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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 National Diploma i n Occupational Therapy P r e t o r i a College of Occupational Therapy, South A f r i c a , 1967 B.Sc. (Occupational Therapy) University of Western Ontario, 1975 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department of Adult Education) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1979 Q Lynette Elizabeth Pickard, 1979 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e 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 , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r 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 by t h e Head o f my D e p a r t m e n t o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f 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 , C a n a d a V6T 1W5 D E - 6 B P 75-51 1 E ABSTRACT The purpose of this study was to test the claim that senior c i t i z e n s who received preventive nursing services which were accessible and empha-sized health promotion (through health education, counselling and early detection of disease) would have s i g n i f i c a n t l y lower health costs and s i g n i -f i c a n t l y greater health status, knowledge and behaviour than those who received nursing services which were less accessible and placed less emphasis on health promotion. Residents of two apartment complexes for senior c i t i z e n s i n the West End of Vancouver (Nicholson and Sunset Towers) were pa r t i c i p a n t s i n this study. The main differences between the nursing programs i n these two complexes are the increased a c c e s s i b i l i t y of the nurses i n Nicholson Towers and the greater amount of health education and counselling which i s done there. A sample of i n d i v i d u a l s from each complex was randomly selected for interviewing. Data c o l l e c t e d from residents i n a structured interview measured health knowledge, health behaviour, health status and variables 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 health knowledge and health status. The Medical Services Plan of B.C. and Pharmacare supplied data on number and cost of health services and cost of medication for i n d i v i d u a l s i n the study over an eight month period. Data were computer analyzed using the University of B r i t i s h Columbia's version of SPSS. Results of the study indicated that average health costs 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 preventive nursing services - i i i -were a v a i l a b l e . Possible reasons for this unexpected f i n d i n g are that Home Care nursing services are c o s t l y , that increased a c c e s s i b i l i t y of Home Care nursing services leads to increased u t i l i z a t i o n and increased costs, that the a b i l i t y to bring about improvement i n health i s l i m i t e d by the aging process and that we may have u n r e a l i s t i c expectations of prevention programs. Residents of Nicholson Towers (who received preventive nursing services) were found to have s i g n i f i c a n t l y greater p h y s i c a l and s o c i a l function than those i n Sunset Towers (who did not receive preventive nursing s e r v i c e s ) . E l i g i b i l i t y f o r Long Term Care accounts for a large percentage of variance i n p hysical function and Nicholson Towers has a s i g n i f i c a n t l y (34% vs. 39%) smaller percentage of residents e l i g i b l e f or Long Term Care. This could account for the s i g n i f i c a n t l y greater physical function of residents i n this complex. The s o c i a l function scale evidenced low ( .43) alpha r e l i a -b i l i t y and low content and convergent v a l i d i t y . Findings regarding the s i g n i f i c a n t differences between the complexes i n terms of s o c i a l function are therefore tenuous. Findings regarding health education i n both complexes support the conclusion that there could be greater use of group methods and techniques of i n s t r u c t i o n . This i s l i k e l y to increase both the effectiveness and e f f i c i e n c y of health education. — i v -TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGMENTS i x Chapter I. INTRODUCTION 1 THE EROBLEM 1 Changing Emphases i n the Health Care System 1 Expenditures on Health of Older People 4 Alternate Forms of Health Care Delivery f o r Older People 6 Effectiveness and Cost-Benefit P o t e n t i a l of Various Health Strategies 9 Summary of Problem 12 PURPOSE OF THE STUDY 14 II . REVIEW OF LITERATURE 16 PREVENTIVE HEALTH CARE 16 HEALTH EDUCATION 20 Research and Theory From Related F i e l d s Germane to Health Education 21 Cultural studies 22 Sociological studies 22 Social-psychological studies 24 Multidisciplinary studies 25 Studies on diffusion of innovations 25 Adult education studies 26 Participation studies 27 Methods, Techniques and Devices i n Health Education . 28 Effectiveness and Cost-Benefit P o t e n t i a l of Health Education 29 EASE AND QUALITY OF CONTACT WITH HEALTH PROFESSIONALS .. 32 MEASUREMENT OF HEALTH 35 C l a s s i f i c a t i o n of Health Status Indices 36 Mo r t a l i t y Based Indices 36 Morbidity Based Indices 36 Un i f i e d Mortality/Morbidity Indices 38 SUMMARY OF LITERATURE REVIEW 40 IMPLICATIONS FOR RESEARCH 41 - V -Chapter I I I . METHODOLOGY 43 SETTING OF STUDY 43 PURPOSE OF STUDY 44 HYPOTHESES 44 DIFFERENCES BETWEEN NURSING SERVICES 46 A c c e s s i b i l i t y 47 Health Education 48 Counselling ,. 50 SAMPLING 50 DATA COLLECTION 52 Introduction 52 Data from Home Care Nurses 55 Data from Medical Services Plan and Pharmacare ... 56 Data from Residents 56 Health knowledge 57 Sources of health information 57 Health behaviours 58 Perceived benefit of nurses 58 Variables related to health knowledge and health status, 58 Health status 59 Development of the Health Knowledge Scale 59 Adaptation of the Physical Function Scale 61 Adaptation of the Emotional Function Scale 62 Adaptation of the Soc i a l Function Scale 64 RELATIONSHIPS INVESTIGATED IN THE STUDY 65 ANALYSIS OF DATA 65 IV. RESULTS 68 INTRODUCTION 68 SCALES DEVELOPED FOR THE STUDY 68 R e l i a b i l i t i e s o f Health Function and Health Knowledge Scales 69 V a l i d i t i e s of Health Function:;and. Health! Knowledge Scales 72 TESTS OF HYPOTHESES 75 DIFFERENCES BETWEEN APARTMENT COMPLEXES 78 Nursing Programs 78 Biographical Data 79 Benefits of Programs 79 Number of Health Related V i s i t s 80 Average Costs of Health Services 80 Sources of Health Information 81 Setting i n which Health Information i s Learned ... 83 Health Behaviour 83 PREDICTORS OF PHYSICAL, EMOTIONAL AND SOCIAL FUNCTION 84 PREDICTORS OF HEALTH COSTS AND NUMBERS OF HEALTH RELATED VISITS . 87 - v i -Chapter DIFFERENCES BETWEEN RESIDENTS RECEIVING DIFFERENT LEVELS OF NURSING SERVICE 94 V. SUMMARY, DISCUSSION OF RESULTS, RECOMMENDATIONS AND CONCLUSIONS 96 SUMMARY OF STUDY 96 IMPLICATIONS OF FINDINGS 103 Implications of Findings on Costs of Health Care ,. 103 Implications of Findings on Health Status 107 Implications of Findings on Health Education 109 Program Planning for Health Education i n Dense Residential Settings 110 RECOMMENDATIONS 117 CONCLUSION 119 REFERENCES 122 APPENDIX 129 - v i i -LIST OF TABLES 1. Canada-Wide Increase i n Numbers of Persons Aged 65 and Over 4 2. Canada-Wide Projections of Numbers of Persons Aged 65 and Over 5 3. Topics Examined i n L i t e r a t u r e Review 16 4. Comparison of Expected Costs and Benefits of Nursing Programs.. 51 5. Health Comparisons of Two R e s i d e n t i a l Groups 53 6. Variables Measured and Method of Measurement 54 7. Health Knowledge Questions 60 8. C o r r e l a t i o n C o e f f i c i e n t s for Individual Items with Health Scales 63 9. Correlations Among Health Function and Health Knowledge Scales. 74 10. Analysis of Variance Between Complexes and Between Levels of Nursing Service 77 11. Analysis of Variance of Sources of Health Information 82 12. Variance i n P h y s i c a l , Emotional and S o c i a l Function Accounted for by Biographical and Health Status Variables 85 13. Variance i n Health Care Costs Accounted for by Biographical and Health Status Variables 89 14. P r e d i c t i o n C o e f f i c i e n t s (Beta) for Health Costs for 16 Variables 90 15. P r e d i c t i o n C o e f f i c i e n t s (Beta) for Numbers of Health Related V i s i t s f o r 16 Variables 91 16. Most E f f e c t i v e Methods and Techniques for Acquiring and Applying Knowledge and S k i l l s 114 - v i i i -LIST OF FIGURES 1. P o l i c y Implications for Health Strategies C l a s s i f i e d According to Effectiveness and Cost-Benefit P o t e n t i a l 10 2. Relationships Investigated i n the Study 66 ACKNOWLEDGEMENTS Many, people ass i s t e d with this study and I wish to thank them a l l . P a r t i c i p a n t s i n this study were 124 residents of Nicholson and Sunset Towers i n the West End of Vancouver. Without t h e i r w illingness to be interviewed, the study would not have been poss i b l e . Dr. Larry Chambers, of MacMaster University, provided valuable information on the health status questionnaire used i n t h i s study. Yvonne L e e - R e i l l y and Ruth McDonald, Home Care nurses, gave me a great deal of assistance with p r a c t i c a l aspects of conducting the study. Anne-Marie L a f l e u r , of the B.C. Housing Management Commission, compiled s t a t i s t i c a l information on residents of the two complexes. Mrs. Joanne Parker, of the B.C. Medical Services Commission, compiled data on costs of health services; and Mr. Pat T i d b a l l , of Pharmacare, provided data on costs of medication. Dr. Annette Stark and Dr. Dale Rusnell, members of my thesis committee, assisted with the design of the study and c r i t i c a l l y reviewed the various drafts of the t h e s i s . Dr. John C o l l i n s , my research supervisor, guided the study with wisdom and f o r e s i g h t . His expertise i n research methodology, s t a t i s t i c s , computing and instrument design were invaluable i n the study. He responded to my need, at times, for support and encouragement; and h i s warmth, understanding, patience and humour helped make the task an enjoyable one. Marilyn Ernest assured me at the beginning of 1977 that I would be able to write a thesis; and my mother and father provided support and encouragement from a long distance away. - 1 -CHAPTER 1 INTRODUCTION THE PROBLEM The purpose of this study was to test the claim that senior citizens who received preventive nursing services which were accessible and emphasized health promotion (through health education, counselling and early detection of disease) would have- significantly lower health costs and significantly greater health status, knowledge and behaviour than those who received nursing services which were less accessible and placed less emphasis on health promotion. Changing Emphases i n the Health Care System Changes i n knowledge of the epidemiology of disease, i n the incidence of i n f e c t i o u s diseases, i n s o c i a l and environmental conditions, i n pu b l i c health p r a c t i c e s and i n public opinion have resulted i n changing emphases i n the health care system. Health education aimed at modifying behaviours presumed to be deleterious to health and thereby improving health, i s receiving increasing attention. Rising standards of l i v i n g and increased control over i n f e c t i o u s diseases since the beginning of t h i s century have resulted i n reductions i n f a t a l i t y from i n f e c t i o u s diseases throughout the world. In contrast, the prevalence of chronic disease has increased. Many modern health problems are s e l f - i n f l i c t e d or s o c i a l l y induced. During 1971, the f i v e major factors responsible f o r reduced l i f e expectancy of Canadians were motor v e h i c l e accidents, ischaemic heart disease, a l l other accidents, - 2 -res p i r a t o r y disease and lung cancer, and sui c i d e . These accounted f o r 213,000, 193,000, 179,000, 140,000 and 69,000 years r e s p e c t i v e l y that were l o s t from a l i f e expectance of seventy years (which for Canada's population of 23 m i l l i o n represents 1.6 b i l l i o n man years) (Lalonde, 1974). A vast amount of money i s spent t r e a t i n g diseases which should have been prevented. M i l l i o n s of d o l l a r s are spent annually t r e a t i n g people who have been i n motor vehi c l e accidents, who have ischaemic heart disease and lung cancer. A very small proportion of the health budget i s all o c a t e d to research and programs aimed at eliminating the causes of these d i s a b i l i t i e s and diseases. However, t h i s s i t u a t i o n i s changing; Federal and P r o v i n c i a l Governments have started a l l o c a t i n g greater resources toward such research and programs. The World Health Organization states that "Health i s a state of complete p h y s i c a l , mental and s o c i a l w ell being and not merely the absence of disease and i n f i r m i t y . " (World Health Organization, 1958, p.459). The World Health Organization intends factors which contribute to health to be viewed very broadly. When examined from the perspective of t h i s d e f i n i t i o n , health care systems seem inadequate and i n e f f e c t i v e . Medical services constitute only one of the many factors which contribute to health. At any one time medical and nursing services are required by only f i v e per cent of the population (McPhee, 1977). In sp i t e of these f a c t s , health care systems have emphasized h o s p i t a l s , acute care and treatment of i l l n e s s . Services have been te c h n o l o g i c a l l y oriented, o f f e r i n g s p e c i f i c solutions to s p e c i f i c problems. Costs of health care i n Canada have escalated i n recent years. Health costs now comprise a substantial proportion of the Gross National Product and of personal expenditures. In 1973 t o t a l health expenditures absorbed - 3 -6.9 per cent of the Gross National Product. Between 1970 and 1973, the average percentage increase i n t o t a l health expenditures was approximately 11 per cent (National Health-Expenditures i n Canada, 1975). By far the greatest (and most r a p i d l y r i s i n g ) costs are those associated with operating h o s p i t a l s . Expenditures on i n s t i t u t i o n a l care i n 1973 amounted to 4.3 b i l l i o n d o l l a r s (52 per cent of t o t a l health expenditures). Expenditures on General and A l l i e d Special h o s p i t a l s (acute care f a c i l i t i e s ) accounted for 3.2 b i l l i o n of t h i s 4.3 b i l l i o n d o l l a r s (Rombout, 1975). Costs re l a t e d to physicians' services constitute the second largest element i n costs (Robertson, 1973). The number of health problems which are s e l f - i n f l i c t e d or s o c i a l l y induced, increased prevalence of chronic diseases and escalation of health care costs, have led to government recognition that a less expensive approach to health care i s e s s e n t i a l . Federal and P r o v i n c i a l Governments have r e a l i z e d that there should be an emphasis on promoting and maintaining health rather than on treatment of disease and d i s a b i l i t y . Health education aimed at changing behaviours which are harmful to health and thereby improving health, i s consequently receiving increasing attention. Demographic changes, i n p a r t i c u l a r the increasing proportion of e l d e r l y people in the population, have led to new areas of focus for health education. S o c i a l changes have also had implications for health education. Increasing complexity and s o p h i s t i c a t i o n of medical p r a c t i c e during the f i r s t h a l f of t h i s century led to increased dependence on medical intervention and decreased emphasis on i n d i v i d u a l health care management and r e s p o n s i b i l i t y . In recent years, however, consumers have become f a r les s subservient. The greater awareness that many health problems are s e l f -i n f l i c t e d has led to the r e a l i z a t i o n that health i s l a r g e l y an i n d i v i d u a l r e s p o n s i b i l i t y . Individual r e s p o n s i b i l i t y f o r health implies learning h e a l t h f u l behaviours; and hence health education. An emphasis on promoting and maintaining health through health education has resulted from s o c i a l , environmental and demographic changes, and changes i n the epidemiology of disease, i n public health practices and i n public opinion. Health education i s in c r e a s i n g l y directed at healthy people; p a r t i c u l a r l y at populations whose socio-demographic and behavioural c h a r a c t e r i s t i c s suggest that they are at r i s k (Richards, 1975). Expenditures on Health of Older People A large proportion of health services i s consumed by older people. Many of these services are the most expensive of the government financed services, e.g. h o s p i t a l care. 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 rates are calculated by combining General Hospital morbidity data with population 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 rates are expressed i n the form of "patient days per person per year". In 1971, for the population as a whole, an average of 1.9 days per person was spent i n h o s p i t a l that year. For people aged 65 and over, the average was 8.3 days per person; f o r people aged 75 and over i t was 12.4 days per person. In 1971 35 per cent of a l l patient days i n General and A l l i e d S p e c i a l h o s p i t a l s was required by people aged 65 and over; yet this group comprised only 8.1 per cent of the population (Rombout, 1975). Since the 1961 census there has been a su b s t a n t i a l increase i n the number of people aged 65 and over i n the population. Only Ontario and Quebec have higher actual numbers of e l d e r l y people i n the popula-ti o n than B r i t i s h Columbia. In 1971 the proportions of e l d e r l y people were higher i n three other provinces than i n B r i t i s h Columbia; but according to S t a t i s t i c s Canada projections, the 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 the Canadian proportion i n 1986. TABLE 1 CANADA WIDE INCREASE IN THE NUMBERS OF PERSONS AGED 65 AND OVER Year Persons 65 Percentage of and over population 1961 1,086,400 7.7 1971 1,744,410 8.1 1976 2,002,345 8.7 SOURCES: Population Age Groups. 1971 Census of Canada. Population Age Groups. 1976 Census of Canada. The increase i n population and i n l i f e expectancy i s a t t r i b u t a b l e c h i e f l y to high b i r t h and immigration rates some years ago, to improved socio-economic conditions and to advances i n health care. The decline i n the b i r t h rate (which a f f e c t s younger age groups) p a r t l y accounts for the increasing proportion of e l d e r l y people. If low f e r t i l i t y rates continue, a decreasing proportion of working people w i l l be responsible for caring for and supporting these increasing numbers of older people (Weaver, et a l . , 1975). Although the rate of increase i n the e l d e r l y population i s expected to decline a f t e r 1986, t o t a l increases w i l l continue u n t i l the end of the century. In 1986, the number of people aged s i x t y - f i v e and over w i l l be almost f i f t y per cent higher than i n 1971. Increasing numbers of older people w i l l necessitate increased expenditure on the health of older people. If 1971 patterns of h o s p i t a l i z a t i o n and d i s t r i b u t i o n of disease continue, 42.5 per cent of a l l - 6 -patient 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 are of a chronic nature. Acute care f a c i l i t i e s are thus not the most e f f e c t i v e way of meeting health care needs of t h i s age group. Older people would also probably prefer to receive health services at home (Rombout, 1975). Increasing numbers of e l d e r l y people, t h e i r disproportionate consumption of the most expensive forms of health services and t h e i r need for health services r e l a t e d to chronic conditions, make i t imperative that unnecessary i n s t i t u t i o n a l care be eliminated and alternate forms of health care d e l i v e r y be explored. TABLE 2 CANADA WIDE PROJECTIONS OF NUMBERS OF PERSONS AGED 65 AND OVER Year Persons 65 Percentage of and over population 1986 2,600,000 9.8 1990 3,000,000 11.4 2001 3,300,000 11.6 SOURCE: Projections for Canada and the Provinces, 1976-2001 S t a t i s t i c s Canada, 1976. Alternate Forms of Health Care  Delivery f o r Older People Approximately 85 per cent of i n d i v i d u a l s over 65 are able to l i v e independently without s p e c i a l s o c i a l or health services; 10 per cent require some type of health services or s o c i a l services (such as Home Care, home-makers or Meals-on-Wheels) i n order to remain i n the community; 5 per cent are i n s t i t u t i o n a l i z e d (McDonell, 1972). Community health services for the e l d e r l y have provided an a l t e r n a t i v e to expensive h o s p i t a l care. These services have, however, been c h i e f l y c u s t o d i a l or curative - 7 -oriented. They have focused very l i t t l e on prevention. L i t t l e attention has been given to the promotion and maintenance of the health of those who are l i v i n g independently and who do not require s p e c i a l health services. However, promotion of health i n older people involves more than treatment of acute and chronic diseases. Preventing accidents, poor n u t r i t i o n , decreased mental and physical a c t i v i t y and feeli n g s of i s o l a t i o n are a l l important aspects of health promotion. Health education i s of cen t r a l importance i n the promotion and maintenance of health of older people. Older people may have acquired le s s health information from the media than young people, may be more hesitant to ask questions and may believe more "old wives t a l e s " (Weaver, et a l . , 1975). Education regarding n u t r i t i o n , medications, accidents and control of chronic diseases (such as diabetes and hypertension) i s p a r t i c u l a r l y important. Studies of medication use by the e l d e r l y have revealed that they lack knowledge i n c e r t a i n areas. Drug nomenclature and ra t i o n a l e f o r use, the nature of drug side e f f e c t s , how drugs should be administered i n order to be e f f e c t i v e , proper dosage regimens and hazards associated with borrowing and lending medications, are a l l areas whose importance i s not f u l l y recognized (Plant, 1977). A study of the n u t r i t i o n a l practices of the e l d e r l y found lack of knowledge to be the basic problem i n those with poor n u t r i t i o n a l practices (Cambridgeshire, Diabetic Dept., 1966). Diabetes, hypertension and coronary heart disease are prevalent among the aged. In a l l of these i l l n e s s e s , diet i s an important factor i n the promotion and maintenance of health. Accidents are a major cause of injury and death among e l d e r l y people. Home safety education programs have been shown to improve the - 8 -p r a c t i c e of home safety and to decrease the numbers of accidents (Steckler, 1973). Gradual d e t e r i o r a t i o n accompanies the aging process; 86 per cent of e l d e r l y people have chronic diseases which require augmented s e l f -maintenance s k i l l s . With diseases such as diabetes and coronary heart disease, knowledge of various aspects of the disease can reduce complica-tions and promote health. In order to manage diabetes e f f e c t i v e l y , the d i a b e t i c person requires good understanding of the disease, the technique of i n s u l i n i n j e c t i o n , urine t e s t i n g , prevention of ketoacidosis, prevention and management of hypoglycemia and diet (Stone, 1961; Beaser, 1956). H o s p i t a l i z a t i o n rates and acute complications have been found to decrease s i g n i f i c a n t l y (from more than 500 admissions for d i a b e t i c ketoacidosis per year to less than 100 per year over a seven year period) when education i s part of a comprehensive improvement i n the c l i n i c a l management of diabetes (Graber, et a l , 1977). Early detection of health problems i s another aspect of prevention which i s e s p e c i a l l y important i n older people. S e l f - r e p o r t i n g of i l l n e s s by the e l d e r l y to the doctor i s an unsatisfactory way of detecting i l l n e s s at an early stage. At a centre established for examining people who are over 55 and had no complaints, many people were found by health personnel to be i n need of services they were not re c e i v i n g . Older people tend not to report i l l n e s s e s to t h e i r doctors or not to report to doctors u n t i l a l a t e stage i n the i l l n e s s . The reason for t h i s may be denial of i l l n e s s (Anderson, 1976), or confusion of symptoms at t r i b u t e d to the aging process with symptoms of disease (Williamson, 1966). Williamson et a l . (1964) demonstrated that when an old person was c e r t a i n that a disease was present, he did inform the doctor; the doctor was, however, often not consulted for - 9 -conditions such as anaemia. Effectiveness and Cost-Benefit P o t e n t i a l of Various Health Strategies Preventive s t r a t e g i e s are aimed at reducing costs of health care and promoting health. Recent increased awareness of the importance of preventive strategies has resulted i n the development of some innovative programs which emphasize health education and early detection of disease. One 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 and maintaining health and reducing costs than those which are purely curative. However, health strategies vary i n terms of effectiveness and p o t e n t i a l payoff i n cost-benefit terms. Resources a v a i l a b l e for health programs are l i m i t e d . It i s thus e s s e n t i a l that resources be directed i n the f i r s t instance at problems and populations where impact and payoff i n cost-benefit terms w i l l be greatest. In Figure 1, P o l i c y Implications for Health Strategies C l a s s i f i e d According to Effectiveness and Cost-Benefit P o t e n t i a l , Green (1978) c l a s s i f i e s health strategies according to t h e i r known effectiveness and cost-benefit p o t e n t i a l . He places strategies i n t o one of four p o l i c y categories (according to recommended investment of resources). In quadrant I effectiveness and payoff are high. Strategies where e f f e c t i v e -ness i s high, but payoff low, are i n quadrant IV. In quadrant III effectiveness of methods and p o t e n t i a l payoff are high. Examples of strategies i n this quadrant include those aimed at smoking cessation, control of obesity and education of people with chronic conditions (where regimens are complex, p a i n f u l or long-term). Green (1978) stresses the importance of evaluative research on methods of health education, to improve effectiveness of strategies i n t h i s quadrant. - 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 surgery, mass screening or health education for rare or t r i v i a l conditions. Family planning, immunization prenatal care, c e r v i c a l and breast cancer screening, genetic screening, defensive d r i v e r t r a i n i n g , swimming i n s t r u c t i o n , s e l f - c a r e education for selected groups. P o l i c y : P o l i c y : Support for applied research to improve cost-effectiveness of methods, or f i n d new methods. Government support universal coverage programs to assure of Low IV. I. High I I I . Examples: II . Examples: POTENTIAL PAYOFF Lung surgery, organ transplants, i n s t r u c t i o n on heart r e s u s c i t a t i o n , long-term care. Smoking cessation, obesity c o n t r o l , seat b e l t usage, long-term regimens to control r i s k f a c t o r s , genetic counseling, school health education, preventive dental education, beofeedback. Po l i c y : P o l i c y : S h i f t research resources to quadrant II and program resources to quadrant I. Support for innovative demonstration programs and evaluative research on new methods. Low Source: Green (1978) - 11 -When viewed i n terms of the major factors responsible for reduced l i f e expectancy of Canadians, i t becomes clear that health problems i n quadrant II require much research emphasis. Seat b e l t usage i s important i n reducing d i s a b i l i t i e s and deaths from motor vehi c l e accidents. Smoking cessation, obesity control and exercise are important i n the treatment and prevention of ischaemic heart disease. Smoking cessation i s of p i v o t a l importance i n the prevention and treatment of r e s p i r a t o r y disease and lung cancer. Adherence to long-term regimens i s important i n the treatment of people with chronic conditions (such as ischaemic heart disease). Preventive strategies r e l a t e d to the major factors responsible for reduced l i f e expectancy require voluntary changes i n behaviour; and hence health education. However, the effectiveness of health education i n these areas i s low both because there are b a r r i e r s to behavioural change and because greater knowledge regarding how to bring about behavioural change i s required. Research regarding methods of health education i s e s s e n t i a l . Only i n t h i s way can effectiveness be improved. Numerous factors influence effectiveness of health education. Responses to health education programs may be affected by c u l t u r a l influences, s o c i a l pressures, socio-demographic fact 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 . It i s thus important to i d e n t i f y which factors might account f o r success or f a i l u r e of health education programs. Some innovative programs (which have developed i n response to increased emphasis on prevention) are characterized by increased a c c e s s i b i l i t y of health professionals. Increased a c c e s s i b i l i t y creates opportunities for health education, early detection of disease, counselling and reassurance. One would a n t i c i p a t e ease and q u a l i t y of contact with - 12 -health professionals to be important i n promotion of health and prevention of i l l n e s s . Empirical studies regarding a c c e s s i b i l i t y are scarce. Increased a c c e s s i b i l i t y of health professionals i s c o s t l y . It i s therefore e s s e n t i a l that programs with increased a c c e s s i b i l i t y be assessed i n cost-benefit terms. Summary of Problem S o c i a l , environmental and demographic changes, and changes i n the incidence of i n f e c t i o u s diseases, i n public health practices and public opinion have resulted i n an emphasis on promoting and maintaining health, and a new emphasis on and approach to health education. Costs of health care i n Canada have escalated enormously i n recent years. Many modern health problems are s e l f - i n f l i c t e d or s o c i a l l y induced. Much money spent tre a t i n g diseases which could have been prevented. Federal and P r o v i n c i a l Governments have started a l l o c a t i n g greater resources to research and programs aimed at reducing s e l f - i n f l i c t e d and s o c i a l l y induced diseases and promoting and maintaining health. Health education which i s aimed at changing behaviours presumed to be harmful to health, i s receiving increasing attention. Healthy people are the targets of many health education programs. Populations whose socio-demographic and behavioural c h a r a c t e r i s t i c s suggest that they are at r i s k are receiving s p e c i a l attention. The e l d e r l y constitute one such population. The increasing proportion of e l d e r l y people i n the population and th e i r disproportionate consumption of the most expensive forms of health service, make imperative the development of alternate forms of health care delivery for th i s age group. Eighty-six per cent of e l d e r l y people have chronic diseases. Health education regarding management of disease and - 13 -health behaviour reduces h o s p i t a l i z a t i o n rates and promotes health. Early detection of health problems i s an important f a c t o r i n the promotion of health of older people. Ease of access to emotional support i n times of c r i s i s and prevention of s o c i a l i s o l a t i o n , also promote health. Alternate forms of health care d e l i v e r y for older people should therefore be community based (rather 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 health through health education and early detection of disease. Preventive strategies are aimed at reducing costs of health care and promoting health. Some innovative programs which emphasize health education and early detection of disease have developed i n response to increased awareness of the importance of preventive s t r a t e g i e s . One would an 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 maintaining health and reducing costs than those which are purely curative i n o r i e n t a t i o n . Health strategies vary, however, i n terms of effectiveness and payoff i n cost-benefit terms. Health strategies can be c l a s s i f i e d according to t h e i r known e f f e c t i v e -ness and cost-benefit p o t e n t i a l . Strategies where effectiveness of methods i s low and p o t e n t i a l payoff high, include those aimed at smoking cessation, obesity control and education of people with chronic conditions (where regimens are complex, p a i n f u l or long-term). These are areas r e l a t e d to major factors responsible f o r reduced l i f e expectancy of Canadians. They require voluntary changes of behaviour. There i s a need for evaluative research which w i l l lead to increased effectiveness of these health education s t r a t e g i e s . - 14 -PURPOSE OF THE STUDY This study investigates two factors presumed to be important i n promoting health of adults (and e l d e r l y people i n p a r t i c u l a r ) . These factors are health education and ease and qu a l i t y of contact with health professionals. The study explores factors which influence the e f f e c t i v e -ness of health education. It i d e n t i f i e s the combination of factors most l i k e l y to be e f f e c t i v e i n bringing about improvements i n health behaviour and concomitant improvements i n health status. It 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 qu a l i t y of contact with health professionals which appear to be most important i n promotion of health of older c i t i z e n s . Community based health programs for older people vary i n the extent to which they emphasize health education and ease and q u a l i t y of contact with health professionals. One would a n t i c i p a t e programs which emphasize health education and ease and q u a l i t y of contact with health professionals to be e f f e c t i v e i n maintaining health and reducing health costs. S i m i l a r l y , one would expect programs which are c h i e f l y curative oriented, and do not emphasize the above f a c t o r s , to be less e f f e c t i v e i n maintaining health and reducing health costs. Health education, counselling and a c c e s s i b i l i t y of nurses are emphasized i n a preventive Home Care nursing program i n a p a r t i c u l a r housing complex for senior c i t i z e n s i n the West End of Vancouver. A l l other Home Care nursing programs for senior c i t i z e n s i n B r i t i s h Columbia are c h i e f l y treatment oriented. A study was designed to determine whether the preventive program was associated with greater health knowledge, health status and lower health costs than a s i m i l a r , but curative oriented program. The study i s s i g n i f i c a n t because i t contributes to knowledge of rela t i o n s h i p s between health education and a c c e s s i b i l i t y of health - 15 -professionals and the following: health knowledge, health behaviour, health status and health costs. Findings of the study have implications for the way i n which health education 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 , for the r e t r a i n i n g of health professionals, for the r e s t r u c t u r i n g of f a c i l i t i e s for the e l d e r l y and f o r the d i r e c t i o n of future government p o l i c y on preventive programs s i m i l a r to those investigated i n t h i s study. - 16 -CHAPTER II REVIEW OF LITERATURE This review of l i t e r a t u r e provides an overview of the area being investigated. It examines re l a t i o n s h i p s between health education, ease and q u a l i t y of contact with health professionals and health promotion. Table 3, page 17, summarizes the review of l i t e r a t u r e by t o p i c . Preventive health care i s defined and the health education aspect of preventive health care delineated. Factors to which the success or f a i l u r e of health education may be a t t r i b u t e d are i d e n t i f i e d . Research and theory which have relevance f o r health education are presented. Methods, techniques and devices which have been proven e f f e c t i v e i n health education are reviewed. Issues r e l a t e d to effectiveness and cost-benefit p o t e n t i a l of health education are explored. 