a l t h s t a t u s .  Health  own  sheets.  questionnaire sources  in their  I n d i v i d u a l s i n both com-  on the i n t e r v i e w sheet  p e r c e i v e d b e n e f i t of nurses;  health status;  i n the  literature  A d i s c u s s i o n of each  follows.  knowledge necessary  to develop an instrument  to measure h e a l t h knowledge.  Questions to measure h e a l t h knowledge were based on i n f o r m a t i o n taught r e s i d e n t s by nurses i n N i c h o l s o n Towers. ledge s c a l e i s d e s c r i b e d l a t e r i n t h i s  Sources  of health  chapter.  information  asked to i d e n t i f y from whom or what he/she f i r s t  tion.  The  c a l c u l a t e d by  s t a t e d that source, by answered  individual  learned this  p r o p o r t i o n of h e a l t h i n f o r m a t i o n an i n d i v i d u a l o b t a i n e d  each source was  correctly.  to  Development of the h e a l t h know-  For each h e a l t h knowledge q u e s t i o n c o r r e c t l y answered, the was  138  i n t e r v i e w e r conducted a l l the i n t e r v i e w s over a f o u r week p e r i o d  (August-September, 1978).  The  Of  dividing  the number of times an  informafrom  individual  the number of h e a l t h knowledge q u e s t i o n s  he/she  - 58 -  Health  behaviours  Fourteen h e a l t h knowledge q u e s t i o n s regarding health behaviour. health behaviours. scored "0".  "1";  had a corresponding  question  The i n d i v i d u a l was asked to i d e n t i f y  his/her  Answers i n d i c a t i n g engagement i n h e a l t h y b e h a v i o u r were  those i n d i c a t i n g engagement i n unhealthy b e h a v i o u r were  scored  An i n d i v i d u a l ' s h e a l t h b e h a v i o u r s c o r e was c a l c u l a t e d by d i v i d i n g  h i s / h e r t o t a l number of h e a l t h y b e h a v i o u r s by the number of h e a l t h behaviour  questions  Perceived  a p p l i c a b l e to him/her.  benefit  of nurses  Questions were designed to measure p e r c e i v e d b e n e f i t and f e e l i n g s of s e c u r i t y from the presence of n u r s e s . rating scale.  Responses were scored  P o s i t i v e responses were s c o r e d  on a  "3", and n e g a t i v e  3-point  responses  "1".  Variables  related  to health  knowledge  and health  status  Other data c o l l e c t e d i n c l u d e d v a r i a b l e s i d e n t i f i e d i n the l i t e r a t u r e as r e l a t e d to h e a l t h knowledge and h e a l t h s t a t u s . t h i s study were sex, age, m a r i t a l s t a t u s , years  The v a r i a b l e s used i n  of s c h o o l i n g ,  employment,  number of m e d i c a l c o n d i t i o n s , socio-economic s t a t u s and number of l i f e change u n i t s . Medical  c o n d i t i o n s i n c l u d e d i n the q u e s t i o n n a i r e were (1) c o n d i t i o n s  i d e n t i f i e d as c h i e f causes of h o s p i t a l i z a t i o n of persons over 65 i n Canada (Rombout, 1975) and (2) c o n d i t i o n s i d e n t i f i e d as major reasons f o r r e c e i p t (by o l d e r people) of Home Care n u r s i n g s e r v i c e s . was s c o r e d  "1";  Presence of a c o n d i t i o n  absence of t h i s c o n d i t i o n was scored  "0".  Number o f  c o n d i t i o n s was c a l c u l a t e d by summation of s c o r e s . The  Blishen  (1967) O c c u p a t i o n a l  socio-economic s t a t u s .  Rating  S c a l e was used to measure  Occupations are ranked and grouped i n t o seven  - 59 c l a s s e s and s c o r e s range from 1 to 7. lawyers and p h y s i c i a n s ; Radio announcers nurses and  Occupations  i n class 1 include  those i n c l a s s 2 i n c l u d e p r o f e s s o r s and  t y p i s t s a r e among the o c c u p a t i o n s i n c l a s s 3 ,  and  farmers a r e among the o c c u p a t i o n s i n c l a s s 4 .  c l a s s 5 i n c l u d e o f f i c e c l e r k s and telephone o p e r a t o r s . p r a c t i c a l nurses f a l l The was  i i n t o c l a s s 6 and cooks  S o c i a l Re-adjustment  utilized  to measure l i f e  c e d i n g the s t u d y .  Occupations i n Sales c l e r k s  The s c a l e c o n s i s t s of 43  life  events such as marriage,  Each event has a n u m e r i c a l v a l u e a c c o r d i n g  w i t h much s t r e s s have h i g h n u m e r i c a l v a l u e s .  Events  those a s s o c i a t e d  Each i n d i v i d u a l i s asked  events he or she has e x p e r i e n c e d d u r i n g the p a s t y e a r  s t r e s s s c o r e i s c a l c u l a t e d by summing n u m e r i c a l v a l u e s on items  to which t h e r e are p o s i t i v e responses.  I n v e s t i g a t i o n s have  the r e l a t i o n s h i p between l i f e s t r e s s and Rahe,  7.  changes of i n d i v i d u a l s d u r i n g the y e a r p r e -  a s s o c i a t e d w i t h l i t t l e s t r e s s have low n u m e r i c a l v a l u e s ;  and a l i f e  and  and j a n i t o r s i n t o c l a s s  the amount of s t r e s s known to be a s s o c i a t e d w i t h t h a t event.  which of these 43  while  S c a l e developed by Holmes & Rahe (1967)  d i v o r c e and t a k i n g a v a c a t i o n . to  chemists.  the onset of i l l n e s s  demonstrated (Holmes &  1967).  Health  status  The h e a l t h index q u e s t i o n n a i r e developed by S a c k e t t , Chambers e t a l . (Chambers & Segovia, 1978) was physical function.  The way  used to measure s o c i a l ,  emotional  and  i n which these t h r e e s c a l e s were adapted f o r  use i n t h i s study i s d e s c r i b e d i n the f o l l o w i n g  section.  Development of the H e a l t h Knowledge S c a l e Questions to measure h e a l t h knowledge were based on i n f o r m a t i o n taught to  r e s i d e n t s by nurses i n N i c h o l s o n Towers.  T a b l e 7 and f a l l i n t o two c a t e g o r i e s :  Questions are l i s t e d i n  (1) f a c t s and b e h a v i o u r s c o n s i d e r e d  - 60 TABLE 7 HEALTH KNOWLEDGE QUESTIONS  Questions Asked of A l l i n d i v i d u a l s How o f t e n s h o u l d one have some form of e x e r c i s e l i k e going f o r walks? How do you d e c i d e when and f o r how l o n g to take p r e s c r i b e d medication? How o f t e n i s a p h y s i c a l check-up a d v i s a b l e f o r people of your age who are f e e l i n g w e l l ? I f one i s l i v i n g a l o n e , how o f t e n do you t h i n k one should have c o n t a c t w i t h o t h e r people? How many days a week should you eat v e g e t a b l e s and f r u i t i n o r d e r t o have enough v i t a m i n s and m i n e r a l s i n your d i e t ? Could you name two t h i n g s you can i n c l u d e i n your d i e t to a s s i s t bowel movements? How many cups of f l u i d should one d r i n k a day? Would you show me what m e d i c a t i o n s you are on? Could you t e l l me what each of these medicat i o n s i s f o r (maximum of 6 m e d i c a t i o n s ) ?  Questions Asked of I n d i v i d u a l s w i t h A r t h r i t i s Can you name a n y t h i n g you can do to get r i d of some of the s t i f f n e s s you may have ( i n the morning, f o r example)? I f you have so much p a i n t h a t you do not f e e l l i k e e a t i n g , what do you do about e a t i n g (and why) ? Questions Asked of I n d i v i d u a l s w i t h a Heart Condition How do you d e c i d e how o f t e n to take m e d i c a t i o n ( s ) f o r your h e a r t ? What s o r t of p h y s i c a l s i g n s would i n d i c a t e to you t h a t your h e a r t was not f u n c t i o n i n g w e l l ? Questions Asked of I n d i v i d u a l s with. Leg U l c e r s Can you name two t h i n g s one can do to reduce s w e l l i n g i n the l e g ? What s o r t of food are e s p e c i a l l y important t o i n c l u d e i n one's d i e t when one has l e g u l c e r s ? Questions Asked of I n d i v i d u a l s w i t h High Blood Pressure What k i n d s of t h i n g s can you do to h e l p keep your b l o o d p r e s s u r e down? I f you f e e l d i z z y when you get up from a l y i n g p o s i t i o n , what should you do? I f you f e e l d i z z y w h i l e you are doing something ( l i k e walking or housework) what should you do?  Scale R e l i a bility i f Item D e l e t e d from 7 item Knowledge Scale  Percentage of People who Answered Question Correctly  .55  93%  .56  91%  .47  67%  .48  58%  .53  79%  .53 .55  62% 46% 95% 94% 95% 92% 91% 92%  76%  77%  100% 80% No one i n sample had leg ulcers  55% 87% 100%  - 61 (by nurses and the l i t e r a t u r e ) b a s i c to h e a l t h maintenance i n o l d e r people; (2) f a c t s and b e h a v i o u r s c o n s i d e r e d b a s i c to the management of p a r t i c u l a r conditions.  A l l i n d i v i d u a l s were asked q u e s t i o n s i n the f i r s t  ( i . e . seven q u e s t i o n s ) .  Questions i n the second category were p r e s e n t e d  only to those i n d i v i d u a l s w i t h these c o n d i t i o n s . s c o r e d "1";  i n c o r r e c t answers were s c o r e d "0".  knowledge s c o r e was  category  C o r r e c t answers were Each i n d i v i d u a l ' s  health  c a l c u l a t e d by d i v i d i n g the t o t a l number of c o r r e c t  responses by the number of q u e s t i o n s a p p l i c a b l e to that i n d i v i d u a l . were 22 h e a l t h knowledge q u e s t i o n s ;  There  a l l i n d i v i d u a l s were asked at l e a s t 7  questions.  A d a p t a t i o n of the P h y s i c a l F u n c t i o n S c a l e Chambers & Segovia  (1978) performed  a l a r g e number of q u e s t i o n s and q u e s t i o n s which b e s t p r e d i c t function.  discriminant function analysis  thereby produced  11 p h y s i c a l  function  the p h y s i c i a n ' s c l i n i c a l assessment  E i g h t of these items were used i n t h i s study.  of p h y s i c a l  Items r e l a t e d to  d r e s s i n g , washing and d r i v i n g a c a r were e l i m i n a t e d f o r two reasons. r e s i d e n t s are independent cars.  i n a c t i v i t i e s of d a i l y l i v i n g ;  on  v e r y few  All  drive  There would t h e r e f o r e be l i t t l e v a r i a t i o n i n response to these  items.  Second, i t was  important to keep the q u e s t i o n n a i r e s h o r t .  items were added to the s c a l e .  These items were developed by S a c k e t t and  Chambers, but not i n c l u d e d i n the 11 q u e s t i o n s b e s t p r e d i c t i n g function.  Two  physical  The items i n c l u d e d were a s e l f - r a t i n g of h e a l t h and how  the i n d i v i d u a l was  far  a b l e to walk.  Chambers & Segovia  (1978) d i c h o t o m i z e d responses to a l l i t e m s .  ponses were judged to r e p r e s e n t good or poor f u n c t i o n i n g . s c o r e s on i n d i v i d u a l items ranged between 1 and 5. that the i n d i v i d u a l e x p e r i e n c e d no d i f f i c u l t y ,  In t h i s  Answers which  some d i f f i c u l t y  Resstudy  indicated  and g r e a t  d i f f i c u l t y performing respectively.  a p h y s i c a l a c t i v i t y were s c o r e d "5", "4" and "3"  Answers which i n d i c a t e d  t h a t the person  c o u l d not do the  a c t i v i t y o r d i d n o t know whether he c o u l d do the a c t i v i t y were s c o r e d "2" and "1" r e s p e c t i v e l y .  A l l items were g i v e n the same w e i g h t i n g .  on items were summed t o produce a t o t a l Table 8 l i s t s a l l items  score.  i n c l u d e d i n the s c a l e s of p h y s i c a l ,  and s o c i a l f u n c t i o n i n t h i s study.  Scores  emotional  The t a b l e i n d i c a t e s which items  a r e from  Sackett and Chamber's s c a l e , which a r e adapted from t h e i r s c a l e , which items  are r e p l i c a t e d i n a l l t h r e e s c a l e s and which a r e new  A d a p t a t i o n of the Emotional Chambers & Segovia  items.  Function Scale  (1978) a l s o i d e n t i f i e d 12 emotional f u n c t i o n  q u e s t i o n s which b e s t p r e d i c t the p h y s i c i a n ' s c l i n i c a l assessment o f emotional  f u n c t i o n through  performing  discriminant function analysis.  E l e v e n of these items were used i n t h i s study. "Most people hatched to  The i t e m e l i m i n a t e d was  don't r e a l i z e how much t h e i r l i v e s a r e c o n t r o l l e d by p l o t s  i n s e c r e t by o t h e r s . "  t h i s item.  S u b j e c t s i n the p r e t e s t r e a c t e d n e g a t i v e l y  An item from the s c a l e o f s o c i a l f u n c t i o n r e g a r d i n g how  happy the i n d i v i d u a l f e e l s , was i n c l u d e d to i n c r e a s e the f a c e v a l i d i t y o f this  scale. Chambers & Segovia  ponses were judged  (1978) dichotomized  responses  to a l l items.  t o r e p r e s e n t good o r poor f u n c t i o n i n g .  s c o r e d on i n d i v i d u a l items  range between 1 and 5.  In t h i s  Answers which  Resstudy  indicated  very good emotional  f u n c t i o n were s c o r e d "5";  answers which  very poor emotional  f u n c t i o n were s c o r e d " I " .  F o r example, on the i t e m  " I am i n c l i n e d  indicated  to f e e l t h a t I am a f a i l u r e " , s t r o n g l y agree was s c o r e d  "1", agree was s c o r e d "2", n e u t r a l "3", d i s a g r e e "4" and s t r o n g l y d i s a g r e e was s c o r e d "5".  A l l items were coded 1 to 5 and g i v e n the same w e i g h t i n g .  - 63 TABLE 8 CORRELATION COEFFICIENTS FOR Item Source  A R,C  INDIVIDUAL ITEMS WITH HEALTH SCALES  P h y s i c a l F u n c t i o n Items 1. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with walking as f a r as a mile? 2. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with climbing up 2 f l i g h t s of s t a i r s (16 s t e p s ) ? 3. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with shopping? 4. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with cooking? 5. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with d u s t i n g or l i g h t housework? 6. Today do you have any p h y s i c a l d i f f i c u l t y at a l l with c l e a n i n g f l o o r s ? 7. Do you have any p h y s i c a l d i f f i c u l t y at a l l t r a v e l l i n g by bus whenever necessary? 8. Do you have any d i f f i c u l t y at a l l t r a v e l l i n g by car whenever necessary? 9. Do you have any t r o u b l e reading o r d i n a r y newsprint? 10. What i s the f a r t h e s t you can walk? 11. How would you say your h e a l t h i s these days?  Physical function  Emotional function  Social function  0.77  0.38  0.31  0.81  0.37  0.28  0.79  0.33  0.34  0.59  0.22  0.16  0.69  0.27  0.17  0.79  0.38  0.29  0.76  0.33  0.37  0.60  0.20  0.23  0.09 0.75 0.63  0.07 0.27 0.60  0.02 0.28 0.47  0.63 0.35  0.60 0.46  0.47 0.28  0.28  0.54  0.22  0.49  0.71  0.43  0.15  0.56  0.31  0. 25  0.26  0.02  0.15  0.55  0.37  0.07 0.12  0.53 0.52  0.27 0.25  0.04  0.37  0.25  0.28  0.66  0.49  0.63  0.60  0.47  0.28  0.66  0.49  0.11  0.22  0.64  0.05  0.20  0.07  -0.14  -0.11  0.05  0.65  0.44  0.55  0.11  0.13  0.04  0.13  0.19  0.56  0.01  0.04  0.14  0.04  0.23  0.23  0.30  0.33  0.52  -0.04  0.19  0.28  0.05 -0.07  0.30 0.18  0.36 0.08  0.86  0.74  0.43  Emotional F u n c t i o n Items R,C C C  How would you say your h e a l t h i s these days? I am u s u a l l y a l e r t . I would say I nearly always f i n i s h things once I s t a r t them. Some people f e e l that they run t h e i r l i v e s p r e t t y much the way they want to and t h i s i s the case with me. 5. There are many people who don't know what to do with t h e i r l i v e s . Nowadays a person has to l i v e p r e t t y much f o r today and l e t tomorrow take care of i t s e l f . In a s o c i e t y where almost everyone i s out f o r h i m s e l f , people soon come to d i s t r u s t each other. Many people are unhappy because they do not know what they want out of l i f e . 9. I am i n c l i n e d to f e e l that I am a f a i l u r e . 10. Have you had any t r o u b l e g e t t i n g along with f r i e n d s / r e l a t i v e s during the past year? 11. Taking a l l things together, how happy would you say you are these days? S o c i a l Function Items  R.C R,C  1. How would you say your h e a l t h i s these days? 2. Taking a l l things together, how happy would you say you are these days? 3. How many times have you used your telephone i n the l a s t week to c a l l a f r i e n d ? 4. How many times have you used your telephone i n the l a s t week to c a l l a r e l a t i v e ? 5. How many times have you used your telephone i n the l a s t week to c a l l a r e l i g i o u s group member? 6. I n c l u d i n g the times you went shopping or f o r your usual outings from home, how many times have you been out of the b u i l d i n g i n the l a s t week? 7. How many times have you been to a movie, f i l m , play or c o n c e r t i n the l a s t month? 8. How many times have you been to a s o c i a l club i n the l a s t month? 9. How many times have you been to church i n the l a s t month? 10. How many times have you v i s i t e d a r e l a t i v e i n the l a s t week? 11. How many times have you v i s i t e d a f r i e n d i n the l a s t week? 12. How many times have you been v i s i t e d by a f r i e n d or r e l a t i v e i n the l a s t week? 13. How long'has i t been s i n c e you l a s t had a h o l i d a y (away from home)? 14. Did you s t a r t r e c e i v i n g Mincome during the l a s t year? C o e f f i c i e n t Alpha R e l i a b i l i t i e s C A R N  = = = =  Item from Sackett & Chamber's s c a l e with adapted response Item and response adapted from Sackett & Chamber's s c a l e Item r e p l i c a t e d i n a l l three s c a l e s New item developed f o r t h i s study  - 64 Scores on items were summed to produce a t o t a l s c o r e .  A d a p t a t i o n o f the S o c i a l F u n c t i o n S c a l e T h i r d l y Chambers and Segovia  i d e n t i f i e d 12 s o c i a l f u n c t i o n q u e s t i o n s  which b e s t p r e d i c t the p h y s i c i a n ' s c l i n i c a l assessment o f s o c i a l f u n c t i o n . Eleven  o f these items were used i n t h i s study.  The i t e m r e l a t e d  to work  was e l i m i n a t e d , s i n c e a l l i n d i v i d u a l s a r e r e t i r e d and t h e r e would f o r e be no v a r i a t i o n i n response w e l f a r e was m o d i f i e d ; added to the s c a l e .  to t h i s item.  Wording o f the q u e s t i o n on  " w e l f a r e " was r e p l a c e d by "mincome". Four o f these items were developed  S i x items were  by S a c k e t t and  Chambers b u t not i n c l u d e d i n the 12 q u e s t i o n s b e s t p r e d i c t i n g function.  These items  related  to movies and s o c i a l c l u b s . and  to v i s i t i n g  Two items  there-  social  friends, being v i s i t e d  r e l a t i n g to t e l e p h o n i n g  going out o f the b u i l d i n g were a l s o added to the s c a l e .  and going  relatives  The r a t i o n a l e  f o r i n c l u s i o n o f these s i x a d d i t i o n a l items was t h a t these a r e s o c i a l activities  i n which o l d e r people  engage, and t h e i r i n c l u s i o n would i n c r e a s e  the f a c e v a l i d i t y and a p p r o p r i a t e n e s s o f t h i s Chambers & Segovia  (1978) dichotomized responses to a l l items, e.g.  "Have you used your telephone or No.)  Responses were judged  i n the l a s t week to c a l l a f r i e n d ? "  (Yes  to r e p r e s e n t good or poor f u n c t i o n i n g . In  t h i s study q u e s t i o n s were phrased  to a l l o w f o r documenting the number o f  times a p a r t i c u l a r a c t i v i t y was performed. v a r i a t i o n s i n response  scale.  Items which had extreme  were grouped, b u t always i n such a way t h a t a h i g h  s c o r e i n d i c a t e d t h a t t h i s a c t i v i t y had been performed a g r e a t number o f times.  Responses were summed to produce a t o t a l  score.  In a l l t h r e e s c a l e s a l a r g e number of response included. respondents  T h i s i n c r e a s e s the v a r i a b i l i t y ,  c a t e g o r i e s was  o f each item, a l l o w s f o r  of " g r e a t e r " s o c i a l h e a l t h to d i s t i n g u i s h themselves from  those w i t h "poorer"  social health.  Computing c o e f f i c i e n t a l p h a  estimates  - 65  -  then t e s t s whether i n c l u d i n g each p a r t i c u l a r i t e m i n t o an o v e r a l l s c a l e improves the r e l i a b i l i t y  of the o v e r a l l measure.  RELATIONSHIPS INVESTIGATED IN THE Figure  2 identifies relationships investigated  r e l a t i o n s h i p s on which l i t e r a t u r e i s a v a i l a b l e . i n v e s t i g a t e d on which l i t e r a t u r e i s not s e r v i c e s which are a c c e s s i b l e and and  STUDY  number of h e a l t h  Relationships  a v a i l a b l e are  offer health  related v i s i t s ,  i n t h i s study  emotional and  related v i s i t s  t o t a l c o s t of h e a l t h  units, e l i g i b i l i t y  s e r v i c e s and  perceived  b e n e f i t of n u r s e s ;  years of s c h o o l i n g ,  number of l i f e  change pre-  (3) t o t a l c o s t of  number of l i f e  b e n e f i t of the n u r s e s ;  change u n i t s ,  emotional and  s o c i a l function;  social function;  (4) h e a l t h knowledge and (5) h e a l t h b e h a v i o u r and  (6) p h y s i c a l f u n c t i o n and  of s e c u r i t y from the presence of nurses and  health  (7) emotional f u n c t i o n and tions, e l i g i b i l i t y  perceived  years of s c h o o l i n g ,  physical,  emotional  b e n e f i t of the  number of m e d i c a l  b e n e f i t of the n u r s e s ;  (8)  perceived  feeling nurses;  condithe  social  number of m e d i c a l c o n d i t i o n s ,  s e c u r i t y from presence of the nurses and  and  physical,  f o r Long Term Care, f e e l i n g of s e c u r i t y from  presence of nurses and f u n c t i o n and  y e a r s of s c h o o l i n g ,  social  eligibility  years of s c h o o l i n g ,  perceived  (2)  behaviour,  Long Term Care, f e e l i n g of s e c u r i t y from the presence of nurses  perceived  and  s o c i a l function;  h e a l t h knowledge, h e a l t h b e h a v i o u r , e m o t i o n a l f u n c t i o n ,  f u n c t i o n , sex, for  health  f o r Long Term Care, f e e l i n g of s e c u r i t y from the  sence of nurses and  (1)  counselling  services,  and h e a l t h knowledge, h e a l t h  s o c i a l f u n c t i o n , years of s c h o o l i n g ,  being  following:  e d u c a t i o n and  knowledge, h e a l t h b e h a v i o u r , p h y s i c a l , emotional and number of h e a l t h  the  and  f e e l i n g of  b e n e f i t of the  nurses.  ANALYSIS OF DATA Raw  d a t a were keypunched onto c a r d s .  The  d a t a were computer a n a l y z e d  - 66 FIGURE 2 RELATIONSHIPS INVESTIGATED IN THE STUDY Differences  Between Programs  Accessibility Health  education  Counselling Biographical  Variables  Sex Age Socio-economic  status  vvXv. Years o f s c h o o l i n g XV'  No. of?,, l i f e  change u n i t s  No. of m e d i c a l Eligibility Benefits  conditions  *xftX  f o r Long Term Care. 99.  o f Programs  No. of h e a l t h  °0y  related  T o t a l c o s t of h e a l t h  visits services  H e a l t h knowledge  v;  Health behaviour  *X** ^X*X  «>,  Physical Emotional Social  function function  function  Security Perceived  v <b  X X^ . V A  from n u r s e s ' presence/ b e n e f i t of nurses  L S  L i t e r a t u r e a v a i l a b l e on r e l a t i o n R e l a t i o n s h i p to be s t u d i e d  A,Xv/  A  ^>X VKV'  - 67 using  -  the U n i v e r s i t y of B r i t i s h Columbia's v e r s i o n of SPSS.  S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s , O p i n i o n Research Centre i n Chicago and  was  modified  written f o r MTS  SPSS, the  at the  National  (the M i c h i g a n  T e r m i n a l System). Analysis N i c h o l s o n and health  of v a r i a n c e was  used to t e s t d i f f e r e n c e s between r e s i d e n t s  Sunset Towers i n terms of h e a l t h knowledge, h e a l t h  s t a t u s , number of h e a l t h  of v a r i a n c e was  service.  procedure was  costs.  Analysis  Pearson c o r r e l a t i o n s were c a l c u l a t e d  Stepwise l i n e a r r e g r e s s i o n  determined which v a r i a b l e s  accounted f o r what percentage of v a r i a n c e related v i s i t s  and h e a l t h  behaviour,  a l s o used to t e s t d i f f e r e n c e s between groups r e c e i v i n g  d i f f e r e n t l e v e l s of n u r s i n g among items.  related v i s i t s  of  and  p h y s i c a l , s o c i a l and  i n c o s t s , number of  emotional f u n c t i o n .  used to compute c o e f f i c i e n t s of r e l i a b i l i t y  health A  reliability  for scales.  - 68 -  CHAPTER IV  RESULTS  INTRODUCTION This  chapter d e s c r i b e s  f i n d i n g s of the study.  I t emphasizes hypo-  t h e s i z e d r e l a t i o n s h i p s , b u t a l s o examines r e l a t i o n s h i p s not f o r m a l l y posited  i n the study.  The f i r s t  s e c t i o n d e a l s w i t h the r e l i a b i l i t y and  v a l i d i t y o f s c a l e s developed f o r t h i s s t u d y . f i n d i n g s r e l a t e d to the f o l l o w i n g f i v e  The chapter then p r e s e n t s  issues:  1.  hypotheses t e s t i n g d i f f e r e n c e s between complexes i n terms of h e a l t h knowledge, h e a l t h b e h a v i o u r , h e a l t h s t a t u s and h e a l t h costs  2.  d i f f e r e n c e s between apartment complexes i n terms of b i o g r a p h i c a l d a t a , h e a l t h e d u c a t i o n , c o u n s e l l i n g , c o s t s and b e n e f i t s , sources o f h e a l t h i n f o r m a t i o n and h e a l t h b e h a v i o u r  3.  variance  i n p h y s i c a l , emotional and s o c i a l  4.  variance costs  i n number o f h e a l t h  5..  d i f f e r e n c e s between r e s i d e n t s nursing service  function  related v i s i t s  and h e a l t h  care  r e c e i v i n g d i f f e r e n t l e v e l s of  SCALES DEVELOPED FOR THE STUDY B e f o r e the study c o u l d be executed i t was n e c e s s a r y to adapt e x i s t i n g s c a l e s and develop one new s c a l e . and  s o c i a l f u n c t i o n developed by S a c k e t t ,  Scales  three  of p h y s i c a l , e m o t i o n a l  Chambers e t a l . (Chambers &  Segovia, 1978) were adapted f o r use w i t h t h i s study group, w i t h the modif i c a t i o n s and a d d i t i o n s  as d e s c r i b e d  i n Chapter I I I .  knowledge was developed f o r use i n t h i s study.  A scale of health  V a l i d i t y and r e l i a b i l i t y  - 69 -  e s t i m a t e s of each o f these f o u r s c a l e s a r e d i s c u s s e d  below.  R e l i a b i l i t i e s of Health Function and H e a l t h Knowledge Scales The  reliabilities  of the s c a l e s u t i l i z e d  because they i n d i c a t e how c o n s i s t e n t measurement they c o n t a i n .  (Chambers, Sackett  floors,  i n the p h y s i c a l f u n c t i o n  capacity  e t a l . , 1976, p.9).  such as w a l k i n g and c l i m b i n g cleaning  the s c a l e s a r e and how much e r r o r o f  Items i n c l u d e d  d e a l w i t h " p h y s i c a l and f u n c t i o n i n g  i n the study a r e examined  on a p h y s i o l o g i c a l  level"  Items d e a l w i t h p h y s i c a l  s t a i r s and a c t i v i t i e s o f d a i l y  cooking and t r a v e l l i n g by bus.  scale  activities  l i v i n g such as  Three items were removed  from Chambers' s c a l e of p h y s i c a l f u n c t i o n and the f o l l o w i n g two items added: "What i s the f a r t h e s t you can w a l k ? " and "How would you say your health  i s these days?"  The f i n a l v e r s i o n o f the s c a l e c o n t a i n e d  Questions i n c l u d e d  i n the e m o t i o n a l f u n c t i o n s c a l e were thought t o  measure the dimensions of ego f u n c t i o n industry, Sackett  ( b a s i c t r u s t , autonomy,  i d e n t i t y and i n t i m a c y ) as w e l l as s e l f esteem  e t a l . , 1976).  11 items.  One i t e m was d e l e t e d  the emotional f u n c t i o n s c a l e .  initiative,  (Chambers,  from the o r i g i n a l v e r s i o n o f  The f i n a l v e r s i o n o f the s c a l e c o n t a i n e d  11  items. Questions i n the s o c i a l f u n c t i o n s c a l e covered the f o l l o w i n g extent of appropriate  community a c t i v i t i e s , s e l e c t e d  (Holmes & Rahe, 1967) and o r g a n i z a t i o n a l membership et a l . , 1976).  critical life (Chambers,  areas: events  Sackett  One i t e m was removed from the s o c i a l f u n c t i o n s c a l e and  s i x items were added to t h i s s c a l e .  The added items r e f e r r e d t o t e l e -  phoning r e l a t i v e s , going out o f the b u i l d i n g , going to movies and c o n c e r t s , attending relatives.  s o c i a l clubs, v i s i t i n g  f r i e n d s and b e i n g v i s i t e d by f r i e n d s and  The f i n a l v e r s i o n o f the s c a l e contained  Items u t i l i z e d  14 items.  to measure p h y s i c a l , e m o t i o n a l and s o c i a l  function  - 70 are l i s t e d  i n T a b l e 8 (page 63).  d i r e c t l y from s c a l e s developed  by  T h i s t a b l e shows which items were  taken  S a c k e t t and Chambers, which items  are  adapted v e r s i o n s of Sackett and Chambers' items developed  items.  all  scales.  three The  The  t a b l e a l s o shows which items are r e p l i c a t e d  reliabilities  of the s c a l e s of p h y s i c a l , s o c i a l and  f u n c t i o n i n the v e r s i o n s developed have never been r e p o r t e d . emotional The  and  The  alpha r e l i a b i l i t i e s  you have any  were d e l e t e d , the a l p h a r e l i a b i l i t y  The .74.  of the m o d i f i e d  t h a t t h i s i s a poor  alpha r e l i a b i l i t y  Each of the 11  trouble reading ordinary  f u n c t i o n s c a l e was r a t h e r too low.  of the m o d i f i e d emotional  group members and  going  the alpha r e l i a b i l i t y  newsprint?" .88,  function scale i s of the o v e r a l l  The m o d i f i e d  to have an a l p h a r e l i a b i l i t y  I f items  study.  item.  items i n c r e a s e s the r e l i a b i l i t y  found  physical,  which i s q u i t e  of the s c a l e would i n c r e a s e to  which i n d i c a t e s t h a t a l l items warrant i n c l u s i o n .  of  to movies, church and  scale,  social  .43 which i s  on Mincome, t e l e p h o n i n g r e l a t i v e s  and  religious  s o c i a l c l u b s were d e l e t e d ,  of t h i s s c a l e would i n c r e a s e but o n l y m a r g i n a l l y .  Thus these a r e q u e s t i o n a b l e items. of  emotional  by Chambers, Sackett et a l . (1976)  of the p h y s i c a l f u n c t i o n s c a l e i s 0.86  I f the item "Do  indicating  across  s o c i a l f u n c t i o n s c a l e s were computed as p a r t of t h i s  alpha r e l i a b i l i t y  good.  and which a r e newly  P o s s i b l e reasons  f o r the low  reliability  the s o c i a l f u n c t i o n s c a l e are examined below. The  t h r e e dimensions of h e a l t h i d e n t i f i e d by  the World H e a l t h  O r g a n i z a t i o n ' s d e f i n i t i o n of h e a l t h are p h y s i c a l , s o c i a l and mental (emotional)  f u n c t i o n (World H e a l t h O r g a n i z a t i o n , 1958).  v a r y i n terms of a m e n a b i l i t y to d e f i n i t i o n , measurement. t i o n , and  These dimensions  operationalizability  P h y s i c a l f u n c t i o n i s the dimension  and  most amenable to d e f i n i -  t h e r e i s good consensus r e g a r d i n g what c o n s t i t u t e s good and  poor  - 71 p h y s i c a l f u n c t i o n and  measurement.  walk a m i l e and  16 s t a i r s w i t h no  greater ties. and  climb  For  example, a person who  i s unable to do  Can  one  (Question 9)  about  i s greater  than a person who  f e e l s he  f e e l s he  e t a l . (1976) i n c l u d e ifamily  and  (1) f e e l i n g s about h e a l t h ,  (2)  Chambers, feelings  f r i e n d s , (3) p a r t i c i p a t i o n i n community a c t i v i t i e s ,  e x p e r i e n c e of s e l e c t e d c r i t i c a l  l i f e events and  These are d i s c r e t e elements which may or comparable.  i s a success  i s not?  i s s u e s which d e f i n e s o c i a l f u n c t i o n as c o n c e i v e d by  I t may  produce a s i n g l e s c o r e  thus not be  not  (5)  n e c e s s a r i l y be m u t u a l l y  u s e f u l to add  (which Chambers and  such d i s p a r a t e  Sackett  i n terms of o p t i m a l s o c i a l f u n c t i o n .  Items are scored  so  However, v i s i t i n g a s o c i a l club numerous times a week may  another, and  i n d i v i d u a l , but may  l a c k of i n n e r - r e s o u r c e f u l n e s s  " R e l i a b i l i t y can be  defined  as  additive  items to  do).  that  an a c t i v i t y i s engaged i n , the h i g h e r the s o c i a l  s o c i a l f u n c t i o n f o r one  to  the more  function.  c o n s t i t u t e good  in a  third.  the r e l a t i v e absence of e r r o r s p.443).  of The  r e l i a b i l i t y of the s o c i a l f u n c t i o n s c a l e d i m i n i s h e s i t s u s e f u l n e s s  and  s o c i a l f u n c t i o n was  contains  as  low a  R e s i d e n t s of N i c h o l s o n Towers were found  to have a' significantly/.'.(27C46.~;vs.. 25.07) h i g h e r l e v e l of s o c i a l than those i n Sunset Towers;  define  i n d i c a t e s o c i a l dependence i n  measurement i n a measuring i n s t r u m e n t " ( K e r l i n g e r , 1973,  measurable concept c o n s i d e r a b l y .  (4)  monetary s i t u a t i o n .  P a r t i c u l a r items i n the s o c i a l f u n c t i o n s c a l e are d i f f i c u l t  frequently  activi-  say w i t h c e r t a i n t y , f o r  example, t h a t the emotional f u n c t i o n of a p e r s o n who  Sackett  these  dimension of emotional f u n c t i o n i s l e s s amenable to d e f i n i t i o n  measurement than p h y s i c a l f u n c t i o n .  The  to  d i f f i c u l t y - c l e a r l y possesses  p h y s i c a l f u n c t i o n than a person who The  i s able  function  i . e . a r e l a t i o n s h i p between apartment  declared.  much e r r o r , the c o n c l u s i o n  complex  However, because u n r e l i a b l e measurement of a d i f f e r e n c e between complexes i s a  - 72 tenuous  one  (Kerlinger,  1973).  The h e a l t h knowledge s c a l e p a r t i c u l a r use i n t h i s s t u d y .  ( T a b l e 7, page 60) was  developed f o r  Questions to measure h e a l t h knowledge were  based on i n f o r m a t i o n taught to r e s i d e n t s by nurses i n N i c h o l s o n Towers. Questions f a l l  i n t o two c a t e g o r i e s :  (by  the l i t e r a t u r e ) b a s i c  nurses and  (1) f a c t s and b e h a v i o u r s c o n s i d e r e d to h e a l t h maintenance i n o l d e r people;  (2) f a c t s and b e h a v i o u r s c o n s i d e r e d b a s i c to the management of p a r t i c u l a r conditions.  A l l i n d i v i d u a l s were asked q u e s t i o n s i n the f i r s t  ( i . e . seven q u e s t i o n s ) .  Questions i n the second c a t e g o r y were p r e s e n t e d  only to those i n d i v i d u a l s w i t h these c o n d i t i o n s . in  category  There were 22 q u e s t i o n s  total. Table 7 (page 60) shows what percentage of i n d i v i d u a l s answered  each h e a l t h knowledge q u e s t i o n c o r r e c t l y and i n d i c a t e s where g r e a t e r h e a l t h e d u c a t i o n i s needed.  The a l p h a r e l i a b i l i t y  (computed as p a r t of the study) was  found to be  of the 7-item  .56.  A l l 7 items are  good items s i n c e they a l l i n c r e a s e the r e l i a b i l i t y o f the s c a l e . 22-item s c a l e , the a l p h a r e l i a b i l i t y  The  two  On  the  f o r 20 q u e s t i o n s which were asked of  i n d i v i d u a l s to whom they a p p l i e d i s .87. items w i t h ho mutual o b s e r v a t i o n s .  scale  This figure i s uncorrected f o r  (No-one i n the sample had l e g u l c e r s .  q u e s t i o n s on l e g u l c e r s were t h e r e f o r e asked of no-one.)  V a l i d i t i e s of H e a l t h F u n c t i o n and H e a l t h Knowledge S c a l e s S a c k e t t , Chambers et a l . (1977) c l a i m t h a t i n i t i a l  e v a l u a t i o n s of the  s c a l e s of p h y s i c a l , emotional and s o c i a l f u n c t i o n i n d i c a t e t h a t possess f a c e v a l i d i t y and p r e d i c t i v e v a l i d i t y validity). of  ( b i o l o g i c and  Content, c o n s t r u c t , convergent and d i s c r i m i n a n t  they  clinical validities  these s c a l e s have never been r e p o r t e d . In  o r d e r f o r i n t e r p r e t a t i o n s from s c a l e s to have meaning, s c a l e s  - 73 should possess v a l i d i t y .  Validity  what one t h i n k s one i s measuring.  i s the degree  to which one i s measuring  Content v a l i d i t y  adequacy o f the content of a s c a l e .  i s the sampling  C o n s t r u c t v a l i d i t y r e f e r s t o the p r o -  p o r t i o n o f the t o t a l s c a l e accounted f o r by the c o n s t r u c t s b e i n g measured. Convergent  v a l i d i t y means that evidence from a v a r i e t y o f sources  the same meaning of the c o n s t r u c t .  indicates  D i s c r i m i n a n t v a l i d i t y means t h a t one  can d i f f e r e n t i a t e the c o n s t r u c t from o t h e r s i m i l a r c o n s t r u c t s and i d e n t i f y what i s not r e l a t e d to t h a t c o n s t r u c t ( K e r l i n g e r , 1973). which s c a l e s u t i l i z e d  The degree to  i n t h i s study evidence these forms of v a l i d i t y i s  e x p l o r e d below. T a b l e 8 (page 63) p r e s e n t s c o r r e l a t i o n s of i n d i v i d u a l items w i t h t o t a l s c a l e s c o r e s f o r each o f the t h r e e s c a l e s .  This table  indicates  the p u r i t y o f items, the a p p r o p r i a t e n e s s o f items to a p a r t i c u l a r  scale  and whether items c o n t r i b u t e more to a p a r t i c u l a r s c a l e than to the o t h e r two  scales. In  g e n e r a l , i n d i v i d u a l items c o r r e l a t e more h i g h l y w i t h the f u n c t i o n  they p u r p o r t to measure than w i t h the o t h e r two f u n c t i o n s , thus s u g g e s t i n g that these items a r e not  confounded  a c r o s s the t h r e e types of measures.  P h y s i c a l f u n c t i o n items have the h i g h e s t i t e m - t o t a l c o r r e l a t i o n s and the alpha r e l i a b i l i t y indicating  (.86) o f t h i s s c a l e i s h i g h e r than the o t h e r two s c a l e s ,  t h a t t h i s s c a l e has the h i g h e s t content v a l i d i t y .  T a b l e 8 (page 63) shows t h a t emotional f u n c t i o n items c o r r e l a t e more h i g h l y w i t h emotional f u n c t i o n than w i t h p h y s i c a l and s o c i a l  function,  s u g g e s t i n g t h a t these items a r e measuring  emotional f u n c t i o n as d i s t i n c t  from the two. o t h e r dimensions  The a l p h a r e l i a b i l i t y  of h e a l t h .  of t h i s  s c a l e i s .74 i n d i c a t i n g t h a t t h i s s c a l e possesses content v a l i d i t y . S o c i a l f u n c t i o n items have the lowest mean i t e m - t o t a l c o r r e l a t i o n s . t h i s s c a l e has an a l p h a r e l i a b i l i t y  That  o f .43 means t h a t i t possesses low  - 74 content  validity.  Table 9 documents c o r r e l a t i o n s among the t h r e e h e a l t h f u n c t i o n s c a l e s and  the two  h e a l t h knowledge s c a l e s .  T h i s t a b l e shows t h a t the  c o e f f i c i e n t s of the s c a l e s of p h y s i c a l and o t h e r s c a l e s are lower than the s c a l e s ' own two  s c a l e s thus evidence  convergent  emotional  correlation  function with a l l  alpha r e l i a b i l i t i e s .  These  validity.  TABLE 9 CORRELATIONS AMONG HEALTH FUNCTIONS HEALTH KNOWLEDGE SCALES Physical Function Scale  Emotional Function Scale  Social Function Scale  AND  7-item Health Knowledge Scale  Physical Function Scale  .86  Emotional Function Scale  .48  .74  Social Function Scale  ,39  .57  .43  7-item Health Knowledge Scale  -.20  .17  ,24  ,57  22-item Health Knowledge Scale  -.27  .14  .19  .85  C o e f f i c i e n t a l p h a r e l i a b i l i t y estimates i n the p r i n c i p a l d i a g o n a l  = .05 = .17, df =  The  22-item Health Knowledge Scale  .87  are  124  two h e a l t h knowledge s c a l e s are h i g h l y (.85)  c o r r e l a t e d , which i s  to be expected s i n c e the items i n the 7-item s c a l e are i n c l u d e d i n the  - 75 22-item s c a l e .  The c o r r e l a t i o n c o e f f i c i e n t s of the h e a l t h knowledge  s c a l e s w i t h the three h e a l t h s c a l e s a r e lower than the s c a l e s ' own reliabilities.  These f i n d i n g s i n d i c a t e t h a t the two h e a l t h  s c a l e s evidence convergent v a l i d i t y .  knowledge  The c o r r e l a t i o n c o e f f i c i e n t of the  s o c i a l f u n c t i o n s c a l e w i t h the e m o t i o n a l f u n c t i o n s c a l e i s h i g h e r than the s c a l e ' s own a l p h a  reliability  alpha  (.57)  (.43) i n d i c a t i n g t h a t the s c a l e of  s o c i a l f u n c t i o n has low convergent v a l i d i t y and i s (at l e a s t p a r t l y ) confounded w i t h the measure of emotional f u n c t i o n . T a b l e 9 shows t h a t there a r e s i g n i f i c a n t b u t moderately s i z e d p o s i t i v e c o r r e l a t i o n s between the three h e a l t h s c a l e s .  The c o r r e l a t i o n s between  the s c a l e s a r e not v e r y h i g h which suggests t h a t the s c a l e s do indeed d i f f e r from one another and measure d i f f e r e n t a s p e c t s of h e a l t h . two  o f the three h e a l t h  scale i t s e l f , validity  suggesting  scales overlap  as much as the components o f the  that these three s c a l e s e v i d e n c e  (Campbell & F i s k e ,  No  discriminant  1967).  Items i n both h e a l t h knowledge s c a l e s r e f e r to a s p e c t s o f p h y s i c a l and  s o c i a l h e a l t h which should be f a m i l i a r to o l d e r p e o p l e .  can  thus be assumed to possess f a c e v a l i d i t y .  The f a c t  These s c a l e s  that the concepts  of p h y s i c a l , e m o t i o n a l , s o c i a l f u n c t i o n and h e a l t h knowledge have been s u c c e s s f u l l y o p e r a t i o n a l i z e d means t h a t these concepts have substance, indicating  that a l l f i v e s c a l e s evidence c o n s t r u c t  validity.  TESTS OF HYPOTHESES Nicholson for  and Sunset Towers a r e B r i t i s h Columbia housing complexes  s e n i o r c i t i z e n s i n the West End of Vancouver.  Since  1974 s e n i o r  c i t i z e n s i n b o t h complexes have r e c e i v e d " d i f f e r e n t n u r s i n g of which a r e p r o v i d e d  by the P r o v i n c e  programs, both  o f B.C. Home Care program.  s e r v i c e s i n Sunset Towers a r e mostly treatment o r i e n t e d .  Nursing  The n u r s i n g  - 76 program i n N i c h o l s o n the l i t e r a t u r e health  Towers i n c o r p o r a t e s  as important and e f f e c t i v e  many of the f a c t o r s i d e n t i f i e d i n i n promoting h e a l t h  and r e d u c i n g  costs.  Hypothesis 1 s t a t e d that h e a l t h knowledge, h e a l t h b e h a v i o u r and h e a l t h s t a t u s of s e n i o r c i t i z e n s  i n Nicholson  than t h a t o f s e n i o r c i t i z e n s  Towers w i l l be s i g n i f i c a n t l y  i n Sunset Towers.  two  complexes are p r e s e n t e d i n T a b l e 10.  had  significantly  Comparisons between the  Residents of Nicholson  (81% v s . 68%) g r e a t e r h e a l t h knowledge,  (87% v s . 73%) more h e a l t h y b e h a v i o u r s , s i g n i f i c a n t l y g r e a t e r p h y s i c a l f u n c t i o n and s i g n i f i c a n t l y social cant  Towers  significantly  (45.69 v s . 44.42)  (27.46 v s .  f u n c t i o n than r e s i d e n t s o f Sunset Towers.  greater  25.07) g r e a t e r  There were no s i g n i f i -  d i f f e r e n c e s i n emotional f u n c t i o n between r e s i d e n t s of the two  complexes.  Based on these r e s u l t s ,  of i t s f i v e  components.  Hypothesis 1 ..was accepted f o r f o u r  Hypothesis 2 s t a t e d that over an 8 month p e r i o d , of h e a l t h r e l a t e d v i s i t s  the average number  made by o r to r e s i d e n t s of N i c h o l s o n  Towers w i l l be s i g n i f i c a n t l y There were no s i g n i f i c a n t  lower i n N i c h o l s o n  and Sunset  than i n Sunset Towers.  d i f f e r e n c e s i n average number o f h e a l t h r e l a t e d  v i s i t s between r e s i d e n t s of the two complexes.  Based on these  results,  Hypothesis 2 was r e j e c t e d . Hypothesis 3 s t a t e d : over an 8 month p e r i o d average c o s t s of a l l h e a l t h s e r v i c e s provided significantly  to r e s i d e n t s o f N i c h o l s o n  lower i n N i c h o l s o n  and Sunset Towers w i l l be  than i n Sunset Towers.  There were no  significant  d i f f e r e n c e s i n average c o s t s between r e s i d e n t s of the two  complexes.  Based on these r e s u l t s ,  Hypothesis 3 was r e j e c t e d , even though  some subcomponents of the t o t a l c o s t f i g u r e s show s i g n i f i c a n t  differences.  Hypothesis 4 s t a t e d : Of those r e s i d e n t s e l i g i b l e f o r Long Term Care, a significantly  g r e a t e r percentage i n N i c h o l s o n  than i n Sunset Towers, w i l l  TABLE 10 : ANALYSIS OF VARIANCE BETWEEN COMPLEXES AND BETWEEN LEVELS OF NURSING SERVICE Receiving nursing s e r v i c e s at time of study Nicholson Sunset Towers Towers  Variable  Number l n each c o n d i t i o n  information  13  15  17  20  29  65  59  2.95 77  2.00 23  3.00 47  2.00 13  — —  — —  2.97 67  2.00 17  .001 .001  .877 .060  .877 .363  80.67 80 10 5.20 7.57 23 47 1.57 60.90  73.77 77 15 4.92 8.61 23 77 2.08 94.31  78.07 80 13 5.67 7.47 13 40 1.60 43.73  71.65 88 6 4.53 9.18 23 59 1.76 66.65  76.60 70 10 5.60 7.55 40 10 0.80 36.55  77.07 72 17 5.10 8.28 24 10 . 0.97 28.79  78.81 77 11 5.43 7.54 26 34 1.34 49.45  74.78 78 14 4.90 8.61 23 39 1.44 54.14  .002 .752 .783 .018 .028 .812 .045 .149 .097  .312 .421 .861 .620 ,851 .394 .001 .001 .001  .048 .847 .582 .390 .736 .433 .322 .701 .201  92 91 43.07 36.90 25.17  71 71 36.00 32.15 17.62  85 95 46.80 39.73 32.40  69 74 44.59 35.94 25.12  64 75 48.80 38.55 27.20  65 74 48.10 40.97 28.38  81 87 45.69 38.06 27.46  68 73 44.42 37.58 26.07  .001 .001 .002 .052 .016  .001 ,020 .001 .001 .003  .025 .001 .038 .011 .098  17 0.13 1.10 37 7 0 1.87 1.57 2.74 1.47  8 0.0 0.15 8 0 0 1.39 0.69 3.00 0.83  0 0.0 0.13 20 0 0 1.53 1.13 2.86 1.27  0 0.0 0.0 0 0 0 0.82 0.12 2.50 0.12  0  0  — — — —  — — — — —  0.3 0.4  0 0.28  — —  — —  8 0.09 0.78 31 4 0 1.31 1.11 2.8 1.40  2 0.0 0.07 3 0 0 0.54 0.32 2.8 0.41  .447 .326 .089 .010 .400 .999 .001 .001 .827 .001  .016 .326 .078 .192 .400 .999 .001 .001 .388 .011  .560 .326 .199 .629 .400 .999 .204 .005 .167 .147  Benefits  Those e l i g i b l e  f o r long term care who continue  Mean number of r e c a l l e d prevented Mean number of r e c a l l e d prevented  Never r e c e i v e d Complex nursing totals Significance services Nicholson Sunset Nicholson Sunset Complex S e r v i c e A + B Towers Towers Towers Towers Level level level (A) (B)  30  D i f f e r e n c e s between nursing programs  Biographical  Receiving nursing s e r v i c e s in past 2 years Nicholson Sunset Towers Towers  to l i v e  hospitalizations physician v i s i t s  —  Number of h e a l t h r e l a t e d v i s i t s 5.80 1.46 .97 9.67 2.57 27.03 48.00  4.54 1.76 1.92 12.08 6.25 13.92 53.23  5.73 1.97 1.53 6.47 4.00 4.07 23.00  7.18 3.00 4.41 7.41 3.88 0.47 25.77  3.95 •1.20 0.30 4.60 0.45 0.0 10.20  5.07 2.41 1.48 6.34 0.79 0.0 14.55  5.22 0.90 0.89 7.37 2.25 13.41 30.60  5.56 0.86 2.42 7.91 2.83 3.20 26.31  .632 .129 .006 .290 .337 .016 .368  .206 .027 .016 .020 .048 .001 .001  .413 .519 .365 .932 .458 .055 .975  70.76 49.70 7.05 139.83 324.54 540.67 3.04 69.88 1205.19  61.81 79.94 17.20 178.89 507.26 278.46 30.08 88.74 1286.18  65.16 40.53 12.20 59.01 377.60 81.33 14.55 36.27 686.64  85.99 72.93 38.99 76.08 294.31 9.41 20.45 74.88 673.04  48.91 26.92 4.02 54.24 100.49 0.0 2.21 46.67 283.45  48.43 20.97 12.91 71.47 133.56 0.0 4.28 36.29 327.92  62.74 40.58 7.31 94.84 267.71 268.31 5.44 54.98 801.91  62.20 48.94 21.37 96.47 257.99 64.07 18.43 58.97 627.34  .713 .177 .002 .435 .783 .016 .129 .183 .847  .101 .043 .011 .020 .294 .001 .027 .032 .001  .480 .452 .243 .947 .785 .055 .519 .233 .980  Costs i n d o l l a r s o f :  Number of comparisons which favour each complex  31  9  32  6  19  10  31  9  - 78 consider  t h a t they are a b l e  nurses are a c c e s s i b l e .  to c o n t i n u e l i v i n g i n the apartment because  T a b l e 10 shows t h a t  d i f f e r e n c e s between r e s i d e n t s Hypothesis 4 was  r e j e c t e d on  Implications  -  of the  two  the b a s i s  there were no s i g n i f i c a n t  complexes on  this variable.  of these r e s u l t s .  of a l l the above f i n d i n g s as w e l l as s i g n i f i c a n t but  non-hypothesized f i n d i n g s are d i s c u s s e d  i n Chapter  V.  DIFFERENCES BETWEEN APARTMENT COMPLEXES T h i s study examined d i f f e r e n c e s i n c o s t s plexes and  between l e v e l s of n u r s i n g  and b e n e f i t s between com-  service.  A n a l y s e s of  between apartment complexes and between l e v e l s of n u r s i n g p r e s e n t e d i n T a b l e 10.  service  are  Sources of v a r i a t i o n t e s t e d i n t h i s study  are  d i f f e r e n c e s between n u r s i n g biographical  variance  programs, c o s t s  and b e n e f i t s of programs  and  variables.  Some q u e s t i o n n a i r e c e i v i n g , or had  items a p p l i e d only  received,  nursing  to i n d i v i d u a l s who  services.  data i n the column headed "Never r e c e i v e d  For  were r e -  these items t h e r e a r e  nursing  services";  and  t o t a l s r e f e r to t o t a l s of i n d i v i d u a l s to whom the item a p p l i e d . ences between l e v e l s of n u r s i n g  s e r v i c e are d i s c u s s e d  no  complex Differ-  later in this  chapter.  N u r s i n g Programs N u r s i n g s e r v i c e s i n N i c h o l s o n Towers are s i g n i f i c a n t l y  (2.97  on a 3 p o i n t  s c a l e ) more a c c e s s i b l e than those i n Sunset Towers.  ficantly  i n d i v i d u a l s v s . 17  (67  2.00  Signi-  i n d i v i d u a l s ) more c o u n s e l l i n g o c c u r s i n  N i c h o l s o n than i n . S u n s e t Towers.  More h e a l t h  N i c h o l s o n than i n Sunset Towers.  Nurses i n N i c h o l s o n Towers spend  mately 90 hours per month e d u c a t i n g r e s i d e n t s ; 15 h o u r s .  