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 contact with health professionals i n health promotion i s reviewed. The ultimate goal of preventive health care i s maintenance and improve-ment of health. Determining the effectiveness of a program i n maintaining or improving health, requires the i d e n t i f i c a t i o n of the various aspects of good health and indices for measuring each. The f i n a l section of the l i t e r a t u r e review focuses on measurement of health status. PREVENTIVE HEALTH CARE The s h i f t i n the causes of morbidity and mortality, the increased proportion of people l i v i n g longer l i v e s and increased costs of health - 17 -TABLE 3 TOPICS EXAMINED IN LITERATURE REVIEW Relationships Between Health Education, Ease  and Quality of Contact and Health Promotion Author Preventive Health Care Importance of preventive health care Operational d e f i n i t i o n of preventive medicine Health education component of preventive health care Health Education D e f i n i t i o n of health education C u l t u r a l factors c e n t r a l to health education S o c i o l o g i c a l factors c e n t r a l to health education Psychological factors 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 to health education Models which explain health 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 adult learner P a r t i c i p a t i o n and dropout from health education programs D. et a l , and L. M. Lalonde, M. Kulak, L.L. and Chisholm, D.M. Green, L.W. Green, L.W. Paul, B.D. Wellin, E. Adeniyi, J . Samora, J . Bice, I.W. White, K. McKinlay, J.B Anderson, J.G Rosenstock, I Koos, E.L. Wadsworth, M.E. Green, L.W. Keyes, L.L. Suchman, E.A. Straus, R. B a t i s t e l l a , R.M Bernstein, D.A. Keyes, L.L. Gibson, G. McKinlay, J.B. Richards, N.D. Mechanic, D. Zola, I.K. Baric, L. Suchman, E.A. Becker, M.H. Haefner, D.P. Richards, N.D Rogers, E.M. Green, L.W. Knowles, M.S. Richards, N.D Ward, A.W. et a l . - 18 -TABLE 3 - CONTINUED Relationships Between Health Education, Ease  and Quality of Contact and Health Promotion Author Methods, techniques and devices Effectiveness and cost-benefit p o t e n t i a l of health education East and Quality of Contact with Health Professionals Measurement of Health M o r t a l i t y based indices Morbidity based indices Un i f i e d mortality/morbidity indices Indices measuring s o c i a l , emotional and physi c a l health separately Verner, C. and Dickinson, G. Young, M.A.C. Knowles, M.S. Lewin, K. Kaplan, A. McKeachie, W.J. Richards, 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. Mullen, 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. et a l . Robertson, H.R. Palmore, E. Moriyama, I.M. Balinsky, W. and Berger, R. G a r f i e l d , S.R. Brodman, K.E.A. et a l . Martin, J . J . et a l . Kisch, A.E. et a l . Hennes, J.D. Abramson, J.H. Friedsam, H. and Martin, H. Heyman, D. and J e f f e r s , F. Maddox, G. Suchman, E.A. Tissue, T. Rosow, I. and Breslan, N. Balinsky, W. and Berger, R. M i l l e r , J.E. Chiang, C L . Lawton, M.P. et a l . Davies, D.F. Sackett, D.L. and Chambers, L.W. Chambers, L.W. and Segovia, J . - 19 -care, are some of the factors which have given r i s e to the increased emphasis on prevention as a strategy of health care. The Lalonde Report (Lalonde, 1974) proposed the Health F i e l d Concept as a conceptual framework for health care. The Health F i e l d Concept i s comprised of four broad elements a f f e c t i n g an i n d i v i d u a l ' s health: l i f e s t y l e , environment, health care organization and human biology. E f f o r t s i n the categories of environment and l i f e s t y l e have the greatest p o t e n t i a l f o r reducing mortality and morbidity and t h e i r r e l a t e d monetary and s o c i a l costs. Preventive medicine i s concerned with l i f e s t y l e and environmental fac t o r s . An operational d e f i n i t i o n of preventive medicine envisions disease as having four stages: 1. Pre-disease stage: emphasis on r i s k factors which make a person more or les s susceptible to developing 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 to reduce r i s k factors and prevent the development of disease are c a l l e d primary prevention. 2. Pre-symptomatic stage: although the person has no symptoms, the disease process has started and can be detected by s p e c i a l procedures. Early secondary prevention involves a c t i v i t i e s whose goal i s early detection of disease and d i s a b i l i t y , followed by intervention to cure the disease or prevent progression to a more serious condition. 3. Symptomatic stage: symptoms of i l l n e s s are evident. E f f o r t s directed at curing or l i m i t i n g the disease are termed l a t e secondary prevention. 4. Chronic and R e h a b i l i t a t i v e stage: not possible to "cure" the disease. E f f o r t s aimed at reducing 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 are termed t e r t i a r y prevention (Kulak & Chisholm, 1974). U n t i l very recently our health care system emphasized l a t e secondary and t e r t i a r y prevention. The Lalonde report, however, proposes health promotion as one of f i v e s trategies for future action. The health promotion strategy focuses l a r g e l y on primary and early secondary prevention (Lalonde, 1974). New objectives of the Mi n i s t r y of Health i n B r i t i s h Columbia include the promotion of programs of a preventive nature and the implementation of - 20 -public education programs (Ministry of Health, 1979). Preventive health care encompasses a vast range of administrative, l e g a l , environmental and educational s t r a t e g i e s . What distinguishes educational strategies from the other three s t r a t e g i e s , i s that educational st r a t e g i e s are designed to encourage voluntary changes i n behaviour. Some preventive measures demand no i n d i v i d u a l action, but many require behavioural change and co-operation on the part of i n d i v i d u a l s . It i s possible to l e g i s l a t e some of the prevention measures which require behavioural change (e.g., seat b e l t usage). Most measures depend, however, on voluntary change. Such behavioural change presupposes adequate health education. The health education aspect of preventive health programs consists of three components. These components are (1) communications aimed at influe n c i n g health knowledge, attitudes and behaviour; (2) community organization a c t i v i t i e s , aimed at inducing adjustment of resources to increase 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 of health services to those who need them; (3) s t a f f development a c t i v i t i e s (such as i n - s e r v i c e and continuing education) aimed at influ e n c i n g the way i n which providers of health care approach patients, c l i e n t s and the public (Green, 1976). This study i s l i m i t e d to examination of that aspect of health education concerned with communications to the p u b l i c , patients and fa m i l i e s . L i t e r a t u r e r e l a t e d to 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 of those aspects of preventive health care which demand action on the part of the i n d i v i d u a l . Health education i s defined as "any combination of learning opportunities designed to - 21 -f a c i l i t a t e voluntary adaptations of behaviour which w i l l improve or maintain health" (Green, 1978, p. 28). At the program l e v e l , the chief concern i s to design learning opportunities i n such a way as to f a c i l i t a t e the maintenance of health most e f f i c i e n t l y . At the p o l i c y l e v e l , the main issue i s s e l e c t i o n of areas of health behaviour, i n which behavioural change has the greatest p o t e n t i a l payoff i n cost-benefit terms, both for i n d i v i d u a l s and society (Green, 1978). The f i r s t part of t h i s section i s concerned with methods and design of health education. The purpose i s not to evaluate i n d i v i d u a l methods, but to i d e n t i f y factors to which success or f a i l u r e of health education may be a t t r i b u t e d . Research and theory which has relevance for health education i s presented. Methods, techniques and devices which have been proven e f f e c t i v e i n health education are reviewed. The l a s t part of t h i s section focuses on effectiveness and cost-benefit p o t e n t i a l of health education st r a t e g i e s . Research and Theory from Related F i e l d s  Germane to Health Education The major goal of health education i s to modify behaviour presumed deleterious to health and thereby improve health. Human behaviour i s , however, extremely complex and the possession of health knowledge i n no way guarantees changes i n behaviour. Health education involves f a r more than merely imparting information. C u l t u r a l , s o c i a l and psychological factors which may f a c i l i t a t e or impede behavioural change, must be taken into account when planning health education programs. Studies which have relevance for health education programs are reviewed below. - 22 -Cultural studies Health education does not exist i n a vacuum. Pressures exerted by groups to which an i n d i v i d u a l belongs are very powerful determinants of behaviour. These pressures must be considered when t r y i n g to bring about change. Many programs f a i l to recognize the r e l a t i o n s h i p between values, b e l i e f s , behaviours 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 necessity for successful programs to consider these factors (Paul, 1955). Wellin (1958), for example, documents the f a i l u r e of e f f o r t s to convince Peruvian housewives of the necessity of b o i l i n g drinking water. In two years, a resident hygiene worker persuaded only eleven housewives to b o i l water. Water b o i l i n g was, however, not an i s o l a t e d action. It was associated with being s i c k . The small response could thus not be at t r i b u t e d to apathy, ignorance or stubbornness. Adeniyi (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 control a cholera epidemic i n Nigeria, because t r a d i t i o n a l b e l i e f s were not considered. Some people believed the epidemic to be the r e s u l t of anger of gods; they made s a c r i f i c e s to appease the gods. A number of people believed cholera should be treated l i k e other diseases with symptoms of diarrhea; they u t i l i z e d native 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 also been shown to a f f e c t an i n d i v i d u a l ' s decision to seek health care and adopt health promoting behaviours. There i s much evidence on the r e l a t i o n s h i p between socio-economic and socio-demographic factors and knowledge of disease (Samora, 1961), use of health services (Bice, 1970; McKinlay, 1972; Anderson, 1973), acceptance of preventive health services (Rosenstock, 1969; - 2 3 -Rosenstock, 1969a) and use of self-medications (Wadsworth, et a l . , 1971). Many studies have found d i f f e r i n g perceptions of symptoms and use of services. Koos (1954) found that persons of lower socio-economic status reported themselves i l l less often, were les s l i k e l y to seek care, had more actual symptoms but reported less i l l n e s s than people of higher socio-economic status. A study by Green (1970a) found socio-economic status to be the most important predictor of adoption of preventive health behaviour. Models of health related behaviours have been formulated to explain health actions. Mechanic (1968) l i s t s the main factors which a f f e c t response to i l l n e s s as symptoms, salience, perceived seriousness of symptoms, interference with a c t i v i t i e s , tolerance threshold, a v a i l a b l e information and c u l t u r a l assumptions regarding symptoms, denial tendencies, competing needs, a c c e s s i b i l i t y of treatment and economic and psychological costs involved. Zola (1966) developed the notion 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 of importance i n a f f e c t i n g an i n d i v i d u a l ' s decision to seek health care. These non-physiological triggers are the following: occurrence of interpersonal c r i s i s focusing attention on symptoms; perceived interference with s o c i a l a c t i v i t i e s ; s o c i a l pressures from others; perceived interference with work; temporalizing of symptoms. Baric (1969) describes a t - r i s k behaviour i n terms of the following phases: a c q u i s i t i o n of information about a health threat; v a l i d a t i o n of th i s information; exploration of the s o c i a l environment regarding the c r e d i b i l i t y of this information, and the preventive action recommended; confirmation from health professionals regarding the directness of the threat; acceptance or r e j e c t i o n of membership of a hig h - r i s k group. This - 24 -formulation has implications for health education of populations at high r i s k . Points of intervention i n t h i s model need exploration (Richards, 1975). Suchman (1969) notes that health educators have been unable to explain the lack of response of people i n low socio-economic groups to preventive health campaigns. He suggests that the structure of s o c i a l groups to which the person belongs and the health orientations the person adheres to, be considered. The form of s o c i a l organization to which a person belongs has been found to be s i g n i f i c a n t l y r e l a t e d to medical o r i e n t a t i o n . "Cosmopoli-tan" types of groups are more l i k e l y to have a " s c i e n t i f i c " health o r i e n t a t i o n and "parochial" groups a "popular" health o r i e n t a t i o n . Implications for health education are that "parochial-popular" groups would respond well to programs which u t i l i z e group approval; "cosmopolitan-s c i e n t i f i c " groups would l i k e l y respond best to programs which are r a t i o n a l . Social-psychological studies Individual needs, b e l i e f s and attitudes may also influence behavioural change. Attitude change s t r a t e g i e s , based on the assumption of a causal r e l a t i o n s h i p between attitudes and behaviour, have severe l i m i t a t i o n s i n bringing about behavioural change (Suchman, 1964; Straus, 1961; B a t i s t e l l a , 1968; Bernstein, 1969). The r e l a t i o n s h i p between attitudes and behaviour i s complex. People may acquire new behaviour without f i r s t having changed t h e i r a t t i t u d e s . They may also change t h e i r attitudes and not t h e i r behaviour. Attitude change strategies have tended to i s o l a t e an a t t i t u d e from other a t t i t u d e s , to i s o l a t e attitudes from underlying value and personality systems and from s o c i o l o g i c a l and s i t u a t i o n v a r i a b l e s . Social norms, s o c i a l distance and s o c i a l perceptions are extremely important intervening variables between knowledge, attitudes and health - 25 -behaviour (Keyes, 1972). The Health B e l i e f Model i s based on a number of research studies of responses to preventive programs. It attempts to explain 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. This model maintains that an i n d i v i d u a l w i l l engage i n preventive health behaviour i f the following conditions e x i s t : he perceives himself susceptible to the i l l n e s s , he believes that contracting i l l n e s s w i l l have serious repercussions for him, he estimates that a p a r t i c u l a r course of action w i l l be b e n e f i c i a l ; he believes that there are no b a r r i e r s ( f i n a n c i a l , psychological or physical) involved i n the action and he experiences a cue to t r i g g e r the appropriate action. I n i t i a l tests of the model provide support for the model (Becker, Haefner, et a l . , 1977). Multidisciplinary studies These c u l t u r a l influences, s o c i a l forces, socio-demographic factors and i n d i v i d u a l needs and perceptions have a l l been used to explain d i f f e r i n g responses to educational programs designed to promote health. There have been various attempts to co-ordinate these approaches (Gibson, 1972; McKinlay, 1972). Consideration of a l l these components and synthesis of data from studies i n d i f f e r e n t f i e l d s should allow better planning of health education programs (Richards, 1975). Young's (.1967; 1967a; 1968; 1968a) review of research and studies r e l a t e d to health education supports t h i s view. Studies on d i f f u s i o n of innovations The work of Rogers (.1962) regarding adoption of innovations, i . e . , the sequence of stages i n the adoption of new practices (awareness, i n t e r e s t , evaluation, t r i a l and adoption); and the categorization of - 26 -adopters as innovators, early adopters, early majority, l a t e majority and laggards, has been u t i l i z e d i n health education (Green, 1975). Concern with maximizing effectiveness of health services has resulted i n increased attention to innovation and factors which influence acceptance and use of new programs. The effectiveness of a program can be judged by the r a p i d i t y with which people accept and use the ideas. Effectiveness may well be influenced by the way i n which health information i s communicated through formal and informal s o c i a l systems (Richards, 1975). The rate at which people adopt a new prac t i c e i s i n i t i a l l y slow. The rate then increases u n t i l the majority of 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 rate of change i s slow, as an attempt i s made to reach more re 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 of the population. Mass media are most e f f e c t i v e at arousing i n t e r e s t , and thus at the awareness stage of the adoption process (Rogers, 1962; Green, 1975). Interpersonal techniques are more e f f e c t i v e at l a t e r stages and at e f f e c t i n g behavioural changes (Green, 1978). Adult education studies Adult health education has u t i l i z e d the research and theory of adult education. In adult education, the teaching-learning process i s seen as a co-operative e f f o r t between teacher and learner; each contributes to learning. The adult learner i s seen as a person who i s s e l f directed, has a wealth of experience to contribute to the learning s i t u a t i o n and whose approach to learning i s a problem oriented one. These c h a r a c t e r i s t i c s have implications f o r the st r u c t u r i n g of the learning s i t u a t i o n (Knowles, 1970). Teaching techniques vary i n terms of appropriateness f o r d i f f e r e n t kinds of learning outcomes; and for learners with, d i f f e r e n t t r a i t s and aptitudes. The lecture and the group discussion are, for example, equally - 27 -e f f e c t i v e at transmitting information; but the group discussion i s superior to the lecture i n changing behaviour (Verner and Dickinson, 1967). Numerous health education studies have found group discussion a powerful technique i n changing behaviours such as increasing v i s i t s to physicians and to c l i n i c s for screening; improving preventive health p r a c t i c e s ; and improving compliance with medical regimens (Young, 1967). Adults 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 choice of i n s t r u c t i o n a l technique. They have a great deal of experience; techniques which allow one to tap t h i s experience should be used. Adults have f i x e d habits and thought patterns which sometimes i n t e r f e r e with learning and behavioural change. Group discussions are more e f f e c t i v e i n i d e n t i f y i n g and a l t e r i n g these attitudes than are techniques such as le c t u r e s , where there i s l i t t l e learner p a r t i c i p a t i o n (Knowles, 1970; Lewin, 1953; Kaplan, 1970). The more ego involvement there i s , the greater w i l l be the learning that takes place. The l i k e l i h o o d of ego-involvement i s greater when the learner i s a c t i v e l y involved (e.g., i n a group discussion), than when he i s a passive r e c i p i e n t of information. Active learning i s more e f f i c i e n t than passive learning (Knowles, 1970; McKeachie, 1969). Techniques which allow and promote learner p a r t i c i p a t i o n are more appropriate f o r use with adult learners than techniques which do not. P a r t i c i p a t i o n studies Studies on p a r t i c i p a t i o n and drop out from educational programs have contributed to greater understanding of va r i a b l e s which influence p a r t i c i p a t i o n . Studies of non-participants 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 preventive programs have i d e n t i f i e d weaknesses of educational approaches and the need f or d i f f e r e n t educational strategies - 28 -(Richards, 1975). A number of studies confirm the value of t h i s approach. For example, Ward's (1971) study on reasons for drop out at a family planning c l i n i c found that behavioural change cannot be effected by one v i s i t or one exposure to a program; a sustained, repeat v i s i t program i s important. Methods, Techniques and Devices i n Health Education Numerous methods, techniques and devices have been u t i l i z e d to encourage people to adopt healthy behaviours. Individual methods (e.g., programmed i n s t r u c t i o n ) and group methods (e.g., the c l a s s , discussion groups, meetings and forums) have been used. Techniques such as l e c t u r e s , speeches, debates, panels, group discussions, buzz groups, seminars and r o l e playing have been used. Devices u t i l i z e d include wallcharts, posters, l e a f l e t s , e x h i b i t s , models, radio, t e l e v i s i o n , f i l m s , s l i d e s and tape recorders (Richards, 1975). The l i t e r a t u r e abounds with reports regarding the e f f e c t s of various techniques. A f i n d i n g which co n s i s t e n t l y emerges from comparison of health education programs with p o s i t i v e versus negative r e s u l t s , i s that "the d u r a b i l i t y of cognitive and behavioural changes are proportional to the degree of active rather than passive p a r t i c i p a t i o n of the learner" (Green, 1978, p. 34). Another consistent f i n d i n g i s that the l i k e l i h o o d of a health education program obtaining 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 to the number of d i f f e r e n t educational techniques used (Green, 1978). There i s seldom behavioural change a f t e r one contact; multiple contacts are needed (Richards, 1975). Even when the behavioural objective i s the same, d i f f e r e n t techniques may be required f o r d i f f e r e n t popultation groups (Richards, 1975). Programs require 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 that i n d i v i d u a l s p e r s i s t with a p a r t i c u l a r health behaviour over long periods of time, then the most e f f e c t i v e health education methods are those that provide support i n the c l i n i c or home. This has been found i n studies on compliance with medical regimens (Becker and Green, 1975), and persistence with diet and smoking cessation (Green, 1970). If the health behaviour should be repeated r e g u l a r l y , then health education methods which give 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 sporadic or one-shot methods. Intensive health education methods, such as i n d i v i d u a l counselling and home v i s i t s , are most e f f e c t i v e when behavioural goals are complex (Green, 1978). Some health education programs have emphasized information g i v i n g , some at t i t u d e change and others behavioural change. The major objective of health education i s to bring about behavioural change. However, the possession of knowledge i n no way guarantees behavioural change; and the r e l a t i o n s h i p between knowledge and attitudes i s unclear. Health education programs should therefore focus on the target behaviours and t h e i r determinants. Numerous c u l t u r a l forces, s o c i a l factors and i n d i v i d u a l needs i n t e r a c t and influence behaviour. E f f e c t i v e i n s t r u c t i o n i s a r e s u l t of an i n t e r a c t i o n between technique and learners. The issue i s thus not whether one technique i s better than another but under what conditions and with what populations are c e r t a i n techniques better than other? Selection of technique should be based on type of learning objective and p r i o r assessment of the a t t i t u d e s , values and b e l i e f s of the target population. Effectiveness and Cost-Benefit P o t e n t i a l of Health Education Health education e f f o r t s have varied greatly 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 , quantity, e f f i c i e n c y and effectiveness. The - 30 -section below addresses issues of effectiveness and payoff i n cost-benefit terms. De f i c i e n c i e s i n the evaluation of health education have hindered assessment of the effectiveness of health education. Evaluation of health education, though accepted i n p r i n c i p l e , has been r e l a t i v e l y neglected i n pr a c t i c e (Green, 1977). P r i o r to the 1950's, evaluation consisted c h i e f l y of a description of the program and the degree of e f f o r t expended. By the mid-1950's, evaluation by objectives was being u t i l i z e d ; programs were evaluated i n terms of the c r i t e r i o n of effectiveness. Concern regarding improving the e f f i c i e n c y of health programs has grown. It has resulted i n increased emphasis on e f f i c i e n c y i n terms of cost-benefit analysis and q u a l i t y control (Cochran, 1964). Evaluations of health education programs have exhibited several d e f i c i e n c i e s . Most evaluations have used p r i m i t i v e pre-experimental and quasi-experimental designs (Green, 1977). The complexity of health behaviour, however, demands a f a c t o r i a l design (Green, 1978). Evaluations of health education programs have made i n s u f f i c i e n t use of s t a t i s t i c a l analysis and have documented procedures i n i n s u f f i c i e n t d e t a i l . There has also been i n s u f f i c i e n t attention to the cumulative b u i l d i n g of theory and research (Green, 1977). Several factors pose problems for the evaluation of health education programs. An approach that works for some i n d i v i d u a l s does not work for a l l . Health education has some e f f e c t s which are immediate and temporary, and others which develop more slowly but l a s t f o r a longer period. This poses problems for the timing of measurement of outcomes (Green, 1977). Limitations of time or resources have also precluded measurement of longer range outcomes. Health education i s often part of a more comprehensive - 31 -program e f f o r t making i t d i f f i c u l t to i s o l a t e the e f f e c t s of health education (Green, 1978). A review of research related to health education p r a c t i c e covering the l i t e r a t u r e from 1961 - 1966 was published by Young (1967; 1967a 1968; 1968a). Numerous educational methods, techniques and objectives are represented i n these studies. Inadequate designs were u t i l i z e d i n many of the studies. Many included no evaluation. There was no attempt to analyze these studies according to t h e i r effectiveness. There has been no review of the research r e l a t e d to health education since that time. It i s therefore not possible to assess the current effectiveness of health education on the basis of published evaluative research. Green (1976a; 1978) reviewed health education l i t e r a t u r e and obtained evidence of consistent r e l a t i o n s h i p s between p a r t i c u l a r health education stragegies and improvements i n s p e c i f i c health behaviours or indices of health. By extrapolating from these consistent r e l a t i o n s h i p s , he made cost-benefit estimates on the trade o f f between investments i n health education and comparative investments i n t e r t i a r y health care. He c l a s s i f i e d medical and health education strategies according to t h e i r known effectiveness and p o t e n t i a l payoff i n cost-benefit terms (Figure 1, page 10). Resources a v a i l a b l e for health education are l i m i t e d . It i s thus e s s e n t i a l that, at the p o l i c y l e v e l , educational resources be directed towards those problems and populations where improvements i n the nation's health w i l l be greatest. The p o l i c y analyst i s faced with two issues: r e l a t i v e need for improvement i n each problem (potential payoff); and r e l a t i v e p o t e n t i a l for improvement (ef f e c t i v e n e s s ) . The p r i o r i t y of a p a r t i c u a l a r health problem i n r e l a t i o n to other health problems varies for - 3 2 -d i f f e r e n t populations. It i s therefore necessary to u t i l i z e a method for assigning d i f f e r e n t p r i o r i t i e s to the same health