vs.  e d u c a t i o n occurs i n approxi-  nurses i n Sunset Towers,  - 79 B i o g r a p h i c a l Data R e s i d e n t s of N i c h o l s o n  Towers were s i g n i f i c a n t l y  74.78 y e a r s ) o l d e r , had s i g n i f i c a n t l y s t a t u s , and s i g n i f i c a n t l y schooling. was  (5.43 v s . 4.90) h i g h e r  (34% v s . 39%) lower percentage of r e s i d e n t s  e l i g i b l e f o r Long Term Care i n N i c h o l s o n  i n terms o f sex, conditions notion  socio-economic  (7.54 y e a r s v s . 8.61 y e a r s ) fewer years o f  A significantly  were no s i g n i f i c a n t  (78.81 y e a r s v s .  than i n Sunset Towers.  There  d i f f e r e n c e s between r e s i d e n t s o f the two complexes  m a r i t a l status, a d d i t i o n a l education,  and number o f l i f e  t h a t the f a v o u r a b l e  change u n i t s .  conditions  number o f m e d i c a l  Thus one can r u l e out the  i n Nicholson  Towers might be due t o  sharp d i f f e r e n c e s i n t h e p r i o r h e a l t h s t a t u s of r e s i d e n t s  it  attracts.  B e n e f i t s d f Programs R e s i d e n t s of N i c h o l s o n h e a l t h knowledge; healthy  a significantly  behaviours;  function;  Towers had s i g n i f i c a n t l y  significantly  and s i g n i f i c a n t l y  (87% v s . 76%) g r e a t e r  percentage o f  (45.69 v s . 44.42) g r e a t e r  (27.46 v s . 25.07) h i g h e r  than those i n Sunset Towers. s c o r e s was 11 to 56.  (81% v s . 68%) g r e a t e r  physical  social  function  The p o s s i b l e range i n p h y s i c a l  function  The observed range i n s o c i a l  f u n c t i o n s c o r e s was  5 t o 61. In N i c h o l s o n  Towers a s i g n i f i c a n t l y h i g h e r  residents recalled  an o c c a s i o n  b e n e f i t o f the nurses i s s i g n i f i c a n t l y  (1.11  and f e e l i n g  3) number of  i n the l a s t y e a r on which c o n s u l t a t i o n w i t h  the nurse l e d to t a k i n g l e s s m e d i c a t i o n .  higher,  (31 v s .  In Nicholson  Towers  perceived  (1.31 v s . 0.54 on a 3 p o i n t  scale)  of s e c u r i t y from presence o f the nurses i s s i g n i f i c a n t l y  v s . 0.32 on a 3 p o i n t s c a l e ) h i g h e r There were no s i g n i f i c a n t  than i n Sunset Towers.  d i f f e r e n c e s between r e s i d e n t s of the two  complexes i n terms o f numbers o f i n d i v i d u a l s e l i g i b l e f o r Long Term Care  - 80 who  considered  they were a b l e to c o n t i n u e l i v i n g  nurses were a c c e s s i b l e . residents  of  -  the  two  There were a l s o no  i n the  complex because  s i g n i f i c a n t d i f f e r e n c e s between  complexes i n terms of e m o t i o n a l f u n c t i o n , number of  r e c o l l e c t i o n s of p h y s i c i a n v i s i t s  and h o s p i t a l i z a t i o n s h a v i n g been p r e -  vented, nurse c o n s u l t a t i o n s which l e d to t a k i n g more m e d i c a t i o n or c a r d i n g m e d i c a t i o n or p e r c e i v e d  Number of H e a l t h R e l a t e d There were no related v i s i t s residents ficantly  (0.89  significantly no  sessions.  Visits  s i g n i f i c a n t d i f f e r e n c e s i n average number of  i n the  of the  b e n e f i t s of c o u n s e l l i n g  two  time p e r i o d January 1 to August 31, complexes.  v s . 2.42)  N i c h o l s o n Towers had,  fewer v i s i t s  (13.41 v s . 3.20)  1978  between  however,  to p a r a m e d i c a l p e r s o n n e l  more n u r s e s ' v i s i t s .  health  signiand  A l t h o u g h there  s i g n i f i c a n t d i f f e r e n c e s between the complexes i n terms of v i s i t s  specialists, regarding  general  visits  p r a c t i t i o n e r s , l a b o r a t o r i e s and h o s p i t a l s ,  to the l a t t e r three  were fewer of these v i s i t s  Average Costs of H e a l t h  two  ficantly  complexes.  findings there  Services  Costs of v i s i t s  1978  health  between  residents  to p a r a m e d i c a l p e r s o n n e l are  signi-  ($7.31 v s . $21.37) lower i n N i c h o l s o n than i n Sunset Towers.  the c o n t r a r y ,  c o s t s of n u r s e s ' v i s i t s  are s i g n i f i c a n t l y  h i g h e r i n N i c h o l s o n than i n Sunset Towers.  (Costs  computed by m u l t i p l y i n g  This  costs.)  to  i n this building.  s e r v i c e s i n the time p e r i o d January 1 to August 31, of the  are  favour N i c h o l s o n Towers i n t h a t  There were no s i g n i f i c a n t d i f f e r e n c e s i n average c o s t s of  no  dis-  each v i s i t by  Examination of T a b l e 10,  further significant  findings regarding  $20.  page 77,  ($268.31 v s .  of n u r s i n g  figure includes  overhead  shows t h a t although t h e r e  of s p e c i a l i s t v i s i t s , l a b o r a t o r y  $64.07)  v i s i t s were  d i f f e r e n c e s between complexes i n terms of  costs  On  visits,  are  costs, post-  - 81 -  operative v i s i t s  and m e d i c a t i o n  f a v o u r N i c h o l s o n Towers.  r e g a r d i n g c o s t o f h o s p i t a l i z a t i o n and v i s i t s  to general  Findings practitioners  f a v o u r Sunset Towers.  Sources o f H e a l t h  Information  Home Care nurses  spend approximately  90 hours a month  educating  r e s i d e n t s i n N i c h o l s o n Towers, and 15 hours i n Sunset Towers.  A n a l y s i s of  v a r i a n c e (Table 10, page 77) shows t h a t r e s i d e n t s of N i c h o l s o n Towers had significantly Towers.  (81% v s . 68%) g r e a t e r h e a l t h knowledge than those i n Sunset  H e a l t h knowledge i s i n f l u e n c e d by such v a r i a b l e s as  s t a t u s and l e v e l of e d u c a t i o n .  socio-economic  With what c o n f i d e n c e can the g r e a t e r  h e a l t h knowledge o f r e s i d e n t s i n N i c h o l s o n Towers be a t t r i b u t e d  to the  g r e a t e r amount of h e a l t h e d u c a t i o n which occurs here? Data were c o l l e c t e d on sources  of h e a l t h i n f o r m a t i o n .  F o r each  h e a l t h q u e s t i o n c o r r e c t l y answered, the i n d i v i d u a l was asked, "From whom, o r what, d i d you f i r s t  learn this?"  Table 11 shows t h a t r e s i d e n t s o f  N i c h o l s o n Towers o b t a i n e d s i g n i f i c a n t l y t i o n from the Home Care nurses;  (19% v s . 1%) more h e a l t h  and a l s o s i g n i f i c a n t l y  informa-  (3% v s . 0%) more  h e a l t h i n f o r m a t i o n from o t h e r r e s i d e n t s i n t h e complex than those i n Sunset Towers.  Residents  of Sunset Towers o b t a i n e d s i g n i f i c a n t l y  more h e a l t h i n f o r m a t i o n from t h e d o c t o r .  (47% v s . 36%)  There were no o t h e r  significant  d i f f e r e n c e s between r e s i d e n t s o f the two complexes i n terms of sources o f health information. These data suggest  very s t r o n g l y t h a t the g r e a t e r h e a l t h knowledge o f  r e s i d e n t s i n N i c h o l s o n Towers can be a t t r i b u t e d t o the g r e a t e r amount of health education to the in-house  (by Home Care nurses) which occurs i n t h i s complex, due a v a i l a b i l i t y of the n u r s e s .  TABLE 11 ANALYSIS OF VARIANCE OF SOURCES OF HEALTH INFORMATION Variable  imber of r e s i d e n t s  Receiving Nursing o • x. Services at Time o f Study  Received Nursing n • • Services i n Past 2 Years  Never Receiv Received \ Nursl Nursing Services  Complex T 1 n Totals  N i c h . Sunset T. T.  N i c h . Sunset T. T.  Nich. Sunset T. T.  Nich. Sunset T. T.  T  „. . . Significance ° r  Complex S e r v i c e Complex level and s e r v i c e level  30  13  15  17  20  29  65  59  %  %  %  %  %  %  %  %  32  61  40  44  40  43  36  47  .003  .497  .012  5  3  2  0  1  1  1  .235  .042  .570  o b t a i n e d from nurse i n apartment complex  30  3  24  1  0  0  1  .001  .001  .001  o b t a i n e d from r e s i d e n t of complex  1  0  1  0  6  0  3  0  .006  .060  .060  o b t a i n e d from relative  1  0  1  4  2  2  1  2  .349  .253  .206  4  8  6  8  10  18  7  13  .143  .048  .690  22  24  20  41  34  31  25  32  .128  .850  .846  5  3  7  3  6  4  6  4  .088  .097  .034  ircentage o f h e a l t h [formation: obtained  from d o c t o r  o b t a i n e d from nurse  3 19  friend/  o b t a i n e d from mass media known f o r a l o n g  time  f o r which source c o u l d not be i d e n t i f i e d  - 83 S e t t i n g I n Which H e a l t h The  Information  i s Learned  l i t e r a t u r e on a d u l t h e a l t h e d u c a t i o n  i d e n t i f i e s many f a c t o r s which  i n f l u e n c e the e f f e c t i v e n e s s of h e a l t h e d u c a t i o n . more e f f e c t i v e a t changing h e a l t h behaviours which a l l o w l i t t l e education  learner participation.  i s to modify b e h a v i o u r .  Group d i s c u s s i o n s a r e  and a t t i t u d e s than  The i n t e r m e d i a t e  techniques  goal of health  Data were c o l l e c t e d on the s e t t i n g i n  which r e s i d e n t s l e a r n e d h e a l t h i n f o r m a t i o n .  F o r each h e a l t h  question  c o r r e c t l y answered, the i n d i v i d u a l was asked, " D i d you l e a r n t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h  other  people?"  There was no v a r i a n c e i n response to these reported having  items.  A l l individuals  l e a r n e d i n f o r m a t i o n on an i n d i v i d u a l b a s i s .  amount of time Home Care nurses i n N i c h o l s o n  Given t h e  Towers spend on e d u c a t i o n ;  the amount o f h e a l t h knowledge c o n s i d e r e d b a s i c to h e a l t h maintenance i n a l l o l d e r people; behaviour; technique  g r e a t e r e f f e c t i v e n e s s of group d i s c u s s i o n s i n changing  i n c r e a s e d e f f e c t i v e n e s s of h e a l t h e d u c a t i o n when more than one i s used;  Home Care nurses i n N i c h o l s o n  p o s s i b i l i t y o f conducting  health education  groups.  Towers c o u l d e x p l o r e t h e T h i s i s examined i n  g r e a t e r d e t a i l l a t e r i n Chapter V.  Health  Behaviour  A n a l y s i s of v a r i a n c e h e a l t h y behaviours  (Table 10, page 77) shows t h a t t h e percentage of  i s higher  than,  o r equal  t o , the percentage o f h e a l t h  knowledge (both between complexes and between s e r v i c e l e v e l s ) . f i n d i n g i s unexpected.  This  People o f t e n know what they should do, b u t do not  engage i n the advocated h e a l t h y b e h a v i o u r .  This contrary f i n d i n g  can be  e x p l a i n e d as f o l l o w s : many r e s i d e n t s d i d n o t know the answers to p a r t i c u l a r h e a l t h knowledge q u e s t i o n s , b u t r e p o r t e d engaging i n h e a l t h y  behaviours.  For example, many r e s i d e n t s r e p o r t e d not knowing how many cups o f l i q u i d  - 84 they s h o u l d d r i n k i n one  day but  -  reported  d r i n k i n g 6-8  cups  (the advocated  amount).  PREDICTORS OF PHYSICAL, EMOTIONAL AND A n a l y s i s of v a r i a n c e and  SOCIAL FUNCTION  identified significant  s o c i a l f u n c t i o n between r e s i d e n t s  of the  two  differences in physical complexes.  N i c h o l s o n Towers were found to have s i g n i f i c a n t l y p h y s i c a l f u n c t i o n and  significantly  f u n c t i o n than r e s i d e n t s influence health conditions).  (27.46 v s .  of Sunset Towers.  variables postulated function.  This  social  social  s t r e s s , number of m e d i c a l  important to assess the i n f l u e n c e of a p a r t i -  r e g r e s s i o n was  to i n f l u e n c e h e a l t h ,  functioning  health.  used to a s s e s s the i n f l u e n c e of  of v a r i a n c e  accounted f o r by  each of these v a r i a b l e s .  the v a r i a n c e  i n p h y s i c a l f u n c t i o n , 41 per cent of the v a r i a n c e  f u n c t i o n and  33 per  i n p h y s i c a l f u n c t i o n can be Term Care, number of l i f e  chiefly  changes  in social  ences i n e m o t i o n a l f u n c t i o n can be  function.  accounted f o r by  ( s t r e s s ) and  cent  Differences  eligibility  f o r Long  apartment complex.  accounted f o r c h i e f l y by  Differences  in social  f u n c t i o n can be  mainly by h e a l t h knowledge, l e v e l of n u r s i n g  Differ-  eligibility and  accounted f o r  s e r v i c e , and  eligibility  f o r Long Term Care. Analysis  of v a r i a n c e  (Table  d i f f e r e n c e s between r e s i d e n t s  10,  page 77)  identified  of  i n emotional  f o r Long Term Care, h e a l t h b e h a v i o u r , number of m e d i c a l c o n d i t i o n s years of s c h o o l i n g .  social  in physical,  t a b l e shows t h a t the 13 l i s t e d v a r i a b l e s account f o r 54 per  cent of the v a r i a n c e  13  on p h y s i c a l , emotional and  T a b l e 12 p r e s e n t s the p r o p o r t i o n s  emotional and  (45.69 v s . 44.42) g r e a t e r  25.07) g r e a t e r  c u l a r v a r i a b l e , t o g e t h e r w i t h o t h e r v a r i a b l e s , on Stepwise l i n e a r  of  Many v a r i a b l e s are known to  (e.g. h e a l t h knowledge, age,  It i s therefore  Residents  significant  of complexes i n terms of age,  sex  and  TABLE 12 VARIANCE IN PHYSICAL, EMOTIONAL AND SOCIAL FUNCTION ACCOUNTED FOR BY BIOGRAPHICAL AND HEALTH STATUS VARIABLES  Variable  Apartment complex and l e v e l of n u r s i n g service Apartment complex L e v e l of n u r s i n g service Biographical variables Age Sex Socio-economic s t a t u s Years of s c h o o l i n g P r i o r medical status Number of m e d i c a l conditions Number of l i f e changes E l i g i b i l i t y for long term care H e a l t h knowledge and behaviour H e a l t h knowledge H e a l t h behaviour Psychological effect of presence of nurses F e e l i n g of s e c u r i t y from presence of nurses Perceived b e n e f i t of nurses  N*  Physical Function Step No. R squared Beta change  Emotional F u n c t i o n Step No. R squared Beta change  S o c i a l Function Step No. R squared Beta change  124  4  .05  -.25  13  .00  .03  7  .01  -.13  124  6  .01  .19  5  .04  .28  2  .07  .16  124 124 124 124  13 9 10 8  .00 .00 .00 .00  -.02 -.06 .06 .10  6 10 11 4  .02 .00 .00 .05  .17 -.08 .07 .26  9 11  .01 .00  5  .02  .09 .00 -.06 .16  124  5  .02  -.11  3  .07  -.21  10  .01  -.08  124  2  .10  -.23  12  .00  -.04  4  .02  -.14  124  1  .30  .36  1  .13  .26  3  .03  .18  124 124  11 12  .00 .00  -.09 .07  7 2  .01 .07  .24 .20  1 12  .13 .00  .08 .34  124  3  .04  -.39  8  .01  -.19  6  .02  -.39  124  7  .02  -.22  9  .01  -.15  8  .01  -.26  P r o p o r t i o n of t o t a l v a r i a n c e accounted for  0.54  0.41  0.33  T o t a l number of steps  13  13  12  N* = Number of persons f o r whom comparisons  were a p p r o p r i a t e .  - 86  -  numbers of people e l i g i b l e f o r Long Term Care. t h a t age  and  s o c i a l and for  sex  account f o r s m a l l p r o p o r t i o n s  emotional f u n c t i o n .  a large proportion  Eligibility  of v a r i a n c e  T a b l e 12  (page 85)  of v a r i a n c e  shows  i n physical,  f o r Long Term Care accounts  i n p h y s i c a l , s o c i a l and  emotional  function. That e l i g i b i l i t y centage of v a r i a n c e  f o r Long Term Care accounts f o r a l a r g e  i n physical function,  (30%)  i s not h a r d to e x p l a i n .  e l i g i b l e f o r Long Term Care have been assessed as such because p h y s i c a l f u n c t i o n i s poor shopping).  function.  The  significantly  34%)  s e r v i c e s at the  received nursing  s e r v i c e s i n the past  received  services.  to a s m a l l  and  had  percentage of  explained  time of the study;  two  years;  as  those who  follows .  categories:  those who had  never  p r e s s u r e to d i s c o n t i n u e  seeing  improves).  physician.  i n d i v i d u a l s as  soon  It is likely  that  of people i n t h i s category were i n poor p h y s i c a l  poor p h y s i c a l  health  function.  N u r s i n g s e r v i c e s i n N i c h o l s o n Towers were b e i n g g i v e n number of i n d i v i d u a l s ;  had  N u r s i n g s e r v i c e s i n Sunset Towers were b e i n g  ( i . e . as soon as p h y s i c a l h e a l t h  proportion  be  residents  (13) number of i n d i v i d u a l s at the r e q u e s t of a  There i s a d m i n i s t r a t i v e  a high  greater  i n each complex were randomly s e l e c t e d from t h r e e  nursing  thus  function.  (39% v s .  those, r e c e i v i n g n u r s i n g  as p o s s i b l e  Decreased  Decreased p h y s i c a l f u n c t i o n may  f o r Long Term Care i n Sunset Towers can be  Individuals  given  importance to o l d e r p e o p l e .  or  s o c i a l f u n c t i o n index measures s o c i a l a c t i v i t i e s , many of  r e f l e c t e d i n decreased s o c i a l  eligible  their  independence p r o b a b l y a f f e c t s e l f esteem and hence e m o t i o n a l  which i n v o l v e p h y s i c a l f u n c t i o n .  The  Residents  ( i . e . they need h e l p w i t h cooking, c l e a n i n g  Independence i s of g r e a t  m o b i l i t y and  per-  i n d i v i d u a l s considered  need of s e r v i c e s of a c u r a t i v e or p r e v e n t i v e  by  to a l a r g e  (75)  Home Care nurses to be  nature.  - I n d i v i d u a l s are  in  seen  - 87 f o r longer periods the p r o p o r t i o n  of time than i n Sunset Towers.  I t i s thus l i k e l y  of people i n t h i s category w i t h poor p h y s i c a l f u n c t i o n i s  lower i n N i c h o l s o n  than i n Sunset Towers.  The same argument a p p l i e s to people i n the category " r e c e i v e d s e r v i c e s i n the two year p e r i o d p r e c e d i n g preceding  the study", i . e . i t i s l i k e l y  Nicholson  nursing  the study but not i n the month  that i n Sunset Towers only  duals w i t h poor p h y s i c a l f u n c t i o n r e c e i v e d n u r s i n g two y e a r s .  that  indivi-  s e r v i c e s i n the past  Many of them may s t i l l have poor p h y s i c a l f u n c t i o n .  In  Towers, on the other hand, a l a r g e r number o f i n d i v i d u a l s r e -  ceived nursing  s e r v i c e s i n the past  2 years.  receiving services of a purely preventive poor p h y s i c a l f u n c t i o n .  Some of them may have been  n a t u r e and may never have had  I t i s thus l i k e l y  that the p r o p o r t i o n  o f people  i n t h i s category w i t h poor p h y s i c a l f u n c t i o n i s lower i n N i c h o l s o n  than  i n Sunset Towers. Eligibility variance only  f o r Long Term Care accounts f o r a l a r g e percentage o f  i n physical function  (30%) and e m o t i o n a l f u n c t i o n  a s m a l l percentage of v a r i a n c e  cantly  (39% v s . 34%) g r e a t e r  i n s o c i a l function  (3%). A s i g n i f i -  percentage o f r e s i d e n t s i n Sunset Towers a r e  e l i g i b l e f o r Long Term Care than i n N i c h o l s o n f o r the f i n d i n g  (13%) b u t f o r  Towers.  This could  that r e s i d e n t s of Sunset Towers have s i g n i f i c a n t l y  v s . 45.69) lower p h y s i c a l f u n c t i o n than r e s i d e n t s of N i c h o l s o n  account (44.42  Towers.  PREDICTORS OF HEALTH COSTS AND NUMBERS OF HEALTH RELATED VISITS Analysis  of variance  i d e n t i f i e d no s i g n i f i c a n t d i f f e r e n c e s between  r e s i d e n t s of the two complexes i n terms o f average c o s t s of h e a l t h services.  A number o f v a r i a b l e s a r e p o s t u l a t e d  health care.  to i n f l u e n c e c o s t s o f  The i n f l u e n c e o f these v a r i a b l e s on h e a l t h  assessed u s i n g stepwise l i n e a r  regression.  c o s t s was  -  88  -  T a b l e 13 p r e s e n t s the p r o p o r t i o n s of v a r i a n c e i n h e a l t h c o s t s f o r by 16 v a r i a b l e s . variance  L e v e l of n u r s i n g s e r v i c e accounts  (14 per c e n t ) , amount of s t r e s s accounts  f o r the most  f o r 5 per cent of  v a r i a n c e and sex f o r 3 per cent of the v a r i a n c e i n t o t a l c o s t s . l e v e l of n u r s i n g s e r v i c e and amount of s t r e s s account c o s t s i s not h a r d to e x p l a i n .  People  category because they are not w e l l ;  accounted  the  That  f o r much v a r i a n c e i n  r e c e i v i n g n u r s i n g s e r v i c e are i n t h i s i t i s to be expected  on the h e a l t h c a r e system would be g r e a t . mented to be a s s o c i a t e d w i t h i l l n e s s ;  t h a t t h e i r demand  Amount of s t r e s s has been docu-  and hence w i t h demand on the h e a l t h  system. Sex accounts  f o r 3 per cent of the v a r i a n c e i n c o s t s .  that males c o s t the system more than females.  T a b l e 14 shows  Males have a h i g h e r demand  f o r h o s p i t a l s e r v i c e s and a lower demand f o r m e d i c a t i o n than any  other  type  of h e a l t h s e r v i c e . Tables 14 and  15 show t h a t a l l v a r i a b l e s combined account  per cent of the v a r i a n c e i n average number of v i s i t s the v a r i a n c e i n average h e a l t h c o s t s . t h e r e f o r e unaccounted f o r .  The  are not i l l ; times  26 per cent of  f o l l o w i n g f a c t o r s c o u l d account  f o r some  not measured;  inter-  some i n d i v i d u a l s v i s i t h e a l t h p e r s o n n e l when they  d i f f e r e n c e s between h e a l t h p e r s o n n e l i n terms of number of  they see a c l i e n t  l a b o r a t o r y procedures  f o r a s p e c i f i c complaint and numbers and  a l l o w f o r some i n t e r e s t i n g o b s e r v a t i o n s . s i g n save the h e a l t h c a r e system money; The  type o f  requested.  E n t r i e s on T a b l e 14 a r e s t a n d a r d i z e d p r e d i c t i o n c o e f f i c i e n t s  the system money.  40  A l a r g e amount of v a r i a n c e i s  of the remaining v a r i a n c e : s e v e r i t y o f i l l n e s s was individual differences;  and  f o r only  and  I.Variables w i t h a n e g a t i v e those w i t h a p o s i t i v e s i g n c o s t  column marked " T o t a l C o s t s " i n d i c a t e s t h a t each  p o i n t on the 3-point answer s c a l e to the q u e s t i o n "Does the f a c t t h a t  TABLE 13 VARIANCE IN HEALTH CARE COSTS ACCOUNTED FOR BY BIOGRAPHICAL AND HEALTH STATUS VARIABLES  Costs In D o l l a r s o f the F o l l o w i n g  N*  Apartment Complex and L e v e l o f Nursing S e r v i c e Apartment complex 124 L e v e l of n u r s i n g s e r v i c e l 2 4 Biographical Variables Age Sex Years of s c h o o l i n g Socio-economic s t a t u s P r i o r M e d i c a l Status Number of medical conditions Number of l i f e change units E l i g i b i l i t y f o r Long Term Care  G.P. Visits Step R s q . No. Change  8 5  .01 .01  124 124 124 124  12 11 15 13  .01 .01 .00 .00  124  16  124  Specialist Visits Step R s q . No. Change  12  .00  5  .01  13  .00  3  Paramedical Visits Step R sq. No. Change  .07 .01  Laboratory Visits Step R sq. No. Change  14 1  .00 .05  Hospital Days Step R sq. No. Change  Post Op. Visits Step R sq. No. Change  9 12  .00 .00  14 6  .00 .03  .00 .06 .01 .01  13 10 15 9  .00 .01 .00 .01  Nurses Visits Step R s q . No. Change  Medication  T o t a l Costs  Step R sq. No. Change  Step R s q . No. Change  .36  13 1  .00 .06  16 1  .00 .14  14 5 6 13  .00 .00 .00 .00  5 9 4 7  .01 .01 .01  8 3 4 9  .00 .03 .01 .00  .01 .03 .03 .00  9  .00  .00  8 5 2 13  12  .00  10 1 4 8  4  .01  10  .01  13  .00  14  .00  8  .01  4  .01  3  .02  13  .00  .02  1  .07  16  .00  3  .02  3  .02  2  .03  15  .00  8  .00  2  .05  6  .00  14  .00  4  .01  3  .02  3  .02  12  .00  11  -.00  .00 .00  3 11  .03 .01  5 10  .02 .00  5 15  .01 .00  12 1  .00 .05  .01 .04  5 12  .01 .00  124  2  .02  H e a l t h Knowledge and Behaviour Health knowledge Health behaviour  124 124  10 9  .01 .01  H e a l t h Status Physical function Emotional f u n c t i o n Social function  124 124 124  1 6 7  .08 .01 .03  11 7 10  .00 .00 .00  12 9 6  .00 .01 .02  11 6 7  .00 .03 .01  2 11 13  .04 .00 .00  11 4 7  .00 .02 .01  11 12 7  .00 .00 .00  15 14  .00 .00  7 15 14  .01 .00 .00  14  .00  2  .02  15  .00  8  .01  7  .01  16  .00  10  .00  11  .00  10  .00  4  .02  3  .12  4  .03  2  .04  6  .02  5  .01  2  .06  10  .00  6  .01  P s y c h o l o g i c a l E f f e c t of Presence of Nurses P e r c e i v e d b e n e f i t of nurses 124 P e r c e i v e d s e c u r i t y from presence of nurses 124 P r o p o r t i o n of t o t a l v a r i a n c e accounted f o r T o t a l number of steps  .01 .01  .23  .26  .26  .21  .17  .20  .49  .16  .26  16  13  16  14  15  16  15  15  16  TABLE 14 PREDICTION  COEFFICIENTS  (BETA) FOR HEALTH COSTS FOR 16  VARIABLES  Costs i n D o l l a r s of Specialist Visits Beta  Paramedical Visits Beta  Laboratory Visits Beta  .13 .27  .00 -.04  .29 -.21  .03 -.18  -.08 -.10 -.03 .05  .00 -.13 .00 .01  -.11 .18 .12 .06  ,02  .14  17  HospItal Days Beta  Mean P r e d i c t i v i t y of Total Total V i s i t s Costs and Costs  Post-operative Beta  Nurses ... ... Visits Beta  Medi. cation Beta  .05 -.04  .04 -.25  .00 -.51  .05 -.17  -.02 .22  .14  .16  .00 -.09 .00 .03  -.05 -.28 -.08 .07  -.03 -.07 .03 .08  .02 .06 -.09 .02  -.13 .05 -.19 -.09  -.05 -.22 -.10 .07  .08  .07  .12  .04  -.01  .15  .12  .09  .05  .14  .02  .11  .12  .10  .01  .10  .15  .10  .10  ,25  .09  .05  .19  .00  -.17  .14  -.04  -.06  Health Knowledge and Behaviour Health knowledge Health behaviour  ,16 ,20  .11 -.08  -.31 -.13  .26 -.10  .15 .02  -.09 -.15  .13 -.14  .12 -.25  .21 -.09  .15  .14  Health Status Physical function Emotional f u n c t i o n Social function  ,04 ,24 ,26  .03 -.12 .05  .08 .11 .16  -.07 -.25 .16  -.21 .05 -.03  .05 .26 -.13  .08 -.04 .11  .03 -.04 .00  -.14 -.03 .06  .11  .11  ,07  -.55  .05  -.20  -.14  -.04  .13  .08  -.12  ,33  -.57  .29  -.42  .24 -.30  .23  -.30  .37  .13  -.18  Percentage of V a r i a n c e Accounted f o r A f t e r A l l Significant Variables  .23  .26  .26  .20  .17  .20  .49  .17  .26  Minimum Standard At Step Number  ,20 8  .24 5  .26 11  .19 8  .16 7  .18 8  .48 9  .15 6  .24 6  G.P. Visits Beta Apartment Complex and L e v e l of Nursing S e r v i c e Apartment complex L e v e l of n u r s i n g s e r v i c e Biographical Variables Age Sex Years of s c h o o l i n g Socio-economic s t a t u s P r i o r M e d i c a l Status Number of m e d i c a l conditions Number of l i f e change units E l i g i b i l i t y f o r Long Term Care  P s y c h o l o g i c a l E f f e c t s of Presence of Nurses Perceived b e n e f i t of nurses Perceived s e c u r i t y from presence of nurses  Error  t  Total „ Costs  J  m  TABLE 15 PREDICTION COEFFICIENTS (BETA) FOR G.P. Visits Beta  NUMBERS OF HEALTH RELATED VISITS FOR  S p e c i a l i s t Paramedical Laboratory Visits Visits Visits Beta Beta Beta  16 VARIABLES  Hospital Days Beta  Nurses Visits Beta  Total Visits Beta  Mean Total Visits  P r e d i c t i v i t y of Total V i s i t s and Costs  Apartment Complex and L e v e l of Nursing S e r v i c e Apartment complex L e v e l of n u r s i n g s e r v i c e  16 29  .00 -.12  .29 -.23  .13 -.26  -.05 -.10  .00 -.50  .10 .42  Biographical V a r i a b l e s Age Sex Years of s c h o o l i n g Socio-economic s t a t u s  10 08 03 10  .08 -.06 .02 .00  -.14 .16 .11 .06  .02 -.12 .00 . -.02  -.03 -.16 -.09 .05  .02 .06 -.09 .02  -.02 -.04 -.06 .05  P r i o r M e d i c a l Status Number of m e d i c a l c o n d i t i o n s Number of l i f e change u n i t s E l i g i b i l i t y f o r Long Term Care  08 13 10  .18 .19 .15  .11 -.03 .05  -.04 .07 .12  .05 .13 -.11  .12 .01 .14  .12 .11 .10  .10  .10  Health Knowledge and Health knowledge H e a l t h behaviour  22 15  .02 .02  -.26 -.14  .20 .05  .08 -.07  .13 -.14  .18 -.14  .13  .14  ifealth Status Physical function Emotional f u n c t i o n Social function  07 17 27  .05 -.19 .10  .09 .10 .22  .05 -.27 .04  -.05 .08 -.06  .08 -.04 .10  .06 -.13 .15  .11  .11  P s y c h o l o g i c a l E f f e c t of Presence of Nurses P e r c e i v e d b e n e f i t of nurses P e r c e i v e d s e c u r i t y from presence of nurses  15 20  -.44 -.55  .03 .29  .07 -.06  -.27 -.42  .13 .37  -.04 .12  .22  .23  .17  .28  .26  .15  .17  .49  .40  .15 10  .26 7  .24 10  .14 6  .15 6  .46 6  .35 4  After A l l S i g n i f i c a n t  .19  .16  .06  .07  I  Behaviour  Variables  Minimum Standard E r r o r At Step Number  92  -  -  nurses come i n t o t h i s b u i l d i n g make you f e e l more s e c u r e ? " saves the system 18 c e n t s . question  S i m i l a r l y each p o i n t  on the 3-point answer s c a l e t o the  "Do you r e c e i v e any b e n e f i t from the nurses i n the b u i l d i n g ? "  saves the system 12 c e n t s .  Each i n d i v i d u a l s c a l e p o i n t  b e h a v i o u r s c a l e saves the system 9 c e n t s . the s t r e s s s c a l e c o s t s l e v e l s of n u r s i n g  and each l e v e l of the t h r e e  the system 22 c e n t s .  I t i s i n t e r e s t i n g t h a t the g r e a t e r presence o f the nurses and the g r e a t e r presence, the g r e a t e r  On the o t h e r hand, each p o i n t on  the system 15 c e n t s ,  costs  on the h e a l t h  the p e r c e i v e d  b e n e f i t from the  the f e e l i n g o f s e c u r i t y from  the economic s a v i n g  t o the h e a l t h  their  c a r e system.  The  sense o f s e c u r i t y which r e s i d e n t s have from the presence o f the nurses t h e r e f o r e has economic b e n e f i t s . 24 hours a day.  Yet the nurses a r e not i n the b u i l d i n g  I t may t h e r e f o r e be the i l l u s i o n o f s e c u r i t y which i s  important o r the c e r t a i n t y o f the a r r i v a l o f the nurse the next day. E n t r i e s on T a b l e 15 a r e a l s o s t a n d a r d i z e d  prediction  V a r i a b l e s w i t h a n e g a t i v e s i g n reduce demand f o r h e a l t h those w i t h a p o s i t i v e s i g n i n c r e a s e l e v e l of the three  demand f o r h e a l t h  l e v e l s of n u r s i n g  system of h a l f a v i s i t .  care v i s i t s ;  care v i s i t s .  Each  s e r v i c e produces a demand on the  Each p o i n t on the h e a l t h knowledge s c a l e produces  a demand f o r .18 o f a v i s i t .  (People w i t h g r e a t e s t  those w i t h p o o r e s t p h y s i c a l f u n c t i o n .  h e a l t h knowledge were  Greater contact  f e s s i o n a l s presumably r e s u l t e d i n g r e a t e r h e a l t h on  coefficients.  with health  knowledge.)  Each  propoint  the h e a l t h b e h a v i o u r and emotional f u n c t i o n s c a l e s reduces demand f o r  health  care v i s i t s by approximately  The  .13 o f a v i s i t .  second l a s t column on T a b l e 14 i n d i c a t e s which v a r i a b l e s a r e  good p r e d i c t o r s  of c o s t s .  The same column on T a b l e 15 shows which v a r i a b l e s  are good p r e d i c t o r s of numbers of h e a l t h  related v i s i t s .  The l a s t  column  on each t a b l e i n d i c a t e s which v a r i a b l e s a r e good p r e d i c t o r s o f c o s t s and  - 93 number of h e a l t h three  cases.  related v i s i t s  Perceived  l e v e l of n u r s i n g  health  knowledge and  the b e s t  s e r v i c e are  The  f i n d i n g s are s i m i l a r i n a l l perceived  predictors.  s e c u r i t y from  Apartment  complex  the next most p o w e r f u l p r e d i c t o r s ;  h e a l t h b e h a v i o u r the  of c o s t s , number of h e a l t h visits  combined.  b e n e f i t of the nurses and  the presence of the nurses are and  -  related v i s i t s  t h i r d most p o w e r f u l and  costs  and  and  predictors  health  related  combined.  Perceived  b e n e f i t from the presence of the nurses and  perceived  s e c u r i t y from the nurses have almost twice as much e x p l a n a t o r y power i n terms of h e a l t h As  c o s t s and  number of v i s i t s  p r e d i c t o r s of c o s t s and  complex and  as h e a l t h knowledge and  number of h e a l t h  l e v e l of n u r s i n g  related v i s i t s ,  Tables 14  and  15 shows t h a t l e v e l of n u r s i n g  p r e d i c t o r of the  two  can be  by  explained  variables.  use  are r e c e i v i n g n u r s i n g  h e a l t h s e r v i c e s a great  Examination of  s e r v i c e i s the  number of h e a l t h  the h e a l t h  three  s e r v i c e s at the b e h a v i o u r and poorest. health  predictor  have never r e c e i v e d c a r e system v e r y  s e r v i c e s are not w e l l and  nursing  little;  are  thus  related v i s i t s  l e v e l s of n u r s i n g  can be  explained  as  had  behaviour  s e r v i c e w i t h those r e c e i v i n g  never r e c e i v e d n u r s i n g  nursing  services having  There were a l s o s i g n i f i c a n t d i f f e r e n c e s i n c o s t s  r e l a t e d v i s i t s between the  three l e v e l s of n u r s i n g  of  follows.  time of the study h a v i n g the b e s t h e a l t h knowledge  those who  using  h e a l t h b e h a v i o u r are good p r e d i c t o r s  There were s i g n i f i c a n t d i f f e r e n c e s i n h e a l t h knowledge and between the  stronger  deal.  That h e a l t h knowledge and c o s t s and  perceived  That t h i s v a r i a b l e i s a s t r o n g  the f a c t that people who  s e r v i c e s are l i k e l y w e l l and those who  apartment  s e r v i c e are almost as p o w e r f u l as  s e c u r i t y and b e n e f i t from the presence of the n u r s e s .  behaviour.  and  and the  number of  service with  those r e c e i v i n g n u r s i n g highest received  number of h e a l t h nursing  s e r v i c e s at the related v i s i t s  s e r v i c e s the lowest.  health professionals  time of the study h a v i n g and  costs  and  those who  had  Those w i t h . t h e g r e a t e s t  thus have the b e s t h e a l t h knowledge and  the never  contact  with  behaviour  and  c o s t the system more than other i n d i v i d u a l s .  DIFFERENCES BETWEEN RESIDENTS RECEIVING DIFFERENT LEVELS OF NURSING SERVICE H y p o t h e s i z e d r e l a t i o n s h i p s r e l a t e d to d i f f e r e n c e s between complexes. One  would a n t i c i p a t e t h a t there would a l s o be  s t a t u s and  h e a l t h knowledge between s e r v i c e l e v e l s  receiving nursing nursing  differences i n costs,  s e r v i c e s at the  s e r v i c e s i n the p a s t ;  ( i . e . between people  time of the study;  and  people who  health  people who  never r e c e i v e d  received  nursing  services). Data on d i f f e r e n c e s  (and  d i r e c t i o n of d i f f e r e n c e s ) between s e r v i c e  l e v e l s are p r e s e n t e d i n T a b l e 10, ences between  residents  at the three  of percentage of r e s i d e n t s r e s i d e n t s who  considered  nurses are a c c e s s i b l e . c a t e g o r i e s was  nursing  s e r v i c e s had  The  highest  significantly  f u n c t i o n than r e s i d e n t s who  and  greater  nursing  i n the  p h y s i c a l and  s e r v i c e s a t the  had  received nursing  had  study.  nursing  p h y s i c a l and  signi-  emotional  s e r v i c e s i n the p a s t .  fewer m e d i c a l c o n d i t i o n s ,  the  never  experienced  emotional f u n c t i o n than those who time of the  above  s e r v i c e s at  never r e c e i v e d  s i g n i f i c a n t l y greater  significantly  complex because  were r e c e i v i n g n u r s i n g  fewer m e d i c a l c o n d i t i o n s , had  had  percentage of  percentage i n each of the  R e s i d e n t s who  differ-  s e r v i c e i n terms  the lowest percentage among those who  services.  i n t u r n , had  l e v e l s of n u r s i n g  they c o u l d c o n t i n u e l i v i n g  f i c a n t l y l e s s s t r e s s and had  latter,  There were s i g n i f i c a n t  e l i g i b l e f o r Long Term Care and  found among those who  time of the study; received  page 77.  The  less stress  were r e c e i v i n g  There were s i g n i f i c a n t d i f f e r e n c e s between r e s i d e n t s l e v e l s of n u r s i n g perceived  s e r v i c e i n terms of h e a l t h knowledge, h e a l t h  b e n e f i t of the nurses and  of the n u r s e s . the study had  Those who  were r e c e i v i n g n u r s i n g  s e r v i c e s at the  the poorest h e a l t h  l e a s t b e n e f i t and had  had  the g r e a t e s t  Those who  had  the  never r e c e i v e d  knowledge and b e h a v i o u r and  nursing  perceived  the  the l e a s t f e e l i n g of s e c u r i t y from the presence of  nurses.  three  l e v e l s of n u r s i n g  l a b o r a t o r i e s , nurses and  s e r v i c e i n terms of number of v i s i t s t o t a l number of h e a l t h  to s p e c i a l i s t s , l a b o r a t o r i e s , n u r s e s , m e d i c a t i o n and  health  services.  the study had  Those who  the g r e a t e s t  never r e c e i v e d n u r s i n g  nursing  were r e c e i v i n g n u r s i n g number of these v i s i t s s e r v i c e s , the l e a s t .  s e r v i c e s i n the past had  s i g n i f i c a n t l y greater p e r s o n n e l and than those who  s i g n i f i c a n t l y greater  l a t t e r , i n t u r n , scored  those who  had  never r e c e i v e d  and  costs;  of  of  those  who  received a  paramedical  to p a r a m e d i c a l p e r s o n n e l  s e r v i c e s at the  services.  costs  s o c i a l function,  to s p e c i a l i s t s and  s i g n i f i c a n t l y h i g h e r on nursing  and  t o t a l cost  R e s i d e n t s who  c o s t s of v i s i t s  were r e c e i v i n g n u r s i n g  the  s e r v i c e s at the time of  s i g n i f i c a n t l y greater  number of v i s i t s  at  to h o s p i t a l s ,  related v i s i t s  visits  The  time of  f e e l i n g of s e c u r i t y  There were a l s o s i g n i f i c a n t d i f f e r e n c e s between r e s i d e n t s  had  presence  the b e s t h e a l t h knowledge and b e h a v i o u r , p e r c e i v e d  from the presence of the n u r s e s .  the  three  behaviour,  f e e l i n g of s e c u r i t y from the  g r e a t e s t b e n e f i t from the nurses and  s e r v i c e s had  at the  time of the  study.  these v a r i a b l e s  than  -  96 -  CHAPTER V  SUMMARY, DISCUSSION OF RESULTS, RECOMMENDATIONS AND CONCLUSIONS  SUMMARY OF STUDY Costs of h e a l t h care i n Canada have r i s e n i s h a r p l y i n r e c e n t F e d e r a l and P r o v i n c i a l Governments have r e c o g n i z e d increased  emphasis on promoting and m a i n t a i n i n g  years.  t h a t t h e r e should be  h e a l t h and a r e implementing  p r e v e n t i v e h e a l t h care programs. A l t e r n a t e forms of h e a l t h care d e l i v e r y s h o u l d be developed f o r e l d e r l y people s i n c e the p r o p o r t i o n o f e l d e r l y people i n the p o p u l a t i o n i s i n c r e a s i n g and they consume a d i s p r o p o r t i o n a t e amount o f the most expensive forms o f h e a l t h s e r v i c e .  E i g h t y s i x p e r cent of e l d e r l y people  have c h r o n i c d i s e a s e s which r e q u i r e s e l f - m a i n t e n a n c e education  about managing d i s e a s e  t i o n r a t e s and promotes h e a l t h .  and p r e v e n t i o n  Health  and h e a l t h y b e h a v i o u r reduces h o s p i t a l i z a F a c t o r s which promote h e a l t h o f o l d e r  people a r e e a r l y d e t e c t i o n o f d i s e a s e , i n times of c r i s i s  skills.  ease of access  of s o c i a l i s o l a t i o n .  to emotional  support  A l t e r n a t e forms  of h e a l t h c a r e d e l i v e r y f o r t h i s age group should be a c c e s s i b l e , emphasize h e a l t h promotion through h e a l t h e d u c a t i o n and be based i n t h e community Two  and e a r l y d e t e c t i o n o f d i s e a s e  ( r a t h e r than i n an i n s t i t u t i o n ) .  f a c t o r s presumed to be important i n promoting h e a l t h of e l d e r l y  people were i n v e s t i g a t e d i n t h i s study.  These f a c t o r s are h e a l t h  t i o n and ease and q u a l i t y o f c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s .  educa-  The  review of l i t e r a t u r e on f a c t o r s which i n f l u e n c e the e f f e c t i v e n e s s of h e a l t h  - 97 -  education  revealed  the f o l l o w i n g : i t i s p r o b a b l e that an i n d i v i d u a l w i l l  engage i n the advocated h e a l t h f u l b e h a v i o u r i f he b e l i e v e s prone to becoming i l l thinks  and t h a t i l l n e s s w i l l have s e r i o u s  a c e r t a i n course o f a c t i o n w i l l be b e n e f i c i a l ;  t h a t he i s  results;  i f he  i f there a r e no  f i n a n c i a l or p s y c h o l o g i c a l b a r r i e r s and i f he e x p e r i e n c e s a cue to t r i g g e r action.  A l s o , b e h a v i o u r change i s p r o b a b l e i f the program p l a n has taken  i n t o account c u l t u r a l and s o c i a l f o r c e s i n the t a r g e t p o p u l a t i o n how people change b e h a v i o u r s and b a r r i e r s t o change); t i o n a l techniques a r e used;  m a i n t a i n e d through  i f s e v e r a l educa-  i f the person i s a c t i v e l y i n v o l v e d  l e a r n i n g process and there a r e many c o n t a c t s .  (such as  Behavioural  i n the  change can be  reinforcement.  There a r e few e m p i r i c a l s t u d i e s on the r o l e o f ease and q u a l i t y o f c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s i n h e a l t h promotion.  Available  i n d i c a t e s t h a t these a r e important f a c t o r s i n promoting h e a l t h . with p h y s i c a l disease disturbance. 70;  health.  The i n c i d e n c e  of p h y s i c a l d i s e a s e  increases  alone.  I n order  to determine how e f f e c t i v e l y a program has m a i n t a i n e d o r  h e a l t h c a r e i s t o m a i n t a i n and improve  i n d i c e s f o r measuring the v a r i o u s  E x i s t i n g i n d i c e s of m o r t a l i t y and m o r b i d i t y  to changes i n s o c i a l ,  emotional and p h y s i c a l w e l l b e i n g .  (as opposed to d i s e a s e )  has c r e a t e d  of h e a l t h a r e q u a l i t a t i v e l y d i s t i n c t ,  One  aspects of  a r e not s e n s i t i v e The new emphasis on  the need f o r an index which  measures s o c i a l , emotional and p h y s i c a l h e a l t h .  social,  a t the age of  goal of preventive  good h e a l t h .  Sackett,  emotional  ultimate  improved h e a l t h one r e q u i r e s  health  Those  and who l i v e alone a r e a t r i s k of d e v e l o p i n g  and many o l d e r c i t i z e n s l i v e The  literature  they should  Since  these three  be measured  dimensions  separately.  Chambers e t a l . (1977) developed an instrument which measures emotional and p h y s i c a l f u n c t i o n  separately.  would a n t i c i p a t e programs which emphasize h e a l t h e d u c a t i o n and  - 98 a c c e s s i b i l i t y and with  q u a l i t y of c o n t a c t w i t h h e a l t h p e r s o n n e l  g r e a t e r h e a l t h and  s i z e these f a c t o r s . c i t i z e n s who and  -  lower h e a l t h  A study was  to be  associated  c o s t s than those which do not  empha-  designed to t e s t the c l a i m t h a t s e n i o r  r e c e i v e d p r e v e n t i v e n u r s i n g s e r v i c e s which were a c c e s s i b l e  emphasized h e a l t h promotion (through  health education,  counselling  and  e a r l y d e t e c t i o n of d i s e a s e ) would have s i g n i f i c a n t l y g r e a t e r h e a l t h knowledge, h e a l t h b e h a v i o u r and h e a l t h s t a t u s and c o s t s than those who and  received nursing  p l a c e d l e s s emphasis on h e a l t h Residents  of two  s i g n i f i c a n t l y lower h e a l t h  s e r v i c e s which; were l e s s a c c e s s i b l e  promotion.  apartment complexes i n the West End  of Vancouver  have been r e c e i v i n g d i f f e r e n t Home Care n u r s i n g programs s i n c e 1974, p a r t i c i p a n t s i n t h i s study.  Nurses i n N i c h o l s o n  and  and  do much h e a l t h e d u c a t i o n  l e s s a c c e s s i b l e and At  45  do l e s s h e a l t h e d u c a t i o n  and  seen by nurses on a r e g u l a r b a s i s ;  i n Sunset Towers had  preceding  two  years but  Nicholson  and  186  not  accessible  47  are  counselling. and  13  i n Sunset  individuals in  Nicholson  r e c e i v e d n u r s i n g s e r v i c e s at some time i n the i n the p r e c e d i n g  i n Sunset Towers had  month;  and  118  individuals in  never r e c e i v e d n u r s i n g s e r v i c e s .  A sample of i n d i v i d u a l s i n each complex was each of t h r e e c a t e g o r i e s  were  Nurses i n Sunset Towers  the time of the study 75 i n d i v i d u a l s i n N i c h o l s o n  were b e i n g and  counselling.  Towers are very  who  randomly s e l e c t e d from  to ensure t h a t i n d i v i d u a l s who  n u r s i n g s e r v i c e s at the time of the study and  those who  were r e c e i v i n g had  n u r s i n g s e r v i c e s i n the past, were adequately r e p r e s e n t e d .  received The  following  c a t e g o r i e s were used: i n d i v i d u a l s r e c e i v i n g n u r s i n g s e r v i c e s at the  time  of the study;  two  i n d i v i d u a l s who  year p e r i o d p r e c e d i n g i n d i v i d u a l s who as f o l l o w s : 65  had  r e c e i v e d n u r s i n g s e r v i c e s i n the  the study but not  i n the month p r e c e d i n g  have never r e c e i v e d n u r s i n g i n d i v i d u a l s from N i c h o l s o n  services.  Towers and  the  study;  Sample s i z e s were 59  from Sunset Towers.  - 99 -  Data c o l l e c t e d from r e s i d e n t s i n a s t r u c t u r e d i n t e r v i e w measured h e a l t h knowledge, sources of h e a l t h i n f o r m a t i o n , h e a l t h b e h a v i o u r s ,  health  s t a t u s , p e r c e i v e d b e n e f i t of nurses and v a r i a b l e s i d e n t i f i e d  i n the  l i t e r a t u r e as r e l a t e d to h e a l t h knowledge and h e a l t h s t a t u s .  Health  knowledge was measured by q u e s t i o n s by nurses i n N i c h o l s o n  Towers.  based on i n f o r m a t i o n  Health  taught to r e s i d e n t s  s t a t u s was measured u s i n g  adapted  v e r s i o n s of s c a l e s o f p h y s i c a l , emotional and s o c i a l f u n c t i o n developed by Sackett,  Chambers e t a l . (1977).  V a r i a b l e s r e l a t e d t o h e a l t h s t a t u s and  h e a l t h c o s t s measured i n t h i s study were sex,  age, years  of schooling,  socio-economic s t a t u s , number o f m e d i c a l c o n d i t i o n s and number o f l i f e change u n i t s .  Blishen's  (1967) O c c u p a t i o n a l  measure socio-economic s t a t u s .  Rating  The S o c i a l Readjustment S c a l e developed by  Holmes and Rahe (1967) was used t o measure l i f e The  changes.  f o l l o w i n g data were c o l l e c t e d from Home Care nurses i n each  b u i l d i n g : amount of h e a l t h e d u c a t i o n which occurs month;  S c a l e was used to  i n each complex p e r  which i n d i v i d u a l s were e l i g i b l e f o r Long Term Care;  Care n u r s i n g v i s i t s  number o f Home  t o i n d i v i d u a l s i n the sample f o r the p e r i o d January 1  to August 31, 1978. The M e d i c a l  S e r v i c e s P l a n o f B.C. and Pharmacare  s u p p l i e d d a t a on number and c o s t o f a l l h e a l t h s e r v i c e s and c o s t o f medicat i o n f o r i n d i v i d u a l s i n the sample f o r the time p e r i o d January 1 t o August 31, 1978. One  i n t e r v i e w e r conducted a l l the i n t e r v i e w s  (August-September, 1978).  I n d i v i d u a l s were i n t e r v i e w e d  ments i n a 40 minute s t r u c t u r e d s c h e d u l e . entered  over a f o u r week p e r i o d  on the i n t e r v i e w sheet  i n t h e i r own a p a r t -  Responses t o q u e s t i o n s  were  and subsequently t r a n s f e r r e d on t o coding  sheets. Raw data were keypunched onto c a r d s .  The data were computer  u s i n g the U n i v e r s i t y o f B r i t i s h Columbia's v e r s i o n of SPSS.  analyzed  Analysis of  -100 variance  was used  to t e s t d i f f e r e n c e s between r e s i d e n t s  of N i c h o l s o n and  Sunset Towers i n terms of h e a l t h knowledge, h e a l t h b e h a v i o u r , h e a l t h number o f h e a l t h  related visits  c a l c u l a t e d among items. v a r i a b l e s accounted health  Stepwise  Pearson c o r r e l a t i o n s were  linear regression  determined  f o r what percentage o f v a r i a n c e  related v i s i t s  reliability  and c o s t s .  status,  what  i n c o s t s , number o f  and p h y s i c a l , s o c i a l and e m o t i o n a l f u n c t i o n .  A  procedure was used to compute c o e f f i c i e n t s o f r e l i a b i l i t y f o r  scales. B e f o r e the study c o u l d be executed, i t was n e c e s s a r y to adapt e x i s t i n g s c a l e s and develop one new s c a l e . and s o c i a l f u n c t i o n developed by S a c k e t t , Segovia, 1978) were adapted h e a l t h knowledge was  Chambers  of p h y s i c a l , emotional e t a l . (Chambers &  f o r use w i t h t h i s p o p u l a t i o n .  A s c a l e of  developed f o r use i n the study.  The r e l i a b i l i t i e s measured.  Scales  three  of s c a l e s developed  f o r use i n t h i s study were  These s c a l e s were subsequently examined f o r c o n t e n t , conver-  gent, d i s c r i m i n a n t  and c o n s t r u c t  validity.  The p h y s i c a l  function  and the 22-item h e a l t h knowledge s c a l e both have good a l p h a  scale  reliabilities  and the emotional f u n c t i o n s c a l e and the 7-item knowledge s c a l e have moderate a l p h a r e l i a b i l i t i e s .  The p h y s i c a l and emotional f u n c t i o n  evidence c o n t e n t , convergent, d i s c r i m i n a n t  and c o n s t r u c t  two h e a l t h knowledge s c a l e s evidence convergent, validity.  Although  discriminant  validity.  construct  and  i t has a low r e l i a b i l i t y Findings  regarding  The  face  the s o c i a l f u n c t i o n s c a l e evidences c o n s t r u c t  validity,  convergent v a l i d i t y .  scales  and  and low c o n t e n t and  s o c i a l function are therefore  tenuous. Hypothesis 1: h e a l t h knowledge, h e a l t h b e h a v i o u r and h e a l t h of s e n i o r  c i t i z e n s i n N i c h o l s o n Towers w i l l  that of s e n i o r  status  be s i g n i f i c a n t l y g r e a t e r  c i t i z e n s i n Sunset Towers, was  than  accepted f o r f o u r o f i t s  - 101 five  components. Hypothesis 2: over an 8 month p e r i o d , the average number o f h e a l t h  r e l a t e d v i s i t s made by o r to r e s i d e n t s o f N i c h o l s o n be s i g n i f i c a n t l y  lower i n N i c h o l s o n  and Sunset Towers w i l l  than i n Sunset Towers, was r e j e c t e d .  Hypothesis 3: over an 8 month p e r i o d , average c o s t s of a l l h e a l t h services provided significantly  to r e s i d e n t s of N i c h o l s o n  lower i n N i c h o l s o n  Hypothesis 4: o f those significantly  and Sunset Towers w i l l be  than i n Sunset Towers, was r e j e c t e d .  