problems i n various populations (Green, 1978). The Q index i s such a method. This index was developed f o r the U.S. Indian Health Service ( M i l l e r , 1970). It combines the dimensions of p o t e n t i a l payoff and effectiveness i n one index. On the basis of assessments of the most productive areas f o r health education i n the U.S., Green (1978) made recommendations f o r p a r t i c u l a r populations and behavioural goals. He recommends that health education resources be directed "to maternity care, preventive c h i l d care, adult preventive care and chronic i l l n e s s care, i n that order of p r i o r i t y " (Green, 1978, p. 58). There are 16 other recommendations regarding resource a l l o c a t i o n . For example, "During pregnancy, i n s t r u c t i o n should be offered on n u t r i t i o n , family planning, s e l f - c a r e , d e l i v e r y , and parenthood: up to s i x hours of group i n s t r u c t i o n each, f o r mother and father". (Green, 1978, p. 58). Given the current state of health education, these p r i o r i t i e s should render the maximum cost-benefit advantage to society. There i s a need for research and evaluation i n areas which are les s e f f e c t i v e but have high payoff (e.g. diet therapy, obesity c o n t r o l , long term management of hypertension and diabetes) (Green, 1978). EASE AND QUALITY OF CONTACT WITH HEALTH PROFESSIONALS One would an t i c i p a t e access to sympathetic care to have preventive, supportive value; that people w i l l do well i f they are sure they can get help and advice when they need i t . It i s reasonable to expect the q u a l i t y of t h i s contact ( i . e . concern with emotional, s o c i a l and phys i c a l health) to be important i n promoting health. It i s d i f f i c u l t to support these - 33 -propositions with 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 of medical services before and af t e r the introduction of medical a i d ; or u t i l i z a t i o n patterns of people with and without medical a i d . Empirical studies on the r o l e of support and reassurance i n health promotion are scarce. Studies on compliance with medical regimens do, however, indicate the importance of the doctor-patient r e l a t i o n s h i p (Becker and Green, 1975; Mullen, 1973). There i s considerable evidence that numerous stresses associated with old age ( i . e . loss of income, i s o l a t i o n , loss of s o c i a l r o l e , bereavement, loss of cognitive functioning) r e s u l t i n higher rates of severe mental i l l n e s s among e l d e r l y people. Measures which reduce stress (such as access to sympathetic care, and prevention of i s o l a t i o n ) can be expected to prevent or reduce mental i l l n e s s (Palmore, 1973). Work with older c i t i z e n s at the Rutherglen Consultative Health Centre i n Scotland also supports the propositions regarding ease and qu a l i t y of contact. The primary causes of emotional disturbances (anxiety and depression) i n e l d e r l y people are physical disease and an adverse environment (which includes l i v i n g alone (Anderson, 1976)). E l d e r l y people have more phys i c a l diseases and chronic conditions than younger people (Palmore, 1973). Many of them l i v e alone. Physical i l l health i s a source of anxiety and depression, and may cause emotional disturbances. There i s an association between d i s a b i l i t y and i l l n e s s and higher rates of mental i l l n e s s ( B e l l i n and Hart, 1958; Kay et a l . , 1964). A study with older people found emotional disturbances i n 13 per cent of healthy men and 18 per cent of healthy women; but i n 31 per cent of men and 38 per cent of women who had some physi c a l disease. Experience at the Rutherglen Consul-t a t i v e Health Centre indicates that the most important method of preventing - 34 -mental i l l n e s s i n older people, i s reassurance regarding physical health; reassurance based on a thorough physical examination (Anderson, 1976). S o c i a l i s o l a t i o n increases 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. Two-thirds of people over 65 who are i n mental hospit a l s are s i n g l e , widowed or divorced. Work at the Rutherglen Consultative Health Centre indicates that home v i s i t i n g by trained personnel improves mental health and prevents l o n e l i n e s s . Providing counselling and support to those who need i t , promotes s o c i a l and emotional health (Anderson, 1976). Results of introduction of preventive health services i n industry, provide further support for the propositions regarding 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 increasing percentage of t h e i r time on preventive services (health education, counselling and assessment) between 1947 and 1974. In 1947, treatment of i l l n e s s and i n j u r i e s accounted for 70 per cent of employee v i s i t s ; and i n 1974, for 40 per cent of v i s i t s . In 1974 there were more v i s i t s f o r health promotion than f o r treatment. Coincident with these changes, were the following: (1) the percentage of employees away from work because of i l l n e s s each day dropped s i g n i f i c a n t l y from 3.2 per cent i n 1948, to 2.2 per cent i n 1970 and (2) sickness d i s a b i l i t y payments for each unit of p a y r o l l , dropped from $17.50 i n 1945 to $7.50 i n 1970. A causal link.between increased attention to health education, counselling and assessment and the above r e s u l t s cannot be established. The r e s u l t s do suggest, however, that ease and q u a l i t y of contact between a person and the providers of health services are important factors i n the promotion of health (Robertson, 1973). - 35 -MEASUREMENT OF HEALTH Preventive health care i s aimed at maintenance and improvement of health. In order to determine the effectiveness of a program i n maintaining or improving health, one needs to i d e n t i f y the various components good health and indices for measuring these. The development of a health index requires d e f i n i t i o n s of health that can be translated into operational terms. Many d e f i n i t i o n s of health, including that of the World Health Organization, are unsatisfactory for measurement purposes because they do not specify c r i t e r i a f o r determining where health begins or ends (Sheldon, 1968). One problem i n op e r a t i o n a l i z i n g health i s that health i s multi-dimensional; another, i s that of measuring the value judgements which draw the l i n e between health and i l l n e s s . Development of a health index involves i d e n t i f y i n g the dimensions or. components of health and assigning weights to each component. These components are considered to be " i n d i c a t o r s " . An index i s a derived measure which combines several i n d i c a t o r s (Lerner, 1973). According to Hennes, although numerous health indices have been developed "there remains today no widespread agreement on what to measure or how to measure, to assess, health i n the community" (1973, p. 1268). Other obstacles to the development of instruments to measure health are s t a t i s t i c a l r e l i a b i l i t y , 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 (Balinsky and Berger, 1975). Most instruments, f o r example, have only s u p e r f i c i a l v a l i d a t i o n (Hennes, 1972). An index of health should possess c e r t a i n c h a r a c t e r i s t s : It should be meaningful and understandable, 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. It should be composed of c l e a r l y defined components, consist of independent parts (I.e., independent contributions to t o t a l variance) and i t should use data that i s available or obtainable (Moriyama, 1968, p. 593). - 36 -C l a s s i f i c a t i o n of Health Status Indices Health status indices can be c l a s s i f i e d as: mortality based, morbidity based or u n i f i e d mortality/morbidity based indices (Balinsky and Berger, 1975). Mo r t a l i t y Based Indices M o r t a l i t y based indices are the t r a d i t i o n a l method of measuring health. They u t i l i z e data on age/sex adjusted l i f e expectancies. Underlying t h i s method of measuring health i s the assumption that there i s a c l e a r r e l a t i o n -ship between the mortality index and health. Rising standards of l i v i n g and increased control over i n f e c t i o u s diseases resulted i n reduction i n f a t a l i t y from disease. The prevalence of chronic diseases, however, increased. M o r t a l i t y rates consequently became i n s e n s i t i v e to c e r t a i n parts of the health spectrum. Attention was then directed to morbidity based data (Moriyama, 1968). Morbidity Based Indices "A morbidity index i s a measure of the prevalence of i l l n e s s or degree of wellness i n a given population" (Balinsky and Berger, 1975, p. 286). Morbidity indices are derived from a number of variables which are less e a s i l y defined and measured than those comprising the mortality index. A morbidity based index can, p o t e n t i a l l y , be a more s e n s i t i v e measurement of health than a mortality index; but attempts at i s o l a t i n g and defining variables have encountered problems of ambiguity (Balinsky and Berger, 1975). Variables such as d i s a b i l i t y , dysfunction, a c t i v i t y and discomfort have been used i n morbidity i n d i c e s . These variables can be grouped into three categories: c l i n i c a l evidence, such as symptoms and r e s u l t s of laboratory t e s t s ; subjective evidence, such as how the person f e e l s ; and - 37 -behavioural evidence, such as absenteeism (Balinsky and Berger, 1975). Examples of health indices which are fundamentally c l i n i c a l are the Kaiser-Permanente Patient Inventory Questionnaire ( G a r f i e l d , 1970), the Cor n e l l Medical Index (Brodman, et a l . , 1949), the Mayo C l i n i c Questionnaire (Martin, et a l . , 1969), and the Kisch, et a l . proxy measure (Kisch, et a l . , 1969). The Corn e l l Medical Index has been the most extensively u t i l i z e d questionnaire (Hennes, 1972). I t i s self-administered and consists of 196 questions to which the i n d i v i d u a l answers yes or no. This index contains questions on the presence of symptoms (respiratory, digestive, e t c . ) , and questions on depression, anxiety and tension (Balinsky and Berger, 1975). Abramson (1966) reviewed the v a l i d i t y of the CMI and found the t o t a l number of p o s i t i v e responses to be a useful i n d i c a t o r of emotional health. The degree of emotional disturbance i n a group i s p o s i t i v e l y correlated with the t o t a l score. Total score on the CMI i s a valuable i n d i c a t o r of general health status. The CMI does, however, not re l a t e to physical health or to s p e c i f i c diseases. The Kisch, et a l . proxy measure contains four questions regarding days of h o s p i t a l i z a t i o n , drug usage, acute conditions and chronic conditions. This self-administered questionnaire was p a r t i a l l y validated against physician evaluations (Kisch, et a l . , 1969). Self-assessments of health may r a i s e questions about the v a l i d i t y of these judgements. There i s , however, a high c o r r e l a t i o n between subjective and objective assessments of the health of older people. Levels of agreement between s e l f - r a t i n g s and ratings of physicians have been found to be approximately seventy-five per cent (Friedsam and Martin, 1963; Heyman and J e f f e r s , 1963; Maddox, 1962; Suchman, et a l . , 1958). There i s a tendency f o r people over seventy to give themselves better health ratings than those under seventy (Busse, 1966; Suchman, et a l . , 1958). S e l f - r a t i n g s - 38 -are subjective responses; they r e f l e c t the i n d i v i d u a l ' s perception of h i s condition to a greater extent than they r e f l e c t incidence of disease or receipt of medical care (Tissue, 1972). The value of s e l f - r a t e d health should not, however, be discounted; a person's functional capacity may be affected far more by his perception of his health than by his technical medical condition (Rosow and Breslan, 1966). Un i f i e d Mortality/Morbidity Indices The Health Problem Index (Q) developed f o r the U.S. Indian Health Service, the mathematical model developed by Chiang, the index developed by the North East Ohio Regional Medical Program and the u t i l i t y index proposed by Torrance, combine mortality and morbidity data. In the Health Problem Index, age and sex adjusted s t a t i s t i c s constitute the mortality component. Data oh h o s p i t a l days, disease days and outpatient v i s i t s , form the morbidi-ty component. A figure describing degree of d i s a b i l i t y i s obtained by weighting morbidity days. There i s , however, no measure of d i s a b i l i t y such 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 (Balinsky and Berger, 19 75). According to M i l l e r (1970) there i s a close c o r r e l a t i o n between the Q value and ratings based on professional judgements. Mathematical models have been used i n the development of health i n d i c e s . Chiang (1965) combined measures of the frequency of i l l n e s s , the duration of i l l n e s s and mortality to produce a health index. A weakness of the model i s i t s inadequacy i n defining 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 unhealthiness could be the r e s u l t of a cold or v i r a l pneumonia (Balinsky and Berger, 1975). Lawton, et a l . (1967) used factor analysis, another mathematically oriented procedure, i n developing a health index. They attempted to i d e n t i f y a common structure or several common structures among t h i r t y d i f f e r e n t indices of health (e.g., number of signs l i s t e d by physician, functional d i s a b i l i t y on a s i x point r a t i n g scale, worry over health on a four point r a t i n g s c a l e ) . For males the factor s o l u t i o n accounted f o r 66.5 per cent of the t o t a l variance; for females i t accounted for 50.9 per cent. Common factors thus accounted for a r e l a t i v e l y low amount of variance. Lawton and his associates conclude that the factor structure of indices of health i s quite complex and we hope that this study and others w i l l put to rest the idea that there i s a si n g l e concept of health which may eventually be reduced to an operational d e f i n i t i o n (Lawton, et a l . , 1967, p. 340). Exi s t i n g indices of mortality and morbidity assess impact of changes i n l i f e s t y l e , environment or health care organization inadequately (Lalonde, 1974). They tend, too, 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 physical well being as i d e n t i f i e d by the World Health Organization (1958). Increased emphasis on prevention and health (as opposed to disease) has increased the need for an index which measures s o c i a l , emotional and physical health (Chambers and Segovia, 1978) . Several features of health can be i d e n t i f i e d : freedom from symptoms, physical health, physical function, s o c i a l and emotional health. Each 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 facets; each feature i s thus q u a l i t a t i v e l y , d i s t i n c t . They can therefore not be added or combined into one health index (Davies, 1975). Sackett, Chambers, et a l . (1977) developed an instrument which produces separate indices of s o c i a l , emotional and physical function. I t i s comprehensive and generally applicable. I n i t i a l evaluations of the instrument ind 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 v a l i d i t y . It i s , however, expensive to administer since i t i s designed for home interviews. The r e l i a b i l i t y of the index has yet to be assessed. - 40 -SUMMARY OF LITERATURE REVIEW Education forms a v i t a l part of those aspects of preventive health care which demand voluntary behaviour change on the part of the i n d i v i d u a l . Health education can, but does not necessarily, r e s u l t i n changes i n behaviour and improvement i n health status. 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 factors influence the effectiveness of health education. According to the l i t e r a t u r e a person w i l l probably engage i n the advocated h e a l t h f u l behaviour i f he considers he may contract the i l l n e s s and that t h i s i l l n e s s w i l l have serious r e s u l t s , i f he thinks a c e r t a i n course of action w i l l be b e n e f i c i a l , i f there are no f i n a n c i a l or psycho-l o g i c a l b a r r i e r s and i f a cue triggers some action on h i s part. Also, there i s l i k e l y to be behavioural change i f c u l t u r a l and s o c i a l forces i n the target population (such as how people change behaviours and b a r r i e r s to change) have been taken into account i n the planning of the program, i f several educational techniques are used, i f the person i s a c t i v e l y involved i n the learning process and there are multiple contacts. Periodic r e i n -forcement helps maintain this behavioural change. Empirical studies on the role of ease and q u a l i t y of contact with health professionals i n promoting health of i n d i v i d u a l s , are scarce. Available l i t e r a t u r e suggests that these are important factors i n health promotion. Populations at r i s k of developing emotional disturbance are those with p h y s i c a l disease and those who l i v e alone. The incidence of physical disease increases at the age of 70 (Anderson, 1976). Numerous older c i t i z e n s l i v e alone. One would thus a n t i c i p a t e that health care for older c i t i z e n s which i s accessible, includes regular home v i s i t s , provides reassurance regarding physical health and has a h o l i s t i c approach to i n d i v i d u a l health, w i l l promote s o c i a l , emotional and phys i c a l health. Maintenance and improvement of health are the ultimate goals of - 41 -preventive health care. Determining how e f f e c t i v e l y a program has main-tained or improved health requires i d e n t i f y i n g the various components of good health and indices for measuring each component. Indices of mortality and morbidity are 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 health. With the new emphasis on health, the need has emerged for an index which measures health (as opposed to disease). Physical, s o c i a l and emotional health are q u a l i t a t i v e l y d i s t i n c t and should be measured separately. Sackett, Chambers et a l . (1977) developed an instrument which measures these three dimensions of health separately. IMPLICATIONS FOR RESEARCH One would expect programs which emphasize health education and a c c e s s i b i l i t y and q u a l i t y of contact with health personnel to be associated with greater health and lower health costs 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 process; and most e l d e r l y people have chronic diseases. Health i s a major concern of older people. It can therefore be argued that most older people w i l l consider actions which promote health to be b e n e f i c i a l . The review of l i t e r a t u r e suggests that there i s l i k e l y to be improvement i n or maintenance of health i f the e l d e r l y person experiences a cue to t r i g g e r action (e.g. i n the form of advice and encouragement from a health p r o f e s s i o n a l ) ; i f such advice i s based on assessment of 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 f a c t ors; i f there are multiple contacts; i f the person i s a c t i v e l y involved i n learning and i s reinforced for e f f o r t s at behavioural change. The l i t e r a t u r e suggests further, that maintenance of or improvement i n health w i l l be enhanced i f the older person feels that the health professional i s accessible and w i l l provide emotional support i n times of c r i s i s . The f i n a l t e s t , of course, - 42 -i s whether resultant improvement i n or maintenance of health i s r e f l e c t e d i n reduced health costs. - 43 -CHAPTER III METHODOLOGY This chapter outlines the methodology of the study. I t describes the se t t i n g of the study and i d e n t i f i e s i t s purpose. It states the hypotheses, describes sampling procedures and outlines data c o l l e c t i o n procedures. I t describes measuring instruments u t i l i z e d i n the study and the way i n which data were analyzed. SETTING OF STUDY Nicholson and Sunset Towers are B r i t i s h Columbia housing complexes for senior c i t i z e n s i n the West End of Vancouver. The B r i t i s h Columbia Housing Management Commission provides sound, affordable accommodation for low to moderate income c i t i z e n s who cannot f i n d s u i t a b l e accommodation i n the private sector. There are 8,400 r e n t a l units i n 48 mu n i c i p a l i t i e s through-out the province. C r i t e r i a for admission to these dwellings are a minimum age of 65 and physical independence on the part of the residents. Nicholson Towers i s a sing l e complex with 240 residents. Sunset Towers consists of two complexes (Buildings A and B), each with approximately 240 residents. The three complexes are almost i d e n t i c a l i n construction, with close proximity to stores and access to public transportation. The r a t i o of male to female residents i n each complex i s 1:3. The mean age of residents i n Nicholson Towers i s 78.76 and i n Sunset Towers, 74.64. Since 1974 senior c i t i z e n s i n these two complexes have received d i f f e r e n t nursing programs, both of which are provided by Home Care. Home Care i s funded by the Province of B.C. and i s administered through the Cit y - 44 -of Vancouver Health Department. Home Care includes a number of services and programs which a s s i s t i n d i v i d u a l s to maintain maximal function and independence at home. These services allow early discharge from acute h o s p i t a l s ; they also prevent h o s p i t a l i z a t i o n . P rovision of Home Care nursing services to residents of Sunset Towers i s at the request of a physician. Services are mostly treatment oriented, and are s i m i l a r to those provided i n other parts of the c i t y and province. Conversely, the nursing program i n Nicholson Towers i s an attempt to f i n d an alternate way of d e l i v e r i n g health care to older people. This alternate program has four goals: intervention at an early stage of unwellness before problems become severe; promotion of health through education about good health habits; promotion of health and independence through education about disease; monitoring of chronic diseases i n order to maintain a stable l e v e l of functioning. PURPOSE OF STUDY The study described below tested the claim that health knowledge, health behaviour and health status of senior c i t i z e n s who received preventive  nursing services which were accessible and emphasized health promotion  (through health education, counselling and early detection of disease),  would be s i g n i f i c a n t l y greater and health costs s i g n i f i c a n t l y lower than  those who received nursing services which were less accessible and placed  less emphasis on health promotion. HYPOTHESES The nursing program at Nicholson Towers incorporates many of the factors 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 health and reducing health costs. The nursing program i n Sunset Towers incorporates fewer of these f a c t o r s . The main differences between, the - 45 -programs are the increased a c c e s s i b i l i t y of the nurses i n Nicholson Towers and the greater amount of health education and counselling which i s done there. Research findings related to health education and ease and q u a l i t y of contact with health professionals, lead one to expect c e r t a i n outcomes. One would a n t i c i p a t e the greater amount of health education and counselling and increased a c c e s s i b i l i t y of nurses i n Nicholson Towers to accomplish c e r t a i n things: prevent the development of c e r t a i n health problems; allow intervention at an early stage of unwellness; r e s u l t i n increased health knowledge and improved health behaviours and health status. Hypothesis 1: Health knowledge, health.. behaviour and health status  of senior c i t i z e n s i n Nicholson Towers w i l l be s i g n i f i c a n t l y greater than  that of senior c i t i z e n s i n Sunset Towers. One would expect that as a r e s u l t of^increased 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 residents i s prevented (because the problem i s dealt with before i t becomes a c r i s i s ) and un-necessary physician v i s i t s are prevented (because the problem i s dealt with by the nurse). Because senior c i t i z e n s i n Nicholson Towers are seen on a regular basis, nurses are able to monitor medication use. They are, f o r example, able to prevent residents from taking medications longer than necessary by advising discontinuance of a c e r t a i n medication (in consulta-t i o n with the physician). One would a n t i c i p a t e reduced number of h o s p i t a l i -zations, physician v i s i t s and medication use to be r e f l e c t e d i n reduced number of health related v i s i t s and average health costs. Hypothesis 2: Over an eight month period, the average number of health  related v i s i t s made by or to residents of Nicholson and Sunset Towers w i l l  be s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers. Health related v i s i t s include v i s i t s to general p r a c t i t i o n e r s , s p e c i a l i s t s , paramedical - 46 -personnel (physiotherapists, p o d i a t r i s t s and chiropractors), l a b o r a t o r i e s , h o s p i t a l s and nurses. Hypothesis 3: Over an eight month period, average costs of a l l health  services provided to residents of Nicholson and Sunset Towers w i l l be  s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers. Costs of health services include costs of v i s i t s to general p r a c t i t i o n e r s , s p e c i a l i s t s , paramedical personnel, laboratories, h o s p i t a l s and costs of post-operative v i s i t s and medication. Approximately 50 residents i n each b u i l d i n g are e l i g i b l e for admission to Long Term Care i n s t i t u t i o n s (Ministry of Health, 1978). This means that they require assistance with c e r t a i n aspects of housekeeping ( i . e . cleaning, cooking and shopping). The cost of caring for 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 higher than the cost of a d a i l y or weekly v i s i t by a Home Care nurse. One would expect the increased a c c e s s i b i l i t y of nurses i n Nicholson Towers to allow a larger 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 i n s t i t u t i o n ) . Hypothesis 4: Of those residents e l i g i b l e f o r Long Term Care, a  s i g n i f i c a n t l y greater percentage i n Nicholson than i n Sunset Towers, w i l l  •consider that they are able to continue l i v i n g i n the apartment because  nurses are accessible. DIFFERENCES BETWEEN NURSING SERVICES The main differences between the nursing services at Nicholson Towers and Sunset Towers are the increased a c c e s s i b i l i t y of the nurses i n Nichol-son Towers and the greater amount of health education and counselling which i s done there. - 47 -A c c e s s i b i l i t y The residents of both Nicholson and Sunset Towers have high a c c e s s i -b i l i t y to health care services. Both are covered by the Medical Services Plan of B r i t i s h Columbia and are e l i g i b l e f o r a free p r e s c r i p t i o n drug program. Residents of both complexes have t h e i r own family doctors. When residents of Sunset Towers require Home Care nursing services, a doctor requests t h i s service, the Home Care nurse comes to the b u i l d i n g , provides the service and then leaves the b u i l d i n g . The resident i s d i s -charged from the service as soon as possible, because there i s administra-t i v e pressure to see residents no longer than absolutely necessary. Nurse turnover may occur as often as every s i x months, which reduces continuity. At Nicholson Towers, two nurses are o f f i c e d i n the b u i l d i n g and spend s i x hours a day there, f i v e days a week. Nurses would discontinue seeing a hypertensive resident i n Sunset Towers a f t e r two or three months. In Nicholson Towers the nurses would continue to see him on a regular basis to monitor h i s health and to educate him regarding factors related to hyper-tension, thereby preventing future problems. The nurses are replaced less often, thus there i s more continuity. The nurses can be contacted at the o f f i c e , by telephone, or i n the hallway and are thus perceived as highly accessible. According to the nurses i n Nicholson Towers, the greater a c c e s s i b i l i t y of the nurses should produce the following e f f e c t s . Residents f e e l more secure; both those who are seen r e g u l a r l y by the nurses, and those who are not. The residents f i n d comfort i n knowing that, should health problems a r i s e , there are knowledgeable people i n the bu i l d i n g to deal with such problems. The nurses are able to prevent c e r t a i n problems from developing. They may, for example, be requested by one resident to check on another resident. The nurses e i t h e r attend to the problem themselves or recommend - 48 -a v i s i t to a doctor. The nurses are able to screen health problems of the residents, thereby preventing unnecessary v i s i t s to the doctor, or f a c i l i t a t i n g early treatment of the condition by advising an immediate appointment with the doctor. The nurses are able to v i s i t someone with an acute condition (e.g., i n f e c t i o n ) as often as three times a day. This would not be possible i n Sunset Towers. There i s higher u t i l i z a t i o n of nursing services; f o r example, intervention to prevent problems and screening of problems as mentioned. Some residents approach the nurses f o r reassurance regarding health problems. This cannot be viewed as unnecessary contact. The reassurance may take only two minutes, but i t s psychological value to the resident may be immeasurable. There are many fears related to aging and approaching death. Anything that helps a l l a y these fears contributes to emotional health and may d i f f u s e to s o c i a l and physi c a l health. One advantage of the continuity of the nurses i n Nicholson Towers, i s that the nurses get to know the residents very w e l l , are f a m i l i a r with t h e i r unique d i f f i c u l t i e s and exactly what was dealt with i n the most recent v i s i t . Remembering unique personal information about a resident transmits to him a f e e l i n g of genuine concern about him. The nurses are able to rein f o r c e relevant behaviours and ask pertinent questions. This i s less e a s i l y done when information regarding the l a s t v i s i t i s transmitted from one nurse to the next i n the form of progress notes, which i s often the case i n Sunset Towers. Health Education The second difference between the two apartment complexes i s that residents i n Nicholson Towers receive a far greater amount of health educa-ti o n than do those i n Sunset Towers. In recent months, health information - 49 -has been posted on the b u l l e t i n board i n the main lobby at Nicholson Towers. Health education i s , however, done c h i e f l y on an i n d i v i d u a l basis. Individual needs are thus considered. Nurses see residents with health problems r e g u l a r l y . There i s a continual dialogue between the nurse and resident, with the resident being a c t i v e l y involved i n the learning process. The nurse l i s t e n s to what the resident says and responds to the l i f e s t y l e of the resident. How much contact does he have with other people? How often does he get out of the building? What does he eat and how does he prepare i t ? The nurse educates the resident regarding the management of his p a r t i c u l a r health problems, and also regarding factors (such as d i e t , physical exercise and s o c i a l contact) which are known to be p a r t i c u l a r l y important i n promoting the health of e l d e r l y people. Because the nurses i n Nicholson Towers see the residents r e g u l a r l y , they are able to reinfor c e the education at regular i n t e r v a l s , monitor changes i n behaviour and health status and give support and reinforcement for e f f o r t s at behavioural change. The a c c e s s i b i l i t y of the nurses allows residents to contact them regarding health questions. Such contacts constitute "teachable moments"; moments when the person's readiness to learn makes him p a r t i c u l a r l y receptive to education (Knowles, 1970). In Sunset Towers, the Home Care nurses provide health education on an i n d i v i d u a l basis to residents whom they v i s i t . The percentage of residents receiving Home Care nursing services at any