r e s i d e n t s e l i g i b l e f o r Long Term Care, a  g r e a t e r percentage i n N i c h o l s o n  c o n s i d e r t h a t they a r e a b l e to c o n t i n u e  than i n Sunset Towers w i l l  l i v i n g i n the apartment because  nurses a r e a c c e s s i b l e , was r e j e c t e d . Home Care nurses spend approximately residents i n Nicholson  90 hours a month  Towers, and 15 hours i n Sunset Towers.  v a r i a n c e showed t h a t r e s i d e n t s o f N i c h o l s o n v s . 68%) g r e a t e r h e a l t h knowledge than those confidence  educating Analysis of  Towers had s i g n i f i c a n t l y (81% i n Sunset Towers.  With what  can the g r e a t e r h e a l t h knowledge o f r e s i d e n t s i n N i c h o l s o n  Towers be a t t r i b u t e d to the greated  amount o f h e a l t h e d u c a t i o n which  occurs  here? Data were c o l l e c t e d on sources  of h e a l t h i n f o r m a t i o n .  F o r each h e a l t h  q u e s t i o n c o r r e c t l y answered, the i n d i v i d u a l was asked, "From whom, o r what, d i d you f i r s t Nicholson tion  learn this?"  Towers o b t a i n e d  A n a l y s i s o f v a r i a n c e showed t h a t r e s i d e n t s of significantly  from Home Care nurses;  (19% v s . 1%) more h e a l t h  and a l s o s i g n i f i c a n t l y  informa-  (3% v s . 0%) more  h e a l t h i n f o r m a t i o n from o t h e r r e s i d e n t s i n the complex than those i n Sunset Towers.  Residents  o f Sunset Towers o b t a i n e d  more h e a l t h i n f o r m a t i o n from d o c t o r s .  significantly  There were no o t h e r  (47% v s . 36%) significant  d i f f e r e n c e s between r e s i d e n t s of the two complexes i n terms of sources o f health information.  These d a t a suggest v e r y s t r o n g l y t h a t the g r e a t e r  - 102 h e a l t h knowledge of r e s i d e n t s i n N i c h o l s o n  Towers can be a t t r i b u t e d t o  the g r e a t e r amount of h e a l t h e d u c a t i o n which i s done by Home Care nurses i n this  complex. Data were c o l l e c t e d on the s e t t i n g i n which r e s i d e n t s l e a r n e d  information.  A l l i n d i v i d u a l s reported having  individual basis.  learned  Home Care nurses i n N i c h o l s o n  d e a l of time on e d u c a t i o n  health  i n f o r m a t i o n on ah  Towers spend a great  and a c e r t a i n amount o f h e a l t h knowledge i s con-  s i d e r e d b a s i c t o h e a l t h maintenance i n a l l o l d e r p e o p l e .  Group d i s c u s s i o n s  are known to be e f f e c t i v e i n changing b e h a v i o u r , and the e f f e c t i v e n e s s of health education  i s i n c r e a s e d when more than one technique i s used.  Care nurses c o u l d t h e r e f o r e e x p l o r e education  the p o s s i b i l i t y o f conducting  i d e n t i f i e d s i g n i f i c a n t d i f f e r e n c e s between  r e s i d e n t s o f the two complexes i n terms o f age, e l i g i b l e f o r Long Term Care.  t h e i n f l u e n c e o f 13 v a r i a b l e s p o s t u l a t e d  complex and l e v e l o f n u r s i n g medical status;  service;  to i n f l u e n c e h e a l t h on  These v a r i a b l e s were apartment  biographical variables;  h e a l t h knowledge and b e h a v i o u r ;  e c t of the presence of nurses. of v a r i a n c e  sex and numbers o f people  Stepwise l i n e a r r e g r e s s i o n was used to  p h y s i c a l , e m o t i o n a l and s o c i a l f u n c t i o n .  Age and sex account f o r s m a l l  i n p h y s i c a l , emotional and s o c i a l f u n c t i o n .  emotional f u n c t i o n .  The s i g n i f i c a n t l y  prior  and the p s y c h o l o g i c a l  i n this  (44.42  vs.  45.69)  for  i n physical  (39% v s . 34%) g r e a t e r  of r e s i d e n t s e l i g i b l e f o r Long Term Care i n Sunset Towers c o u l d f o r the s i g n i f i c a n t l y  eff-  proportions  Eligibility  Long Term Care accounts f o r a l a r g e p r o p o r t i o n o f v a r i a n c e and  health  groups.  Analysis of variance  assess  Home-  percentage account  lower p h y s i c a l f u n c t i o n of r e s i d e n t s  complex.  A n a l y s i s of v a r i a n c e  i d e n t i f i e d no s i g n i f i c a n t d i f f e r e n c e s between  r e s i d e n t s of the two complexes i n average number o f h e a l t h r e l a t e d v i s i t s  - 103 and h e a l t h c o s t s .  -  Stepwise l i n e a r r e g r e s s i o n was  i n f l u e n c e of 16 v a r i a b l e s on h e a l t h c o s t s . accounts f o r most of the v a r i a n c e  used to assess  L e v e l of n u r s i n g  i n costs.  service  Amount of s t r e s s and  are the v a r i a b l e s which account f o r the next l a r g e s t amounts of i n costs. variance  A l l v a r i a b l e s combined account f o r o n l y 40 i n number of h e a l t h r e l a t e d v i s i t s  in health costs.  Much v a r i a n c e  and  cents.  On  regarding 18 and  and  variance  26 per cent  the  of the  care  each p o i n t on the s t r e s s s c a l e c o s t s the system  the o t h e r hand, each p o i n t on the answer s c a l e s to the perceived  12 cents  15  questions  s e c u r i t y and b e n e f i t from the nurses saves the  system  respectively.  Implications  FINDINGS  of f i n d i n g s on c o s t s of h e a l t h c a r e , on h e a l t h  on h e a l t h e d u c a t i o n  Implications  variance  i s thus unaccounted f o r .  IMPLICATIONS OF  and  sex  per cent of  Each l e v e l of the t h r e e l e v e l s of n u r s i n g c o s t s the h e a l t h system 22 cents  the  are d i s c u s s e d  status  i n this section.  of F i n d i n g s on Costs of H e a l t h  Care  Costs of h e a l t h c a r e i n Canada have e s c a l a t e d enormously i n recent years.  Preventive  s t r a t e g i e s are aimed at r e d u c i n g  and  promoting h e a l t h .  Included  two  d i f f e r e n t n u r s i n g programs.  emphasized h e a l t h e d u c a t i o n be a s s o c i a t e d w i t h program, was  The h y p o t h e s i s  care  a comparison of c o s t s of  t h a t the program which  a c c e s s i b i l i t y of n u r s i n g p e r s o n n e l  would  lower h e a l t h care c o s t s than the treatment o r i e n t e d  rejected.  care c o s t s were not  and  i n t h i s study was  c o s t s of h e a l t h  Results  of the study i n d i c a t e t h a t average h e a l t h  s i g n i f i c a n t l y lower i n the b u i l d i n g i n which  preventive  s e r v i c e s were a v a i l a b l e . An  unexpected f i n d i n g i s t h a t there are no  significant differences  between complexes i n terms of c o s t of h o s p i t a l i z a t i o n and v i s i t s  to  general  - 104 practitioners.  One would have a n t i c i p a t e d t h a t as a r e s u l t of t h e i n -  c r e a s e d a c c e s s i b i l i t y o f the nurses i n N i c h o l s o n Towers, h o s p i t a l i z a t i o n of some r e s i d e n t s would have been prevented w i t h b e f o r e i t becomes a c r i s i s ) ;  (because  and t h a t unnecessary  g e n e r a l p r a c t i t i o n e r would have been prevented w i t h the problem).  the problem i s d e a l t  (because  visits  the nurse d e a l t  Another unexpected f i n d i n g i s t h a t of no s i g n i f i c a n t  d i f f e r e n c e s i n c o s t of m e d i c a t i o n between t h e complexes. N i c h o l s o n Towers v i s i t a b l e to monitor tions  Nurses i n  s e n i o r c i t i z e n s on a r e g u l a r b a s i s .  They a r e thus  m e d i c a t i o n use and a d v i s e d i s c o n t i n u a n c e of c e r t a i n medica-  ( i n c o n s u l t a t i o n w i t h the p h y s i c i a n ) .  r e f l e c t e d i n decreased for  to t h e  cost of medication  T h i s was expected  i n t h i s complex.  to be  P o s s i b l e reasons  f i n d i n g no s i g n i f i c a n t d i f f e r e n c e s between complexes i n average  h e a l t h c o s t s a r e e x p l o r e d below. Firstly,  Home Care n u r s i n g s e r v i c e s are meant to s e r v e as a s u b s t i t u t e  f o r more expensive  forms o f m e d i c a l care such as h o s p i t a l i z a t i o n .  Home Care n u r s i n g s e r v i c e s a r e not i n e x p e n s i v e . visit  One Home Care n u r s i n g  $20 compared to a f o l l o w - u p v i s i t  c o s t s approximately  to a g e n e r a l  p r a c t i t i o n e r which c o s t s $6.30 ( M i n i s t r y o f H e a l t h , 1 9 7 8 ( a ) ) . h e a l t h s e r v i c e s to people's homes i s more c o s t l y s e r v i c e s from a c e n t r a l Home Care nurses normally  D e l i v e r y of  than d e l i v e r y o f these  location.  i n N i c h o l s o n Towers v i s i t  receive nursing services.  people who would not  Increased a c c e s s i b i l i t y l e a d s to  i n c r e a s e d u t i l i z a t i o n and i n c r e a s e d c o s t s .  A t the time of the study  i n d i v i d u a l s i n N i c h o l s o n Towers were r e c e i v i n g n u r s i n g s e r v i c e s , w i t h 13 i n Sunset Towers.  ficantly  75  compared  The mean number o f n u r s i n g v i s i t s p e r person  i n N i c h o l s o n Towers was 1 3 . 4 1 and i n Sunset Towers 3 . 2 0 . v a r i a n c e found  However,  Analysis of  c o s t o f n u r s i n g s e r v i c e s i n N i c h o l s o n Towers to be s i g n i -  ($268.31 v s . $ 6 4 . 0 7 ) h i g h e r than i n Sunset Towers.  Cost o f  - 105 nurses' v i s i t s service  i n Nicholson  (see T a b l e 10,  page  Towers was  a c t u a l c o s t of p r o v i d i n g n u r s i n g per v i s i t .  t r a v e l s from one  per v i s i t no  type of  home to another.  services i n Nicholson  doubt c o n t r i b u t e s  The  a r t i f i c i a l l y high  to the h i g h  A f a c t o r which must not be  c o s t of n u r s i n g  discounted,  cal-  services i n  Towers.  increased  u t i l i z a t i o n of these s e r v i c e s because they are a c c e s s i b l e  however, i s and  costs.  Demand f o r s e r v i c e tends to expand to meet supply. cations f o r planning p l a n should  less  amount of  Nicholson  resultant increased  The  Towers must be  Home Care does, however, not have a method of  c u l a t i n g c o s t s which r e f l e c t s t h i s f a c t . $20.  other  Towers are a b l e to see many more people  than a Home Care nurse who  than $20.  more c o s t l y than any  77).  Home Care nurses i n N i c h o l s o n per day  -  T h i s has  impli-  f u t u r e d e l i v e r y of s e r v i c e i n these b u i l d i n g s .  A  c o n t a i n a s e t of p r i o r i t i e s developed from a knowledge of  s i z e , demographic c h a r a c t e r i s t i c s and  needs of the p o p u l a t i o n  c o n s i d e r a t i o n of the c o s t s  of v a r i o u s  types of s e r v i c e s .  residents i n Nicholson  Sunset Towers expressed a d e s i r e f o r a 24-hour  and  and  the  Many of  the  nursing  s e r v i c e i n the b u i l d i n g .  nursing  s e r v i c e s i n these b u i l d i n g s s h o u l d be based on an assessment of  need of the t o t a l p o p u l a t i o n . i s at request  P r o v i s i o n of s e r v i c e at the p r e s e n t  accounted f o r by  the f a c t t h a t 86 per cent  e l d e r l y p e o p l e have c h r o n i c h e a l t h problems. . Chronic r e q u i r e r e c u r r i n g treatment and hence v i s i t s  by  the aging  aging.  The  time  s i g n i f i c a n t d i f f e r e n c e s between complexes i n average  c o s t s c o u l d a l s o be  personnel.  P r o v i s i o n of  of a p h y s i c i a n or the i n d i v i d u a l h i m s e l f .  F i n d i n g no health  Is t h e r e a need f o r t h i s ?  a  The  ability  process.  problems  to h o s p i t a l s and  of  often health  to b r i n g about improvement i n h e a l t h i s l i m i t e d One  cannot h a l t the d e t e r i o r a t i o n which i s p a r t  of  primary o b j e c t i v e of h e a l t h care w i t h the e l d e r l y i s mainten-  - 106 ance of p h y s i c a l , emotional and s o c i a l f u n c t i o n . the h e a l t h care p r o c e s s . t i c a l significance;  Economic outcomes a r e l i k e l y  significantly of  to be o f no p r a c -  i . e . i t i s p o s s i b l e that preventive h e a l t h care with  e l d e r l y does n o t have economic b e n e f i t s . logical benefits;  These a r e outcomes of  I t does, however, have  r e s i d e n t s of N i c h o l s o n Towers f e e l ,  psycho-  f o r example,  (1.11 v s . 0.32 on a 3 p o i n t s c a l e ) more s e c u r e than r e s i d e n t s  Sunset Towers because nurses come i n t o t h e i r b u i l d i n g . The  f o u r t h p o s s i b l e reason f o r f i n d i n g no s i g n i f i c a n t  differences  between complexes i n average h e a l t h c o s t s c o u l d be t h a t t h e v a r i a b l e s listed of  i n T a b l e 13  (page 89) account  the v a r i a n c e i n c o s t s .  for.  f o r o n l y a p p r o x i m a t e l y 25 p e r cent  There i s thus much v a r i a n c e which i s unaccounted  The f o l l o w i n g f a c t o r s c o u l d account  f o r some o f the remaining  v a r i a n c e : s e v e r i t y o f i l l n e s s was n o t measured; ences;  inter-individual  differ-  some i n d i v i d u a l s v i s i t h e a l t h p e r s o n n e l when they a r e n o t i l l ;  d i f f e r e n c e s between h e a l t h p e r s o n n e l i n terms o f numbers o f times they see a client  f o r a s p e c i f i c complaint and numbers and type  procedures  of laboratory  requested.  Fifthly,  the emergence of p r e v e n t i o n programs which focus on h e a l t h  e d u c a t i o n and e a r l y d e t e c t i o n o f d i s e a s e was based r i s i n g c o s t s and the b e l i e f  on d i s s a t i s f a c t i o n w i t h  that i t i s b e t t e r t o prevent than to c u r e .  We s h o u l d , however, not have u n r e a l i s t i c e x p e c t a t i o n s o f p r e v e n t i o n p r o grams.  What can be reasonably expected  of a p r e v e n t i o n program a f t e r a  s t a t e d p e r i o d of time s h o u l d be s p e c i f i c a l l y  identified.  A particular  percentage decrease i n h o s p i t a l admissions may, f o r example, be expected (Green, 1978).  T a b l e 13, which compares numbers of v i s i t s  and c o s t s i n  each b u i l d i n g , shows t h a t i n almost a l l i n s t a n c e s numbers o f v i s i t s and c o s t s a r e lower i n N i c h o l s o n than i n Sunset  Towers.  d i f f e r e n c e s i n c o s t s a r e , however, s i g n i f i c a n t .  Very few of the  Perhaps i t i s u n r e a l i s t i c  - 107 to expect s i g n i f i c a n t when N i c h o l s o n Towers and  d i f f e r e n c e s i n c o s t s between b u i l d i n g s  Towers has  s i g n i f i c a n t l y more n u r s i n g v i s i t s  these v i s i t s appear to be so  Implications The  -  of F i n d i n g s  on H e a l t h  purpose of t h i s study was  especially than Sunset  costly.  Status to examine r e l a t i o n s h i p s between type  of n u r s i n g program and h e a l t h knowledge, h e a l t h s t a t u s and h e a l t h A n a l y s i s of v a r i a n c e significantly  identified  t h a t r e s i d e n t s of N i c h o l s o n  There were no plexes  significant  had  significantly  f u n c t i o n than r e s i d e n t s of Sunset Towers.  d i f f e r e n c e s between r e s i d e n t s of the two  com-  i n terms of emotional f u n c t i o n .  Can Towers be  the g r e a t e r p h y s i c a l and  social  f u n c t i o n of r e s i d e n t s i n  a t t r i b u t e d to the n u r s i n g program i n N i c h o l s o n  issues r e l a t e significant age,  Towers  (45.69 v s . 44.42) g r e a t e r p h y s i c a l f u n c t i o n and  (27.46 v s . 25.07) g r e a t e r s o c i a l  costs.  sex and  to t h i s q u e s t i o n .  First,  Towers?  a n a l y s i s of v a r i a n c e  d i f f e r e n c e s between r e s i d e n t s of the two  Nicholson Several  identified  complexes i n terms of  numbers of people e l i g i b l e f o r Long Term Care.  Age  and  account f o r s m a l l p r o p o r t i o n s  of v a r i a n c e  social  f o r Long Term Care accounts f o r a l a r g e  function.  Eligibility  p r o p o r t i o n of v a r i a n c e cantly  (39% v s . 34%)  i n p h y s i c a l and  i n p h y s i c a l , emotional  emotional f u n c t i o n .  The  45.69) lower p h y s i c a l f u n c t i o n of r e s i d e n t s i n t h i s Second, the s o c i a l reliability  regarding social  and  f u n c t i o n s c a l e was  low  the s i g n i f i c a n t  f u n c t i o n are,  and  signifi-  g r e a t e r percentage of r e s i d e n t s e l i g i b l e f o r Long  Term Care i n Sunset Towers c o u l d account f o r the s i g n i f i c a n t l y  alpha  sex  content  and  (44.42 v s .  complex.  found to possess a low  convergent v a l i d i t y .  (.45)  Findings  d i f f e r e n c e s between the complexes i n terms of  therefore,  tenuous.  T h i r d , because no measure of h e a l t h s t a t u s was  taken b e f o r e  introduc-  - 108 -  t i o n of the program, any the  two  d i f f e r e n c e i n h e a l t h s t a t u s between r e s i d e n t s  complexes cannot be  c a u s a l l y l i n k e d to the n u r s i n g programs.  of The  methodology of t h i s study i n c l u d e d measures of h e a l t h s t a t u s of i n d i v i d u a l s i n each complex a t a p a r t i c u l a r p o i n t i n time and between complexes and w i t h i n complexes.  allowed  comparison  Other methodologies might have  measured h e a l t h knowledge and h e a l t h s t a t u s of samples of people who and had  not  received nursing  s e r v i c e s i n each complex;  same i n d i v i d u a l s a f t e r three months.  First,  not  the i n d i v i d u a l s who  have c h r o n i c d i s e a s e s  and  and  For s e v e r a l reasons,  selected.  c o n s t i t u t e d the p o p u l a t i o n  are not  measured these  Changes i n h e a l t h knowledge  h e a l t h s t a t u s c o u l d thereby have been compared. however, t h i s methodology was  and  had  likely  s t a t u s over a t h r e e to s i x month p e r i o d .  i n this  study  to have l a r g e changes i n h e a l t h Instruments c u r r e n t l y a v a i l a b l e  f o r measuring h e a l t h s t a t u s are not s e n s i t i v e to s m a l l changes i n an individual's health; h e a l t h between two  they may,  however, measure s t a t i c d i f f e r e n c e s i n  groups of p e o p l e .  Second, the people who  are r e c e i v i n g  n u r s i n g s e r v i c e s i n each complex have r e c e i v e d these s e r v i c e s f o r v a r y i n g periods  of time.  i n Nicholson  S i x t y per cent of the people r e c e i v i n g n u r s i n g  Towers at any  than t h r e e months (and  one  time have r e c e i v e d these s e r v i c e s f o r  some of them f o r l o n g e r  than a y e a r ) .  because of the a d m i n i s t r a t i v e p r e s s u r e  of  time  p a t i e n t s as soon as  T h i s renders comparison of changes i n h e a l t h s t a t u s between  complexes v e r y d i f f i c u l t . s i g n i f i c a n t l y during  An  i n d i v i d u a l ' s h e a l t h s t a t u s may  the f i r s t  and  reveal l i t t l e  change d u r i n g  changes i n i n d i v i d u a l s who  the nurse;  s t a t u s at month s i x and month n i n e  t h i s t h r e e month p e r i o d .  have had  have improved  second months of c o n t a c t w i t h  but measurement of h e a l t h knowledge and may  to d i s c h a r g e  longer  Individuals  i n Sunset Towers r e c e i v e n u r s i n g s e r v i c e s f o r f a r s h o r t e r p e r i o d s  possible.  services  d i f f e r i n g lengths  Comparison of  of c o n t a c t w i t h  the  - 109 nurse was thus  difficult.  This problem c o u l d have been avoided  by i n c l u d i n g i n the study  only  i n d i v i d u a l s commencing w i t h n u r s i n g s e r v i c e s a t the time o f the study. Since o n l y  three o r f o u r i n d i v i d u a l s i n each complex who have not p r e v i o u s l y  received nursing  s e r v i c e s s t a r t r e c e i v i n g these s e r v i c e s each month,  numbers i n v o l v e d would have been too s m a l l . the focus  o f the study.  This would a l s o have changed  I t was the i n t e n t of the study to examine the  impact o f the presence of nurses on the h e a l t h of a l l r e s i d e n t s i n a complex.  I t was not the i n t e n t to examine what happens to an i n d i v i d u a l  i n a complex when he r e c e i v e s a p a r t i c u l a r type o f n u r s i n g s e r v i c e .  Implications The  of Findings  on Health  Education  data do n o t i n d i c a t e t h a t h e a l t h c o s t s a r e lower i n the b u i l d i n g  i n which h e a l t h e d u c a t i o n was emphasized.  H e a l t h knowledge and h e a l t h  b e h a v i o u r were, however, s i g n i f i c a n t l y  greater  the b u i l d i n g i n which h e a l t h e d u c a t i o n  was n o t emphasized.  (page 74) shows t h a t people w i t h g r e a t e s t h e a l t h knowledge.  the poorest  T h i s i s probably  i n t h i s b u i l d i n g than i n Table 9  p h y s i c a l f u n c t i o n had the because these people a r e i n  c o n t a c t w i t h h e a l t h p r o f e s s i o n a l s on a r e g u l a r b a s i s and r e c e i v e h e a l t h education  from these p r o f e s s i o n a l s .  This t a b l e a l s o shows t h a t people  w i t h h i g h h e a l t h knowledge had h i g h emotional and s o c i a l f u n c t i o n .  Health  knowledge does thus make a d i f f e r e n c e i n terms o f people's h e a l t h . There was no v a r i a t i o n i n data l e a r n i n g of health information; health information  i n terms o f i n d i v i d u a l and group  a l l i n d i v i d u a l s reported having  on an i n d i v i d u a l b a s i s .  I t was t h e r e f o r e not p o s s i b l e  to t e s t whether the h e a l t h knowledge o f people whp l e a r n e d h e a l t h tion individually differed t i o n i n groups.  learned  from t h a t o f those who l e a r n e d h e a l t h  A c o n s i s t e n t f i n d i n g i n the l i t e r a t u r e on h e a l t h  informainformaeducation  - 110 is  that the l i k e l i h o o d  of a h e a l t h e d u c a t i o n program o b t a i n i n g p o s i t i v e  results, i s directly related d e v i c e s used.  to the number o f e d u c a t i o n a l techniques and  Numerous h e a l t h e d u c a t i o n s t u d i e s have found  to be a powerful  technique  i n changing  group d i s c u s s i o n  behaviour.  The u l t i m a t e g o a l of h e a l t h e d u c a t i o n i s improvement i n , o r maintenance of, h e a l t h .  The i n t e r m e d i a t e g o a l i s t o modify behaviour  d e l e t e r i o u s to h e a l t h .  presumed to be  The n u r s i n g program'in N i c h o l s o n Towers i n c o r p o r a t e s  many o f the f a c t o r s i d e n t i f i e d about b e h a v i o u r a l change.  i n the l i t e r a t u r e as e f f e c t i v e i n b r i n g i n g  Home Care nurses  t h e r e g i v e a d v i c e and encour-  agement based on assessment o f i n d i v i d u a l , s o c i a l and c u l t u r a l They i n v o l v e the person  factors.  i n learning, reinforce efforts at behavioural  change and have many c o n t a c t s w i t h  the person.  Two f a c t o r s known- to be  e f f e c t i v e i n a c h i e v i n g b e h a v i o u r a l change a r e not i n c o r p o r a t e d i n the n u r s i n g program i n N i c h o l s o n Towers. many e d u c a t i o n a l methods, techniques  These f a c t o r s a r e u t i l i z a t i o n o f and d e v i c e s ;  and u t i l i z a t i o n of  group methods o f i n s t r u c t i o n . The  approximate t o t a l amount o f time spent by Home Care nurses  r e s i d e n t s i n N i c h o l s o n Towers i s 130 hours p e r month. t h a t 50 p e r cent of t h e i r month.  time i s spent  educating;  These nurses  estimate  i . e . 90 hours p e r  Thus 1.2 hours i s spent e d u c a t i n g each r e s i d e n t p e r month.  t i o n takes p l a c e almost  with  e x c l u s i v e l y on an i n d i v i d u a l b a s i s .  Instruc-  Nurses c o u l d  e x p l o r e t h e p o s s i b i l i t y o f g r e a t e r use o f group methods and techniques of instruction.  This i s l i k e l y  to i n c r e a s e t h e e f f e c t i v e n e s s o f h e a l t h  e d u c a t i o n , and be a more e f f i c i e n t use o f r e s o u r c e s .  Program P l a n n i n g f o r H e a l t h E d u c a t i o n i n Dense R e s i d e n t i a l S e t t i n g s I t i s important be both  t h a t h e a l t h e d u c a t i o n i n a dense r e s i d e n t i a l  e f f e c t i v e and e f f i c i e n t .  setting  The s e c t i o n below o u t l i n e s the s t e p s  - Ill which should be f o l l o w e d when p l a n n i n g h e a l t h e d u c a t i o n The  i n t e r m e d i a t e g o a l of h e a l t h e d u c a t i o n  focus of e d u c a t i o n a l programs s h o u l d  Green  thus be b e h a v i o u r a l change.  persistence, earliness,  dimensions are e x p l o r e d below. niques  and  d e v i c e s are then  quality  and  range.  The  Programs  types of  (1978) i d e n t i f i e s f i v e dimensions of behaviour  These are frequency,  settings.  i s b e h a v i o u r a l change.  r e q u i r e d i f f e r e n t emphases i n order to achieve d i f f e r e n t a l change.  i n such  behaviourchange. These  I m p l i c a t i o n s f o r c h o i c e of methods, t e c h -  discussed.  