one time i s much lower i n Sunset Towers (4 per cent) than i n Nicholson Towers (31 per cent). Less health education thus occurs here than i n Nicholson Towers. In addition, i n Sunset Towers there i s less continuity of nurses, less a c c e s s i b i l i t y and there are fewer contacts with each resident. There are thus fewer opportunities to rein f o r c e educational points, to reinfor c e e f f o r t s at behavioural change and to use teachable moments. - 50 -Counselling The t h i r d difference between the two apartment complexes, i s the greater amount of counselling which occurs i n Nicholson Towers. Home Care nurses i n both complexes spend f a r less time counselling than educating; counselling does thus not constitute a major part of t h e i r jobs. Counsel-l i n g can be distinguished from health education i n that i t i s supportive and therapeutic, and not aimed at voluntary changes i n health behaviour (Green, 1978). Nurses i n Nicholson Towers provide residents with emotional support at times when th i s i s needed; (e.g., when there i s a disagreement with r e l a t i v e s , or when a spouse d i e s ) . In Sunset Towers there i s less continuity and a c c e s s i b i l i t y of nurses. There are fewer contacts with each person and fewer residents are seen; thus there i s less counselling. Differences between the nursing programs and expected costs and benefits of programs are summarized i n Table 4, page 51. SAMPLING At the time of the study (August-September, 1978), of the 240 r e s i -dents i n Nicholson Towers, 75 (31 per cent) were being seen by the nurses on a regular basis; 47 a d d i t i o n a l i n d i v i d u a l s (19 per cent) had been seen by the nurses at some time during the preceding two years, but not i n the month preceding the study; 118 residents (50 per cent) had never received nursing services. Of the 244 residents i n Sunset Towers (Building A), 10 (4 per cent) were being seen by a nurse from Home Care: 45 in d i v i d u a l s (19 per cent) had received Home Care nursing services at some time i n the preceding two years, but not i n the preceding month; 186 i n d i v i d u a l s (77 per cent) had never received nursing services. To ensure that i n d i v i d u a l s who were receiving nursing services at the - 51 -TABLE 4. COMPARISON OF EXPECTED COSTS AND BENEFITS OF NURSING PROGRAMS Variable Nursing Programs Differences between nursing  programs A c c e s s i b i l i t y of nurses Amount of health education which occurs Amount of counselling which occurs Nicholson Towers ^ Sunset Towers Nicholson Towers ^> Sunset Towers Nicholson Towers Sunset Towers Expected costs Cost of nurses' v i s i t s Cost of physician v i s i t s Cost of h o s p i t a l i z a t i o n Cost of medications Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Expected benefits Number of physician v i s i t s Number of days of h o s p i t a l i z a t i o n Number of prescribed medications per person Number of i n d i v i d u a l s e l i g i b l e for Long Term Care who consider they are able to continue l i v i n g i n apartment because nurses are accessible Health knowledge of i n d i v i d u a l s Health behaviour of i n d i v i d u a l s Physical function of i n d i v i d u a l s Emotional function of i n d i v i d u a l s S o c i a l function of i n d i v i d u a l s Feelings of security and benefit from presence of nurses Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Nicholson Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers Sunset Towers - 52 -time of the study and those who had received nursing services i n the past, were adequately represented, a sample of i n d i v i d u a l s i n each complex was randomly selected from each of three categories. The categories were the following: i n d i v i d u a l s receiving nursing services at the time of the study; i n d i v i d u a l s who had received nursing services i n the two year period pre-ceding the study but not i n the month preceding the study; i n d i v i d u a l s who had never received nursing s e r v i c e s . So that s i m i l a r proportions of i n d i v i d u a l s i n each of the three categories i n Nicholson and Sunset Towers were interviewed, only i n d i v i d u a l s i n Nicholson Towers and ind i v i d u a l s i n Building A of Sunset Towers (and not those i n Building B) were interviewed. There was, however, one small exception. A small number of residents (ten) i n Building A of Sunset Towers was receiving nursing services at the time of the study. The three i n d i v i d u a l s i n Building B of Sunset Towers who were receiving nursing services, were thus included i n the study. Since there was no known differences between in d i v i d u a l s i n Buildings A and B of Sunset Towers, in c l u s i o n of these i n d i v i d u a l s was not expected to influence the outcome of the study i n any way. Sample and population sizes are shown i n Table 5. DATA COLLECTION Introduction A summary of variables measured and method of measurement i s presented i n Table 6. Measurements f a l l into four categories: biographical data, differences between nursing programs, costs and expected benefits of nursing programs. Data were c o l l e c t e d from three sources: nurses and nursing charts; Medical Services Plan of B.C. and Pharmacare; and residents i n the sample themselves. The following 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 GROUPS Receiving nursing services at time of study Received nursing services i n two year period preceding study but not i n month preceding study Never received nursing services Total Nicholson Towers Sample Population Size Size Sunset Towers Sample Population Size Size 30 75 13 13 15 47 17 45 20 118 29 186 65 240 59 244 - 54 -TABLE 6 VARIABLES MEASURED AND METHOD OF MEASUREMENT Source of Variable Measurement of Variable Data Differences Between Nursing Programs A c c e s s i b i l i t y Questions re how e a s i l y nurses can be Residents Health education contacted. Nurses Mean number of hours spent by nurses with residents per month, m u l t i p l i e d by percentage of time spent educating. Counselling Question re whether resident has ever Residents talked to the nurse when worried about a personal or family problem. Biographical Information Sex Item completed by interviewer. Residents Age Question re. age. Residents M a r i t a l status Question re. marital status. Residents Years of schooling Question re. years of schooling. Residents Socio-economic Blishen Occupational Rating Scale. Residents status Number of l i f e S ocial Readjustment Scale (Holmes & Rahe). Residents change units Number of medical Questions on presence or absence of Residents conditions p a r t i c u l a r conditions. E l i g i b i l i t y for Nurses Long Term Care Number and Costs of Health Related V i s i t s Number of v i s i t s to: Medical GP, s p e c i a l i s t s , Services paramedical Plan of personnel, B.C. laboratories, hospitals Number of v i s i t s to Nursing nurses charts Costs i n do l l a r s of Medical v i s i t s to hospitals Services GPs, s p e c i a l i s t s , Plan of paramedical B.C. personnel, laboratories, post-operative v i s i t s Cost of nursing $ 2 0 . per v i s i t . Home Care v i s i t s Cost of medication Pharmacare Expected Benefits Health knowledge Questions based on information taught by Residents nurses i n Nicholson Towers. Health behaviours Questions re. health behaviours. Residents Physical function Physical function scale. Residents Emotional function Emotional funcation scale. Residents Social function Socia l function scale. Residents Residents e l i g i b l e Question to residents e l i g i b l e for long term Residents for Long Term Care care re whether they could continue l i v i n g who consider they i n complex i f nurses were not accessible. can continue l i v i n g i n a complex because nurses are accessible Feeling of security Question re. presence of nurses i s Residents from presence of associated with greater feeli n g s of security nurses - 55 -b u i l d i n g : amount of health education which occurs i n each complex; per month; which i n d i v i d u a l s were e l i g i b l e for Long Term Care; number of Home Care nursing v i s i t s to i n d i v i d u a l s i n the sample for the period January 1 to August 31, 1978. The Medical Services Plan of B.C. and Pharma-care supplied data on number and cost of a l l health services and cost of medication for residents i n the sample for the time period January 1 to August 31, 1978. Data c o l l e c t e d from residents i n a structured interview (Appendix)" measured health knowledge; sources of health information; health be-haviours; health status; perceived benefit of nurses; and variables i d e n t i f i e d i n the l i t e r a t u r e as rela t e d to health knowledge and health status. Health knowledge was measured by questions based on information taught to residents by nurses i n Nicholson Towers. Health status was measured using adapted versions of scales of physi c a l , emotional and s o c i a l function developed by Sackett, Chambers et a l . (Chambers & Segovia, 1978). Variables related to health status and health costs measured i n th i s study were sex, age, years of schooling, socio-economic status, number of medical conditions and number of l i f e change u n i t s . Blishen's (1967) Occupational Rating Scale was used to measure socio-economic status. The Soc i a l Re-adjustment Scale 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 discussed i n d e t a i l i n the following section. Data from Home Care Nurses Amount of health education which occurs i n each complex was measured (1) by determining the mean number of hours spent by nurses with residents i n each b u i l d i n g per month and (2) by asking nurses i n each b u i l d i n g to - 56 -estimate what percentage of th e i r time i s spent educating. M u l t i p l i c a t i o n of these figures produced the approximate number of hours spent on health education i n each b u i l d i n g per month. Information regarding which i n d i -viduals were e l i g i b l e for Long Term Care was also obtained from the nurses, as were the number of nursing v i s i t s to each i n d i v i d u a l f o r the time period January 1 - August 31, 1978. The Home Care O f f i c e provided informa-t i o n that each v i s i t by a Home Care nurse costs approximately $20. Data from Medical Services Plan and Pharmacare The Medical Services Plan of B r i t i s h Columbia supplied data on numbers and costs of v i s i t s to ho s p i t a l s , G.P.s, s p e c i a l i s t s , paramedical personnel and laboratories for the time period January 1 - August 31, 1978. Data on cost of medication f o r the same time period were obtained from Pharmacare. Data from Residents Some information could be obtained only from residents personally. Therefore a questionnaire was designed s p e c i f i c a l l y for this purpose. The questionnaire was developed to determine health knowledge, health be-haviours, health status, perceived benefit of the nurses and variables known to be rela t e d to health knowledge and health status. The questionnaire was pretested on ten residents who were not part of the population ( i . e . residents of Sunset Towers, Building B). C l a r i t y of questions, responses to questions and length of interview were thereby assessed. Adjustments i n the questionnaire were made accordingly. A sample s t r a t i f i e d according to l e v e l of nursing service was drawn from each df the two bu i l d i n g s . Individuals i n the sample were n o t i f i e d of the study by l e t t e r . They were then contacted by telephone regarding t h e i r willingness to p a r t i c i p a t e i n the study; the date and time of the interview were set. For each i n d i v i d u a l who refused to p a r t i c i p a t e i n the - 57 -study, a replacement was randomly drawn from the appropriate sample. Of 138 i n d i v i d u a l s approached, 14 i n d i v i d u a l s refused to p a r t i c i p a t e i n the study. The number of people interviewed was 124. One interviewer conducted a l l the interviews over a four week period (August-September, 1978). Individuals were Interviewed i n t h e i r own apartments i n a 40 minute structured schedule. Individuals i n both com-plexes were interviewed each day to control for e f f e c t s of time. Responses to questions were entered on the interview sheet and subsequently trans-ferred onto coding sheets. The questionnaire (Appendix) %'> was designed to measure health know-ledge; sources of health information; health behaviours; health status; perceived benefit of nurses; and variables i d e n t i f i e d i n the l i t e r a t u r e as related to health knowledge and health status. A discussion of each section of the interview schedule follows. Health knowledge I t was necessary to develop an instrument to measure health knowledge. Questions to measure health knowledge were based on information taught to residents by nurses i n Nicholson Towers. Development of the health know-ledge scale i s described l a t e r i n t h i s chapter. Sources of health information For each health knowledge question c o r r e c t l y answered, the i n d i v i d u a l was asked to i d e n t i f y from whom or what he/she f i r s t learned this informa-t i o n . The proportion of health information an i n d i v i d u a l obtained from each source was calculated by d i v i d i n g the number of times an i n d i v i d u a l stated that source, by the number of health knowledge questions he/she answered c o r r e c t l y . - 58 -Health behaviours Fourteen health knowledge questions had a corresponding question regarding health behaviour. The i n d i v i d u a l was asked to i d e n t i f y his/her health behaviours. Answers i n d i c a t i n g engagement i n healthy behaviour were scored "1"; those i n d i c a t i n g engagement i n unhealthy behaviour were scored "0". An i n d i v i d u a l ' s health behaviour score was calculated by d i v i d i n g his/her t o t a l number of healthy behaviours by the number of health be-haviour questions applicable to him/her. Perceived benefit of nurses Questions were designed to measure perceived benefit and feelings of security from the presence of nurses. Responses were scored on a 3-point r a t i n g scale. P o s i t i v e responses were scored "3", and negative responses "1". Variables related to health knowledge and health status Other data c o l l e c t e d included variables i d e n t i f i e d i n the l i t e r a t u r e as related to health knowledge and health status. The variables used i n this study were sex, age, marital status, years of schooling, employment, number of medical conditions, socio-economic status and number of l i f e change u n i t s . Medical conditions included i n the questionnaire were (1) conditions i d e n t i f i e d as chief 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) conditions i d e n t i f i e d as major reasons f or receipt (by older people) of Home Care nursing s e r v i c e s . Presence of a condition was scored "1"; absence of this condition was scored "0". Number of conditions was calculated by summation of scores. The Blishen (1967) Occupational Rating Scale was used to measure socio-economic status. Occupations are ranked and grouped into seven - 59 -classes and scores range from 1 to 7. Occupations i n class 1 include lawyers and physicians; those i n class 2 include professors and chemists. Radio announcers and t y p i s t s are among the occupations i n class 3 , while nurses and farmers are among the occupations i n class 4 . Occupations i n class 5 include o f f i c e clerks and telephone operators. Sales clerks and p r a c t i c a l nurses f a l l i i n t o class 6 and cooks and j a n i t o r s i n t o class 7. The S o c i a l Re-adjustment Scale developed by Holmes & Rahe (1967) was u t i l i z e d to measure l i f e changes of i n d i v i d u a l s during the year pre-ceding the study. The scale consists of 43 l i f e events such as marriage, divorce and taking a vacation. Each event has a numerical value according to the amount of stress known to be associated with that event. Events associated with l i t t l e stress have low numerical values; those associated with much stress have high numerical values. Each i n d i v i d u a l i s asked which of these 43 events he or she has experienced during the past year and a l i f e stress score i s calculated by summing numerical values on items to which there are p o s i t i v e responses. Investigations have demonstrated the r e l a t i o n s h i p between l i f e stress and the onset of i l l n e s s (Holmes & Rahe, 1967). Health status The health index questionnaire developed by Sackett, Chambers et a l . (Chambers & Segovia, 1978) was used to measure s o c i a l , emotional and physical function. The way i n which these three scales were adapted for use i n t h i s study i s described i n the following section. Development of the Health Knowledge Scale Questions to measure health knowledge were based on information taught to residents by nurses i n Nicholson Towers. Questions are l i s t e d i n Table 7 and f a l l into two categories: (1) fa c t s and behaviours considered - 60 -TABLE 7 HEALTH KNOWLEDGE QUESTIONS Questions Asked of A l l i n d i v i d u a l s How often should one have some form of exer-c i s e l i k e going for walks? How do you decide when and for how long to take prescribed medication? How often i s a ph y s i c a l check-up advisable for people of your age who are f e e l i n g well? If one i s l i v i n g alone, how often do you think one should have contact with other people? 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 diet? Could you name two things you can include 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 drink a day? Would you show me what medications you are on? Could you t e l l me what each of these medica-tions i s for (maximum of 6 medications)? Questions Asked of Individuals with A r t h r i t i s 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 (in the morning, f o r example)? If you have so much pain that you do not f e e l l i k e eating, what do you do about eating (and why) ? Questions Asked of Individuals with a Heart  Condition How do you decide how often to take medication(s) for your heart? What sort of ph y s i c a l signs would indicate to you that your heart was not functioning well? Questions Asked of Individuals with. Leg Ulcers Can you name two things one can do to reduce swelling i n the leg? What sort of food are e s p e c i a l l y important to include i n one's diet when one has leg ulcers? Questions Asked of Individuals with High Blood  Pressure What kinds of things can you do to help keep your blood pressure down? If you f e e l dizzy when you get up from a l y i n g p o s i t i o n , what should you do? If you f e e l dizzy while you are doing something ( l i k e walking or housework) what should you do? Scale R e l i a -b i l i t y i f Item Deleted from 7 item Knowledge Scale Percentage of People who Answered Question Correctly .55 .56 .47 .48 .53 .53 .55 93% 91% 67% 58% 79% 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 ic to health maintenance i n older people; (2) facts and behaviours considered basic 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 questions i n the f i r s t category ( i . e . seven questions). Questions i n the second category were presented only to those i n d i v i d u a l s with these conditions. Correct answers were scored "1"; incorrect answers were scored "0". Each i n d i v i d u a l ' s health knowledge score was calculated by d i v i d i n g the t o t a l number of correct responses by the number of questions applicable to that i n d i v i d u a l . There were 22 health knowledge questions; a l l i n d i v i d u a l s were asked at l e a s t 7 questions. Adaptation of the Physical Function Scale Chambers & Segovia (1978) performed discriminant function analysis on a large number of questions and thereby produced 11 physical function questions which best predict the physician's c l i n i c a l assessment of physical function. Eight of these items were used i n this study. Items rel a t e d to dressing, washing and d r i v i n g a car were eliminated for two reasons. A l l residents are independent i n a c t i v i t i e s of d a i l y l i v i n g ; very few drive cars. There would therefore 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 questionnaire short. Two items were added to the scale. These items were developed by Sackett and Chambers, but not included i n the 11 questions best p r e d i c t i n g physical function. The items included were a s e l f - r a t i n g of health and how far the i n d i v i d u a l was able to walk. Chambers & Segovia (1978) dichotomized responses to a l l items. Res-ponses were judged to represent good or poor functioning. In t h i s study scores on i n d i v i d u a l items ranged between 1 and 5. Answers which indicated that the i n d i v i d u a l experienced no d i f f i c u l t y , some d i f f i c u l t y and great d i f f i c u l t y performing a physical a c t i v i t y were scored "5", "4" and "3" resp e c t i v e l y . Answers which indicated that the person could not do the a c t i v i t y or did not know whether he could do the a c t i v i t y were scored "2" and "1" re s p e c t i v e l y . A l l items were given the same weighting. Scores on items were summed to produce a t o t a l score. Table 8 l i s t s a l l items included i n the scales of phys i c a l , emotional and s o c i a l function i n this study. The table indicates which items are from Sackett and Chamber's scale, which are adapted from t h e i r scale, which items are r e p l i c a t e d i n a l l three scales and which are new items. Adaptation of the Emotional Function Scale Chambers & Segovia (1978) also i d e n t i f i e d 12 emotional function questions which best predict the physician's c l i n i c a l assessment of emotional function through performing discriminant function a n a l y s i s . Eleven of these items were used i n th i s study. The item eliminated was "Most people don't r e a l i z e how much t h e i r l i v e s are co n t r o l l e d by plots hatched i n secret by others." Subjects i n the pretest reacted negatively to t h i s item. An item from the scale of s o c i a l function regarding how happy the i n d i v i d u a l f e e l s , was included to increase the face v a l i d i t y of this scale. Chambers & Segovia (1978) dichotomized responses to a l l items. Res-ponses were judged to represent good or poor functioning. In th i s study scored on i n d i v i d u a l items range between 1 and 5. Answers which indicated very good emotional function were scored "5"; answers which indicated very poor emotional function were scored " I " . For example, on the item " 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 " , strongly agree was scored "1", agree was scored "2", neutral "3", disagree "4" and strongly disagree was scored "5". A l l items were coded 1 to 5 and given the same weighting. - 63 -TABLE 8 CORRELATION COEFFICIENTS FOR INDIVIDUAL ITEMS WITH HEALTH SCALES Item Source A R,C R,C C C R.C R,C Physical Function Items 1. Today do you have any physical d i f f i c u l t y at a l l with walking as far as a mile? 2. Today do you have any physical 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 steps)? 3. Today do you have any physical d i f f i c u l t y at a l l with shopping? 4. Today do you have any physical d i f f i c u l t y at a l l with cooking? 5. Today do you have any physical d i f f i c u l t y at a l l with dusting or l i g h t housework? 6. Today do you have any physical d i f f i c u l t y at a l l with cleaning floors? 7. Do you have any physical 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 trouble reading ordinary newsprint? 10. What i s the farthest you can walk? 11. How would you say your health i s these days? Emotional Function Items 5. 9. 10. 11. How would you say your health is these days? I am usually a l e r t . I would say I nearly always f i n i s h things once I st a r t them. Some people f e e l that they run their l i v e s pretty much the way they want to and this is the case with me. There are many people who don't know what to do with their l i v e s . Nowadays a person has to l i v e pretty much for today and l e t tomorrow take care of i t s e l f . In a society where almost everyone i s out for himself, people soon come to di 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 . I am inclined to f e e l that I am a f a i l u r e . Have you had any trouble getting along with friends/relatives during the past year? Taking a l l things together, how happy would you say you are these days? Social Function Items 1. How would you say your health is 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 la s t week to c a l l a friend? 4. How many times have you used your telephone i n the l a s t week to c a l l a relative? 5. How many times have you used your telephone i n the last week to c a l l a religious group member? 6. Including the times you went shopping or for your usual outings from home, how many times have you been out of the building i n the l a s t week? 7. How many times have you been to a movie, fi l m , play or concert 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 last 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 la s t week? 11. How many times have you v i s i t e d a friend i n the l a s t week? 12. How many times have you been v i s i t e d by a friend or rela t i v e i n the last week? 13. How long'has i t been since you l a s t had a holiday (away from home)? 14. Did you start receiving Mincome during the l a s t year? Coefficient Alpha R e l i a b i l i t i e s Physical function 0.77 0.81 0.79 0.59 0.69 0.79 0.76 0.60 0.09 0.75 0.63 0.63 0.35 0.28 0.49 0.15 0. 25 0.15 0.07 0.12 0.04 0.28 0.63 0.28 0.11 0.05 -0.14 0.65 0.11 0.13 0.01 0.04 0.30 -0.04 0.05 -0.07 0.86 Emotional function 0.38 0.37 0.33 0.22 0.27 0.38 0.33 0.20 0.07 0.27 0.60 0.60 0.46 0.54 0.71 0.56 0.26 0.55 0.53 0.52 0.37 0.66 0.60 0.66 0.22 0.20 -0.11 0.44 0.13 0.19 0.04 0.23 0.33 0.19 0.30 0.18 0.74 Social function 0.31 0.28 0.34 0.16 0.17 0.29 0.37 0.23 0.02 0.28 0.47 0.47 0.28 0.22 0.43 0.31 0.02 0.37 0.27 0.25 0.25 0.49 0.47 0.49 0.64 0.07 0.05 0.55 0.04 0.56 0.14 0.23 0.52 0.28 0.36 0.08 0.43 C = Item from Sackett & Chamber's scale with adapted response A = Item and response adapted from Sackett & Chamber's scale R = Item replicated i n a l l three scales N = New item developed for this study - 64 -Scores on items were summed to produce a t o t a l score. Adaptation of the Soci a l Function Scale Th 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 function questions which best predict the physician's c l i n i c a l assessment of s o c i a l function. Eleven of these items were used i n th i s study. The item related to work was eliminated, since a l l i n d i v i d u a l s are r e t i r e d and there would there-fore be no v a r i a t i o n i n response to this item. Wording of the question on welfare was modified; "welfare" was replaced by "mincome". Six items were added to the scale. Four of these items were developed by Sackett and Chambers but not included i n the 12 questions best p r e d i c t i n g s o c i a l function. These items related to v i s i t i n g f r i e n d s , being v i s i t e d and going to movies and s o c i a l clubs. Two items r e l a t i n g to telephoning r e l a t i v e s and going out of the b u i l d i n g were also added to the scale. The ra t i o n a l e for i n c l u s i o n of these s i x a d d i t i o n a l items was that these are s o c i a l a c t i v i t i e s i n which older people engage, and t h e i r i n c l u s i o n would increase the face v a l i d i t y and appropriateness of th i s s c ale. Chambers & Segovia (1978) dichotomized responses to a l l items, e.g. "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 ? " (Yes or No.) Responses were judged to represent good or poor functioning. In this study questions were phrased to allow f o r documenting the number of times a p a r t i c u l a r a c t i v i t y was performed. Items which had extreme varia t i o n s i n response were grouped, but always i n such a way that a high score indicated that this a c t i v i t y had been performed a great number of times. Responses were summed to produce a t o t a l score. In a l l three scales a large number of response categories was included. This increases the v a r i a b i l i t y , of each item, allows f o r respondents of "greater" s o c i a l health to d i s t i n g u i s h themselves from those with "poorer" s o c i a l health. Computing c o e f f i c i e n t alpha estimates - 65 -then tests whether including each p a r t i c u l a r item into an o v e r a l l scale 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 STUDY Figure 2 i d e n t i f i e s r e l a t i o n s h i p s investigated i n t h i s study and 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 . Relationships being investigated on which l i t e r a t u r e i s not a v a i l a b l e are the following: (1) services which are accessible and o f f e r health education and counselling and number of health r e l a t e d v i s i t s , t o t a l cost of health services, health knowledge, health behaviour, p h y s i c a l , emotional and s o c i a l function; (2) number of health r e l a t e d v i s i t s and health knowledge, health behaviour, emotional and s o c i a l function, years of schooling, number of l i f e change uni t s , e l i g i b i l i t y for Long Term Care, f e e l i n g of s e c u r i t y from the pre-sence of nurses and perceived benefit of nurses; (3) t o t a l cost of health services and health knowledge, health behaviour, emotional function, s o c i a l function, sex, years of schooling, number of l i f e change units, e l i g i b i l i t y for Long Term Care, f e e l i n g of s e c u r i t y from the presence of nurses and perceived benefit of the nurses; (4) health knowledge and p h y s i c a l , emotional and s o c i a l function; (5) health behaviour and physical, emotional and s o c i a l function; (6) physical function and years of schooling, f e e l i n g of security from the presence of nurses and perceived benefit of the nurses; (7) emotional function and years of schooling, number of medical condi-tions, e l i g i b i l i t y for Long Term Care, f e e l i n g of s e c u r i t y from the presence of nurses and perceived benefit of the nurses; (8) s o c i a l function and years of schooling, number of medical conditions, f e e l i n g of security from presence of the nurses and perceived benefit of the nurses. ANALYSIS OF DATA Raw data were keypunched onto cards. The data were computer analyzed - 66 -FIGURE 2 RELATIONSHIPS INVESTIGATED IN THE STUDY Differences Between Programs A c c e s s i b i l i t y Health education Counselling Biographical Variables Sex Age Socio-economic status v v X v . Years of schooling No. of?,, l i f e change units No. of medical conditions E l i g i b i l i t y for Long Term Care. XV' Benefits of Programs 99. *xftX A , X v / A No. of health related v i s i t s T o tal cost of health services °0y ^>X VKV' Health knowledge Health behaviour Physical function *X* X^*X * Emotional function S o c i a l function Security from nurses' presence/ Perceived b e n e f i t of nurses v ; «>, <b X v . V A X^  L 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 S Relationship to be studied - 67 -using the University of B r i t i s h Columbia's version of SPSS. SPSS, the S t a t i s t i c a l Package for the S o c i a l Sciences, was written at the National Opinion Research Centre i n Chicago and modified for MTS (the Michigan Terminal System). Analysis of variance was used to test differences between residents of Nicholson and Sunset Towers i n terms of health knowledge, health behaviour, health status, number of health r e l a t e d v i s i t s and health costs. Analysis of variance was also used to test differences between groups receiving d i f f e r e n t l e v e l s of nursing service. Pearson co r r e l a t i o n s were calculated among items. Stepwise l i n e a r regression determined which variables accounted for what percentage of variance i n costs, number of health related v i s i t s and p h y s i c a l , s o c i a l and emotional function. A r e l i a b i l i t y procedure was 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 f o r scales. - 68 -CHAPTER IV RESULTS INTRODUCTION This chapter describes findings of the study. It emphasizes hypo-thesized r e l a t i o n s h i p s , but also examines re l a t i o n s h i p s not formally posited i n the study. The f i r s t section deals with the r e l i a b i l i t y and v a l i d i t y of scales developed for this study. The chapter then presents findings related to the following f i v e issues: 1. hypotheses t e s t i n g differences between complexes i n terms of health knowledge, health behaviour, health status and health costs 2. differences between apartment complexes i n terms of biographical data, health