Frequency: i f the h e a l t h behaviour s h o u l d be repeated p e r i o d i c a l l y (e.g. annual p h y s i c i a n v i s i t s ) , then h e a l t h e d u c a t i o n methods w i t h g i v e n cues a t p a r t i c u l a r i n t e r v a l s are more e f f e c t i v e than s p o r a d i c o r one-shot methods. P e r s i s t e n c e : i f i t i s important t h a t i n d i v i d u a l s p e r s i s t w i t h a p a r t i c u l a r h e a l t h behaviour over l o n g p e r i o d s of time (e.g. w i t h regimens f o r d i a b e t e s or h y p e r t e n s i o n ) , then the most e f f e c t i v e h e a l t h e d u c a t i o n methods are those t h a t p r o v i d e support i n the c l i n i c or home. E a r l i n e s s : the g o a l of a h e a l t h e d u c a t i o n program may be r e d u c i n g delay i n adopting p r e v e n t i v e a c t i o n s or d e l a y i n s e e k i n g t r e a t ment f o r symptoms. Mass media have been found u s e f u l i n r e d u c i n g delay i n p r e v e n t i v e a c t i o n , but not as e f f e c t i v e i n r e d u c i n g delay i n s e e k i n g treatment f o r i l l n e s s . Reducing delay i n s e e k i n g treatment f o r symptoms i s most e f f e c t i v e l y accomplished by r e i n forcement i n home and c l i n i c environments. Q u a l i t y : the g o a l of a h e a l t h e d u c a t i o n program may be t h a t the a p p r o p r i a t e n e s s of h e a l t h b e h a v i o u r s improve. P r i o r e x p e r i e n c e w i t h the source of care or w i t h the product i s the most i n f l u e n t i a l f a c t o r i n d e t e r m i n i n g q u a l i t y of c h o i c e . When q u a l i t y of c h o i c e i s r e l a t e d to a v a i l a b i l i t y of h e a l t h s e r v i c e s and p r o d u c t s , community o r g a n i z a t i o n methods are most a p p r o p r i a t e (Cauffman, L l o y d et a l . , 1973). Communication v i a mass media o r food l a b e l i n g can i n c r e a s e awareness of those who are a l r e a d y motivated i n t h i s d i r e c t i o n ( L i t t l e f i e l d , 1974). Range: when a person i s r e q u i r e d to adopt a range of d i f f e r e n t h e a l t h b e h a v i o u r s , the complexity of the b e h a v i o u r i s i n c r e a s e d . In these i n s t a n c e s , i n d i v i d u a l c o u n s e l l i n g and home v i s i t s are the most e f f e c t i v e h e a l t h e d u c a t i o n methods (Green, 1978). Behavioural  goals which s p e c i f y b e h a v i o u r a l outcomes i n terms of  above dimensions p r o v i d e more v a l u a b l e guidance f o r h e a l t h programs than goals which l i s t  different  the  education  types of h e a l t h behaviour  (e.g.  - 112 utilization,  compliance).  The reason i s t h a t h e a l t h b e h a v i o u r s may  i n terms of b e h a v i o u r a l dimensions. regimen may  For example, compliance w i t h  differ one  r e q u i r e p e r s i s t e n c e , whereas compliance w i t h another may  frequent behaviour. behaviour  -  In t h i s example t h e r e i s s i m i l a r i t y i n type of h e a l t h  (compliance), b u t not i n b e h a v i o u r a l dimension.  health behaviour,  require  Another  e.g. consumption o f a p a r t i c u l a r product may  s i m i l a r to one compliance  i n terms of b e h a v i o u r a l dimension  type of  be f a r more  (Green,  S p e c i f y i n g b e h a v i o u r a l outcomes i n terms of b e h a v i o u r a l  1978).  dimensions  r e q u i r e s a n a l y s i s of the outcome i n terms of these dimensions.  For example  i n d i v i d u a l s w i t h h i g h b l o o d p r e s s u r e s h o u l d decrease s a l t i n t a k e , r e s t f r e q u e n t l y , e x e r c i s e d a i l y and a v o i d s t r e s s f u l s i t u a t i o n s . i n v o l v e the b e h a v i o u r a l dimensions  These outcomes  of e a r l i n e s s and p e r s i s t e n c e .  The next step i n program p l a n n i n g i s to s e l e c t the most a p p r o p r i a t e e d u c a t i o n a l methods, techniques and d e v i c e s f o r t e a c h i n g these b e h a v i o u r s . The method i d e n t i f i e s ways o f o r g a n i z i n g i n d i v i d u a l s f o r the purpose education. methods.  Verner c l a s s i f i e s methods as i n d i v i d u a l , group or community I n d i v i d u a l methods i n c l u d e c o u n s e l l i n g which has  orientation,  correspondence  study, a p p r e n t i c e s h i p , d i r e c t e d  study and programmed i n s t r u c t i o n . workshops. Booth,  of  an  instructional  individual  Group methods i n c l u d e c l a s s e s  Community methods i n c l u d e community development  and  (Verner &  1964).  The  f o l l o w i n g s t e p i n program p l a n n i n g i s to i d e n t i f y the most  p r i a t e techniques f o r t e a c h i n g p a r t i c u l a r b e h a v i o u r s .  Techniques  appro-  describe  ways of e s t a b l i s h i n g a r e l a t i o n s h i p "between the l e a r n e r and the l e a r n i n g task"  (Verner & Booth,  1964,  p. 75).  Verner c l a s s i f i e s  techniques on  b a s i s of the type of l e a r n i n g task f o r which i t i s most u s e f u l ; techniques f o r a c q u i r i n g i n f o r m a t i o n , f o r a c q u i r i n g a s k i l l knowledge.  the  i.e.  or f o r a p p l y i n g  - 113 The  f i n a l s t e p i s to i d e n t i f y d e v i c e s which may i n c r e a s e the e f f e c t i v e -  ness of a p a r t i c u l a r method o r t e c h n i q u e . i l l u s t r a t i v e devices r a d i o ) , environmental devices  Devices  can be c l a s s i f i e d as  (e.g. f i l m s ) , e x t e n s i o n d e v i c e s devices  (e.g. t e l e v i s i o n and  (e.g. s e a t i n g arrangements) and m a n i p u l a t i v e  (e.g. t o o l s and equipment) (Verner & Booth, 1964).  In t h i s study, h e a l t h i n f o r m a t i o n which a l l o l d people and h e a l t h i n f o r m a t i o n which people w i t h possess, was i d e n t i f i e d . formulated.  Table  Questions  16 l i s t s  p a r t i c u l a r conditions  and i d e n t i f i e s  each q u e s t i o n .  imethod f o r t e a c h i n g t h i s b e h a v i o u r .  e f f e c t i v e health education and  should  the d e s i r e d  I t i d e n t i f i e s the  b e h a v i o u r a l dimension i n v o l v e d i n each i n s t a n c e and the most educational  possess  t o t e s t knowledge i n these areas were  these q u e s t i o n s  b e h a v i o u r a l outcome a s s o c i a t e d w i t h  should  techniques  effective  I t also l i s t s  the most  f o r a c q u i r i n g and a p p l y i n g knowledge  behaviours. T a b l e 16 shows t h a t w i t h almost a l l b e h a v i o u r a l outcomes, the most  e f f e c t i v e h e a l t h e d u c a t i o n methods a r e group methods. education and  When the g o a l o f  i s t h a t i n d i v i d u a l s a c q u i r e knowledge and/or s k i l l s ,  l e c t u r e - t y p e techniques  are e f f e c t i v e .  that i n d i v i d u a l s apply knowledge and s k i l l s groups u t i l i z i n g most a p p r o p r i a t e .  such techniques  When, however, the g o a l i s and change b e h a v i o u r ,  small  as group d i s c u s s i o n o r buzz groups a r e  S i n c e the g o a l of h e a l t h e d u c a t i o n  b e h a v i o u r a l change the use of s m a l l groups techniques Planning  l a r g e groups  and implementing h e a l t h e d u c a t i o n  i s to b r i n g about i s most a p p r o p r i a t e .  programs s h o u l d be based  on knowledge o f the a d u l t l e a r n e r and on knowledge o f d e s i g n i n g and managing l e a r n i n g e x p e r i e n c e s .  A fundamental p r i n c i p l e  h e a l t h e d u c a t i o n programs i s involvement the program.  They should be a c t i v e l y  i n planning adult  o f the l e a r n e r s i n a l l steps o f  involved i n diagnosing  l e a r n i n g needs, f o r m u l a t i n g o b j e c t i v e s , d e v e l o p i n g  their  a design of a c t i v i t i e s ,  TABLE 16 MOST EFFECTIVE METHODS AND TECHNIQUES FOR ACQUIRING AND APPLYING KNOWLEDGE AND SKILLS  Health Knowledge  Questions  Desired Behavioural Outcome  Behavioural Dimension  Important Aspects of Method  Most Effective Health Ed. Methods  Techniques f o r Applying Knowledge and/or S k i l l s  Size of Group Small Illustrative Bu2z group devices Group d i s c u s s i o n Small Individual practice Technique  Asked of a l l i n d i v i d u a l s Support  Techniques f o r A c q u i r i n g Knowledge and/or S k i l l s  Technique Lecture/speech Symposium Interview  Size of Group Any s i z e Medium/large Any s i z e  Devices Illustrative and extension devices  How o f t e n should one have some form of e x e r c i s e l i k e going f o r walks?  Having some form of e x e r c i s e d a i l y or s e v e r a l times a week  Persistence Earliness (prevention)  Social  How do you decide when and for how long to take p r e s c r i b e d medication?  Taking medications e x a c t l y as recommended by the doctor or nurse  Persistence Range  S o c i a l Support Individual C o u n s e l l i n g and Reinforcement  Individual methods  Individual i n s t r u c t i o n and practice  How o f t e n i s a p h y s i c a l check-up a d v i s a b l e f o r people of your age who are f e e l i n g well?  Having a p h y s i c a l check-up every 6 to 18 months  Frequency  P r o v i d i n g cues at i n t e r v a l s  Group methods  Buzz groups Group d i s c u s s i o n  Small Small  Illustrative devices  Lecture/speech Symposium  Any s i z e Medium/large  Illustrative and extension devices  If one i s l i v i n g alone, how o f t e n do you think one should have contact with other people?  Having d a i l y contact with other people ( e i t h e r face to face contact or over telephone)  Persistence Earliness (prevention)  Social  Group methods  Buzz groups Group d i s c u s s i o n Group p r a c t i c e  Small Small Small  Illustrative devices  Lecture/speech Symposium Interview  Any s i z e Medium/large Any s i z e  Illustrative and extension devices  How many days a week should you eat vegetables and f r u i t i n order to have enough vitamins and minerals i n your d i e t ?  Eating vegetables and f r u i t 5, 6 or 7 days a week  Persistence Earliness (prevention)  Social  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  Lecture/speech Symposium Interview Demonstration  Any s i z e Medium/large Any s i z e Any s i z e  Illustrative and extension devices  Could you name two things you can include i n your d i e t to a s s i s t bowel movements?  Including 2 of the f o l l o w i n g i n d i e t : high bulk foods, bran, prune juice, dried f r u i t , c e l e r y , f r u i t , 8 cups of l i q u i d  Persistence Earliness (prevention)  S o c i a l Support  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  Lecture/speech Symposium Interview Demonstration  Any s i z e Medium/large Any s i z e Any s i z e  Illustrative and extension devices  How many cups of f l u i d should one d r i n k a day?  Drinking 6 or more cups of f l u i d a day  Persistence Earliness (prevention)  Social  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  Lecture/speech Any s i z e Symposium Medium/large Interview Any s i z e  Illustrative and extension devices  Would you show me what medications you are on? Could you t e l l me what each of these medications are for?  Informed use of medication  Individual methods  Individual instruction  Support  Support  Support  Group methods  I  TABLE 16 - CONTINUED  Health Knowledge Questions  Asked o f I n d i v i d u a l s with Arthritis Can you name anything you can do to get r i d of some of the s t i f f n e s s you may have ( i n the morning, f o r example)?  Desired Behavioural Outcome  Behavioural Dimension  Important Aspects of Method  Most Effective Health Ed. Methods  Techniques  f o r Applying Knowledge and/or s k i l l s  Technique  Size of Group Small Small  Devices  Persistence Earliness  Social Support Reinforcement  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  E a t i n g some food to maintain s t r e n g t h  Earliness Quality  Reinforcement Prior Experience with Behaviour  Group methods  Buzz groups Group d i s c u s s i o n  Small Small  Taking medication regularly  Persistence  Social Support  Group methods  Buzz groups Group d i s c u s s i o n  Small Small  Illustrative devices  Being aware of s w e l l i n g of ankles and s h o r t ness o f breath and then taking a p p r o p r i a t e action.  Earliness Quality  Reinforcement Prior Experience with Behaviour  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  Can you name two things one can do to reduce s w e l l i n g i n the leg?  Wearing heavy supportive stockings Keeping the foot elevated  Earliness Quality  Reinforcement Prior Experience with Behaviour  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  What s o r t o f food are e s p e c i a l l y important to i n c l u d e In one's d i e t when one has l e g u l c e r s ?  E a t i n g foods high i n protein  Quality  Prior Experience with Behaviour  Group methods  Buzz groups Group d i s c u s s i o n  Small Small  Illustrative devices  Decreasing s a l t i n t a k e Resting f r e q u e n t l y Exercising daily Avoiding s t r e s s f u l situations  Earliness Social (prevention) Support Persistence  Group methods  Buzz groups Group d i s c u s s i o n Individual practice  Small Small  Illustrative devices  If you f e e l d i z z y when you get up from a l y i n g p o s i t i o n , what should you do?  G e t t i n g up slowly o r s i t t i n g down again  Quality  Prior Experience with Behaviour  Group methods  Buzz groups Group d i s c u s s i o n  Small Small  If you f e e l d i z z y while you are doing something ( l i k e walking or housework) what should you do?  Stopping a c t i v i t y and r e s t i n g when f e e l i n g dizzy  Quality  Prior Experience with Behaviour  Group methods  Buzz groups Gruop d i s c u s s i o n  Small Small  If you have so much pain that you do not f e e l l i k e e a t i n g , what do you do about e a t i n g (,... and why)? Asked of I n d i v i d u a l s with a Heart C o n d i t i o n How do you decide how o f t e n to take medication(s) f o r your heart? What s o r t of p h y s i c a l s i g n s sould i n d i c a t e to you that your heart was not f u n c t i o n i n g well?  Keeping Keeping  mobile active  Illustrative devices  Asked o f I n d i v i d u a l s with Leg U l c e r s  Asked o f I n d i v i d u a l s with High Blood Pressure What kinds of things can you do to help keep your blood pressure down?  SOURCES:  Verner and Booth, 1964;  Green, 1978  - 116  -  o p e r a t i n g the a c t i v i t i e s and r e d i a g n o s i n g needs l e a r n e r involvement  is crucial.  r e c e i v e s much a t t e n t i o n , be v a s t l y  Active  U n l e s s t h i s f a c e t of program p l a n n i n g  the v a l u e and e f f e c t i v e n e s s of the program w i l l  diminished.  Home Care nurses i n t o groups of 6-8 a l dimensions group.  (Knowles, 1970).  c o u l d group i n d i v i d u a l s w i t h s i m i l a r h e a l t h problems  individuals.  D e s i r e d b e h a v i o u r a l outcomes and  behaviour-  i n v o l v e d would thus be common f o r a l l i n d i v i d u a l s i n each  S i m i l a r i t y of h e a l t h problems i s an e f f e c t i v e way  h e a l t h e d u c a t i o n which u t i l i z e s s m a l l groups.  of  approaching  Small groups a l l o w group  members to tap f e l l o w group members' e x p e r i e n c e r e g a r d i n g management of a h e a l t h problem and  the o p p o r t u n i t y f o r past l e a r n i n g c o n s u l t a t i o n arid  c o r r o b o r a t i o n w i t h o t h e r l e a r n e r s i s maximized. r e s p e c t the judgement of those who  tend to t r u s t  have a s i m i l a r problem.  p e r t i n e n t d i s c u s s i o n and r e i n f o r c e m e n t i s h i g h . s i m i l a r socio-economic  People  Grouping  The  and  q u a l i t y of  people w i t h  s t a t u s promotes more r e l e v a n t , c r e d i b l e d i s c u s s i o n  of s o l u t i o n s to problems  (Green, W e r l i n e t a l . , 1977;  Young,  1967(a)).  Groups of people w i t h h y p e r t e n s i o n , d i a b e t e s , c a r d i a c c o n d i t i o n s or groups of people w i t h two c o i n c i d i n g c o n d i t i o n s would meet r e g u l a r l y . nurse would a c t as r e s o u r c e person and  guide, and a l l o w the  The  group members  to d e c i d e what they needed and wanted to l e a r n r e g a r d i n g the c o n d i t i o n and how  they would go about l e a r n i n g t h i s .  I f there are l a r g e numbers of  w i t h a p a r t i c u l a r c o n d i t i o n , s e v e r a l s m a l l groups can be The  formed.  i n i t i a t i o n of these groups would take time and energy, b u t  they were running they would not be time consuming. more e f f e c t i v e a t changing b e h a v i o u r s a l s o a more e f f i c i e n t use of n u r s e s ' In a d d i t i o n to grouping  people  once  Such groups would be  than i n d i v i d u a l t e a c h i n g methods and time.  i n d i v i d u a l s a c c o r d i n g to h e a l t h problems,  nurses c o u l d be r e s p o n s i b l e f o r o r g a n i z i n g e d u c a t i o n a l s e s s i o n s f o r a l l  - 117 people i n t h e complex.  The content  o f these s e s s i o n s would be t h a t  i n f o r m a t i o n which a l l o l d e r people should possess r e g a r d i n g h e a l t h maintenance.  The l e c t u r e technique  c o u l d be u t i l i z e d  numbers of people c o u l d a t t e n d media c o u l d be prepared,  the s e s s i o n s .  i n these s e s s i o n s and l a r g e F i l m s o r other a u d i o - v i s u a l  as c o u l d be a manual on h e a l t h maintenance f o r  use by a l l r e s i d e n t s . No such program should be implemented without evaluation.  adequate p r o v i s i o n f o r  Instruments should be developed to measure h e a l t h knowledge  and b e h a v i o u r of i n d i v i d u a l s i n t h e v a r i o u s groups b e f o r e started.  H e a l t h knowledge and b e h a v i o u r should  t h e program i s  then be measured  after  the program has been o p e r a t i n g f o r a s p e c i f i e d p e r i o d of time. The and  formation  socially.  Belonging  o f these  groups would be of v a l u e both e d u c a t i o n a l l y  Many o l d e r people l i v e alone  and a r e extremely l o n e l y .  to a s m a l l group might h e l p a l l e v i a t e t h i s l o n e l i n e s s .  s h i p s and i n f o r m a l support  systems might develop from these  L a r g e and s m a l l s i t t i n g seldom used. likelihood  rooms i n N i c h o l s o n  A few p h y s i c a l changes to these  o f t h e i r use;  Friend-  groups.  and Sunset Towers a r e  rooms would i n c r e a s e the  f o r example, grouping  s m a l l numbers of c h a i r s  around t a b l e s and p l a c i n g newspapers o r magazines on t h e t a b l e s as f o c a l points f o r i n t e r a c t i o n . i n v o l v e d i n the changes. be  Here again,  the r e s i d e n t s themselves should be  S e v e r a l s m a l l committees i n each b u i l d i n g c o u l d  r e s p o n s i b l e f o r changes i n the l a r g e s i t t i n g room, the a r t s and c r a f t s  room, the games room and the l i b r a r y .  RECOMMENDATIONS The the  following l i s t  o f recommendations emerged from the f i n d i n g s o f  study.  Recommendations which emerged from f i n d i n g s r e l a t e d t o hypotheses: (1)  That the needs of r e s i d e n t s i n N i c h o l s o n  and Sunset Towers f o r o n - s i t e  - 118 -  h e a l t h s e r v i c e s be assessed. That o n - s i t e h e a l t h s e r v i c e s be p r o v i d e d i n accordance w i t h the assessed need, s i n c e demand f o r s e r v i c e always expands to meet s u p p l y . (2)  That a d m i n i s t r a t o r s o f Home Care n u r s i n g s e r v i c e s develop a system f o r c a l c u l a t i n g the r e a l c o s t of p r o v i d i n g n u r s i n g s e r v i c e s i n dense r e s i d e n t i a l s e t t i n g s such as N i c h o l s o n and Sunset Towers.  (3)  That once the above system has been developed, data a l r e a d y c o l l e c t e d on c o s t s of h e a l t h s e r v i c e s to r e s i d e n t s o f N i c h o l s o n and Sunset Towers over an e i g h t month p e r i o d be r e a n a l y z e d .  Recommendations which emerged from o t h e r f i n d i n g s : (1)  That Home Care nurses i n N i c h o l s o n Towers e s t a b l i s h b e h a v i o u r a l o b j e c t i v e s f o r h e a l t h e d u c a t i o n programs which s p e c i f y d e s i r e d b e h a v i o u r a l outcomes i n terms o f the dimensions of frequency, p e r s i s t e n c e , e a r l i n e s s , q u a l i t y and range.  (2)  That Home Care nurses i n N i c h o l s o n Towers p l a n and implement educat i o n a l programs which i n c o r p o r a t e (1) group methods and techniques and (2) a g r e a t e r v a r i e t y o f e d u c a t i o n a l techniques and d e v i c e s .  (3)  That Home Care nurses i n N i c h o l s o n Towers u t i l i z e l a r g e group t e c h niques when the g o a l i s t h a t i n d i v i d u a l s a c q u i r e knowledge and/or s k i l l s and s m a l l group techniques when the g o a l i s t h a t i n d i v i d u a l s apply knowledge and s k i l l s .  (4)  That e d u c a t i o n a l programs i n N i c h o l s o n Towers a c t i v e l y r e s i d e n t s i n a l l f a c e t s o f the program.  (5)  That Home Care nurses i n N i c h o l s o n Towers make p r o v i s i o n f o r e v a l u a t i o n of e d u c a t i o n a l programs. H e a l t h knowledge and b e h a v i o u r should be measured b e f o r e i n t r o d u c t i o n of the program and a f t e r the program has been o p e r a t i n g f o r a s p e c i f i e d p e r i o d o f time.  (6)  That e d u c a t i o n a l programs s i m i l a r to those i n N i c h o l s o n Towers be expanded to Sunset Towers i f e v a l u a t i o n o f the program i n N i c h o l s o n Towers i n d i c a t e s t h a t t h i s i s warranted.  (7)  That Home Care nurses i n v o l v e d i n e d u c a t i o n shops on a d u l t e d u c a t i o n .  (8)  That r e s i d e n t s o f b o t h complexes be i n v o l v e d i n making such p h y s i c a l changes to the s i t t i n g rooms which would i n c r e a s e the l i k e l i h o o d o f t h e i r use.  (9)  That f i n d i n g s of t h i s study r e g a r d i n g the r e l i a b i l i t y and v a l i d i t y of the t h r e e h e a l t h s c a l e s be made a v a i l a b l e t o r e s e a r c h e r s i n t h e f i e l d o f h e a l t h measurement.  (10)  involve  a t t e n d courses  o r work-  That the M i n i s t r y o f Health p r o v i d e funds f o r employing an o c c u p a t i o n a l t h e r a p i s t i n one s e n i o r c i t i z e n s ' complex i n the p r o v i n c e and t h a t p r o v i s i o n be made to e v a l u a t e the impact o f these s e r v i c e s on h e a l t h and h e a l t h c o s t s . P o s i t i v e outcomes o f the e v a l u a t i o n s h o u l d r e s u l t  - 119  -  i n extending these s e r v i c e s to o t h e r complexes. An o c c u p a t i o n a l t h e r a p i s t c o u l d promote h e a l t h of e l d e r l y people by h e l p i n g them to' fulfil the need f o r a c t i v i t y , the need to occupy l e i s u r e time i n a s a t i s f a c t o r y way, the need f o r s e l f - e x p r e s s i o n and mental s t i m u l a t i o n , the need to be u s e f u l and to enjoy companionship.  CONCLUSION Costs of h e a l t h care i n Canada have e s c a l a t e d enormously i n r e c e n t years.  The  e l d e r l y consume a l a r g e p r o p o r t i o n of h e a l t h s e r v i c e s and  p r o p o r t i o n of e l d e r l y people i n the p o p u l a t i o n  is rising.  In an  the  effort  to reduce c o s t s , the t r e n d i n h e a l t h s e r v i c e s has been toward communitybased treatment and Prevention  promotion of h e a l t h and  i s a philosophy,  I t i s concerned w i t h  a way  prevention  of t h i n k i n g and  of  disability.  approaching problems.  the q u a l i t y of l i v e s of i n d i v i d u a l s and w i t h  interdependence of p e o p l e .  How  S o l v i n g problems of d i s e a s e  the  b e a u t i f u l l y t h i s i s d e s c r i b e d by Dubos: i s not  the same t h i n g as  creating health the task of h e a l t h demands a k i n d of wisdom and v i s i o n which transcends s p e c i a l i z e d knowledge of remedies and treatments and which apprehends i n a l l t h e i r c o m p l e x i t i e s and s u b t l e t i e s , the r e l a t i o n between l i v i n g t h i n g s and t h e i r t o t a l environment. (Dubos, 1959, p.22) Dubos p o i n t s out  t h a t "the  knowledge of remedies and  task of h e a l t h  .....  t r e a t m e n t s " (Dubos, 1959,  transcends s p e c i a l i z e d p.22).  The  new  focus  on maintenance and promotion of h e a l t h r e q u i r e s p a r a l l e l changes i n the r o l e s and  r e s p o n s i b i l i t i e s of h e a l t h p r o f e s s i o n a l s .  have to adapt to emerging r o l e s as h e a l t h agents and of educator r e q u i r e s l e a r n i n g about e d u c a t i o n Prevention things and  i n v o l v e s "apprehending  and  Health  professionals  educators.  about how  p.22).  role  adults l e a r n .  the r e l a t i o n between  t h e i r t o t a l environment" (Dubos, 1959,  The  living  Promoting  the  h e a l t h of e l d e r l y people i n c l u d e s p r o v i d i n g an environment i n which each person i s f r e e to reach h i s f u l l e s t p o t e n t i a l . environment i s a complex task.  