education, counselling, costs and be n e f i t s , sources of health information and health behaviour 3. variance i n phys i c a l , emotional and s o c i a l function 4. variance i n number of health related v i s i t s and health care costs 5.. differences between residents receiving d i f f e r e n t l e v e l s of nursing service SCALES DEVELOPED FOR THE STUDY Before the study could be executed i t was necessary to adapt three e x i s t i n g scales and develop one new scale. Scales of ph y s i c a l , emotional and s o c i a l function developed by Sackett, Chambers et a l . (Chambers & Segovia, 1978) were adapted f o r use with t h i s study group, with the modi-f i c a t i o n s and additions as described i n Chapter I I I . A scale of health knowledge was developed for use i n th i s study. V a l i d i t y and r e l i a b i l i t y - 69 -estimates of each of these four scales are discussed below. R e l i a b i l i t i e s of Health Function  and Health Knowledge Scales The r e l i a b i l i t i e s of the scales u t i l i z e d i n the study are examined because they indicate how consistent the scales are and how much error of measurement they contain. Items included i n the physical function scale deal with "physical and functioning capacity on a p h y s i o l o g i c a l l e v e l " (Chambers, Sackett et a l . , 1976, p.9). Items deal with phy s i c a l a c t i v i t i e s such as walking and climbing s t a i r s and a c t i v i t i e s of d a i l y l i v i n g such as cleaning f l o o r s , cooking and t r a v e l l i n g by bus. Three items were removed from Chambers' scale of physical function and the following two items added: "What i s the farthest you can walk?" and "How would you say your health i s these days?" The f i n a l version of the scale contained 11 items. Questions included i n the emotional function scale were thought to measure the dimensions of ego function (basic t r u s t , autonomy, i n i t i a t i v e , industry, i d e n t i t y and intimacy) as well as s e l f esteem (Chambers, Sackett et a l . , 1976). One item was deleted from the o r i g i n a l version of the emotional function scale. The f i n a l version of the scale contained 11 items. Questions i n the s o c i a l function scale covered the following areas: extent of appropriate community a c t i v i t i e s , selected c r i t i c a l l i f e events (Holmes & Rahe, 1967) and organizational membership (Chambers, Sackett et a l . , 1976). One item was removed from the s o c i a l function scale and si x items were added to th i s s c a l e . The added items referred to t e l e -phoning r e l a t i v e s , going out of the b u i l d i n g , going to movies and concerts, attending s o c i a l clubs, v i s i t i n g friends and being v i s i t e d by friends and r e l a t i v e s . The f i n a l version of the scale contained 14 items. Items u t i l i z e d to measure ph y s i c a l , emotional and s o c i a l function - 70 -are l i s t e d i n Table 8 (page 63). This table shows which items were taken d i r e c t l y from scales developed by Sackett and Chambers, which items are adapted versions of Sackett and Chambers' items and which are newly developed items. The table also shows which items are r e p l i c a t e d across a l l three scales. The r e l i a b i l i t i e s of the scales of p h y s i c a l , s o c i a l and emotional function i n the versions developed by Chambers, Sackett et a l . (1976) have never been reported. The alpha r e l i a b i l i t i e s of the modified physical, emotional and s o c i a l function scales were computed as part of t h i s study. The alpha r e l i a b i l i t y of the p h y s i c a l function scale i s 0.86 which i s quite good. If the item "Do you have any trouble reading ordinary newsprint?" were deleted, the alpha r e l i a b i l i t y of the scale would increase to .88, i n d i c a t i n g that this i s a poor item. The alpha r e l i a b i l i t y of the modified emotional function scale i s .74. Each of the 11 items increases the r e l i a b i l i t y of the o v e r a l l scale, which indicates that a l l items warrant i n c l u s i o n . The modified s o c i a l function scale was found to have an alpha r e l i a b i l i t y of .43 which i s rather too low. If items on Mincome, telephoning r e l a t i v e s and r e l i g i o u s group members and going to movies, church and s o c i a l clubs were deleted, the alpha r e l i a b i l i t y of this scale would increase but only marginally. Thus these are questionable items. Possible reasons f o r the low r e l i a b i l i t y of the s o c i a l function scale are examined below. The three dimensions of health i d e n t i f i e d by the World Health Organization's d e f i n i t i o n of health are p h y s i c a l , s o c i a l and mental (emotional) function (World Health Organization, 1958). These dimensions vary i n terms of amenability to d e f i n i t i o n , o p e r a t i o n a l i z a b i l i t y and measurement. Physical function i s the dimension most amenable to d e f i n i -t i o n , and there i s good consensus regarding what constitutes good and poor - 71 -physical function and measurement. For example, a person who i s able to walk a mile and climb 16 s t a i r s with no d i f f i c u l t y -clearly possesses greater p h y s i c a l function than a person who i s unable to do these a c t i v i -t i e s . The dimension of emotional function i s less amenable to d e f i n i t i o n and measurement than physical function. Can one say with certainty, for example, that the emotional function of a person who f e e l s he i s a success (Question 9) i s greater than a person who f e e l s he i s not? The issues which define s o c i a l function as conceived by Chambers, Sackett et a l . (1976) include (1) f e e l i n g s about health, (2) feelings about ifamily and friends, (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 , (4) experience of selected c r i t i c a l l i f e events and ( 5 ) monetary s i t u a t i o n . These are d i s c r e t e elements which may not necessarily be mutually additive or comparable. It may thus not be useful to add such disparate items to produce a s i n g l e score (which Chambers and Sackett do). P a r t i c u l a r items i n the s o c i a l function scale are d i f f i c u l t to define i n terms of optimal s o c i a l function. Items are scored so that the more frequently an a c t i v i t y i s engaged i n , the higher the s o c i a l function. However, v i s i t i n g a s o c i a l club numerous times a week may constitute good s o c i a l function for one i n d i v i d u a l , but may i n d i c a t e s o c i a l dependence i n another, and lack of inner-resourcefulness i n a t h i r d . " R e l i a b i l i t y can be defined as the r e l a t i v e absence of errors of measurement i n a measuring instrument" (Kerlinger, 1973, p.443). The low r e l i a b i l i t y of the s o c i a l function scale diminishes i t s usefulness as a measurable concept considerably. Residents of Nicholson Towers were found to have a' significantly/.'.(27C46.~;vs.. 25.07) higher l e v e l of s o c i a l function than those i n Sunset Towers; i . e . a r e l a t i o n s h i p between apartment complex and s o c i a l function was declared. However, because u n r e l i a b l e measurement contains much error, the conclusion of a difference between complexes i s a - 72 -tenuous one (Kerlinger, 1973). The health knowledge scale (Table 7, page 60) was developed for p a r t i c u l a r use i n this study. Questions to measure health knowledge were based on information taught to residents by nurses i n Nicholson Towers. Questions f a l l i nto two categories: (1) facts and behaviours considered (by nurses and the l i t e r a t u r e ) basic to health maintenance i n older people; (2) facts and behaviours considered basic 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 questions i n the f i r s t category ( i . e . seven questions). Questions i n the second category were presented only to those i n d i v i d u a l s with these conditions. There were 22 questions i n t o t a l . Table 7 (page 60) shows what percentage of i n d i v i d u a l s answered each health knowledge question c o r r e c t l y and indicates where greater health education i s needed. The alpha r e l i a b i l i t y of the 7-item scale (computed as part of the study) was found to be .56. A l l 7 items are good items since they a l l increase the r e l i a b i l i t y of the scale. On the 22-item scale, the alpha r e l i a b i l i t y for 20 questions which were asked of i n d i v i d u a l s to whom they applied i s .87. This figure i s uncorrected for items with ho mutual observations. (No-one i n the sample had leg u l c e r s . The two questions on leg ulcers were therefore asked of no-one.) V a l i d i t i e s of Health Function  and Health Knowledge Scales Sackett, Chambers et a l . (1977) claim that i n i t i a l evaluations of the scales of phy s i c a l , emotional and s o c i a l function i n d i c a t e that they possess face 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 ( b iologic and c l i n i c a l v a l i d i t y ) . Content, construct, convergent and discriminant v a l i d i t i e s of these scales have never been reported. In order for interpretations from scales to have meaning, scales - 73 -should possess v a l i d i t y . V a l i d i t y i s the degree to which one i s measuring what one thinks one i s measuring. Content v a l i d i t y i s the sampling adequacy of the content of a scale. Construct v a l i d i t y r e f e r s to the pro-portion of the t o t a l scale accounted for by the constructs being measured. Convergent v a l i d i t y means that evidence from a v a r i e t y of sources indicates the same meaning of the construct. Discriminant v a l i d i t y means that one can d i f f e r e n t i a t e the construct from other s i m i l a r constructs and i d e n t i f y what i s not rela t e d to that construct (Kerlinger, 1973). The degree to which scales u t i l i z e d i n this study evidence these forms of v a l i d i t y i s explored below. Table 8 (page 63) presents correlations of i n d i v i d u a l items with t o t a l scale scores for each of the three scales. This table indicates the purity of items, the appropriateness of items to a p a r t i c u l a r scale and whether items contribute more to a p a r t i c u l a r scale than to the other two scales. In general, i n d i v i d u a l items co r r e l a t e more highly with the function they purport to measure than with the other two functions, thus suggesting that these items are not confounded across the three types of measures. Physical function items have the highest item-total correlations and the alpha r e l i a b i l i t y (.86) of this scale i s higher than the other two scales, i n d i c a t i n g that this scale has the highest content v a l i d i t y . Table 8 (page 63) shows that emotional function items correlate more highly with emotional function than with physical and s o c i a l function, suggesting that these items are measuring emotional function as d i s t i n c t from the two. other dimensions of health. The alpha r e l i a b i l i t y of this scale i s .74 i n d i c a t i n g that t h i s scale possesses content v a l i d i t y . S o c i a l function items have the lowest mean item-total c o r r e l a t i o n s . That this scale has an alpha r e l i a b i l i t y of .43 means that i t possesses low - 74 -content v a l i d i t y . Table 9 documents correlations among the three health function scales and the two health knowledge scales. This table shows that 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 scales of physical and emotional function with a l l other scales are lower than the scales' own alpha r e l i a b i l i t i e s . These two scales thus evidence convergent v a l i d i t y . TABLE 9 CORRELATIONS AMONG HEALTH FUNCTIONS AND HEALTH KNOWLEDGE SCALES Physical Emotional S o c i a l 7-item 22-item Function Function Function Health Health Scale Scale Scale Knowledge Knowledge Scale Scale Physical Function Scale .86 Emotional Function Scale .48 .74 S o c i a l Function Scale ,39 .57 .43 7-item Health Knowledge Scale -.20 .17 ,24 ,57 22-item Health Knowledge Scale -.27 .14 .19 .85 .87 C o e f f i c i e n t alpha r e l i a b i l i t y estimates are i n the p r i n c i p a l diagonal = .05 = .17, df = 124 The two health knowledge scales are highly (.85) correlated, which i s to be expected since the items i n the 7-item scale are included i n the - 75 -22-item scale. 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 health knowledge scales with the three health scales are lower than the scales' own alpha r e l i a b i l i t i e s . These findings i n d i c a t e that the two health knowledge scales evidence convergent v a l i d i t y . 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 function scale with the emotional function scale i s higher (.57) than the scale's own alpha r e l i a b i l i t y (.43) i n d i c a t i n g that the scale of s o c i a l function has low convergent v a l i d i t y and i s (at l e a s t partly) confounded with the measure of emotional function. Table 9 shows that there are s i g n i f i c a n t but moderately sized p o s i t i v e correlations between the three health scales. The correlations between the scales are not very high which suggests that the scales do indeed d i f f e r from one another and measure d i f f e r e n t aspects of health. No two of the three health scales overlap as much as the components of the scale i t s e l f , suggesting that these three scales evidence discriminant v a l i d i t y (Campbell & Fiske, 1967). Items i n both health knowledge scales r e f e r to aspects of ph y s i c a l and s o c i a l health which should be f a m i l i a r to older people. These scales can thus be assumed to possess face v a l i d i t y . The fact that the concepts of physical, emotional, s o c i a l function and health knowledge have been succ e s s f u l l y operationalized means that these concepts have substance, i n d i c a t i n g that a l l f i v e scales evidence construct v a l i d i t y . TESTS OF HYPOTHESES Nicholson and Sunset Towers are B r i t i s h Columbia housing complexes for senior c i t i z e n s i n the West End of Vancouver. Since 1974 senior c i t i z e n s i n both complexes have received " d i f f e r e n t nursing programs, both of which are provided by the Province of B.C. Home Care program. Nursing services i n Sunset Towers are mostly treatment oriented. The nursing - 76 -program i n Nicholson Towers incorporates many of the factors 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 health and reducing health costs. Hypothesis 1 stated that health knowledge, health behaviour and health  status of senior c i t i z e n s i n Nicholson Towers w i l l be s i g n i f i c a n t l y greater  than that of senior c i t i z e n s i n Sunset Towers. Comparisons between the two complexes are presented i n Table 10. Residents of Nicholson Towers had s i g n i f i c a n t l y (81% vs. 68%) greater health knowledge, s i g n i f i c a n t l y (87% vs. 73%) more healthy behaviours, s i g n i f i c a n t l y (45.69 vs. 44.42) greater p h y s i c a l function and s i g n i f i c a n t l y (27.46 vs. 25.07) greater s o c i a l function than residents of Sunset Towers. There were no s i g n i f i -cant differences i n emotional function between residents of the two complexes. Based on these r e s u l t s , Hypothesis 1 ..was accepted for four of i t s f i v e components. Hypothesis 2 stated that over an 8 month period, the average number  of health related v i s i t s made by or to residents of Nicholson and Sunset  Towers w i l l be s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers. There were no s i g n i f i c a n t differences i n average number of health r e l a t e d v i s i t s between residents of the two complexes. Based on these r e s u l t s , Hypothesis 2 was rejected. Hypothesis 3 stated: over an 8 month period average costs of a l l health  services provided to residents of Nicholson and Sunset Towers w i l l be  s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers. There were no s i g n i f i c a n t differences i n average costs between residents of the two complexes. Based on these r e s u l t s , Hypothesis 3 was rejected, even though some subcomponents of the t o t a l cost figures show s i g n i f i c a n t d i f f e r e n c e s . Hypothesis 4 stated: Of those residents e l i g i b l e f or Long Term Care, a s i g n i f i c a n t l y greater percentage i n Nicholson than i n Sunset Towers, w i l l TABLE 10 : ANALYSIS OF VARIANCE BETWEEN COMPLEXES AND BETWEEN LEVELS OF NURSING SERVICE Receiving nursing Receiving nursing Never received Complex Variable services at time services in nursing totals Significance of study past 2 years services Nicholson Sunset Nicholson Sunset Nicholson Sunset Nicholson Sunset Complex Service A + B Towers Towers Towers Towers Towers Towers Towers Towers Level l e v e l l e v e l (A) (B) Number l n each condition 30 13 15 17 20 29 65 59 Differences between nursing programs 2.95 2.00 3.00 2.00 — — 2.97 2.00 .001 .877 .877 77 23 47 13 — — 67 17 .001 .060 .363 Biographical information .048 80.67 73.77 78.07 71.65 76.60 77.07 78.81 74.78 .002 .312 80 77 80 88 70 72 77 78 .752 .421 .847 10 15 13 6 10 17 11 14 .783 .861 .582 5.20 4.92 5.67 4.53 5.60 5.10 5.43 4.90 .018 .620 .390 7.57 8.61 7.47 9.18 7.55 8.28 7.54 8.61 .028 ,851 .736 23 23 13 23 40 24 26 23 .812 .394 .433 47 77 40 59 10 10 . 34 39 .045 .001 .322 1.57 2.08 1.60 1.76 0.80 0.97 1.34 1.44 .149 .001 .701 60.90 94.31 43.73 66.65 36.55 28.79 49.45 54.14 .097 .001 .201 Benefits 92 71 85 69 64 65 81 68 .001 .001 .025 91 71 95 74 75 74 87 73 .001 ,020 .001 43.07 36.00 46.80 44.59 48.80 48.10 45.69 44.42 .002 .001 .038 36.90 32.15 39.73 35.94 38.55 40.97 38.06 37.58 .052 .001 .011 25.17 17.62 32.40 25.12 27.20 28.38 27.46 26.07 .016 .003 .098 Those e l i g i b l e for long term care who continue to l i v e .447 .016 .560 17 8 0 0 0 0 8 2 Mean number of recalled prevented hospitalizations 0.13 0.0 0.0 0.0 — — 0.09 0.0 .326 .326 .326 Mean number of recalled prevented physician v i s i t s 1.10 0.15 0.13 0.0 — — 0.78 0.07 .089 .078 .199 37 8 20 0 — — 31 3 .010 .192 .629 7 0 0 0 — — 4 0 .400 .400 .400 0 0 0 0 — — 0 0 .999 .999 .999 1.87 1.39 1.53 0.82 0.3 0 1.31 0.54 .001 .001 .204 1.57 0.69 1.13 0.12 0.4 0.28 1.11 0.32 .001 .001 .005 2.74 3.00 2.86 2.50 — — 2.8 2.8 .827 .388 .167 1.47 0.83 1.27 0.12 — — 1.40 0.41 .001 .011 .147 Number of health related v i s i t s 5.80 4.54 5.73 7.18 3.95 5.07 5.22 5.56 .632 .206 .413 1.46 1.76 1.97 3.00 •1.20 2.41 0.90 0.86 .129 .027 .519 .97 1.92 1.53 4.41 0.30 1.48 0.89 2.42 .006 .016 .365 9.67 12.08 6.47 7.41 4.60 6.34 7.37 7.91 .290 .020 .932 2.57 6.25 4.00 3.88 0.45 0.79 2.25 2.83 .337 .048 .458 27.03 13.92 4.07 0.47 0.0 0.0 13.41 3.20 .016 .001 .055 48.00 53.23 23.00 25.77 10.20 14.55 30.60 26.31 .368 .001 .975 Costs i n dollars of: 70.76 61.81 65.16 85.99 48.91 48.43 62.74 62.20 .713 .101 .480 49.70 79.94 40.53 72.93 26.92 20.97 40.58 48.94 .177 .043 .452 7.05 17.20 12.20 38.99 4.02 12.91 7.31 21.37 .002 .011 .243 139.83 178.89 59.01 76.08 54.24 71.47 94.84 96.47 .435 .020 .947 324.54 507.26 377.60 294.31 100.49 133.56 267.71 257.99 .783 .294 .785 540.67 278.46 81.33 9.41 0.0 0.0 268.31 64.07 .016 .001 .055 3.04 30.08 14.55 20.45 2.21 4.28 5.44 18.43 .129 .027 .519 69.88 88.74 36.27 74.88 46.67 36.29 54.98 58.97 .183 .032 .233 1205.19 1286.18 686.64 673.04 283.45 327.92 801.91 627.34 .847 .001 .980 Number of comparisons which favour each complex 31 9 32 6 19 10 31 9 - 78 -consider that they are able to continue l i v i n g i n the apartment because  nurses are accessible. Table 10 shows that there were no s i g n i f i c a n t differences between residents of the two complexes on this v a r i a b l e . Hypothesis 4 was rejected on the basis of these r e s u l t s . Implications of a l l the above findings as well as s i g n i f i c a n t but non-hypothesized findings are discussed i n Chapter V. DIFFERENCES BETWEEN APARTMENT COMPLEXES This study examined differences i n costs and benefits between com-plexes and between l e v e l s of nursing service. Analyses of variance between apartment complexes and between l e v e l s of nursing service are presented i n Table 10. Sources of v a r i a t i o n tested i n this study are differences between nursing programs, costs and benefits of programs and biographical v a r i a b l e s . Some questionnaire items applied only to i n d i v i d u a l s who were re-c e i v i n g , or had received, nursing s e r v i c e s . For these items there are no data i n the column headed "Never received nursing services"; and complex tota 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 applied. D i f f e r -ences between l e v e l s of nursing service are discussed l a t e r i n this chapter. Nursing Programs Nursing services i n Nicholson Towers are s i g n i f i c a n t l y (2.97 vs. 2.00 on a 3 point scale) more accessible than those i n Sunset Towers. S i g n i -f i c a n t l y (67 i n d i v i d u a l s vs. 17 i n d i v i d u a l s ) more counselling occurs i n Nicholson than in.Sunset Towers. More health education occurs i n Nicholson than i n Sunset Towers. Nurses i n Nicholson Towers spend approxi-mately 90 hours per month educating residents; nurses i n Sunset Towers, 15 hours. - 79 -Biographical Data Residents of Nicholson Towers were s i g n i f i c a n t l y (78.81 years vs. 74.78 years) older, had s i g n i f i c a n t l y (5.43 vs. 4.90) higher socio-economic status, and s i g n i f i c a n t l y (7.54 years vs. 8.61 years) fewer years of schooling. A s i g n i f i c a n t l y (34% vs. 39%) lower percentage of residents was e l i g i b l e f o r Long Term Care i n Nicholson than i n Sunset Towers. There were no s i g n i f i c a n t differences between residents of the two complexes i n terms of sex, marital status, a d d i t i o n a l education, number of medical conditions and number of l i f e change units. Thus one can rule out the notion that the favourable conditions i n Nicholson Towers might be due to sharp differences i n the p r i o r health status of residents i t a t t r a c t s . Benefits df Programs Residents of Nicholson Towers had s i g n i f i c a n t l y (81% vs. 68%) greater health knowledge; a s i g n i f i c a n t l y (87% vs. 76%) greater percentage of healthy behaviours; s i g n i f i c a n t l y (45.69 vs. 44.42) greater physical function; and s i g n i f i c a n t l y (27.46 vs. 25.07) higher s o c i a l function than those i n Sunset Towers. The possible range i n physical function scores was 11 to 56. The observed range i n s o c i a l function scores was 5 to 61. In Nicholson Towers a s i g n i f i c a n t l y higher (31 vs. 3) number of residents r e c a l l e d an occasion i n the l a s t year on which consultation with the nurse led to taking less medication. In Nicholson Towers perceived benefit of the nurses i s s i g n i f i c a n t l y (1.31 vs. 0.54 on a 3 point scale) higher, and f e e l i n g of sec u r i t y from presence of the nurses i s s i g n i f i c a n t l y (1.11 vs. 0.32 on a 3 point scale) higher than i n Sunset Towers. There were no s i g n i f i c a n t differences between residents of the two complexes i n terms of numbers of i n d i v i d u a l s e l i g i b l e f or Long Term Care - 80 -who considered they were able to continue l i v i n g i n the complex because nurses were accessible. There were also no s i g n i f i c a n t differences between residents of the two complexes i n terms of emotional function, number of r e c o l l e c t i o n s of physician v i s i t s and h o s p i t a l i z a t i o n s having been pre-vented, nurse consultations which led to taking more medication or d i s -carding medication or perceived benefits of counselling sessions. Number of Health Related V i s i t s There were no s i g n i f i c a n t differences i n average number of health r e l a t e d v i s i t s i n the time period January 1 to August 31, 1978 between residents of the two complexes. Nicholson Towers had, however, s i g n i -f i c a n t l y (0.89 vs. 2.42) fewer v i s i t s to paramedical personnel and s i g n i f i c a n t l y (13.41 vs. 3.20) more nurses' v i s i t s . Although there are no s i g n i f i c a n t differences between the complexes i n terms of v i s i t s to s p e c i a l i s t s , general p r a c t i t i o n e r s , laboratories and h o s p i t a l s , findings regarding v i s i t s to the l a t t e r three favour Nicholson Towers i n that there were fewer of these v i s i t s i n t h i s b u i l d i n g . Average Costs of Health Services There were no s i g n i f i c a n t differences i n average costs of health services i n the time period January 1 to August 31, 1978 between residents of the two complexes. Costs of v i s i t s to paramedical personnel are s i g n i -f i c a n t l y ($7.31 vs. $21.37) lower i n Nicholson than i n Sunset Towers. On the contrary, costs of nurses' v i s i t s are s i g n i f i c a n t l y ($268.31 vs. $64.07) higher i n Nicholson than i n Sunset Towers. (Costs of nursing v i s i t s were computed by multiplying each v i s i t by $20. This figure includes overhead costs.) Examination of Table 10, page 77, shows that although there are no further s i g n i f i c a n t differences between complexes i n terms of costs, findings regarding costs of s p e c i a l i s t v i s i t s , laboratory v i s i t s , post-- 81 -operative v i s i t s and medication favour Nicholson Towers. Findings regarding cost 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 p r a c t i t i o n e r s favour Sunset Towers. Sources of Health Information Home Care nurses spend approximately 90 hours a month educating residents i n Nicholson Towers, and 15 hours i n Sunset Towers. Analysis of variance (Table 10, page 77) shows that residents of Nicholson Towers had s i g n i f i c a n t l y (81% vs. 68%) greater health knowledge than those i n Sunset Towers. Health knowledge i s influenced by such variables as socio-economic status and l e v e l of education. With what confidence can the greater health knowledge of residents i n Nicholson Towers be at t r i b u t e d to the greater amount of health education which occurs here? Data were c o l l e c t e d on sources of health information. For each health question 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, or what, did you f i r s t l earn t h i s ? " Table 11 shows that residents of Nicholson Towers obtained s i g n i f i c a n t l y (19% vs. 1%) more health informa-ti o n from the Home Care nurses; and also s i g n i f i c a n t l y (3% vs. 0%) more health information from other residents i n the complex than those i n Sunset Towers. Residents of Sunset Towers obtained s i g n i f i c a n t l y (47% vs. 36%) more health information from the doctor. There were no other s i g n i f i c a n t differences between residents of the two complexes i n terms of sources of health information. These data suggest very strongly that the greater health knowledge of residents i n Nicholson Towers can be at t r i b u t e d to the greater amount of health education (by Home Care nurses) which occurs i n this complex, due to the in-house a v a i l a b i l i t y of the nurses. TABLE 11 ANALYSIS OF VARIANCE OF SOURCES OF HEALTH INFORMATION Variable Receiving Received Never Nursing Nursing Receiv Services at Services i n Nursl Time of Study Past 2 Years Services Received Complex „. . r. o • x. n • • \ T T 1 n Significance rsing Totals ° Nich. Sunset Nich. Sunset Nich. Sunset Nich. Sunset Complex Service Complex T. T. T. T. T. T. T. T. l e v e l and service l e v e l imber of residents 30 13 15 17 20 29 65 59 ircentage of health [formation: % % % % % % % % obtained from doctor 32 61 40 44 40 43 36 47 .003 .497 .012 obtained from nurse 5 3 2 0 1 1 3 1 .235 .042 .570 obtained from nurse i n apartment complex 30 3 24 1 0 0 19 1 .001 .001 .001 obtained from resident of complex 1 0 1 0 6 0 3 0 .006 .060 .060 obtained from f r i e n d / r e l a t i v e 1 0 1 4 2 2 1 2 .349 .253 .206 obtained from mass media 4 8 6 8 10 18 7 13 .143 .048 .690 known for a long time 22 24 20 41 34 31 25 32 .128 .850 .846 for which source could not be i d e n t i f i e d 5 3 7 3 6 4 6 4 .088 .097 .034 - 83 -Setting In Which Health Information i s Learned The l i t e r a t u r e on adult health education i d e n t i f i e s many factors which influence the effectiveness of health education. Group discussions are more e f f e c t i v e at changing health behaviours and attitudes than techniques which allow l i t t l e learner p a r t i c i p a t i o n . The intermediate goal of health education i s to modify behaviour. Data were c o l l e c t e d on the s e t t i n g i n which residents learned health information. For each health question c o r r e c t l y answered, the i n d i v i d u a l was asked, "Did you learn this on a one-to-one basis or i n a s e t t i n g with other people?" There was no variance i n response to these items. A l l i n d i v i d u a l s reported having learned information on an i n d i v i d u a l b a s i s . Given the amount of time Home Care nurses i n Nicholson Towers spend on education; the amount of health knowledge considered basic to health maintenance i n a l l older people; greater effectiveness of group discussions i n changing behaviour; increased effectiveness of health education when more than one technique i s used; Home Care nurses i n Nicholson Towers could explore the p o s s i b i l i t y of conducting health education groups. This i s examined i n greater d e t a i l l a t e r i n Chapter V. Health Behaviour Analysis of variance (Table 10, page 77) shows that the percentage of healthy behaviours i s higher than, or equal to, the percentage of health knowledge (both between complexes and between service l e v e l s ) . This f i n d i n g i s unexpected. People often know what they should do, but do not engage i n the advocated healthy behaviour. This contrary f i n d i n g can be explained as follows: many residents did not know the answers to p a r t i c u l a r health knowledge questions, but reported engaging i n healthy behaviours. For example, many residents reported not knowing how many cups of l i q u i d - 84 -they should drink i n one day but reported drinking 6-8 cups (the advocated amount). PREDICTORS OF PHYSICAL, EMOTIONAL AND SOCIAL FUNCTION Analysis of variance i d e n t i f i e d s i g n i f i c a n t differences i n p h y s i c a l and s o c i a l function between residents of the two complexes. Residents of Nicholson Towers were found to have s i g n i f i c a n t l y (45.69 vs. 44.42) greater physical function and s i g n i f i c a n t l y (27.46 vs. 25.07) greater s o c i a l function than residents of Sunset Towers. Many variables are known to influence health (e.g. health knowledge, age, s t r e s s , number of medical conditions). I t i s therefore important to assess the influence of a p a r t i -cular v a r i a b l e , together with other v a r i a b l e s , on health. Stepwise l i n e a r regression was used to assess the influence of 13 variables postulated to influence health, on p h y s i c a l , emotional and s o c i a l function. Table 12 presents the proportions of variance i n physical, emotional and s o c i a l functioning accounted for by each of these v a r i a b l e s . This table shows that the 13 l i s t e d variables account for 54 per cent of the variance i n physical function, 41 per cent of the variance i n emotional function and 33 per cent of the variance i n s o c i a l function. Differences i n p h y s i c a l function can be c h i e f l y accounted for by e l i g i b i l i t y for Long Term Care, number of l i f e changes (stress) and apartment complex. D i f f e r -ences i n emotional function can be accounted for c h i e f l y by e l i g i b i l i t y f o r Long Term Care, health behaviour, number of medical conditions and years of schooling. Differences i n s o c i a l function can be accounted for mainly by health knowledge, l e v e l of nursing service, and e l i g i b i l i t y for Long Term Care. Analysis of variance (Table 10, page 77) i d e n t i f i e d s i g n i f i c a n t differences between residents 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 Physical Function Social Function Variable Emotional Function  N* Step No. R squared Beta Step No. R squared Beta Step No. R squared Beta change change change  Apartment complex and  l e v e l of nursing  service Apartment complex Level of nursing service Biographical  variables Age Sex Socio-economic status Years of schooling P r i o r medical status Number of medical conditions Number of l i f e changes E l i g i b i l i t y for long term care Health knowledge  and behaviour Health knowledge Health behaviour Psychological e f f e c t  of presence of nurses Feeling of security from presence of nurses Perceived benefit of nurses Proportion of t o t a l variance accounted for T otal number of steps 124 4 .05 -.25 13 .00 .03 7 .01 -.13 124 6 .01 .19 5 .04 .28 2 .07 .16 124 13 .00 -.02 6 .02 .17 9 .01 .09 124 9 .00 -.06 10 .00 -.08 11 .00 .00 124 10 .00 .06 11 .00 .07 -.06 124 8 .00 .10 4 .05 .26 5 .02 .