Achieving  T h i s , too, i s a new  a  supportive  role for health  pro-  - 120 f e s s i o n a l s and one which r e q u i r e s much p e r f e c t i o n .  I t i s the r e s p o n s i b i l i t y  of h e a l t h p e r s o n n e l to improve t h e q u a l i t y o f a l l a s p e c t s o f o l d e r p e r s o n s ' lives.  Health  problems a r e i n t e r r e l a t e d w i t h a l l other  aspects of l i f e .  One cannot attempt to s o l v e h e a l t h problems w i t h o u t b e i n g  aware of the  i n f l u e n c e o f many s o c i a l f a c t o r s on h e a l t h . The  finding  significantly  o f t h i s study was t h a t c o s t s o f h e a l t h s e r v i c e s were n o t  lower i n the complex which o f f e r e d o n - s i t e p r e v e n t i v e  s e r v i c e s than i n the complex which o f f e r e d o n - c a l l , c u r a t i v e services. the aging  The a b i l i t y process.  to b r i n g about improvement i n h e a l t h  I t i s possible that preventive  health  nursing  nursing i s l i m i t e d by  care  for elderly  people does not have economic b e n e f i t s . On economic grounds alone there i s p r e s e n t l y argument t o extend Home Care n u r s i n g Nicholson  Towers t o other  l i t t l e basis  f o r an  s e r v i c e s o f the type o f f e r e d i n  s e n i o r c i t i z e n s complexes i n B r i t i s h  Columbia.  I t must, however, be noted that average c o s t s o f h e a l t h s e r v i c e s i n N i c h o l son and Sunset Towers d i d n o t d i f f e r s i g n i f i c a n t l y f i c i a l l y high  cost of nursing  services.  i n s p i t e o f the a r t i -  N u r s i n g s e r v i c e s were the most  c o s t l y o f a l l h e a l t h s e r v i c e s to r e s i d e n t s of N i c h o l s o n and  the c o s t of n u r s i n g  than i n Sunset Towers.  and Sunset Towers;  s e r v i c e s was s i g n i f i c a n t l y h i g h e r  i n Nicholson  Were Home Care to develop a system f o r c a l c u l a t i n g  the r e a l c o s t o f p r o v i d i n g n u r s i n g  services i n Nicholson  and Sunset Towers,  the f i n d i n g might w e l l be that c o s t s o f h e a l t h s e r v i c e s a r e s i g n i f i c a n t l y lower i n N i c h o l s o n Our  Towers.  h e a l t h c a r e system should be concerned w i t h the q u a l i t y o f l i v e s  of i n d i v i d u a l s .  On the b a s i s of q u a l i t y of . c a r e ,  argument f o r extending Home Care n u r s i n g Nicholson  Towers t o other s e n i o r c i t i z e n s  there i s a s t r o n g  s e r v i c e s o f the type o f f e r e d i n complexes i n B r i t i s h  Columbia.  - 121 P e r c e i v e d b e n e f i t and f e e l i n g o f s e c u r i t y from the presence o f the nurses are s i g n i f i c a n t l y  g r e a t e r i n N i c h o l s o n than i n Sunset Towers.  s e r v i c e s a r e what e l d e r l y people themselves a b l e to those who need them; need.  desire.  They s h o u l d be a v a i l -  and emotional need i s as v a l i d as p h y s i c a l  Each o l d e r person i n t h i s p r o v i n c e has a r i g h t to those  which w i l l  These  services  a s s i s t him to a c h i e v e and m a i n t a i n h i s h i g h e s t l e v e l of human  functioning.  - 122  -  REFERENCES Abramson, J . H. The C o r n e l l M e d i c a l Index as an E p i d e m i o l o g i c a l T o o l . American J o u r n a l of P u b l i c H e a l t h , February.1966, 52, 2, 287-298. A d e n i y i , J . D. C h o l e r a C o n t r o l : Problem of B e l i e f and A t t i t u d e s . I n t e r n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1972, 15, 238. Anderson, J . G. Health Services U t i l i z a t i o n : H e a l t h S e r v i c e s Research, 1973, 8, 184.  Framework and  Anderson, W. F. P r a c t i c a l Management of the E l d e r l y . S c i e n t i f i c P u b l i c a t i o n s , 1976.  Review.  London: B l a c k w e l l  B a l i n s k y , W., and Berger, R. A Review of the Research on G e n e r a l Status Indexes. M e d i c a l Care, A p r i l , 1975, 13, 4, 283-293.  Health  B a r i c , L. R e c o g n i t i o n of the "At R i s k " Role - A Means to I n f l u e n c e H e a l t h Behaviour. I n t e r n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1969, 12, 24. B a t t i s t e l l a , R. M. L i m i t a t i o n s i n Use of the Concept of P s y c h o l o g i c a l Readiness to I n i t i a t e H e a l t h Care. M e d i c a l Care, July-August 1968, 6, 308-319. Beaser,  S. B.  Teaching  the D i a b e t i c P a t i e n t .  Diabetes,  1956,  5, 146-149.  Becker, M. H., and Green, L. B. A F a m i l y Approach to Compliance w i t h M e d i c a l Regimens. A S e l e c t i v e Review of the L i t e r a t u r e . Internat i o n a l J o u r n a l o f H e a l t h E d u c a t i o n , 1975, 18, 2-11. Becker, M. H., Haefner, D. P., e t a l . S e l e c t e d P s y c h o s o c i a l Models and C o r r e l a t e s of I n d i v i d u a l H e a l t h - R e l a t e d Behaviours. M e d i c a l Care, May 1977, 15, 5, Supplement 27-46. B e l l i n , S., and Hardt, R. M a r i t a l Status and Mental D i s o r d e r s of the Aged. American S o c i o l o g i c a l Review^ 1958, 23, 155-162. B e r n s t e i n , D. A. M o d i f i c a t i o n of Smoking Behaviour: P s y c h o l o g i c a l B u l l e t i n , 1969, 71, 418-440.  An E v a l u a t i o n Review.  B i c e , I. W., and White, K. L. F a c t o r s R e l a t e d to the Use of H e a l t h Services: An I n t e r n a t i o n a l Comparative Study. M e d i c a l Care, 1970, 11, 104. B l i s h e n , B. R. A Socio-Economic Index f o r Occupations i n Canada. The Canadian Review of S o c i o l o g y and Anthropology, 1967, 4, 41-53. Brodman, K. E. A., Lorge, I., and W o l f f , H. D. The C o r n e l l M e d i c a l Index: An Adjunct to M e d i c a l I n t e r v i e w . J o u r n a l of the American M e d i c a l A s s o c i a t i o n , 1948, 140, 530. Busse, E. W. S o c i a l F a c t o r s i n I n f l u e n c i n g Care and H e a l t h of the E l d e r l y . In McKinney, J . C , and De Vyver, F. T. ( E d s . ) , Aging and S o c i a l P o l i c y , New York: A p p l e t o n - C e n t u r y - C r o f t s , 1966.  - 123  -  Cambridgeshire, D i e t e t i c Department, Adderbrookes H o s p i t a l , the E l d e r l y . N u t r i t i o n , 1966, 20, 115.  N u t r i t i o n of  Campbell, D. T., and F i s k e , D. W. Convergent and D i s c r i m i n a n t V a l i d a t i o n by the M u l t i t r a i t - M u l t i m e t h o d M a t r i x . In F i s h b e r n , M. (Ed.), Readings i n A t t i t u d e , Theory and Measurement. New York: John Wiley & Sons (1967). Cauffman, J . G., L l o y d , J . S., e t a l . H e a l t h I n f o r m a t i o n and R e f e r r a l S e r v i c e s W i t h i n Los Angeles County. American J o u r n a l of P u b l i c H e a l t h , 1973, 63, 872-877. Chambers, L. C., S a c k e t t , D. L., et a l . The Development and A p p l i c a t i o n of Indexes of H e a l t h . P r o j e c t supported by PR 146, M i n i s t r y of H e a l t h , O n t a r i o , 1976. Chambers, L. W., and Segovia, J . Lay and P r o f e s s i o n a l P e r s p e c t i v e s of P h y s i c a l , S o c i a l and Emotional F u n c t i o n Used as Indexes of H e a l t h . Paper p r e s e n t e d to the Learned S o c i e t y i n London, O n t a r i o , May 19 78. Chiang, C. L. An Index of H e a l t h Mathematical Models. N a t i o n a l C e n t r e f o r H e a l t h S t a t i s t i c s : V i t a l and H e a l t h S t a t i s t i c s . PHS P u b l i c a t i o n No. 1000, S e r i e s 2, No. 5. P u b l i c H e a l t h S e r v i c e s , Washington, 1965. Cochran, D. L. Developments i n E v a l u a t i o n . T h e i r I m p l i c a t i o n s f o r H e a l t h Education P r a c t i c e . H e a l t h E d u c a t i o n Monographs, 1964, 20, 59-69. D a v i e s , D. F. Progress Towards Assessment of H e a l t h S t a t u s . M e d i c i n e , 1975, 4, 3, 282-295. Dubos, R.  Mirage of H e a l t h .  New  York:  Harper,  Preventive  1959.  Friedsam, H., and M a r t i n , H. A Comparison of S e l f and P h y s i c i a n s ' H e a l t h Ratings i n an O l d e r P o p u l a t i o n . J o u r n a l of H e a l t h and Human Behaviour, 1963, 4, 179-183. G a r f i e l d , S. R. 15, 222.  The D e l i v e r y of M e d i c a l Care.  S c i e n t i f i c American,  1970,  Gibson, G. E x p l a n a t o r y Models and S t r a t e g i e s f o r S o c i a l Change i n H e a l t h Care Behaviour. S o c i a l S c i e n c e and M e d i c i n e , 1972, 6, 635. Graber, A. L., Christman, B. C , Alogna, M. T., and Davidson, J . K. E v a l u a t i o n of Diabetes P a t i e n t E d u c a t i o n Programs. Diabetes, January 1977, 26, 1, 61-64. Green, L. W. Should H e a l t h E d u c a t i o n Abandon A t t i t u d e Change S t r a t e g i e s ? P e r s p e c t i v e s from Recent Research. H e a l t h E d u c a t i o n Monographs, 1970, 1, 30, 25-48. Green, L. W. Status I d e n t i t y and P r e v e n t i v e H e a l t h Behaviour. H e a l t h E d u c a t i o n Reports, 1970(a), 1.  Pacific  - 124 -  Green, L. W. The A p p l i c a t i o n o f D i f f u s i o n Theory to C a r d i o v a s c u l a r R i s k Behaviour i n the P u b l i c . I n Endow, A., and Henderson, J . B. ( E d s . ) , A p p l y i n g B e h a v i o u r a l Sciences t o C a r d i o v a s c u l a r R i s k . New York: American Heart A s s o c i a t i o n , 1975. Green, L. W. Methods A v a i l a b l e to E v a l u a t e the H e a l t h E d u c a t i o n Components of P r e v e n t i v e H e a l t h Programs. In Fogarty, J . E. P r e v e n t a t i v e M e d i c i n e U.S.A. H e a l t h Promotion and Consumer H e a l t h E d u c a t i o n . New York: Produst, 1976. Green, L. W. The P o t e n t i a l o f H e a l t h E d u c a t i o n Includes C o s t - E f f e c t i v e n e s s . H o s p i t a l s , J.A.H.A., May 1, 1976(a), 50, 57-61. Green, L. W. E v a l u a t i o n and Measurement: Some Dilemmas f o r H e a l t h Education. American J o u r n a l o f P u b l i c H e a l t h , February 1977, 67, 2, 155-161. Green, L. W. Determining the Impact and E f f e c t i v e n e s s o f Health E d u c a t i o n as i t R e l a t e s to F e d e r a l P o l i c y . H e a l t h E d u c a t i o n Monographs, 1978, 6, Supplement 1, 28-66. Green, L. W., W e r l i n , S. H., e t a l . Research and Demonstration Issues i n S e l f - C a r e : Measuring the D e c l i n e o f M e d i c o c e n t r i s m . Health Education Monographs, 1977, 5, 2, 161-184. Hennes, J . D. The Measurement o f H e a l t h . 1268-1288.  M e d i c a l Care Review, 1972, 11,  Heyman, D., and J e f f e r s , F. E f f e c t o f Time Lapse on C o n s i s t e n c y o f S e l f H e a l t h and M e d i c a l E v a l u a t i o n s o f E l d e r l y Persons. Journal of Gerontology, 1963, 18, 160-164. Holmes, T. H., and Rahe, R. H. The S o c i a l Readjustment R a t i n g J o u r n a l of Psychosomatic Research, 1967, 11, 213-218. Kaplan, A. Study D i s c u s s i o n i n the L i b e r a l A r t s . E d u c a t i o n , 1960. Kay,  Scale.  New York: Fund f o r A d u l t  D. W. K., Beamish, P., and Roth, M. O l d Age Mental D i s o r d e r s i n Newcastle-upon-Tyne. B r i t i s h J o u r n a l o f P s y c h i a t r y , 1964, 110, 668-682.  K e r l i n g e r , F. N. Foundations o f B e h a v i o r a l Research. R i n e h a r t & Winston Inc., 1973.  New York: H o l t ,  Keyes, L. L. H e a l t h E d u c a t i o n i n P e r s p e c t i v e - An Overview. E d u c a t i o n Monographs, 1972, 31, 18-18. K i s c h , A. E., Koyner, J . W., H a r r i s , L. J . , and K l i n e , G. Measure f o r H e a l t h S t a t u s . H e a l t h S e r v i c e s Research, 223-230.  Health  A New Proxy 1969, 4, 3,  - 125 Knowles, M. S. The Modern P r a c t i c e of A d u l t E d u c a t i o n . A s s o c i a t i o n P r e s s , 1970. Koos, E. L . The H e a l t h of R e g i o n v i l l e . P r e s s , 1954.  New York:  New York: Columbia U n i v e r s i t y  Kulak, L. L., and Chisholm, D. M. The P o t e n t i a l Role o f P r e v e n t i v e M e d i c i n e i n B r i t i s h Columbia. I n F o u l k e s , R. G. (Ed.), H e a l t h S e c u r i t y f o r B r i t i s h Columbians. V i c t o r i a : Queen's P r i n t e r , 1974. Lalonde, M. A New P e r s p e c t i v e on the H e a l t h o f Canadians. I n f o r m a t i o n Canada, 1975.  Ottawa:  Lawton, M. P., Ward, M., and Y a f f e , S. I n d i c e s o f H e a l t h i n an A g i n g Population. J o u r n a l o f Gerontology, 1967, 22, 3, 334-342. L e r n e r , M. C o n c e p t u a l i z a t i o n of H e a l t h and S o c i a l W e l l - B e i n g . In Berg, R. L. (Ed.), H e a l t h Status Indexes. Chicago: H o s p i t a l Research and E d u c a t i o n a l T r u s t , 1973. Lewin, K. S t u d i e s i n Group D e c i s i o n . I n C a r t w r i g h t , D., and Zarker, A. ( E d s . ) , Group Dynamics: Research and Theory. I l l i n o i s : Row, P e t e r s o n and Co., 1953. Littlefield, tions. 1974.  J . L. N u t r i t i o n a l L a b e l i n g R e v i s i t e d . R e g u l a t o r y C o n s i d e r a Paper Presented a t Food Update X I I I , S c o t t s d a l e , A r i z o n a ,  Maddox, G. Some C o r r e l a t e s o f D i f f e r e n c e s i n Self-Assessment o f H e a l t h Status Among the E l d e r l y . J o u r n a l of Gerontology, 1962, 17, 180-185. M a r t i n , J . J . , Mayne, J . G., T a y l o r , W. F., and Swenson, M. N. A H e a l t h Q u e s t i o n n a i r e Based on P a p e r - a n d - P e n c i l Medium, I n d i v i d u a l i z e d and Produced by Computer I I : T e s t i n g and E v a l u a t i o n . J o u r n a l o f the American M e d i c a l A s s o c i a t i o n , 1969, 208, 11, 2064. McDonnell, C. E. S o c i o - M e d i c a l Aspects ence, Vancouver, 1972.  of Aging.  Focus on A g i n g  McKeachie, W. J . Teaching T i p s . A Guidebook f o r the Beginning Teacher. Massachusetts: D. C. Heath and Co., 1969.  Confer-  College  McKinlay, J . B. Some Approaches and Problems i n the Study o f the Use of S e r v i c e s - An Overview. J o u r n a l o f H e a l t h and S o c i a l Behaviour, 1972, 13, 113. McPhee, M. H e a l t h Care o r H e a l t h . The Development o f a P l a n t o Address the H e a l t h Needs o f the E l d e r l y i n B r i t i s h Columbia. Report S : l , D i v i s i o n o f H e a l t h S e r v i c e s Research and Development, U n i v e r s i t y o f B r i t i s h Columbia, 1977. Mechanic, D.  Medical Sociology.  New York: Free P r e s s , 1968.  - 126  -  M i l l e r , J . E. An I n d i c a t o r to A i d Management i n A s s i g n i n g Program Priorities. P u b l i c H e a l t h Reports, August 1970, 85, 725-731. M i n i s t r y of H e a l t h . I n t r o d u c t i o n to the Program f o r Long Term Care. P r o v i n c e of B r i t i s h Columbia, Victoria, 1978. M i n i s t r y of H e a l t h . Payment Schedule, A p r i l 1, 1978. Medical Services Commission, P r o v i n c e of B r i t i s h Columbia, V i c t o r i a , 1978(a) M i n i s t r y of H e a l t h . Long Term O b j e c t i v e s . Victoria, 1979.  P r o v i n c e of B r i t i s h  Morgan, R. A t t i t u d e s Towards Smallpox and Measles i n N i g e r i a . n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1969, 12, 77.  Columbia,  Inter-  Moriyama, I . M. Problems i n the Measurement of H e a l t h S t a t u s . In Sheldon, E., and Moore, W. ( E d s . ) , I n d i c a t o r s of S o c i a l Change. New York: R u s s e l l Sage Foundation, 1968. M u l l e n , P. F. H e a l t h E d u c a t i o n f o r Heart P a t i e n t s i n C r i s i s . S e r v i c e s Reports, 1978, 88, 669-675.  Health  N a t i o n a l H e a l t h Expenditures i n Canada: 1960-1973. H e a l t h Economics and S t a t i s t i c s D i v i s i o n , H e a l t h Programs Branch, H e a l t h & W e l f a r e Canada, Ottawa,. 1975. Palmore, E. B. S o c i a l F a c t o r s i n Mental I l l n e s s of the Aged. In Busse, E. W., Gibbons, J . P., and P f e i f f e r , E. (Eds.) Mental I l l n e s s i n Later L i f e . Washington, D. C : American P s y c h i a t r i c A s s o c i a t i o n ,  WTT.  P a u l , B. D. (Ed.). Sage, 1955. Plant, J . April  Educating 16, 1977,  H e a l t h , C u l t u r e and Community.  New  the E l d e r l y i n Safe M e d i c a t i o n Use. 51, 97-102.  P o p u l a t i o n Age Groups ( B u l l e t i n S t a t i s t i c s Canada, 1971).  1.2-3).  P o p u l a t i o n Age Groups ( B u l l e t i n S t a t i s t i c s Canada, 1976).  2.4).  1971  1976  York: R u s s e l l  Hospitals,  Census of Canada.  Census of Canada.  P r o j e c t i o n s f o r Canada and the P r o v i n c e s , 1976-2001 (Catalogue (Ottawa: S t a t i s t i c s Canada, 1976).  (Ottawa:  (Ottawa:  91.520).  R i c h a r d s , N. D. Methods and E f f e c t i v e n e s s of H e a l t h E d u c a t i o n . The Past, P r e s e n t and Future of S o c i a l S c i e n t i f i c Involvement. S o c i a l S c i e n c e and M e d i c i n e , 1975, 9, 141-156. Robertson, H. R. H e a l t h Care i n Canada: A Commentary. C o u n c i l of Canada, S p e c i a l Study No. 29, 1973.  Ottawa:  Science  - 127 Rogers, E. M.  D i f f u s i o n of I n n o v a t i o n s .  New York: Free P r e s s , 1962.  Rombout, M. H o s p i t a l s and the E l d e r l y : P r e s e n t and F u t u r e Trends. Ottawa, Department o f N a t i o n a l H e a l t h and Welfare, Long Range P l a n n i n g Branch, 1975. Rosenstock, I . M. Why People Use H e a l t h S e r v i c e s . Fund Q u a r t e r l y , 1969, 44, 94.  M i l l b a n k Memorial  Rosenstock, I . M. P r e v e n t i o n of I l l n e s s and Maintenance of H e a l t h . I n Kosa, J . , Antonovsky, A., and Zda, I . K. ( E d s . ) , P o v e r t y and H e a l t h : A S o c i o l o g i c a l A n a l y s i s . Cambridge: Harvard U n i v e r s i t y P r e s s , 1969(a). S a c k e t t , D. L., Chambers, L. W., e t a l . The Development and A p p l i c a t i o n of I n d i c e s o f H e a l t h : General Methods and a Summary of R e s u l t s . American J o u r n a l of P u b l i c H e a l t h , May 1977, 67, 5, 423-428. Samora, J . , e t a l . M e d i c a l Vocabulary Knowledge Among H o s p i t a l P a t i e n t s . J o u r n a l of H e a l t h and Human Behaviour, 1961, 2, 83. Sheldon, E. B., and Moore, W. E. ( E d s . ) , I n d i c a t o r s of S o c i a l Change. New York: R u s s e l l Sage Foundation, 1968. Simonds, S. K. H e a l t h E d u c a t i o n : F a c i n g Issues o f P o l i c y , E t h i c s and Social Justice. H e a l t h E d u c a t i o n Monographs, 1978, 6, Supplement, 18-27. S t e c k l e r , A. A P i l o t Study: Home S a f e t y E d u c a t i o n f o r the E l d e r l y . I n t e r n a t i o n a l J o u r n a l of H e a l t h E d u c a t i o n , 1973, 16, 2, 136-142. Stone, D. B. A Study o f the I n c i d e n c e and Causes of Poor C o n t r o l i n P a t i e n t s w i t h Diabetes M e l l i t u s . American J o u r n a l of M e d i c a l S c i e n c e s , 1961, 241, 64-69. S t r a u s , R. Determinants o f H e a l t h B e l i e f s and Behaviour: S o c i o l o g i c a l Determinants. American J o u r n a l of P u b l i c H e a l t h , October 1961, 51, 1547-1549. Suchman, E. A. S o c i o m e d i c a l V a r i a t i o n s Among E t h n i c Groups. J o u r n a l of S o c i o l o g y , November 1964, 70, 319-331. Suchman, E. A. S o c i a l F a c t o r s i n I l l n e s s Behaviour. Fund Q u a r t e r l y , 1969, 47, 85.  American  M i l l b r o o k Memorial  Suchman, E. A., S t r e i b , G., and P h i l i p s , B. An A n a l y s i s o f the V a l i d i t y of H e a l t h Q u e s t i o n n a i r e s . S o c i a l F o r c e s , 1958, 36, 223-232. T i s s u e , T. Another Look a t S e l f - R a t e d H e a l t h Among the E l d e r l y . of Gerontology, 1972, 27, 1, 95-101.  Journal  Verner, C , and Booth, A. A d u l t E d u c a t i o n . New York: The Centre f o r A p p l i e d Research i n E d u c a t i o n , Inc., 1964.  - 128 -  Verner, C , and Dickenson, G. The L e c t u r e , An A n a l y s i s and Review of Research. A d u l t E d u c a t i o n , Winter 1967, 85. Wadsworth, M. E. J . , B u t t e r f i e l d , W. J . H., and B l a r e y , R. H e a l t h and S i c k n e s s : The Choice of Treatment. London, T a v i s t o c k , 1971. Ward, A. W. Why Family P l a n n i n g P a t i e n t s Drop Out. S c i e n c e , 1971, 3, 301.  Journal of B i o l o g i c a l  Weaver, H. G., McPhee, M., and Lambert, P. G r e a t e r Vancouver R e g i o n a l H o s p i t a l D i s t r i c t : G e r i a t r i c s Report 1975. Vancouver, 1975. W e l l i n , E. I m p l i c a t i o n s of L o c a l C u l t u r e f o r P u b l i c H e a l t h . O r g a n i z a t i o n , 1958, 16, 16. W i l l i a m s o n , J . Ageing i n Modern S o c i e t y . Paper p r e s e n t e d S o c i e t y o f H e a l t h , Edinburgh, November 1966.  Human  to the Royal  W i l l i a m s o n , J . Stokoe, J . H., Gray, S., e t a l . O l d People At Home: T h e i r Unreported Needs. Lancet, 1964, 1, 1117. World H e a l t h O r g a n i z a t i o n . C o n s t i t u t i o n of the World H e a l t h O r g a n i z a t i o n , Annex 1. I n , The F i r s t Ten Years of the World H e a l t h O r g a n i z a t i o n . W.H.O., Geneva, 1958. Young, M. A. C. Review of Research and S t u d i e s R e l a t e d to H e a l t h E d u c a t i o n P r a c t i c e (1961-1966): What People Know, B e l i e v e and Do About H e a l t h . H e a l t h E d u c a t i o n Monographs, 1967, 23. Young, M. A. C. Review o f Research and S t u d i e s R e l a t e d to H e a l t h E d u c a t i o n P r a c t i c e (1961-1966): Communication: Methods and M a t e r i a l s . H e a l t h E d u c a t i o n Monographs, 1967(a), 25. Young, M. A. C. Review of Research R e l a t e d and S t u d i e s R e l a t e d t o H e a l t h E d u c a t i o n P r a c t i c e (1961-1966): P a t i e n t E d u c a t i o n . Health Education Monographs, 1968, 26. Young, M. A. C. Review of Research and S t u d i e s R e l a t e d t o H e a l t h E d u c a t i o n P r a c t i c e (1961-1966): Programme P l a n n i n g and E v a l u a t i o n . H e a l t h E d u c a t i o n Monographs, 1968(a), 27. Z o l a , I . K. C u l t u r e and Symptoms - An A n a l y s i s o f P a t i e n t s P r e s e n t i n g Complaints. American S o c i o l o g i c a l Review, 1966, 31, 615.  - 129 -  APPENDIX QUESTIONNAIRE USED WITH STUDY PARTICIPANTS  1.  Respondent l i v e s  i n N i c h o l s o n Towers  (1)  Sunset Towers  (2)  2.  Respondent i s male  (1) | |  female  3.  Respondent i s c u r r e n t l y r e c e i v i n g n u r s i n g Respondent has r e c e i v e d n u r s i n g s e r v i c e s two years b u t n o t i n the past month. Respondent has never r e c e i v e d n u r s i n g  4.  |_J  (2) | |  services.  (3)  •  (2)  •  (1)  P  i n the l a s t  services.  Respondent i s e l i g i b l e f o r admission to a Long Term Care Yes No  5.  •  (2) (1)  Number of v i s i t s made by the nurse t o the respondent s i n c e January 1, 1978  institution.  - 130 -  I am Lyn P i c k a r d . see you today.  I c a l l e d you on  about coming to  T h i s i s a form which s t a t e s t h a t you agree complete i t ?  6.  Would you t e l l me your date of b i r t h ?  7.  What i s your p r e s e n t m a r i t a l s t a t u s ? (1) (2) (3) (4)  I  to be i n t e r v i e w e d .  Would you  single married divorced o r separated ) widowed  8.  What i s the h i g h e s t grade of f o r m a l s c h o o l i n g t h a t you have completed?  9.  What was your o c c u p a t i o n b e f o r e r e t i r e m e n t ? P l e a s e be v e r y s p e c i f i c . ( I f respondent s t a t e s t h a t she was a housewife f o r most o f h e r a d u l t l i f e , w r i t e "housewife" and ask: Could you t e l l me the t i t l e o f the work your husband d i d ? )  10. Have you been admitted Yes No  t o h o s p i t a l as a p a t i e n t s i n c e l a s t  (2) (1)  Go to Go to  Christmas?  11 14  11. On how many s e p a r a t e o c c a s i o n s have you been admitted s i n c e l a s t Christmas?  to h o s p i t a l  occasions  12. How many days a l t o g e t h e r have you spent i n h o s p i t a l s i n c e days  Christmas?  - 131 -  Vancouver General H o s p i t a l St. Paul's H o s p i t a l St. V i n c e n t ' s H o s p i t a l Shaughnessy H o s p i t a l L i o n s ' Gate H o s p i t a l Health Sciences H o s p i t a l Other ( s p e c i f y ) _  (1) (2) (3) (4) (5) (6) (7)  13.  In what h o s p i t a l was t h i s ?  14.  Can you r e c a l l any o c c a s i o n on which c o n s u l t i n g w i t h the nurse i n t h i s b u i l d i n g prevented your needing to be admitted to h o s p i t a l ? Yes No  Go t o 15 Go to 16  (2) (1)  15.  How many times d i d t h i s happen?  16.  How many times have you v i s i t e d your d o c t o r (G.P.) s i n c e Christmas?  1 I times  last  ( I f 0 times, go to 18)  times  17.  I  How many times s i n c e l a s t Christmas have you had a complete p h y s i c a l examination? times  18.  Have you v i s i t e d  a s p e c i a l i s t since last  Yes No  19.  (2) (1)  What k i n d o f s p e c i a l i s t was t h i s ? Orthopaedic, • (1) Neurologist, (2) Internist (3) Rheumatologist (4)  20.  Christmas?  How many times d i d you v i s i t  this  Surgeon Eye s p e c i a l i s t E.N.T. Dermatologist  specialist?  (5) (6) (7) (8)  times  - 132 21.  What o t h e r s p e c i a l i s t  have you v i s i t e d s i n c e l a s t  Orthopaedic Neurologist Internist Rheumatologist  (1) (2) (3) (4)  Surgeon Eye s p e c i a l i s t E.N.T. Dermatologist  Christmas? (5) (6) (7) (8)  22.  