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 11 .00 -.09 7 .01 .24 1 .13 .08 124 12 .00 .07 2 .07 .20 12 .00 .34 124 3 .04 -.39 8 .01 -.19 6 .02 -.39 124 7 .02 -.22 9 .01 -.15 8 .01 -.26 0.54 0.41 0.33 13 13 12 N* = Number of persons for whom comparisons were appropriate. - 86 -numbers of people e l i g i b l e for Long Term Care. Table 12 (page 85) shows that age and sex account for small proportions of variance i n physical, s o c i a l and emotional function. E l i g i b i l i t y for Long Term Care accounts for a large proportion of variance 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 for Long Term Care accounts for a large (30%) per-centage of variance i n physical function, i s not hard to explain. Residents e l i g i b l e for Long Term Care have been assessed as such because t h e i r physical function i s poor ( i . e . they need help with cooking, cleaning or shopping). Independence i s of great importance to older people. Decreased mobility and independence probably a f f e c t s e l f esteem and hence emotional function. The s o c i a l function index measures s o c i a l a c t i v i t i e s , many of which involve p h y s i c a l function. Decreased physical function may thus be r e f l e c t e d i n decreased s o c i a l function. The s i g n i f i c a n t l y (39% vs. 34%) greater percentage of residents e l i g i b l e for Long Term Care i n Sunset Towers can be explained as follows . Individuals i n each complex were randomly selected from three categories: those, receiving nursing services at the time of the study; those who had received nursing services i n the past two years; those who had never received nursing s e r v i c e s . Nursing services i n Sunset Towers were being given to a small (13) number of i n d i v i d u a l s at the request of a physician. There i s administrative pressure to discontinue seeing i n d i v i d u a l s as soon as possible ( i . e . as soon as physical health improves). I t i s l i k e l y that a high proportion of people i n this category were i n poor physical health and had poor physical function. Nursing services i n Nicholson Towers were being given to a large (75) number of i n d i v i d u a l s ; i n d i v i d u a l s considered by Home Care nurses to be i n need of services of a curative or preventive nature. -Individuals are seen - 87 -for longer periods of time than i n Sunset Towers. I t i s thus l i k e l y that the proportion of people i n this category with poor phy s i c a l function i s lower i n Nicholson than i n Sunset Towers. The same argument applies to people i n the category "received nursing services i n the two year period preceding the study but not i n the month preceding the study", i . e . i t i s l i k e l y that i n Sunset Towers only i n d i v i -duals with poor physical function received nursing services i n the past two years. Many of them may s t i l l have poor physical function. In Nicholson Towers, on the other hand, a larger number of i n d i v i d u a l s re-ceived nursing services i n the past 2 years. Some of them may have been receiving services of a purely preventive nature and may never have had poor physical function. It i s thus l i k e l y that the proportion of people i n this category with poor physical function i s lower i n Nicholson than i n Sunset Towers. E l i g i b i l i t y for Long Term Care accounts for a large percentage of variance i n physical function (30%) and emotional function (13%) but for only a small percentage of variance i n s o c i a l function (3%). A s i g n i f i -cantly (39% vs. 34%) greater percentage of residents i n Sunset Towers are e l i g i b l e f o r Long Term Care than i n Nicholson Towers. This could account for the fi n d i n g that residents of Sunset Towers have s i g n i f i c a n t l y (44.42 vs. 45.69) lower physical function than residents of Nicholson 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 differences between residents of the two complexes i n terms of average costs of health services. A number of variables are postulated to influence costs of health care. The influence of these variables on health costs was assessed using stepwise l i n e a r regression. - 88 -Table 13 presents the proportions of variance i n health costs accounted for by 16 v a r i a b l e s . Level of nursing service accounts for the most variance (14 per cent), amount of stress accounts for 5 per cent of the variance and sex for 3 per cent of the variance i n t o t a l costs. That l e v e l of nursing service and amount of stress account for much variance i n costs i s not hard to explain. People receiving nursing service are i n t h i s category because they are not w e l l ; i t i s to be expected that t h e i r demand on the health care system would be great. Amount of stress has been docu-mented to be associated with i l l n e s s ; and hence with demand on the health system. Sex accounts for 3 per cent of the variance i n costs. Table 14 shows that males cost the system more than females. Males have a higher demand for h o s p i t a l services and a lower demand for medication than any other type of health service. Tables 14 and 15 show that a l l variables combined account for only 40 per cent of the variance i n average number of v i s i t s and 26 per cent of the variance i n average health costs. A large amount of variance i s therefore unaccounted f o r . The following factors could account for some of the remaining variance: severity of i l l n e s s was not measured; i n t e r -i n d i v i d u a l differences; some ind i v i d u a l s v i s i t health personnel when they are not i l l ; differences between health personnel i n terms of number of times they see a c l i e n t f o r a s p e c i f i c complaint and numbers and type of laboratory procedures requested. Entries on Table 14 are standardized p r e d i c t i o n c o e f f i c i e n t s and allow for some i n t e r e s t i n g observations. I.Variables with a negative sign save the health care system money; those with a p o s i t i v e sign cost the system money. The column marked "Total Costs" indicates that each point on the 3-point answer scale to the question "Does the fact that TABLE 13 VARIANCE IN HEALTH CARE COSTS ACCOUNTED FOR BY BIOGRAPHICAL AND HEALTH STATUS VARIABLES Costs In Dollars of the Following Medication Total Costs G.P. S p e c i a l i s t Paramedical Laboratory Hospital Post Op. Nurses V i s i t s V i s i t s V i s i t s V i s i t s Days V i s i t s V i s i t s Step R sq. Step R sq. Step R sq. Step R sq. Step R sq. Step R sq. Step R sq. Step R sq. Step R sq. No. Change No. Change No. Change No. Change No. Change No. Change No. Change No. Change No. Change N * Apartment Complex and Level of Nursing Service Apartment complex 124 8 Level of nursing servicel24 5 Biographical Variables .01 .01 12 .00 .07 .01 14 1 .00 .05 9 12 .00 .00 14 6 .00 .03 .36 13 1 .00 .06 Prior Medical Status Number of medical conditions Number of l i f e change units E l i g i b i l i t y for Long Term Care Health Knowledge and Behaviour Health knowledge Health behaviour Health Status 124 124 10 9 .01 .01 .00 .00 3 11 .03 .01 5 10 .02 .00 5 15 .01 .00 12 1 .00 .05 .01 .01 .01 .04 16 1 5 12 .00 .14 Age 124 12 .01 8 .01 10 .00 13 .00 14 .00 5 .01 8 .00 Sex 124 11 .01 5 .01 5 .03 9 .00 1 .06 10 .01 5 .00 9 3 .03 Years of schooling 124 15 .00 2 .03 4 .01 15 .00 6 .00 4 .01 4 .01 Socio-economic status 124 13 .00 13 .00 13 .00 12 .00 8 .01 9 .01 13 .00 7 .01 9 .00 124 16 .00 4 .01 10 .01 13 .00 14 .00 8 .01 4 .01 3 .02 13 .00 124 3 .02 1 .07 16 .00 3 .02 3 .02 2 .03 15 .00 8 .00 2 .05 124 2 .02 6 .00 14 .00 4 .01 3 .02 3 .02 12 .00 11 -.00 .01 .00 Physical function 124 1 .08 11 .00 12 .00 11 .00 2 .04 11 .00 11 .00 15 .00 7 .01 Emotional function 124 6 .01 7 .00 9 .01 6 .03 11 .00 4 .02 12 .00 14 .00 15 .00 Social function 124 7 .03 10 .00 6 .02 7 .01 13 .00 7 .01 7 .00 14 .00 Psychological Effect of Presence of Nurses Perceived benefit of nurses 124 14 .00 2 .02 15 .00 8 .01 7 .01 16 .00 10 .00 11 .00 10 .00 Perceived security from presence of nurses 124 4 .02 3 .12 4 .03 2 .04 6 .02 5 .01 2 .06 10 .00 6 .01 Proportion of t o t a l variance accounted for .23 .26 .26 .21 .17 .20 .49 .16 .26 Total number of steps 16 13 16 14 15 16 15 15 16 TABLE 14 PREDICTION COEFFICIENTS (BETA) FOR HEALTH COSTS FOR 16 VARIABLES Costs i n Dollars of G.P. V i s i t s Beta Spec-i a l i s t V i s i t s Beta Para-medical V i s i t s Beta Labor- Hosp-atory I t a l V i s i t s Days Beta Beta Mean ... ... t . Total P r e d i c t i v i t y of V i s i t s cation „ m J Costs Total Total V i s i t s Costs and Costs Post-op- Nurses Medi-erative Beta Beta Beta Apartment Complex and  Level of Nursing Service Apartment complex .13 .00 .29 .03 .05 .04 .00 .05 -.02 Level of nursing service .27 -.04 -.21 -.18 -.04 -.25 -.51 -.17 .22 Biographical Variables Age -.08 .00 -.11 .00 -.05 -.03 .02 -.13 -.05 Sex -.10 -.13 .18 -.09 -.28 -.07 .06 .05 -.22 Years of schooling -.03 .00 .12 .00 -.08 .03 -.09 -.19 -.10 Socio-economic status .05 .01 .06 .03 .07 .08 .02 -.09 .07 Prior Medical Status Number of medical conditions Number of l i f e change units E l i g i b i l i t y for Long Term Care Health Knowledge and  Behaviour Health knowledge Health behaviour Health Status Physical function Emotional function Social function Psychological Effects of  Presence of Nurses Perceived benefit of nurses Perceived security from presence of nurses Percentage of Variance Accounted for After A l l Sig n i f i c a n t Variables Minimum Standard Error At Step Number .14 .08 .16 .07 ,02 .14 .12 .04 -.01 .15 .12 .09 .05 17 .14 .02 .11 .12 .10 .01 .10 .15 .10 .10 ,25 .09 .05 .19 .00 -.17 .14 -.04 -.06 ,16 .11 -.31 .26 .15 -.09 .13 .12 .21 .15 .14 ,20 -.08 -.13 -.10 .02 -.15 -.14 -.25 -.09 ,04 .03 .08 -.07 -.21 .05 .08 .03 -.14 ,24 -.12 .11 -.25 .05 .26 -.04 -.04 -.03 .11 .11 ,26 .05 .16 .16 -.03 -.13 .11 .00 .06 ,07 -.55 .05 -.20 -.14 -.04 .13 .08 -.12 .24 .23 ,33 -.57 .29 -.42 -.30 -.30 .37 .13 -.18 .23 .26 .26 .20 .17 .20 .49 .17 .26 ,20 .24 .26 .19 .16 .18 .48 .15 .24 8 5 11 8 7 8 9 6 6 TABLE 15 PREDICTION COEFFICIENTS (BETA) FOR NUMBERS OF HEALTH RELATED VISITS FOR 16 VARIABLES G.P. S p e c i a l i s t Paramedical Laboratory Hospital Nurses Apartment Complex and Level of Nursing Service Apartment complex Level of nursing service Biographical Variables Age Sex Years of schooling Socio-economic status Prior Medical 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 Health Knowledge and Behaviour Health knowledge Health behaviour ifealth Status Physical function Emotional function Social function Psychological E f f e c t of Presence of Nurses Perceived benefit of nurses Perceived security from presence of nurses V i s i t s V i s i t s Beta Beta V i s i t s Beta V i s i t s Beta Days Beta V i s i t s Beta Total V i s i t s Beta 16 .00 .29 .13 -.05 .00 .10 29 -.12 -.23 -.26 -.10 -.50 .42 10 .08 -.14 .02 -.03 .02 -.02 08 -.06 .16 -.12 -.16 .06 -.04 03 .02 .11 .00 . -.09 -.09 -.06 10 .00 .06 -.02 .05 .02 .05 08 .18 .11 -.04 .05 .12 .12 13 .19 -.03 .07 .13 .01 .11 10 .15 .05 .12 -.11 .14 .10 22 .02 -.26 .20 .08 .13 .18 15 .02 -.14 .05 -.07 -.14 -.14 07 .05 .09 .05 -.05 .08 .06 17 -.19 .10 -.27 .08 -.04 -.13 27 .10 .22 .04 -.06 .10 .15 15 -.44 .03 .07 -.27 .13 -.04 20 -.55 .29 -.06 -.42 .37 .12 Mean P r e d i c t i v i t y of Total Total V i s i t s V i s i t s and Costs .19 .06 .10 .13 .11 .22 .16 .07 .10 .14 .11 .23 I After A l l S i g n i f i c a n t Variables .17 .28 .26 .15 .17 .49 .40 Minimum Standard Error At Step Number .15 .26 .24 .14 .15 .46 .35 10 7 10 6 6 6 4 - 92 -nurses come into this b u i l d i n g make you f e e l more secure?" saves the system 18 cents. S i m i l a r l y each point on the 3-point answer scale to the question "Do you receive any benefit from the nurses i n the b u i l d i n g ? " saves the system 12 cents. Each i n d i v i d u a l scale point on the health behaviour scale saves the system 9 cents. On the other hand, each point on the stress scale costs the system 15 cents, and each l e v e l of the three l e v e l s of nursing costs the system 22 cents. It i s i n t e r e s t i n g that the greater the perceived b e n e f i t from the presence of the nurses and the greater the f e e l i n g of security from t h e i r presence, the greater the economic saving to the health care system. The sense of s e c u r i t y which residents have from the presence of the nurses therefore has economic b e n e f i t s . Yet the nurses are not i n the b u i l d i n g 24 hours a day. I t may therefore be the i l l u s i o n of security which i s important or the cert a i n t y of the a r r i v a l of the nurse the next day. Entries on Table 15 are also standardized p r e d i c t i o n c o e f f i c i e n t s . Variables with a negative sign reduce demand for health care v i s i t s ; those with a p o s i t i v e sign increase demand for health care v i s i t s . Each l e v e l of the three l e v e l s of nursing service produces a demand on the system of h a l f a v i s i t . Each point on the health knowledge scale produces a demand for .18 of a v i s i t . (People with greatest health knowledge were those with poorest physical function. Greater contact with health pro-fessionals presumably resulted i n greater health knowledge.) Each point on the health behaviour and emotional function scales reduces demand for health care v i s i t s by approximately .13 of a v i s i t . The second l a s t column on Table 14 indicates which variables are good predictors of costs. The same column on Table 15 shows which variables are good predictors of numbers of health r e l a t e d v i s i t s . The l a s t column on each table indicates which variables are good predictors of costs and - 93 -number of health related v i s i t s combined. The findings are s i m i l a r i n a l l three cases. Perceived b e n e f i t of the nurses and perceived security from the presence of the nurses are the best p r e d i c t o r s . Apartment complex and l e v e l of nursing service are the next most powerful predictors; and health knowledge and health behaviour the t h i r d most powerful predictors of costs, number of health r e l a t e d v i s i t s and costs and health r e l a t e d v i s i t s combined. Perceived b e n e f i t from the presence of the nurses and perceived security from the nurses have almost twice as much explanatory power i n terms of health costs and number of v i s i t s as health knowledge and behaviour. As predictors of costs and number of health related v i s i t s , apartment complex and l e v e l of nursing service are almost as powerful as perceived security and b e n e f i t from the presence of the nurses. Examination of Tables 14 and 15 shows that l e v e l of nursing service i s the stronger predictor of the two v a r i a b l e s . That this v a r i a b l e i s a strong predictor can be explained by the f a c t that people who have never received nursing services are l i k e l y w e l l and use the health care system very l i t t l e ; those who are receiving nursing services are not w e l l and are thus using health services a great deal. That health knowledge and health behaviour are good predictors of costs and number of health related v i s i t s can be explained as follows. There were s i g n i f i c a n t differences i n health knowledge and behaviour between the three l e v e l s of nursing service with those receiving nursing services at the time of the study having the best health knowledge and behaviour and those who had never received nursing services having the poorest. There were also s i g n i f i c a n t differences i n costs and number of health r e l a t e d v i s i t s between the three l e v e l s of nursing service with those receiving nursing services at the time of the study having the highest number of health related v i s i t s and costs and those who had never received nursing services the lowest. Those with.the greatest contact with health professionals thus have the best health knowledge and behaviour and cost 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 Hypothesized r e l a t i o n s h i p s related to differences between complexes. One would a n t i c i p a t e that there would also be differences i n costs, health status and health knowledge between service l e v e l s ( i . e . between people receiving nursing services at the time of the study; people who received nursing services i n the past; and people who never received nursing s e r v i c e s ) . Data on differences (and d i r e c t i o n of differences) between service l e v e l s are presented i n Table 10, page 77. There were s i g n i f i c a n t d i f f e r -ences between residents at the three l e v e l s of nursing service i n terms of percentage of residents e l i g i b l e f or Long Term Care and percentage of residents who considered they could continue l i v i n g i n the complex because nurses are accessible. The highest percentage i n each of the above categories was found among those who were receiving nursing services at the time of the study; the lowest percentage among those who had never received nursing services. Residents who had never received nursing services had s i g n i f i c a n t l y fewer medical conditions, had experienced s i g n i -f i c a n t l y l e s s stress and had s i g n i f i c a n t l y greater physical and emotional function than residents who had received nursing services i n the past. The l a t t e r , i n turn, had s i g n i f i c a n t l y fewer medical conditions, less stress and greater p h y s i c a l and emotional function than those who were re c e i v i n g nursing services at the time of the study. There were s i g n i f i c a n t differences between residents at the three l e v e l s of nursing service i n terms of health knowledge, health behaviour, perceived benefit of the nurses and f e e l i n g of security from the presence of the nurses. Those who were receiving nursing services at the time of the study had the best health knowledge and behaviour, perceived the greatest b e n e f i t from the nurses and had the greatest f e e l i n g of s e c u r i t y from the presence of the nurses. Those who had never received nursing services had the poorest health knowledge and behaviour and perceived the l e a s t benefit and had 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 the nurses. There were also s i g n i f i c a n t differences between residents at the three l e v e l s of nursing service i n terms of number of v i s i t s to h o s p i t a l s , laboratories, nurses and t o t a l number of health r e l a t e d v i s i t s and costs of v i s i t s to s p e c i a l i s t s , l a b o r a t o r i e s , nurses, medication and t o t a l cost of health services. Those who were re c e i v i n g nursing services at the time of the study had the greatest number of these v i s i t s and costs; those who had never received nursing services, the l e a s t . Residents who received nursing services i n the past had s i g n i f i c a n t l y greater s o c i a l function, a s i g n i f i c a n t l y greater number of v i s i t s to s p e c i a l i s t s and paramedical personnel and s i g n i f i c a n t l y greater costs of v i s i t s to paramedical personnel than those who were receiving nursing services at the time of the study. The l a t t e r , i n turn, scored s i g n i f i c a n t l y higher on these variables than those who had never received nursing services. - 9 6 -CHAPTER V SUMMARY, DISCUSSION OF RESULTS, RECOMMENDATIONS AND CONCLUSIONS SUMMARY OF STUDY Costs of health care i n Canada have r i s e n isharply i n recent years. Federal and P r o v i n c i a l Governments have recognized that there should be increased emphasis on promoting and maintaining health and are implementing preventive health care programs. Alternate forms of health care delivery should be developed for e l d e r l y people since the proportion of e l d e r l y people i n the population i s increasing and they consume a disproportionate amount of the most expensive forms of health service. Eighty s i x per cent of el d e r l y people have chronic diseases which require self-maintenance s k i l l s . Health education about managing disease and healthy behaviour reduces h o s p i t a l i z a -tion rates and promotes health. Factors which promote health of older people are early detection of disease, ease of access to emotional support i n times of c r i s i s and prevention of s o c i a l i s o l a t i o n . Alternate forms of health care delivery for this age group should be accessible, emphasize health promotion through health education and early detection of disease and be based i n the community (rather than i n an i n s t i t u t i o n ) . Two factors presumed to be important i n promoting health of e l d e r l y people were investigated i n this study. These factors are health educa-t i o n and ease and qua l i t y of contact with health professionals. The review of l i t e r a t u r e on factors which influence the effectiveness of health - 97 -education revealed the following: i t i s probable 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 behaviour i f he believes that he i s prone to becoming i l l and that i l l n e s s w i l l have serious r e s u l t s ; i f he thinks a c e r t a i n course of action w i l l be b e n e f i c i a l ; i f there are no f i n a n c i a l or psychological b a r r i e r s and i f he experiences a cue to t r i g g e r a c t i o n . Also, behaviour change i s probable i f the program plan has taken into account c u l t u r a l and s o c i a l forces i n the target population (such as how people change behaviours and b a r r i e r s to change); i f several educa-t i o n a l techniques are used; i f the person i s a c t i v e l y involved i n the learning process and there are many contacts. Behavioural change can be maintained through reinforcement. There are few empirical studies on the r o l e of ease and q u a l i t y of contact with health professionals i n health promotion. A v a i l a b l e l i t e r a t u r e indicates that these are important factors i n promoting health. Those with ph y s i c a l disease and who l i v e alone are at r i s k of developing emotional disturbance. The incidence of physical disease increases at the age of 70; and many older c i t i z e n s l i v e alone. The ultimate goal of preventive health care i s to maintain and improve health. In order to determine how e f f e c t i v e l y a program has maintained or improved health one requires indices for measuring the various aspects of good health. E x i s t i n g indices of mortality and morbidity are not s e n s i t i v e to changes i n s o c i a l , emotional and physical wellbeing. The new emphasis on health (as opposed to disease) has created the need for an index which measures s o c i a l , emotional and physical health. Since these three dimensions of health are q u a l i t a t i v e l y d i s t i n c t , they should be measured separately. Sackett, Chambers et a l . (1977) developed an instrument which measures s o c i a l , emotional and physical function separately. One would a n t i c i p a t e programs which emphasize health education and - 98 -a c c e s s i b i l i t y and q u a l i t y of contact with health personnel to be associated with greater health and lower health costs than those which do not empha-s i z e these factors. A study was designed to test the claim that senior c i t i z e n s who received preventive nursing services which were accessible and emphasized health promotion (through health education, counselling and early detection of disease) would have s i g n i f i c a n t l y greater health know-ledge, health behaviour and health status and s i g n i f i c a n t l y lower health costs than those who received nursing services which; were less accessible and placed l e s s emphasis on health promotion. Residents of two apartment complexes i n the West End of Vancouver who have been receiving d i f f e r e n t Home Care nursing programs since 1974, were par t i c i p a n t s i n t h i s study. Nurses i n Nicholson Towers are very accessible and do much health education and counselling. Nurses i n Sunset Towers are less accessible and do less health education and counselling. At the time of the study 75 i n d i v i d u a l s i n Nicholson and 13 i n Sunset were being seen by nurses on a regular basis; 47 i n d i v i d u a l s i n Nicholson and 45 i n Sunset Towers had received nursing services at some time i n the preceding two years but not i n the preceding month; and 118 i n d i v i d u a l s i n Nicholson and 186 i n Sunset Towers had never received nursing 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 randomly selected from each of three categories to ensure that i n d i v i d u a l s who were receiving nursing services at the time of the study and those who had received nursing services i n the past, were adequately represented. The following categories were used: i n d i v i d u a l s receiving nursing services at the time of the study; i n d i v i d u a l s who had received nursing services i n the two year period preceding the study but not i n the month preceding the study; in d i v i d u a l s who have never received nursing services. Sample sizes were as follows: 65 i n d i v i d u a l s from Nicholson Towers and 59 from Sunset Towers. - 99 -Data c o l l e c t e d from residents i n a structured interview measured health knowledge, sources of health information, health behaviours, health status, perceived b e n e f i t of nurses and variables i d e n t i f i e d i n the l i t e r a t u r e as related to health knowledge and health status. Health knowledge was measured by questions based on information taught to residents by nurses i n Nicholson Towers. Health status was measured using adapted versions of scales of physi c a l , emotional and s o c i a l function developed by Sackett, Chambers et a l . (1977). Variables related to health status and health costs measured i n th i s study were sex, age, years of schooling, socio-economic status, number of medical conditions and number of l i f e change units. Blishen's (1967) Occupational Rating Scale was used to measure socio-economic status. The So c i a l Readjustment Scale developed by Holmes and Rahe (1967) was used to measure l i f e changes. The following 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 health education which occurs i n each complex per month; which i n d i v i d u a l s were e l i g i b l e for Long Term Care; number of Home Care nursing v i s i t s to i n d i v i d u a l s i n the sample f o r the period January 1 to August 31, 1978. The Medical Services Plan of B.C. and Pharmacare supplied data on number and cost of a l l health services and cost of medica-tio n for i n d i v i d u a l s i n the sample for the time period January 1 to August 31, 1978. One interviewer conducted a l l the interviews over a four week period (August-September, 1978). Individuals were interviewed i n t h e i r own apart-ments i n a 40 minute structured schedule. Responses to questions were entered on the interview sheet and subsequently transferred on to coding sheets. Raw data were keypunched onto cards. The data were computer analyzed using the University of B r i t i s h Columbia's version of SPSS. Analysis of -100 -variance was used to test differences between residents of Nicholson and Sunset Towers i n terms of health knowledge, health behaviour, health status, number of health r e l a t e d v i s i t s and costs. Pearson co r r e l a t i o n s were calculated among items. Stepwise l i n e a r regression determined what variables accounted for what percentage of variance i n costs, number of health related v i s i t s and phys i c a l , s o c i a l and emotional function. A r e l i a b i l i t y procedure was 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 for scales. Before the study could be executed, i t was necessary to adapt three e x i s t i n g scales and develop one new scale. Scales of p h y s i c a l , emotional and s o c i a l function developed by Sackett, Chambers et a l . (Chambers & Segovia, 1978) were adapted f or use with t h i s population. A scale of health knowledge was developed for use i n the study. The r e l i a b i l i t i e s of scales developed for use i n t h i s study were measured. These scales were subsequently examined for content, conver-gent, discriminant and construct v a l i d i t y . The physical function scale and the 22-item health knowledge scale both have good alpha r e l i a b i l i t i e s and the emotional function scale and the 7-item knowledge scale have moder-ate alpha r e l i a b i l i t i e s . The phys i c a l and emotional function scales evidence content, convergent, discriminant and construct v a l i d i t y . The two health knowledge scales evidence convergent, construct and face v a l i d i t y . Although the s o c i a l function scale evidences construct and discriminant v a l i d i t y , i t has a low r e l i a b i l i t y and low content and convergent v a l i d i t y . Findings regarding s o c i a l function are therefore tenuous. Hypothesis 1: health knowledge, health behaviour and health status of senior c i t i z e n s i n Nicholson Towers w i l l be s i g n i f i c a n t l y greater than that of senior c i t i z e n s i n Sunset Towers, was accepted for four of i t s - 101 -f i v e components. Hypothesis 2: over an 8 month period, the average number of health related v i s i t s made by or to residents of Nicholson and Sunset Towers w i l l be s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers, was rejected. Hypothesis 3: over an 8 month period, average costs of a l l health services provided to residents of Nicholson and Sunset Towers w i l l be s i g n i f i c a n t l y lower i n Nicholson than i n Sunset Towers, was rejected. Hypothesis 4: of those residents e l i g i b l e f o r Long Term Care, a s i g n i f i c a n t l y greater percentage i n Nicholson than i n Sunset Towers w i l l consider that they are able to continue l i v i n g i n the apartment because nurses are accessible, was rejected. Home Care nurses spend approximately 90 hours a month educating residents i n Nicholson Towers, and 15 hours i n Sunset Towers. Analysis of variance showed that residents of Nicholson Towers had s i g n i f i c a n t l y (81% vs. 68%) greater health knowledge than those i n Sunset Towers. With what confidence can the greater health knowledge of residents i n Nicholson Towers be at t r i b u t e d to the greated amount of health education which occurs here? Data were c o l l e c t e d on sources of health information. For each health question 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, or what, did you f i r s t l earn t h i s ? " Analysis of variance showed that residents of Nicholson Towers obtained s i g n i f i c a n t l y (19% vs. 1%) more health informa-ti o n from Home Care nurses; and also s i g n i f i c a n t l y (3% vs. 0%) more health information from other residents i n the complex than those i n Sunset Towers. Residents of Sunset Towers obtained s i g n i f i c a n t l y (47% vs. 36%) more health information from doctors. There were no other s i g n i f i c a n t differences between residents of the two complexes i n terms of sources of health information. These data suggest very strongly that the greater - 102 -health knowledge of residents i n Nicholson Towers can be at t r i b u t e d to the greater amount of health education 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 residents learned health information. A l l i n d i v i d u a l s reported having learned information on ah in d i v i d u a l b a s i s . Home Care nurses i n Nicholson Towers spend a great deal of time on education and a ce r t a i n amount of health knowledge i s con-sidered basic to health maintenance i n a l l older people. Group discussions are known to be e f f e c t i v e i n changing behaviour, and the effectiveness of health education i s increased when more than one technique i s used. Home-Care nurses could therefore explore the p o s s i b i l i t y of conducting health education groups. Analysis of variance i d e n t i f i e d s i g n i f i c a n t differences between residents of the two complexes i n terms of age, sex and numbers of people e l i g i b l e f o r Long Term Care. Stepwise l i n e a r regression was used to assess the influence of 13 variables postulated to influence health on physical, emotional and s o c i a l function. These variables were apartment complex and l e v e l of nursing service; biographical v a r i a b l e s ; p r i o r medical status; health knowledge and behaviour; and the psychological e f f -ect of the presence of nurses. Age and sex account for small proportions of variance i n physi c a l , emotional and s o c i a l function. E l i g i b i l i t y for Long Term Care accounts for a large proportion of variance i n physical and emotional function. The s i g n i f i c a n t l y (39% vs. 34%) greater percentage of residents e l i g i b l e for Long Term Care i n Sunset Towers could account for the s i g n i f i c a n t l y (44.42 vs. 45.69) lower physical function of residents i n this complex. 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 differences between residents of the two complexes i n average number of health related v i s i t s - 103 -and health costs. Stepwise l i n e a r regression was used to assess the influence of 16 variables on health costs. Level of nursing service accounts for most of the variance i n costs. Amount of stress and sex are the variables which account for the next largest amounts of variance i n costs. A l l variables combined account for only 40 per cent of the variance i n number of health r e l a t e d v i s i t s and 26 per cent of the variance i n health costs. Much variance i s thus unaccounted f o r . Each l e v e l of the three l e v e l s of nursing costs the health care system 22 cents and each point on the stress scale costs the system 15 cents. On the other hand, each point on the answer scales to the questions regarding perceived security and benefit from the nurses saves the system 18 and 12 cents r e s p e c t i v e l y . IMPLICATIONS OF FINDINGS Implications of findings on costs of health care, on health status and on health education are discussed i n this s e c t i o n . Implications of Findings on Costs of Health Care Costs of health care i n Canada have escalated enormously i n recent years. Preventive strategies are aimed at reducing costs of health care and promoting health. Included i n t h i s study was a comparison of costs of two d i f f e r e n t nursing programs. The hypothesis that the program which emphasized health education and a c c e s s i b i l i t y of nursing personnel would be associated with lower health care costs than the treatment oriented program, was rejected. Results of the study ind i c a t e that average health care costs 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 preventive services were a v a i l a b l e . An unexpected f i n d i n g i s that there are no s i g n i f i c a n t differences between complexes i n terms of cost 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 -p r a c t i t i o n e r s . One would have anticipated that as a r e s u l t of the i n -creased a c c e s s i b i l i t y of the nurses i n Nicholson Towers, h o s p i t a l i z a t i o n of some residents would have been prevented (because the problem i s dealt with before i t becomes a c r i s i s ) ; and that unnecessary v i s i t s to the general p r a c t i t i o n e r would have been prevented (because the nurse dealt with the problem). Another unexpected f i n d i n g i s that of no s i g n i f i c a n t differences i n cost of medication between the complexes. Nurses i n Nicholson Towers v i s i t senior c i t i z e n s on a regular b a s i s . They are thus able to monitor medication use and advise discontinuance of c e r t a i n medica-tions (in consultation with the physician). This was expected to be re f l e c t e d i n decreased cost of medication i n t h i s complex. Possible reasons for 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 health costs are explored below. F i r s t l y , Home Care nursing services are meant to serve as a substitute for more expensive forms of medical care such as h o s p i t a l i z a t i o n . However, Home Care nursing services are not inexpensive. One Home Care nursing v i s i t costs approximately $20 compared to a follow-up v i s i t to a general p r a c t i t i o n e r which costs $6.30 (Ministry of Health, 1978(a)). Delivery of health services to people's homes i s more co s t l y than d e l i v e r y of these services from a cent r a l l o c a t i o n . Home Care nurses i n Nicholson Towers v i s i t people who would not normally receive nursing services. Increased a c c e s s i b i l i t y leads to increased u t i l i z a t i o n and increased costs. At the time of the study 75 i n d i v i d u a l s i n Nicholson Towers were receiving nursing services, compared with 13 i n Sunset Towers. The mean number of nursing v i s i t s per person i n Nicholson Towers was 13.41 and i n Sunset Towers 3 .20 . Analysis of variance found cost of nursing services i n Nicholson Towers to be s i g n i -f i c a n t l y ($268.31 vs. $64.07) higher than i n Sunset Towers. Cost of - 105 -nurses' v i s i t s i n Nicholson Towers was more costly than any other type of service (see Table 10, page 77). Home Care nurses i n Nicholson Towers are able to see many more people per day than a Home Care nurse who travels from one home to another. The actual cost of providing nursing services i n Nicholson Towers must be l e s s than $20. per v i s i t . Home Care does, however, not have a method of c a l -c ulating costs which r e f l e c t s t h i s f a c t . The a r t i f i c i a l l y high amount of $20. per v i s i t no doubt contributes to the high cost of nursing services i n Nicholson Towers. A factor which must not be discounted, however, i s increased u t i l i z a t i o n of these services because they are accessible and resultant increased costs. Demand for service tends to expand to meet supply. This has i m p l i -cations for planning future delivery of service i n these b u i l d i n g s . A plan should contain a set of p r i o r i t i e s developed from a knowledge of the s i z e , demographic c h a r a c t e r i s t i c s and needs of the population and a consideration of the costs of various types of services. Many of the residents i n Nicholson and Sunset Towers expressed a desire for a 24-hour nursing service i n the b u i l d i n g . Is there a need for this? Provision of nursing services i n these buildings should be based on an assessment of need of the t o t a l population. Provision of service at the present time i s at request of a physician or the i n d i v i d u a l himself. Finding no s i g n i f i c a n t differences between complexes i n average health costs could also be accounted for by the f a c t that 86 per cent of e l d e r l y people have chronic health problems. . Chronic problems often require recurring treatment and hence v i s i t s to h o s p i t a l s and health personnel. The a b i l i t y to bring about improvement i n health i s l i m i t e d by the aging process. One cannot h a l t the d e t e r i o r a t i o n which i s part of aging. The primary objective of health care with the e l d e r l y i s mainten-- 106 -ance of ph y s i c a l , emotional and s o c i a l function. These are outcomes of the health care process. Economic outcomes are l i k e l y to be of no prac-t i c a l s i g n i f i c a n c e ; i . e . i t i s possible that preventive health care with e l d e r l y does not have economic b e n e f i t s . I t does, however, have psycho-l o g i c a l b e n e f i t s ; residents of Nicholson Towers f e e l , for example, s i g n i f i c a n t l y (1.11 vs. 0.32 on a 3 point scale) more secure than residents of Sunset Towers because nurses come into t h e i r b u i l d i n g . The fourth possible reason f o r fi n d i n g no s i g n i f i c a n t differences between complexes i n average health costs could be that the variables l i s t e d i n Table 13 (page 89) account for only approximately 25 per cent of the variance i n costs. There i s thus much variance which i s unaccounted for . The following factors could account for some of the remaining variance: s e v e r i t y of i l l n e s s was not measured; i n t e r - i n d i v i d u a l d i f f e r -ences; some i n d i v i d u a l s v i s i t health personnel when they are not i l l ; d ifferences between health personnel i n terms of numbers of times they see a c l i e n t for a s p e c i f i c complaint and numbers and type of laboratory procedures requested. F i f t h l y , the emergence of prevention programs which focus on health education and early detection of disease was based on d i s s a t i s f a c t i o n with r i s i n g costs and the b e l i e f that i t i s better to prevent than to cure. We should, however, not have u n r e a l i s t i c expectations of prevention pro-grams. What can be reasonably expected of a prevention program a f t e r a stated period of time should be s p e c i f i c a l l y i d e n t i f i e d . A p a r t i c u l a r percentage decrease i n h o s p i t a l admissions may, for example, be expected (Green, 1978). Table 13, which compares numbers of v i s i t s and costs i n each b u i l d i n g , shows that i n almost a l l instances numbers of v i s i t s and costs are lower i n Nicholson than i n Sunset Towers. Very few of the differences i n costs are, however, s i g n i f i c a n t . 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 differences i n costs between buil d i n g s e s p e c i a l l y when Nicholson Towers has s i g n i f i c a n t l y more nursing v i s i t s than Sunset Towers and these v i s i t s appear to be so c o s t l y . Implications of Findings on Health Status The purpose of this study was to examine r e l a t i o n s h i p s between type of nursing program and health knowledge, health status and health costs. Analysis of variance i d e n t i f i e d that residents of Nicholson Towers had s i g n i f i c a n t l y (45.69 vs. 44.42) greater physical function and s i g n i f i c a n t l y (27.46 vs. 25.07) greater s o c i a l function than residents of Sunset Towers. There were no s i g n i f i c a n t differences between residents of the two com-plexes i n terms of emotional function. Can the greater physical and s o c i a l function of residents i n Nicholson Towers be a t t r i b u t e d to the nursing program i n Nicholson Towers? Several issues r e l a t e to t h i s question. F i r s t , analysis of variance i d e n t i f i e d s i g n i f i c a n t differences between residents of the two complexes i n terms of age, sex and numbers of people e l i g i b l e for Long Term Care. Age and sex account for small proportions of variance i n p h y s i c a l , emotional and s o c i a l function. E l i g i b i l i t y f o r Long Term Care accounts for a large proportion of variance i n p h y s i c a l and emotional function. The s i g n i f i -cantly (39% vs. 34%) greater percentage of residents e l i g i b l e for Long Term Care i n Sunset Towers could account for the s i g n i f i c a n t l y (44.42 vs. 45.69) lower physical function of residents i n this complex. Second, the s o c i a l function scale was found to possess a low (.45) alpha r e l i a b i l i t y and low content and convergent v a l i d i t y . Findings regarding the s i g n i f i c a n t differences between the complexes i n terms of s o c i a l function are, therefore, tenuous. Third, because no measure of health status was taken before introduc-- 108 -t i o n of the program, any difference i n health status between residents of the two complexes cannot be causally linked to the nursing programs. The methodology of this study included measures of health status of i n d i v i d u a l s i n each complex at a p a r t i c u l a r point i n time and allowed comparison between complexes and within complexes. Other methodologies might have measured health knowledge and health status of samples of people who had and had not received nursing services i n each complex; and measured these same i n d i v i d u a l s a f t e r three months. Changes i n health knowledge and health status could thereby have been compared. For several reasons, however, this methodology was not selected. F i r s t , the i n d i v i d u a l s who constituted the population i n t h i s study have chronic diseases and are not l i k e l y to have large changes i n health status over a three to s i x month period. Instruments currently a v a i l a b l e for measuring health status are not s e n s i t i v e to small changes i n an i n d i v i d u a l ' s health; they may, however, measure s t a t i c differences i n health between two groups of people. Second, the people who are receiving nursing services i n each complex have received these services for varying periods of time. Sixty per cent of the people receiving nursing services i n Nicholson Towers at any one time have received these services for longer than three months (and some of them f o r longer than a year). Individuals i n Sunset Towers receive nursing services for far shorter periods of time because of the administrative pressure to discharge patients as soon as possible. This renders comparison of changes i n health status between complexes very d i f f i c u l t . An i n d i v i d u a l ' s health status may have improved s i g n i f i c a n t l y during the f i r s t and second months of contact with the nurse; but measurement of health knowledge and status at month s i x and month nine may reveal l i t t l e change during t h i s three month period. Comparison of changes i n i n d i v i d u a l s who have had d i f f e r i n g lengths of contact with the - 109 -nurse was thus d i f f i c u l t . This problem could have been avoided by including i n the study only i n d i v i d u a l s commencing with nursing services at the time of the study. Since only three or four i n d i v i d u a l s i n each complex who have not previously received nursing services s t a r t receiving these services each month, numbers involved would have been too small. This would also have changed the focus of the study. I t was the intent of the study to examine the impact of the presence of nurses on the health of a l l residents i n a complex. I t was not the intent to examine what happens to an i n d i v i d u a l i n a complex when he receives a p a r t i c u l a r type of nursing s e r v i c e . Implications of Findings on Health Education The data do not indic a t e that health costs are lower i n the b u i l d i n g i n which health education was emphasized. Health knowledge and health behaviour were, however, s i g n i f i c a n t l y greater i n th i s b u i l d i n g than i n the b u i l d i n g i n which health education was not emphasized. Table 9 (page 74) shows that people with the poorest physical function had the greatest health knowledge. This i s probably because these people are i n contact with health professionals on a regular basis and receive health education from these professionals. This table also shows that people with high health knowledge had high emotional and s o c i a l function. Health knowledge does thus make a differ e n c e i n terms of people's health. There was no v a r i a t i o n i n data i n terms of i n d i v i d u a l and group learning of health information; a l l i n d i v i d u a l s reported having learned health information on an i n d i v i d u a l b a s i s . It was therefore not possible to test whether the health knowledge of people whp learned health informa-t i o n i n d i v i d u a l l y d i f f e r e d from that of those who learned health informa-t i o n i n groups. A consistent f i n d i n g i n the l i t e r a t u r e on health education - 110 -is that the l i k e l i h o o d of a health education program obtaining 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 to the number of educational techniques and devices used. Numerous health education studies have found group discussion to be a powerful technique i n changing behaviour. The ultimate goal of health education i s improvement i n , or maintenance of, health. The intermediate goal i s to modify behaviour presumed to be deleterious to health. The nursing program'in Nicholson Towers incorporates many of the factors i d e n t i f i e d 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 bringing about behavioural change. Home Care nurses there give advice and encour-agement based on assessment of 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 f a c t o r s . They involve the person i n learning, r e i n f o r c e e f f o r t s at behavioural change and have many contacts with the person. Two factors known- to be e f f e c t i v e i n achieving behavioural change are not incorporated i n the nursing program i n Nicholson Towers. These factors are u t i l i z a t i o n of many educational methods, techniques and devices; and u t i l i z a t i o n of group methods of i n s t r u c t i o n . The approximate t o t a l amount of time spent by Home Care nurses with residents i n Nicholson Towers i s 130 hours per month. These nurses estimate that 50 per cent of the i r time i s spent educating; i . e . 90 hours per month. Thus 1.2 hours i s spent educating each resident per month. Instruc-t i o n takes place almost 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 . Nurses could explore the p o s s i b i l i t y of greater use of group methods and techniques of i n s t r u c t i o n . This i s l i k e l y to increase the effectiveness of health education, and be a more e f f i c i e n t use of resources. Program Planning for Health Education i n Dense Residential Settings It i s important that health education i n a dense r e s i d e n t i a l s e t t i n g be both e f f e c t i v e and e f f i c i e n t . The section below outlines the steps - I l l -which should be followed when planning health education i n such se t t i n g s . The intermediate goal of health education i s behavioural change. The focus of educational programs should thus be behavioural change. Programs require d i f f e r e n t emphases i n order to achieve d i f f e r e n t types of behaviour-a l change. Green (1978) i d e n t i f i e s f i v e dimensions of behaviour change. These are frequency, persistence, e a r l i n e s s , q u a l i t y and range. These dimensions are explored below. Implications for choice of methods, tech-niques and devices are then discussed. Frequency: i f the health behaviour should be repeated p e r i o d i c a l l y (e.g. annual physician v i s i t s ) , then health education methods with given 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 spora-dic or one-shot methods. Persistence: i f i t i s important that i n d i v i d u a l s p e r s i s t with a p a r t i c u l a r health behaviour over long periods of time (e.g. with regimens for diabetes or hypertension), then the most e f f e c t i v e health education methods are those that provide support i n the c l i n i c or home. Ea r l i n e s s : the goal of a health education program may be reducing delay i n adopting preventive actions or delay i n seeking t r e a t -ment for symptoms. Mass media have been found u s e f u l i n reducing delay i n preventive action, but not as e f f e c t i v e i n reducing delay i n seeking treatment for i l l n e s s . Reducing delay i n seeking treatment for 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. Quality: the goal of a health education program may be that the appropriateness of health behaviours improve. P r i o r experience with the source of care or with the product i s the most i n f l u e n t i a l f actor i n determining q u a l i t y of choice. When qu a l i t y of choice i s r e l a t e d to a v a i l a b i l i t y of health services and products, com-munity organization methods are most appropriate (Cauffman, Lloyd et a l . , 1973). Communication v i a mass media or food l a b e l i n g can increase awareness of those who are already 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 required to adopt a range of d i f f e r e n t health behaviours, the complexity of the behaviour i s increased. In these instances, i n d i v i d u a l counselling and home v i s i t s are the most e f f e c t i v e health education methods (Green, 1978). Behavioural goals which specify behavioural outcomes i n terms of the above dimensions provide more valuable guidance for health education programs than goals which l i s t d i f f e r e n t types of health behaviour (e.g. - 112 -u t i l i z a t i o n , compliance). The reason i s that health behaviours may d i f f e r i n terms of behavioural dimensions. For example, compliance with one regimen may require persistence, whereas compliance with another may require frequent behaviour. In this example there i s s i m i l a r i t y i n type of health behaviour (compliance), but not i n behavioural dimension. Another type of health behaviour, e.g. consumption of a p a r t i c u l a r product may be f a r more s i m i l a r to one compliance i n terms of behavioural dimension (Green, 1978). Specifying behavioural outcomes i n terms of behavioural dimensions requires analysis of the outcome i n terms of these dimensions. For example in d i v i d u a l s with high blood pressure should decrease s a l t intake, rest frequently, exercise d a i l y and avoid s t r e s s f u l s i t u a t i o n s . These outcomes involve the behavioural dimensions of earliness and persistence. The next step i n program planning i s to s e l e c t the most appropriate educational methods, techniques and devices for teaching these behaviours. The method i d e n t i f i e s ways of organizing i n d i v i d u a l s for the purpose of education. 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 methods. Individual methods include counselling which has an i n s t r u c t i o n a l o r i e n t a t i o n , correspondence study, apprenticeship, directed i n d i v i d u a l study and programmed i n s t r u c t i o n . Group methods include classes and workshops. Community methods include community development (Verner & Booth, 1964). The following step i n program planning i s to i d e n t i f y the most appro-pr i a t e techniques f o r teaching p a r t i c u l a r behaviours. Techniques 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 learner and the learning task" (Verner & Booth, 1964, p. 75). Verner c l a s s i f i e s techniques on the basis of the type of learning task for which i t i s most u s e f u l ; i . e . techniques for acquiring information, for acquiring a s k i l l or for applying knowledge. - 113 -The f i n a l step i s to i d e n t i f y devices which may increase the e f f e c t i v e -ness of a p a r t i c u l a r method or technique. Devices can be c l a s s i f i e d as i l l u s t r a t i v e devices (e.g. f i l m s ) , extension devices (e.g. t e l e v i s i o n and radio), environmental devices (e.g. seating arrangements) and manipulative devices (e.g. tools and equipment) (Verner & Booth, 1964). In t h i s study, health information which a l l old people should possess and health information which people with p a r t i c u l a r conditions should possess, was i d e n t i f i e d . Questions to test knowledge i n these areas were formulated. Table 16 l i s t s these questions and i d e n t i f i e s the desired behavioural outcome associated with each question. I t i d e n t i f i e s the behavioural dimension involved i n each instance and the most e f f e c t i v e educational imethod for teaching this behaviour. It also l i s t s the most e f f e c t i v e health education techniques for acquiring and applying knowledge and behaviours. Table 16 shows that with almost a l l behavioural outcomes, the most e f f e c t i v e health education methods are group methods. When the goal of education i s that i n d i v i d u a l s acquire knowledge and/or s k i l l s , large groups and lecture-type techniques are e f f e c t i v e . When, however, the goal i s that i n d i v i d u a l s apply knowledge and s k i l l s and change behaviour, small groups u t i l i z i n g such techniques as group discussion or buzz groups are most appropriate. Since the goal of health education i s to bri n g about behavioural change the use of small groups techniques i s most appropriate. Planning and implementing health education programs should be based on knowledge of the adult learner and on knowledge of designing and managing learning experiences. A fundamental p r i n c i p l e i n planning adult health education programs i s involvement of the learners i n a l l steps of the program. They should be a c t i v e l y involved i n diagnosing t h e i r learning needs, formulating objectives, developing 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 Asked of a l l individuals Desired Behavioural Outcome Behavioural Dimension Important Aspects of Method Most Effective Health Ed. Methods Techniques for Applying Knowledge and/or S k i l l s Techniques for Acquiring Knowledge and/or S k i l l s Technique Size of Group Technique Size of Group Devices How often should one have some form of exercise l i k e going for walks? How do you decide when and for how long to take prescribed medication? Having some form of exercise daily or several times a week Taking medications exactly as recommended by the doctor or nurse Persistence Earliness (prevention) Persistence Range Social Support Social Support Individual Counselling and Reinforcement Group methods Individual methods Bu2z group Group discussion Individual practice Individual instruction and practice Small I l l u s t r a t i v e Lecture/speech Any size I l l u s t r a t i v e Small devices Symposium Medium/large and extension Interview Any size devices How often i s a physical check-up advisable for people of your age who are feeling well? Having a physical check-up every 6 to 18 months Frequency Providing cues at intervals Group methods Buzz groups Group discussion Small Small I l l u s t r a t i v e devices Lecture/speech Any size Symposium Medium/large I l l u s t r a t i v e and extension devices If one i s l i v i n g alone, how often do you think one should have contact with other people? Having daily contact with other people (either face to face contact or over telephone) Persistence Earliness (prevention) Social Support Group methods Buzz groups Group discussion Group practice Small I l l u s t r a t i v e Lecture/speech Any size I l l u s t r a t i v e Small devices Symposium Medium/large and extension Small Interview Any size devices I How many days a week should you eat vegetables and f r u i t in order to have enough vitamins and minerals in your diet? Could you name two things you can include in your diet to assist bowel movements? Eating vegetables and f r u i t 5, 6 or 7 days a week Including 2 of the following i n diet: high bulk foods, bran, prune juice, dried f r u i t , celery, f r u i t , 8 cups of l i q u i d Persistence Earliness (prevention) Social Support Group methods Buzz groups Group discussion Individual practice Small I l l u s t r a t i v e Lecture/speech Any size Small devices Symposium Medium/large Interview Any size Demonstration Any size Persistence Social Support Group Buzz groups Small Earliness methods Group discussion Small (prevention) Individual practice I l l u s t r a t i v e Lecture/speech Any size devices Symposium Medium/large Interview Any size Demonstration Any size I l l u s t r a t i v e and extension devices I l l u s t r a t i v e and extension devices How many cups of f l u i d should one drink a day? Drinking 6 or more cups Persistence of f l u i d a day Earliness (prevention) Social Support Group methods Buzz groups Group discussion Individual practice Small I l l u s t r a t i v e Lecture/speech Any size I l l u s t r a t i v e Small devices Symposium Medium/large and extension Interview Any size 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 TABLE 16 - CONTINUED Health Knowledge Questions Desired Behavioural Outcome Behavioural Dimension Important Aspects of Method Most Effective Health Ed. Methods Techniques for Applying Knowledge and/or s k i l l s Asked of Individuals with  A r t h r i t i s Can you name anything you can do to get r i d of some of the st i f f n e s s you may have (in the morning, for example)? Keeping mobile Keeping active If you have so much pain that Eating some food to you do not feel l i k e eating, maintain strength what do you do about eating (,... and why)? Persistence Earliness Earliness Quality Social Support Reinforcement Group methods Reinforcement Group Prior methods Experience with Behaviour Technique Buzz groups Group discussion Individual practice Size of  Group Small Small Buzz groups Small Group discussion Small Devices I l l u s t r a t i v e devices Asked of Individuals with a  Heart Condition How do you decide how often to take medication(s) for your heart? What sort of physical signs sould indicate to you that your heart was not functioning well? Taking medication regularly Persistence Social Support Being aware of swelling Earliness of ankles and short- Quality ness of breath and then taking appropriate action. Group methods Reinforcement Group Prior methods Experience with Behaviour Buzz groups Group discussion Buzz groups Group discussion Individual practice Small Small Small Small I l l u s t r a t i v e devices I l l u s t r a t i v e devices Asked of Individuals with  Leg Ulcers Can you name two things one can do to reduce swelling in the leg? What sort of food are especially important to include In one's diet when one has leg ulcers? Asked of Individuals with  High Blood Pressure What kinds of things can you do to help keep your blood pressure down? Wearing heavy suppor-tive stockings Keeping the foot elevated Eating foods high i n protein Decreasing s a l t intake Resting frequently Exercising daily Avoiding s t r e s s f u l situations Earliness Quality Quality Reinforcement Group Prior methods Experience with Behaviour Prior Experience with Behaviour Earliness Social (prevention) Support Persistence Group methods Group methods Buzz groups Group discussion Individual practice Buzz groups Group discussion Buzz groups Group discussion Individual practice Small Small Small Small Small Small I l l u s t r a t i v e devices I l l u s t r a t i v e devices I l l u s t r a t i v e devices If you f e e l dizzy when you get up from a lying position, what should you do? If you f e e l dizzy while you are doing something (li k e walking or housework) what should you do? Getting up slowly or Quality s i t t i n g down again Stopping a c t i v i t y and Quality resting when feeling dizzy Prior Group Experience with methods Behaviour Prior Experience with Behaviour Group methods Buzz groups Group discussion Buzz groups Gruop discussion Small Small Small Small SOURCES: Verner and Booth, 1964; Green, 1978 - 116 -operating the a c t i v i t i e s and rediagnosing needs (Knowles, 1970). A c t i v e learner involvement i s c r u c i a l . Unless this facet of program planning receives much attention, the value and effectiveness of the program w i l l be v a s t l y diminished. Home Care nurses could group i n d i v i d u a l s with s i m i l a r health problems into groups of 6-8 i n d i v i d u a l s . Desired behavioural outcomes and behaviour-a l dimensions involved would thus be common for a l l i n d i v i d u a l s i n each group. S i m i l a r i t y of health problems i s an e f f e c t i v e way of approaching health education which u t i l i z e s small groups. Small groups allow group members to tap fellow group members' experience regarding management of a health problem and the opportunity for past learning consultation arid corroboration with other learners i s maximized. People tend to trust and respect the judgement of those who have a s i m i l a r problem. The q u a l i t y of pertinent discussion and reinforcement i s high. Grouping people with s i m i l a r socio-economic status promotes more relevant, credible discussion of solutions to problems (Green, Werlin et a l . , 1977; Young, 1967(a)). Groups of people with hypertension, diabetes, cardiac conditions or groups of people with two c o i n c i d i n g conditions would meet re g u l a r l y . The nurse would act as resource person and guide, and allow the group members to decide what they needed and wanted to learn regarding the condition and how they would go about learning t h i s . I f there are large numbers of people with a p a r t i c u l a r condition, several small groups can be formed. The i n i t i a t i o n of these groups would take time and energy, but once they were running they would not be time consuming. Such groups would be more e f f e c t i v e at changing behaviours than i n d i v i d u a l teaching methods and also a more e f f i c i e n t use of nurses' time. In addition to grouping i n d i v i d u a l s according to health problems, nurses could be responsible for organizing educational sessions for a l l - 117 -people i n the complex. The content of these sessions would be that information which a l l older people should possess regarding health mainten-ance. The l e c t u r e technique could be u t i l i z e d i n these sessions and large numbers of people could attend the sessions. Films or other audio-visual media could be prepared, as could be a manual on health maintenance for use by a l l residents. No such program should be implemented without adequate p r o v i s i o n for evaluation. Instruments should be developed to measure health knowledge and behaviour of i n d i v i d u a l s i n the various groups before the program i s started. Health knowledge and behaviour should then be measured a f t e r the program has been operating f o r a s p e c i f i e d period of time. The formation of these groups would be of value both educationally and s o c i a l l y . Many older people l i v e alone and are extremely l o n e l