How many times d i d you v i s i t  23.  Can you r e c a l l any o c c a s i o n s i n c e Christmas on which t a l k i n g w i t h the nurse i n t h i s b u i l d i n g r e s u l t e d i n your d e c i d i n g that you d i d not need t o v i s i t your doctor? Yes No  this  (2) (1)  specialist?  Go t o 24 Go to 25  24.  How many times has t h i s happened s i n c e  25.  Do you have d i a b e t e s ? Yes No  26.  (1) (0)  Do you have asthma? Yes No  27.  l _ |  Q  Do you have c h r o n i c b r o n c h i t i s ? Yes No  28.  (1) (0)  (1) (0)  Do you have u l c e r s ? Yes No  (1) (0)  times  Christmas?  times  -133  29.  Do you have cancer? Yes No  30.  Do you have  (1) (0)  arthritis? Yes No  31.  -  B  (1) (0)  Go to 31 Go t o 38  Can you name a n y t h i n g you can do to get r i d o f some of the s t i f f n e s s you may have ( i n the morning, f o r example)? (1) (0)  P U  c  correct iin c o r r e c t  (Answers that i n d i c a t e : keep m o b i l e , keep a c t i v e w i l l be c o n s i d e r e d correct)  32.  Do you do t h i s ?  33.  From whom o r what d i d you f i r s t _learn t h i s ? (1) d o c t o r (2) nurse Go t o 34 (3) nurse i n t h i s b u i l d i n g (4) r e s i d e n t i n t h i s building (5) f r i e n d / r e l a t i v e (6) TV, r a d i o , newspaper, Go to 35 magazine, book | | (7) do not know [n (8) I have known t h i s f o r a l o n g time  (Yes. No)  (1) (0)  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  B  34.  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people? (1) one-to-one s e t t i n g | (2) group s e t t i n g  - 134 35.  I f you have so much p a i n t h a t you do n o t f e e l l i k e e a t i n g , what do you do about e a t i n g (... and why)? (1) (0) LJ  36.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  37.  Go to 37  Go to 38  condition? (1) (0)  |Z] L|  Go t o 39 Go to 46  How do you d e c i d e how o f t e n t o take m e d i c a t i o n ( s ) f o r your (1) (0)  Do you do t h i s ?  people?  j j one-to-one s e t t i n g ing j _ J group s e t t  Do you have a h e a r t Yes No  40.  learn this?  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r  (2)  39.  (Answers t h a t i n d i c a t e the importance of e a t i n g to m a i n t a i n s t r e n g t h w i l l be c o n s i d e r e d correct)  doctor nurse nurse i n t h i s b u i l d i n g r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a long time  (1)  38.  correct incorrect  correct incorrect  (Yes. No)  heart?  (Answers that i n d i c a t e the importance of t a k i n g m e d i c a t i o n r e g u l a r l y w i l l be c o n s i d e r e d c o r r e c t )  (1) I I Engages i n h e a l t h y b e h a v i o u r (0) L J Does not engage i n h e a l t h y behaviour  - 135 41.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  42.  correct incorrect  From whom o r what d i d you f i r s t  to you that  your h e a r t  (An answer o f one of the f o l l o w i n g w i l l be c o n s i d e r e d c o r r e c t : s w e l l i n g o f a n k l e s , s h o r t n e s s of breath)  learn  this?  doctor nurse nurse i n t h i s b u i l d i n g resident of this b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go to 45  Go t o 46  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h other people? (1) (2)  46.  Go t o 43  (1) one-to-one s e t t i n g (2) group s e t t i n g  What s o r t o f p h y s i c a l s i g n s would i n d i c a t e was n o t f u n c t i o n i n g w e l l ?  (1) (2) (3) (4) (5) (6) (7) (8)  45.  Go to 42  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people?  (1) (0)  44,  this?  doctor nurse nurse i n t h i s b u i l d i n g resident i n this building friend/relative TV, r a d i o , newspaper, magazine, book do n o t know I have known t h i s f o r a l o n g time _  _  43.  learn  one-to-one s e t t i n g group s e t t i n g  Do you have l e g u l c e r s ? Yes No  ;(1) (0)  — —  Go to 47 Go t o 55  - 136 -  47.  Can you name two t h i n g s (1) (0)  48.  one can do to reduce s w e l l i n g  I I correct |_J i n c o r r e c t  Do you do t h i s ?  (Yes. No)  (Answers t h a t i n d i c a t e heavy s u p p o r t i v e and keeping the f o o t e l e v a t e d w i l l be considered correct)  (1)  (oo:  49.  From whom or what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  50.  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  learn this?  doctor nurse nurse i n t h i s b u i l d i n g r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a long time _  Was t h i s on a one-to-one b a s i s (1) r~i  i n the leg?  Go to 50  Go to 51  o r i n a s e t t i n g w i t h o t h e r people?  one-to-one s e t t i n g  (2) J J group s e t t i n g  51.  What s o r t s of food are e s p e c i a l l y important to i n c l u d e when one has l e g u l c e r s ? (1) (0)  correct incorrect  i n one's d i e t  (Answers t h a t i n d i c a t e a d i e t h i g h i n p r o t e i n w i l l be c o n s i d e r e d c o r r e c t )  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  - 137 53.  From whom o r what d i d you f i r s t  _  54.  55.  (1) (2) (3) (4) (5) (6) (7) (8)  this?  doctor nurse nurse i n t h i s b u i l d i n g _ resident i n this building friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go t o 54  Go to 55  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r  a  (1) (2)  people?  one-to-one s e t t i n g group s e t t i n g  Do you have h i g h b l o o d Yes No  56.  learn  pressure?  (1) (0)  — -  Go to 56 Go to 68  What k i n d s o f t h i n g s can you do t o h e l p keep your b l o o d p r e s s u r e down? (1) (0)  correct incorrect  57.  Do you do t h i s ?  58.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  (Yes. No)  (Answers which c o n t a i n two of the f o l l o w i n g w i l l be c o n s i d e r e d c o r r e c t : decrease s a l t i n t a k e , r e s t f r e q u e n t l y , d a i l y exercise, avoid s t r e s s f u l situations)  (1) (0)  learn  Engages i n h e a l t h y behaviour Does not engage i n h e a l t h y behaviour  this?  doctor nurse nurse i n t h i s b u i l d i n g r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go to 59  Go to 60  - 138 59.  Was t h i s on a one-to-one b a s i s or i n a s e t t i n g w i t h o t h e r people? (1) (2)  60.  one-to-one s e t t i n g group s e t t i n g  I f you f e e l d i z z y when you get up from a l y i n g p o s i t i o n , what s h o u l d you do? (1) (0) (2)  correct (Answers o f : g e t up s l o w l y o r s i t down a g a i n w i l l be c o n s i d e r e d c o r r e c t ? incorrect do not g e t d i z z y  61.  Do you do t h i s ?  (Yes. No)  62.  From whom o r what d i d you f i r s t  (1) (0)  learn  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  this?  (1) doctor _| (2) ..nurse (3) nurse i n t h i s b u i l d i n g (4) resident i n this building (5) friend/relative (6) TV, r a d i o , newspaper, magazine, book (7) do not know (8) I have known t h i s f o r a l o n g time  63.  one-to-one s e t t i n g group s e t t i n g  I f you f e e l d i z z y w h i l e you a r e doing something housework) what s h o u l d you do? (1) (0) (2)  65.  Go t o 64  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people? (1) (2)  64.  Go to 63  ( l i k e walking or  (Answers that i n d i c a t e s t o p a c t i v i t y and correct incorrect r e s t w i l l be c o n s i d e r e d c o r r e c t ) do n o t get d i z z y  Do you do t h i s ?  (Yes. No)  (1) I j Engages i n h e a l t h y b e h a v i o u r (0) M Does n o t engage i n h e a l t h y behaviour  - 139 66.  From whom or what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  67.  Was  68.  learn  basis  Do you r e c e i v e building?  any b e n e f i t  from the presence of the nurse i n the  (3) (2) (1)  -  Go to 70 Go to 70 Go to 69  Is t h i s because: You d i d not know that nurses come i n t o the b u i l d i n g ? You see your d o c t o r when you f e e l unwell? You do not need n u r s i n g s e r v i c e s ? The nurse does not spend encugh time i n b u i l d i n g ? Other ( s p e c i f y )  Does the f a c t t h a t nurses come i n t o t h i s b u i l d i n g make you f e e l more secure? (3) (2) (1)  71.  Go to 68  one-to-one s e t t i n g group s e t t i n g  (1) (2) (3) (4) (5)  70.  Go to 67  or i n a s e t t i n g w i t h o t h e r people?  A g r e a t d e a l of b e n e f i t Some b e n e f i t No b e n e f i t  69.  this?  doctor nurse nurse i n t h i s b u i l d i n g resident i n this building friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  t h i s on a one-to-one (1) I (2)  -  Very much more secure S l i g h t l y more s e c u r e No more secure a t a l l  In your e x p e r i e n c e can the nurses be c o n t a c t e d e a s i l y ? Always  (4) Q  Sometimes  (3)L~J.  Never  Q  (1)  Have never t r i e d to c o n t a c t nurse (2)Q  - 140 72.  Can you r e c a l l any o c c a s i o n on which you t r i e d t o c o n t a c t the n u r s e and were unable to do so? Yes (3) • Go to 73 I am aware o f the hours the nurses are a v a i l a b l e and do not t r y t o ^ \ i — i qq 74 c o n t a c t them a t times o t h e r than these hours No (1) • Go to 74 t  73.  What do you do i f you a r e unable t o c o n t a c t the nurse when you need her'i Try a g a i n l a t e r the same day Wait u n t i l the next day Phone the d o c t o r V i s i t - t h e doctor Leave a message f o r the nurse Other ( s p e c i f y )  (1) (2) (3) (4) (5) (6)  74.  Do you go t o the nurse w i t h s m a l l h e a l t h problems Often  75.  Sometimes  (2)Q  Never  (1) Q  (2) •  No  (1) U  Have you ever t a l k e d to the nurse when you have been w o r r i e d o r upset about a p e r s o n a l o r f a m i l y problem? Yes No  77.  (3) Q  of health questions?  Does the f a c t t h a t nurses come i n t o t h i s b u i l d i n g mean t h a t they check on your h e a l t h more o f t e n ? Yes  76.  o  (2) (1) |_J  D i d t a l k i n g t o the nurse make you f e e l (4) j (3) _ (2) (1) j  v e r y much b e t t e r a l i t t l e better no d i f f e r e n t worse  -  Go to 77 Go t o 78  - 141 -  78.  A r e you e l i g i b l e f o r a p e r s o n a l c a r e home? Yes No  79.  Do you t h i n k you c o u l d c o n t i n u e to l i v e i n t h i s b u i l d i n g i f t h e r e were no nurses i n the b u i l d i n g ? Yes No  80.  Go to 79 Go to 81  (2) (1)  (2) (1)  p Q  - Go to 81 - Go to 80  Is t h i s because: (1) (2) (3) (4)  I t makes you f e e l more secure They can check on you more o f t e n You can c o n t a c t them e a s i l y when you need h e l p Other ( s p e c i f y )  Next I'd l i k e to ask you about the p h y s i c a l a c t i v i t i e s you r i g h t now. Today do you (or would you) have any p h y s i c a l d i f f i c u l t y at a l l w i t h :  No Difficulty  Some Difficulty  Great Diffic ulty  a r e a b l e to do  Cannot Do Activity  Do Not Know  81.  Walking as f a r as a mile  5  4  3  2  1  82.  C l i m b i n g up 2 f l i g h t s of s t a i r s (16 s t e p s )  5  4  3  2  1  83.  Shopping  5  4  3  2  1  84.  Cooking  5  4  3  2  1  85.  D u s t i n g o r l i g h t housework  - 142 No Dif f i e ulty  Some D i f f'i'culty  Great Difficulty  Cannot Do Activity  Do Not Know  86.  Cleaning f l o o r s  5  4  3  2  1  87.  Do you (or would you) have any p h y s i c a l d i f f i c u l t y at a l l t r a v e l l i n g by bus whenever necessary  5  4  3  2  1  88.  Do you have any d i f f i c u l t y at a l l t r a v e l l i n g by c a r whenever necessary?  89.  Do you have any t r o u b l e r e a d i n g o r d i n a r y  90.  (4)  No, never  (3) (2) (1)  No, not i f I wear my Yes, sometimes Yes, always  j  glasses  At p r e s e n t a r e you a b l e t o walk out of doors when the weather i s good? Yes No  91.  newsprint?  (2) (1)  •  Ll  What i s the f a r t h e s t  you can walk?  Are you a b l e to walk:  (6)  Q  one m i l e or more  (5)  0  l e s s than one m i l e b u t more than 30 f e e t  (2) Q  between rooms  less  (1) j I  o n l y w i t h i n a room  (4)  0  than 30 f e e t  (3) I I to d i f f e r e n t p a r t s of the b u i l d i n g  - 143 -  O f t e n people's h e a l t h a f f e c t s the way they f e e l about l i f e . On t h i s c a r d are l i s t e d p o s s i b l e responses to the statements I am about to make. (Show the c a r d to the respondent and e x p l a i n i t ) . F o r example, i f I were to make the statement: " L i f e to me seems always e x c i t i n g " . I f you agree you would say? I f you d i s a g r e e d you would say? That's good. Now ... Strongly Agree 92.  I am u s u a l l y  alert.  93.  I would say t h a t I n e a r l y always f i n i s h t h i n g s once I s t a r t them.  94.  Some people f e e l t h a t they r u n t h e i r l i v e s p r e t t y much the way they want t o , and t h i s i s the case w i t h me.  95.  There a r e many people who don't know what to do with their l i v e s .  96.  Nowadays a person has to l i v e p r e t t y much f o r today and l e t tomorrow take c a r e of i t s e l f .  97.  In a s o c i e t y where almost everyone i s out f o r hims e l f , people soon come to d i s t r u s t each o t h e r .  98.  Many people a r e unhappy because they do n o t know what they want out of life.  Agree  Neutral  Disagree  Strongly Disagree  - 144 Strongly Agree  Agree  99.  I am i n c l i n e d to f e e l t h a t I am a f a i l u r e .  100.  Have you had t r o u b l e g e t t i n g a l o n g w i t h the p a s t year? (1) I (2) (3) (4) I  101.  Have you Yes No  retired (1) (2)  How would you health i s : (5) (4) (3)  103.  Taking days?  from work d u r i n g  104.  f r i e n d s or r e l a t i v e s  during  the l a s t year?  •  on g e n e r a l h e a l t h and  say your h e a l t h i s these  Extremely good Very good F a i r l y good  days?  (2) (1)  on your  Would you  say  happy would you  say you  are  Extremely happy Very happy F a i r l y happy S l i g h t l y happy Not happy at a l l  (2) |__| (1) •  social  your  S l i g h t l y good Not good at a l l  Do you have a telephone? Yes No  Strongly Disagree  p  a l l t h i n g s t o g e t h e r , how Would you say you a r e :  (5) (4) (3) (2) (1)  Disagree  A great d e a l of t r o u b l e A f a i r amount of t r o u b l e A l i t t l e trouble No t r o u b l e at a l l  This s e c t i o n c o n t a i n s some q u e s t i o n s activities.  102.  Neutral  -  Go Go  to to  105 113  these  - 145 105.  How many times have you used your telephone i n the l a s t week t o c a l l a friend? •  106.  How many times have you used your a relative? 0 1 2 3 4  107.  telephone i n the l a s t week to c a l l  None 1 to 4 5 to 8 9 to 12 _ 12 and over  How many times have you used your telephone i n the l a s t week to c a l l a r e l i g i o u s group member? (1) (0)  108.  t lmes i  1 t o 5 times None  How many times have you been c a l l e d i n the l a s t week?  Li  by a s o c i a l  agency r e p r e s e n t a t i v e  t imes  109.  I n c l u d i n g the times you went shopping o r f o r your u s u a l o u t i n g s from home, how many times have you been out of the b u i l d i n g i n the l a s t week? Q times  110.  How many times have you been t o a movie, f i l m , the l a s t month? <Q times  111.  How many times have you been t o a s o c i a l month? CJ times  112.  How many times have you been t o church i n the l a s t month? Q times  play or concert i n  club i n the l a s t  - 146 113.  How many times have you v i s i t e d "1 times  a relative  114.  How many times have you v i s i t e d times  a friend  115.  How many times have you been v i s i t e d the l a s t week? I I I times  116.  How l o n g has i t been s i n c e you l a s t had a h o l i d a y  or r e l a t i v e i n  (away from home)?  year?  (1) (2)  D i d you s t a r t Yes No  r e c e i v i n g Mincome d u r i n g the l a s t  year?  (1) (2)  The f o l l o w i n g a r e q u e s t i o n s about d i e t 119.  by a f r i e n d  Have you become s e p a r a t e d from your spouse d u r i n g the l a s t Yes No  118.  i n t h e l a s t week?  Less than 1 year 1 to 4 y e a r s 5 to 8 y e a r s Over.8 y e a r s  (4) (3) (2) (1)  117.  i n the l a s t week?  and a c t i v i t y .  How o f t e n s h o u l d one have some form of e x e r c i s e l i k e going f o r walks? (1) (0)  B  correct incorrect  (Answers t h a t i n d i c a t e d a i l y , f r e q u e n t l y , s e v e r a l times a week, w i l l be considered correct)  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  - 147 121.  From whom o r what d i d you f i r s t (1) (2) (3) . (4) (5) (6) (7) - (8)  122.  doctor Go to 122 nurse nurse i n t h i s b u i l d i n g —> r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book Go to 123 do n o t know I have known t h i s f o r a l o n g time  one-to-one group s e t t i n g  How do you d e c i d e when and f o r how l o n g t o take p r e s c r i b e d medicine"! (1) (0)  correct incorrect  (1) rj Engages i n h e a l t h y b e h a v i o u r (0) 1 I Does n o t engage i n h e a l t h y behaviour  Do you do t h i s ?  125.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  (Yes. No)  (Answers t h a t i n d i c a t e p r e s c r i b e d m e d i c a t i o n s h o u l d be taken e x a c t l y as recommended by the d o c t o r o r nurse w i l l be c o n s i d e r e d c o r r e c t )  124.  126.  this?  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people? (1) (2)  123.  learn  learn  this?  doctor nurse nurse i n t h i s b u i l d i n g r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go to 126  Go to 127  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people? (1) (2)  one-to-one s e t t i n g group s e t t i n g  - 148 127.  How o f t e n i s a p h y s i c a l check-up a d v i s a b l e f o r people are f e e l i n g w e l l ? (1) (0)  (Answers o f numbers of months r a n g i n g between 6 and 18 w i l l be c o n s i d e r e d correct)  correct incorrect  (1) (0)  128.  Do you do t h i s ?  129.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  130.  Engages i n h e a l t h y behaviour Does not engage i n h e a l t h y behaviour  learn  this?  doctor nurse nurse i n t h i s b u i l d i n g resident i n this building friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go t o  130  Go t o  131  people?  one-to-one s e t t i n g group s e t t i n g  I f one i s l i v i n g alone, how o f t e n do you t h i n k one s h o u l d have c o n t a c t w i t h o t h e r people?  (1)  (0)  132.  No)  Was t h i s on a one-to-one b a s i s or i n a s e t t i n g w i t h o t h e r (1) (2)  131.  (Yes,  of your age  correct incorrect  Do you do t h i s ?  (Yes. No)  (Answers t h a t i n d i c a t e d a i l y c o n t a c t w i l l be c o n s i d e r e d c o r r e c t )  (1) (0)  I j Engages i n h e a l t h y behaviour I 1 Does not engage i n h e a l t h y behaviour Does not l i v e alone  a  - 149 133.  From whom o r what d i d you f i r s t (1) (2) (3) . (4) (5) (6) (7) (8)  134.  doctor nurse nurse i n t h i s b u i l d i n g resident of this building friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go to 138  Go t o 139  one-to-one s e t t i n g group s e t t i n g  How many days a week s h o u l d you e a t v e g e t a b l e s and f r u i t have enough v i t a m i n s and m i n e r a l s i n your d i e t ?  B  (1) (0)  correct incorrect  Do you do t h i s ?  137.  From whom o r what d i d you f i r s t (1) (2) (3) (4) (5) (6) (7) (8)  (Yes. No)  i n o r d e r to  (An answer of 5, 6 o r 7 days w i l l be considered correct)  136.  138.  this?  Was t h i s on a one-to-one b a s i s o r i n a s e t t i n g w i t h o t h e r people? (1) (2)  135.  learn  (1) f_| (0) L J  learn  Engages i n h e a l t h y b e h a v i o u r Does n o t engage i n h e a l t h y behaviour  this?  doctor nurse nurse i n t h i s b u i l d i n g resident of this b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do n o t know I have known t h i s f o r a l o n g time  Go to 138  Go to 139  Was t h i s on a one-to-one b a s i s or i n a s e t t i n g w i t h o t h e r people? (1) M one-to-one s e t t i n g (2) j [ group s e t t i n g  - 150 139.  Could you name two bowel movements? (1) LJi (0) I I  you  correct incorrect  Do  141.  From whom or what d i d you  142.  143.  Was  How  this?  (Yes.  can  i n c l u d e i n your d i e t to  assist  (Respondent must name 2 of the following: h i g h b u l k foods, b r a n , prune j u i c e , d r i e d f r u i t , c e l e r y , f r u i t , 8 cups of liquids)  140.  (1) (2) (3) (4) (5) (6) (7) (8)  do  t h i n g s you  -  No)  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  (1) |_ (0)  first  learn  this?  doctor nurse nurse i n t h i s b u i l d i n g r e s i d e n t of t h i s b u i l d i n g friend/relative TV, r a d i o , newspaper, magazine, book do not know I have known t h i s f o r a l o n g time  Go  to  142  Go  to  143  t h i s on  a one-to-one b a s i s or i n a s e t t i n g w i t h o t h e r people?  (1) (2)  one-to-one s e t t i n g group s e t t i n g  many cups of (1) L J (2) (J.  fluid  correct incorrect  s h o u l d one  d r i n k a day?  (Answers of 6 cups or more w i l l considered correct)  be  Engages i n h e a l t h y b e h a v i o u r Does not engage i n h e a l t h y behaviour  - 151 145.  From whom o r what d i d you f i r s t _(1) (2) (3) (4) (5) (6) (7) (8)  146.  doctor nurse nurse i n t h i s b u i l d i n g resident of this building friend/relative TV, r a d i o , newspaper, magazine, book do n o t know I have known t h i s f o r a l o n g time  Was t h i s on a one-to-one b a s i s (1) (2)  learn this?  Name o f m e d i c a t i o n from b o t t l e l a b e l  or i n a s e t t i n g with other  you a r e on?  people?  Could you t e l l me what  Resident s t a t e s i t i s for:  Who t o l d you t h i s ?  147.  (1) I Icorrect (0) I (incorrect  149,  (1) (0)  153.  Go t o 147  one-to-one s e t t i n g group s e t t i n g  Would you show me what m e d i c a t i o n s each o f these m e d i c a t i o n s i s f o r ?  151.  Go t o 146  correct incorrect  148. (1)" (2) (3)  doctor nurse other (specify)  150 (1) (2) (3)  doctor nurse other (specify)  (1) I | c o r r e c t (0) tl i n c o r rect  152. (1) ' (2) (3)  doctor nurse i n b l d g . other (specify)  (1) i I c o r r e c t (0) i j j i n c o r rect  154 (1) (2) (3)  doctor nurse i n b l d g . other (specify)  - 152 155.  157.  159.  (1) (0)  correct incorrect  156 (1) (2) (3)  doctor nurse i n b l d g . other ( s p e c i f y )  (1) (0)  correct incorrect  158 (1) (2) (3)j  doctor nurse i n b l d g . other ( s p e c i f y )  Can you r e c a l l any o c c a s i o n i n the l a s t y e a r on which t a l k i n g to the nurse i n t h i s b u i l d i n g r e s u l t e d i n your: taking less  B  medication  Yes No  (2) (1)  160,  t a k i n g more m e d i c a t i o n  Yes No  (2) | I (1) •  161.  d i s c a r d i n g o l d medications  Yes  (2) T  No  (1)  Li  What i s your M e d i c a l S e r v i c e s P l a n Number?  Sometimes changes i n one's l i f e a f f e c t one's h e a l t h . The f i n a l q u e s t i o n s are about the changes t h a t have o c c u r r e d i n your l i f e d u r i n g the l a s t y e a r . Many o f the q u e s t i o n s may not apply to you. Would you answer Yes o r No to the f o l l o w i n g q u e s t i o n s . During  the l a s t year have you e x p e r i e n c e d :  Yes(l)  162.  A change i n your u s u a l s l e e p i n g p a t t e r n ( s l e e p i n g a l o t more o r a l o t l e s s , o r change i n p a r t o f day when you s l e e p ) ?  163.  A change i n your e a t i n g h a b i t s ( e i t h e r a l o t more or a l o t l e s s e a t i n g o r v e r y d i f f e r e n t meals, hours o r surroundings)?  164.  A b i g change i n your p e r s o n a l h a b i t s associations, etc.)?  ( d r e s s , manner,  No(0)  - 153 Yes 165.  A b i g change i n your u s u a l amount and/or recreation?  type o f  166.  A b i g change i n your u s u a l s o c i a l ( c l u b s , movies, v i s i t i n g f r i e n d s ,  167.  A b i g change i n your church a c t i v i t y ( e i t h e r a l o t more or a l o t l e s s o r a change i n denomination)?  168.  A b i g change i n f a m i l y get t o g e t h e r s ( p i c n i c s , holidays, etc.)?  169.  A l o t more o r a l o t l e s s f i n a n c i a l  170.  A l o t more o r a l o t l e s s arguments w i t h my husband or w i f e ( f o r example, over p e r s o n a l h a b i t s o r money)?  171.  A l o t more o r a l o t l e s s s e x u a l d i f f i c u l t i e s ?  172.  Have you l o s t your husband/wife by death d u r i n g the l a s t year?  173.  Have you m a r r i e d d u r i n g the l a s t year?  174.  Have you become d i v o r c e d d u r i n g the l a s t year?  175.  Have you s e p a r a t e d from your husband/wife the l a s t year?  176.  Have you e x p e r i e n c e d major i l l n e s s , i n j u r y o r s u b s t a n t i a l h e a l t h change (e.g. menopause, l a r g e weight g a i n or l o s s ) ?  177.  Have you l o s t a c l o s e f a m i l y member (other than your w i f e o r husband)?  178.  Have you l o s t a c l o s e f r i e n d by death?  179.  Has t h e r e been a major change i n the h e a l t h o r b e h a v i o u r o f a f a m i l y member?  180.  Have you changed  181.  Have you been found g u i l t y o f minor i n f r a c t i o n s of the law ( t r a f f i c t i c k e t s , e t c . ) ?  182.  Have you had a l o t more o r a l o t l e s s w i t h your spouse?  activities etc.)?  problems?  during  your p l a c e o f r e s i d e n c e ?  contact  (1)  No(0)  

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