y . Belonging to a small group might help a l l e v i a t e t h i s l o n e l i n e s s . Friend-ships and informal support systems might develop from these groups. Large and small s i t t i n g rooms i n Nicholson and Sunset Towers are seldom used. A few physical changes to these rooms would increase the l i k e l i h o o d of t h e i r use; for example, grouping small numbers of chairs around tables and placing newspapers or magazines on the tables as f o c a l points f o r i n t e r a c t i o n . Here again, the residents themselves should be involved i n the changes. Several small committees i n each b u i l d i n g could be responsible f o r changes i n the large s i t t i n g room, the arts and c r a f t s room, the games room and the l i b r a r y . RECOMMENDATIONS The following l i s t of recommendations emerged from the findings of the study. Recommendations which emerged from findings related to hypotheses: (1) That the needs of residents i n Nicholson and Sunset Towers for on-site - 118 -health services be assessed. That on-site health services be pro-vided i n accordance with the assessed need, since demand for service always expands to meet supply. (2) That administrators of Home Care nursing services develop a system for c a l c u l a t i n g the r e a l cost of providing nursing services i n dense r e s i d e n t i a l settings such as Nicholson and Sunset Towers. (3) That once the above system has been developed, data already c o l l e c t e d on costs of health services to residents of Nicholson and Sunset Towers over an eight month period be reanalyzed. Recommendations which emerged from other findings: (1) That Home Care nurses i n Nicholson Towers e s t a b l i s h behavioural objectives for health education programs which specify desired behavioural outcomes i n terms of the dimensions of frequency, persistence, 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 Nicholson Towers plan and implement educa-t i o n a l programs which incorporate (1) group methods and techniques and (2) a greater v a r i e t y of educational techniques and devices. (3) That Home Care nurses i n Nicholson Towers u t i l i z e large group tech-niques when the goal i s that i n d i v i d u a l s acquire knowledge and/or s k i l l s and small group techniques when the goal i s that i n d i v i d u a l s apply knowledge and s k i l l s . (4) That educational programs i n Nicholson Towers a c t i v e l y involve residents i n a l l facets of the program. (5) That Home Care nurses i n Nicholson Towers make pr o v i s i o n for evaluation of educational programs. Health knowledge and behaviour should be measured before introduction of the program and a f t e r the program has been operating for a s p e c i f i e d period of time. (6) That educational programs s i m i l a r to those i n Nicholson Towers be expanded to Sunset Towers i f evaluation of the program i n Nicholson Towers indicates that this i s warranted. (7) That Home Care nurses involved i n education attend courses or work-shops on adult education. (8) That residents of both complexes be involved i n making such physical changes to the s i t t i n g rooms which would increase the l i k e l i h o o d of their use. (9) That findings of this study regarding the r e l i a b i l i t y and v a l i d i t y of the three health scales be made ava i l a b l e to researchers i n the f i e l d of health measurement. (10) That the Ministry of Health provide funds for employing an occupational therapist i n one senior citizens' complex i n the province and that provision be made to evaluate the impact of these services on health and health costs. P o s i t i v e outcomes of the evaluation should r e s u l t - 119 -i n extending these services to other complexes. An occupational therapist could promote health of e l d e r l y people by helping them to' f u l f i l the need for 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 for self-expression and mental stimulation, the need to be useful and to enjoy companionship. CONCLUSION Costs of health care i n Canada have escalated enormously i n recent years. The e l d e r l y consume a large proportion of health services and the proportion of e l d e r l y people i n the population i s r i s i n g . In an e f f o r t to reduce costs, the trend i n health services has been toward community-based treatment and promotion of health and prevention of d i s a b i l i t y . Prevention i s a philosophy, a way of thinking and approaching problems. It i s concerned with 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 with the interdependence of people. How b e a u t i f u l l y this i s described by Dubos: Solving problems of disease i s not the same thing as creating health the task of health demands a kind 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 complexities 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 things and t h e i r t o t a l environment. (Dubos, 1959, p.22) Dubos points out that "the task of health ..... transcends s p e c i a l i z e d knowledge of remedies and treatments" (Dubos, 1959, p.22). The new focus on maintenance and promotion of health requires p a r a l l e l changes i n the roles and r e s p o n s i b i l i t i e s of health professionals. Health professionals have to adapt to emerging roles as health agents and educators. The r o l e of educator requires learning about education and about how adults learn. Prevention involves "apprehending the r e l a t i o n between l i v i n g things and t h e i r t o t a l environment" (Dubos, 1959, p.22). Promoting the health of e l d e r l y people includes providing an environment i n which each person i s free to reach h i s f u l l e s t p o t e n t i a l . Achieving a supportive environment i s a complex task. This, too, i s a new r o l e for health pro-- 120 -fessionals and one which requires much perfect i o n . I t i s the r e s p o n s i b i l i t y of health personnel to improve the quality of a l l aspects of older persons' l i v e s . Health problems are i n t e r r e l a t e d with a l l other aspects of l i f e . One cannot attempt to solve health problems without being aware of the influence of many s o c i a l factors on health. The f i n d i n g of this study was that costs of health services were not s i g n i f i c a n t l y lower i n the complex which offered on-site preventive nursing services than i n the complex which offered o n - c a l l , curative nursing services. The a b i l i t y to bring about improvement i n health i s l i m i t e d by the aging process. I t i s possible that preventive health care for e l d e r l y people does not have economic b e n e f i t s . On economic grounds alone there i s presently l i t t l e basis f o r an argument to extend Home Care nursing services of the type offered i n Nicholson Towers to other senior c i t i z e n s complexes i n B r i t i s h Columbia. It must, however, be noted that average costs of health services i n Nichol-son and Sunset Towers did not d i f f e r s i g n i f i c a n t l y i n s p i t e of the a r t i -f i c i a l l y high cost of nursing services. Nursing services were the most costly of a l l health services to residents of Nicholson and Sunset Towers; and the cost of nursing services was s i g n i f i c a n t l y higher i n Nicholson than i n Sunset Towers. Were Home Care to develop a system for c a l c u l a t i n g the r e a l cost of providing nursing services i n Nicholson and Sunset Towers, the f i n d i n g might well be that costs of health services are s i g n i f i c a n t l y lower i n Nicholson Towers. Our health care system should be concerned with 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 . On the basis of q u a l i t y of .care, there i s a strong argument f or extending Home Care nursing services of the type offered i n Nicholson Towers to other senior c i t i z e n s complexes i n B r i t i s h Columbia. - 121 -Perceived benefit and f e e l i n g of se c u r i t y from the presence of the nurses are s i g n i f i c a n t l y greater i n Nicholson than i n Sunset Towers. These services are what e l d e r l y people themselves desire. They should be a v a i l -able to those who need them; and emotional need i s as v a l i d as physical need. Each older person i n this province has a r i g h t to those services which w i l l a s s i s t him to achieve and maintain h i s highest l e v e l of human functioning. - 122 -REFERENCES Abramson, J. H. The Co r n e l l Medical Index as an Epidemiological Tool. American Journal of Public Health, February.1966, 52, 2, 287-298. Adeniyi, J. D. Cholera Control: Problem of B e l i e f and A t t i t u d e s . International Journal of Health Education, 1972, 15, 238. Anderson, J . G. Health Services U t i l i z a t i o n : Framework and Review. Health Services Research, 1973, 8, 184. Anderson, W. F. P r a c t i c a l Management of the E l d e r l y . London: Blackwell S c i e n t i f i c P ublications, 1976. Balinsky, W., and Berger, R. A Review of the Research on General Health Status Indexes. 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K. Culture and Symptoms - An Analysis of Patients Presenting 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 Nicholson Towers (1) • Sunset Towers (2) |_J 2. Respondent i s male (1) | | female (2) | | 3. Respondent i s currently receiving nursing s e r v i c e s . (3) • Respondent has received nursing services i n the l a s t two years but not i n the past month. (2) • Respondent has never received nursing se r v i c e s . (1) P 4. Respondent i s e l i g i b l e for admission to a Long Term Care i n s t i t u t i o n . Yes (2) No (1) 5. Number of v i s i t s made by the nurse to the respondent since January 1, 1978 - 130 -I am Lyn Pickard. I c a l l e d you on about coming to see you today. This i s a form which states that you agree to be interviewed. Would you complete i t ? 6. Would you t e l l me your date of bi r t h ? 7. What i s your present m a r i t a l status? (1) I s i n g l e (2) married (3) divorced or separated (4) ) widowed 8. What i s the highest grade of formal schooling that you have completed? 9. What was your occupation before retirement? Please be very s p e c i f i c . (If respondent states that she was a housewife for most of her adult l i f e , write "housewife" and ask: Could you t e l l me the t i t l e of the work your husband did?) 10. Have you been admitted to h o s p i t a l as a patient since l a s t Christmas? Yes No (2) (1) Go Go to 11 to 14 11. On how many separate occasions have you been admitted to h o s p i t a l since l a s t Christmas? occasions 12. How many days altogether have you spent i n h o s p i t a l since Christmas? days - 131 -13. In what h o s p i t a l was this? Vancouver General Hospital (1) St. Paul's Hospital (2) St. Vincent's Hospital (3) Shaughnessy Hospital (4) Lions' Gate Hospital (5) Health Sciences Hospital (6) Other (specify)_ (7) 14. Can you r e c a l l any occasion on which consulting with the nurse i n this b u i l d i n g prevented your needing to be admitted to hospital? Yes No (2) (1) Go to 15 Go to 16 15. How many times did this happen? I 1 I t i m e s 16. How many times have you v i s i t e d your doctor (G.P.) since l a s t Christmas? times (If 0 times, go to 18) 17. How many times since l a s t Christmas have you had a complete phy 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 l a s t Christmas? Yes (2) No (1) 19. What kind of s p e c i a l i s t was this? Orthopaedic, • (1) Neurologist, (2) Internist (3) Rheumatologist (4) Surgeon (5) Eye s p e c i a l i s t (6) E.N.T. (7) Dermatologist (8) 20. How many times did you v i s i t t h i s s p e c i a l i s t ? times - 132 -21. What other s p e c i a l i s t have you v i s i t e d since l a s t Christmas? Orthopaedic (1) Neurologist (2) Int e r n i s t (3) Rheumatologist (4) Surgeon (5) Eye s p e c i a l i s t (6) E.N.T. (7) Dermatologist (8) 22. How many times did you v i s i t t his s p e c i a l i s t ? times 23. Can you r e c a l l any occasion since Christmas on which t a l k i n g with the nurse i n th i s b u i l d i n g resulted i n your deciding that you did not need to v i s i t your doctor? Yes (2) No (1) Go to 24 Go to 25 24. How many times has th i s happened since Christmas? times 25. Do you have diabetes? Yes (1) No (0) 26. Do you have asthma? Yes (1) l _ | No (0) Q 27. Do you have chronic bronchitis? Yes (1) No (0) 28. Do you have ulcers? Yes (1) No (0) -133 -29. Do you have cancer? Yes No (1) (0) 30. Do you have a r t h r i t i s ? Yes (1) No (0) B Go to 31 Go to 38 31. 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, for example)? (1) (0) P c U i correct (Answers that i n d i c a t e : keep mobile, incor r e c t keep active w i l l be considered correct) 32. Do you do this? (Yes. No) (1) (0) Engages i n healthy behaviour Does not engage i n healthy behaviour Go to 34 33. From whom or what did you f i r s t _learn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident i n this b u i l d i n g B (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book | | (7) do not know [n (8) I have known this for a long time Go to 35 34. Was this on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g | (2) group s e t t i n g - 134 -35. If you have so much pain that you do not f e e l l i k e eating, what do you do about eating (... and why)? (1) correct (Answers that i n d i c a t e the impor-(0) LJ i n c o r r e c t tance of eating to maintain strength w i l l be considered correct) 36. From whom or what did you f i r s t learn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this for a long time Go to 37 Go to 38 37. Was t h i s on a one-to-one basis o (1) j j one-to-one (2) j_J group s e t t r i n a s e t t i n g with other people? s e t t i n g ing 38. Do you have a heart condition? Yes (1) |Z] Go to 39 No (0) L| Go to 46 39. How do you decide how often to take medication(s) for your heart? (1) (0) correct (Answers that i n d i c a t e the import-incor r e c t ance of taking medication r e g u l a r l y w i l l be considered correct) 40. Do you do this? (Yes. No) (1) I I Engages i n healthy behaviour (0) L J Does not engage i n healthy behaviour - 135 -41. From whom or what did you f i r s t l earn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident i n this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this for a long time _ Go to 42 Go to 43 42. Was th i s on a one-to-one basis or i n a se t t i n g with other people? (1) one-to-one s e t t i n g _ (2) group s e t t i n g 43. What sort of physi c a l signs would indicate to you that your heart was not functioning well? (1) (0) correct (An answer of one of the following incorrect w i l l be considered correct: swelling of ankles, shortness of breath) 44, From whom or what did you f i r s t l earn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this for a long time Go to 45 Go to 46 45. Was t h i s on a one-to-one basis or i n a s e t t i n g with other people? (1) (2) one-to-one s e t t i n g group s e t t i n g 46. Do you have leg ulcers? Yes ;(1) No (0) — Go to 47 — Go to 55 - 136 -47. Can you name two things one can do to reduce swelling i n the leg? (1) I I correct (Answers that i n d i c a t e heavy supportive (0) |_J incor r e c t and keeping the foot elevated w i l l be considered correct) 48. Do you do this? (Yes. No) (1) (oo: Engages i n healthy behaviour Does not engage i n healthy behaviour 49. From whom or what did you f i r s t l e a r n this? (1) doctor (2) nurse Go to 50 (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book Go to 51 (7) do not know (8) I have known this for a long time _ 50. Was th i s on a one-to-one basis or i n a s e t t i n g with other people? (1) r~i one-to-one s e t t i n g (2) J J group se t t i n g 51. What sorts of food are e s p e c i a l l y important to include i n one's d i e t when one has leg ulcers? correct (Answers that indicate a di e t high i n incorr e c t protein w i l l be considered correct) (1) (0) Engages i n healthy behaviour Does not engage i n healthy behaviour - 137 -53. From whom or what did you f i r s t l e a r n this? (1) (2) (3) (4) (5) (6) (7) _ (8) doctor nurse Go to 54 nurse i n this b u i l d i n g _ resident i n th i s b u i l d i n g f r i e n d / r e l a t i v e TV, radio, newspaper, magazine, book Go to 55 do not know I have known this for a long time 54. Was this on a one-to-one basis or i n a set t i n g with other people? a (1) one-to-one s e t t i n g (2) group s e t t i n g 55. Do you have high blood pressure? Yes (1) No (0) — Go to 56 - Go to 68 56. What kinds of things can you do to help keep your blood pressure down? (1) (0) correct in c o r r e c t (Answers which contain two of the following w i l l be considered correct: decrease s a l t intake, rest frequently, d a i l y exercise, avoid s t r e s s f u l s i t u a t i o n s ) 57. Do you do this? (Yes. No) (1) (0) Engages i n healthy behaviour Does not engage i n healthy behaviour 58. From whom or what did you f i r s t learn this? (1) doctor (2) nurse Go to 59 (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book Go to 60 (7) do not know (8) I have known t h i s f o r a long time - 138 -59. Was this on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g (2) group s e t t i n g 60. If you f e e l dizzy when you get up from a l y i n g p o s i t i o n , what should you do? (1) (0) (2) correct i n c o r r e c t do not get dizzy (Answers of: get up slowly or s i t down again w i l l be considered correct? 61. Do you do this? (Yes. No) (1) (0) Engages i n healthy behaviour Does not engage i n healthy behaviour 62. From whom or what did you f i r s t l e a r n 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 th i s b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this for a long time Go to 63 Go to 64 63. Was th i s on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g (2) group s e t t i n g 64. If you f e e l dizzy while you are doing something ( l i k e walking or housework) what should you do? (1) (0) (2) correct incorrect (Answers that i n d i c a t e stop a c t i v i t y and rest w i l l be considered correct) do not get dizzy 65. Do you do this? (Yes. No) (1) I j Engages i n healthy behaviour (0) M Does not engage i n healthy behaviour - 139 -66. From whom or what did you f i r s t learn this? (1) doctor (2) nurse Go to 67 (3) nurse i n this b u i l d i n g (4) resident i n t h i s b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book Go to 68 (7) do not know (8) I have known th i s for a long time 67. Was t h i s on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g I (2) group s e t t i n g 68. Do you receive any benefit from the presence of the nurse i n the building? A great deal of benefit (3) Some benefit (2) No be n e f i t (1) - Go to 70 - Go to 70 - Go to 69 69. Is t h i s because: (1) (2) (3) (4) (5) You did not know that nurses come into the building? You see your doctor when you f e e l unwell? You do not need nursing services? The nurse does not spend encugh time i n building? Other (specify) 70. Does the fa c t that nurses come into t h i s b u i l d i n g make you f e e l more secure? (3) (2) (1) Very much more secure S l i g h t l y more secure No more secure at a l l 71. In your experience can the nurses be contacted e a s i l y ? Always (4) Q Sometimes (3)L~J. Have never t r i e d to contact nurse ( 2 ) Q Never (1) Q - 140 -72. Can you r e c a l l any occasion on which you t r i e d to contact the nurse and were unable to do so? Yes (3) • Go to 73 I am aware of the hours the nurses are a v a i l a b l e and do not try to ^ \ i — i qq t o 74 contact them at times other than these hours No (1) • Go to 74 73. What do you do i f you are unable to contact the nurse when you need her'i (1) (2) (3) (4) (5) (6) Try again l a t e r the same day Wait u n t i l the next day Phone the doctor V i s i t - t h e doctor Leave a message f or the nurse Other (specify) 74. Do you go to the nurse with small health problems of health questions? Often (3) Q Sometimes (2)Q Never (1) Q 75. Does the fac t that nurses come into t h i s b u i l d i n g mean that they check on your health more often? Yes (2) • No (1) U 76. Have you ever talked to the nurse when you have been worried or upset about a personal or family problem? Yes (2) - Go to 77 No (1) |_J - Go to 78 77. Did t a l k i n g to the nurse make you f e e l (4) j very much better (3) _ a l i t t l e better (2) no d i f f e r e n t (1) j worse - 141 -78. Are you e l i g i b l e for a personal care home? Yes (2) No (1) Go to 79 Go to 81 79. Do you think you could continue to l i v e i n th i s b u i l d i n g i f there were no nurses i n the building? Yes (2) p No (1) Q - Go to 81 - Go to 80 80. Is this because: (1) (2) (3) (4) It makes you f e e l more secure They can check on you more often You can contact them e a s i l y when you need help Other (specify) Next I'd l i k e to ask you about right now. the p h y s i c a l a c t i v i t i e s you are able to do Today do you (or would you) have any physical d i f f i c u l t y at a l l with: No D i f f i c -u l t y Some D i f f i c -u l t y Great D i f f i c u l t y Cannot - Do A c t i v i t y Do Not Know 81. Walking as far as a mile 5 4 3 2 1 82. Climbing up 2 f l i g h t s of s t a i r s (16 steps) 5 4 3 2 1 83. Shopping 5 4 3 2 1 84. Cooking 5 4 3 2 1 85. Dusting or l i g h t house-work - 142 -No Some Great Cannot Do Dif f i e - Dif f'i'c- D i f f i c - Do Not u l t y u l t y u l t y A c t i v i t y Know 86. Cleaning f l o o r s 5 4 3 2 1 87. Do you (or would you) have any physical d i f f i c u l t y at a l l 5 4 3 2 1 t r a v e l l i n g by bus when-ever necessary 88. Do you have any d i f f i -culty at a l l t r a v e l l i n g by car whenever neces-sary? 89. Do you have any trouble reading ordinary newsprint? (4) No, never (3) No, not i f I wear my glasses (2) Yes, sometimes (1) j Yes, always 90. At present are you able to walk out of doors when the weather i s good? Yes (2) • No (1) Ll 91. What i s the farthest you can walk? Are you able to walk: (6) Q one mile or more (3) I I to d i f f e r e n t parts of the b u i l d i n g (5) 0 less than one mile but more than 30 feet (2) Q between rooms (4) 0 l e s s than 30 feet (1) j I only within a room - 143 -Often people's health a f f e c t s the way they f e e l about l i f e . On th i s card are l i s t e d possible responses to the statements I am about to make. (Show the card to the respondent and explain i t ) . For 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 " . If you agree you would say? I f you disagreed you would say? That's good. Now ... Strongly Agree Neutral Disagree Strongly  Agree Disagree 92. I am usually a l e r t . 93. I would say that I nearly always f i n i s h things once I s t a r t them. 94. Some people f e e l that they run t h e i r l i v e s pretty much the way they want to, and th i s i s the case with me. 95. There are many people who don't know what to do with t h e i r l i v e s . 96. Nowadays a person has to l i v e pretty much for today and l e t tomorrow take care of i t s e l f . 97. In a society where almost everyone i s out for him-s e l f , people soon come to d i s t r u s t each other. 98. Many people are unhappy because they do not know what they want out of l i f e . - 144 -Strongly Agree Neutral Disagree Strongly  Agree Disagree 99. 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 . 100. Have you had trouble getting along with friends or r e l a t i v e s during the past year? (1) I A great deal of trouble (2) A f a i r amount of trouble (3) A l i t t l e trouble (4) I No trouble at a l l 101. Have you r e t i r e d from work during the l a s t year? Yes (1) p No (2) • This section contains some questions on general health and on your s o c i a l a c t i v i t i e s . 102. How would you say your health i s these days? health i s : Would you say your (5) (4) (3) Extremely good Very good F a i r l y good (2) (1) S l i g h t l y good Not good at a l l 103. Taking a l l things together, how happy would you say you are these days? Would you say you are: (5) Extremely happy (4) Very happy (3) F a i r l y happy (2) S l i g h t l y happy (1) Not happy at a l l 104. Do you have a telephone? Yes (2) |__| No (1) • - Go to 105 - Go to 113 - 145 -105. How many times have you used your telephone i n the l a s t week to c a l l a friend? • t i lmes 106. 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 ? 0 1 2 3 4 None 1 to 4 5 to 8 9 to 12 _ 12 and over 107. 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) 1 to 5 times None 108. How many times have you been c a l l e d by a s o c i a l agency representative i n the l a s t week? L i t imes 109. Including the times you went shopping or for 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? Q times 110. How many times have you been to a movie, f i l m , play or concert i n the l a s t month? <Q times 111. How many times have you been to a s o c i a l club i n the l a s t month? CJ times 112. How many times have you been to church i n the l a s t month? Q times - 146 -113. 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? "1 times 114. 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? times 115. 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? I I I times 116. How long has i t been since you l a s t had a holiday (away from home)? (4) (3) (2) (1) Less than 1 year 1 to 4 years 5 to 8 years Over.8 years 117. Have you become separated from your spouse during the l a s t year? Yes (1) No (2) 118. Did you s t a r t r e ceiving Mincome during the l a s t year? Yes (1) No (2) The following are questions about diet and a c t i v i t y . 119. How often should one have some form of exercise l i k e going for walks? (1) (0) B correct in c o r r e c t (Answers that in d i c a t e d a i l y , frequent-l y , several times a week, w i l l be considered correct) Engages i n healthy behaviour Does not engage i n healthy behaviour - 147 -121. From whom or what did you f i r s t l earn this? (1) doctor (2) nurse Go to 122 (3) nurse i n this b u i l d i n g —> . (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book Go to 123 (7) do not know - (8) I have known th i s for a long time 122. Was this on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one (2) group s e t t i n g 123. How do you decide when and for how long to take prescribed medicine"! (1) (0) correct incorrect (Answers that i n d i c a t e prescribed medication should be taken exactly as recommended by the doctor or nurse w i l l be considered correct) 124. Do you do this? (Yes. No) (1) rj Engages i n healthy behaviour (0) 1 I Does not engage i n healthy behaviour 125. From whom or what did you f i r s t l earn this? (1) doctor (2) nurse (3) nurse i n t h i s b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this for a long time Go to 126 Go to 127 126. Was th i s on a one-to-one basis or i n a s e t t i n g with other people? (1) (2) one-to-one s e t t i n g group s e t t i n g - 148 -127. How often i s a physical check-up advisable f o r people of your age are f e e l i n g well? (1) correct (0) i n c o r r e c t (Answers of numbers of months ranging between 6 and 18 w i l l be considered correct) 128. Do you do this? (Yes, No) (1) (0) Engages i n healthy behaviour Does not engage i n healthy behaviour 129. From whom or what did you f i r s t learn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident i n th i s b u i l d i n g ( 5 ) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known th i s for a long time Go to 130 Go to 131 130. Was t h i s on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g (2) group s e t t i n g 131. If one i s l i v i n g alone, how often do you think one should have contact with other people? (1) (0) correct incorrect (Answers that ind i c a t e d a i l y contact w i l l be considered correct) 132. Do you do this? (Yes. No) (1) I j Engages i n healthy behaviour (0) I 1 Does not engage i n healthy a behaviour Does not l i v e alone - 149 -133. From whom or what did you f i r s t l e a r n this? (1) doctor (2) nurse (3) . nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this f o r a long time Go to 138 Go to 139 134. Was th i s on a one-to-one basis or i n a s e t t i n g with other people? (1) one-to-one s e t t i n g (2) group s e t t i n g 135. 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 diet? B (1) correct (An answer of 5, 6 or 7 days w i l l be (0) inc o r r e c t considered correct) 136. Do you do this? (Yes. No) (1) f_| Engages i n healthy behaviour (0) L J Does not engage i n healthy behaviour 137. From whom or what did you f i r s t l e a r n this? (1) doctor (2) nurse Go to 138 (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book Go to 139 (7) do not know (8) I have known th i s for a long time 138. Was this on a one-to-one basis or i n a s e t t i n g with other 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 things you can include i n your d i e t to a s s i s t bowel movements? (1) LJi correct (Respondent must name 2 of the following: (0) I I incorrect high bulk foods, bran, prune j u i c e , dried f r u i t , celery, f r u i t , 8 cups of l i q u i d s ) 140. Do you do this? (Yes. No) (1) |_ (0) Engages i n healthy behaviour Does not engage i n healthy behaviour 141. From whom or what did you f i r s t l earn this? (1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known th i s for a long time Go to 142 Go to 143 142. Was this on a one-to-one basis or i n a s e t t i n g with other people? (1) (2) one-to-one s e t t i n g group s e t t i n g 143. How many cups of f l u i d should one drink a day? (1) L J correct (Answers of 6 cups or more w i l l be (2) (J. i n c o r r e c t considered correct) Engages i n healthy behaviour Does not engage i n healthy behaviour - 151 -145. From whom or what did you f i r s t l e a r n this? _(1) doctor (2) nurse (3) nurse i n this b u i l d i n g (4) resident of this b u i l d i n g (5) f r i e n d / r e l a t i v e (6) TV, radio, newspaper, magazine, book (7) do not know (8) I have known this f o r a long time Go to 146 Go to 147 146. Was th i s on a one-to-one basis or i n a s e t t i n g with other people? (1) (2) one-to-one s e t t i n g group s e t t i n g Would you show me what medications you are on? Could you t e l l me what each of these medications i s for? Name of medication from b o t t l e l a b e l Resident states i t i s f o r : 147. (1) I Icorrect (0) I (incor-rect Who t o l d you this? 148. (1)" (2) (3) doctor nurse other (specify) 149, (1) (0) correct i n c o r -rect 150 (1) (2) (3) doctor nurse other (specify) 151. (1) I | correct (0) tl i n c o r -rect 152. (1) ' (2) (3) doctor nurse i n bldg. other (specify) 153. (1) i I correct (0) i j j i n c o r -rect 154 (1) (2) (3) doctor nurse i n bldg. other (specify) - 152 -155. (1) (0) correct i n c o r -rect 156 (1) (2) (3) doctor nurse i n bldg. other (specify) 157. (1) (0) correct i n c o r -rect 158 (1) (2) doctor nurse i n bldg. (3)j other (specify) 159. Can you r e c a l l any occasion i n the l a s t year on which t a l k i n g to the nurse i n this b u i l d i n g resulted i n your: taking less medication Yes No (2) (1) B 160, taking more medication Yes (2) | I No (1) • 161. discarding old medications Yes (2) T No (1) L i What i s your Medical Services Plan Number? Sometimes changes i n one's l i f e a f f e c t one's health. The f i n a l questions are about the changes that have occurred i n your l i f e during the l a s t year. Many of the questions may not apply to you. Would you answer Yes or No to the following questions. During the l a s t year have you experienced: 162. A change i n your usual sleeping pattern (sleeping a l o t more or a l o t l e s s , or change i n part of day when you sleep)? 163. A change i n your eating habits (either a l o t more or a l o t less eating or very d i f f e r e n t meals, hours or surroundings)? 164. A b i g change i n your personal habits (dress, manner, associations, etc.)? Yes(l) No(0) - 153 -Yes (1) No(0) 165. A b i g change i n your usual amount and/or type of recreation? 166. A b i g change i n your usual s o c i a l a c t i v i t i e s (clubs, movies, v i s i t i n g friends, etc.)? 167. A b i g change i n your church a c t i v i t y (either a l o t more or a l o t less or a change i n denomination)? 168. A b i g change i n family get togethers (picnics, holidays, etc.)? 169. A l o t more or a l o t less f i n a n c i a l problems? 170. A l o t more or a l o t less arguments with my husband or wife (for example, over personal habits or money)? 171. A l o t more or a l o t less sexual d i f f i c u l t i e s ? 172. Have you l o s t your husband/wife by death during the l a s t year? 173. Have you married during the l a s t year? 174. Have you become divorced during the l a s t year? 175. Have you separated from your husband/wife during the l a s t year? 176. Have you experienced major i l l n e s s , i n jury or sub s t a n t i a l health change (e.g. menopause, large weight gain or loss)? 177. Have you l o s t a close family member (other than your wife or husband)? 178. Have you l o s t a close f r i e n d by death? 179. Has there been a major change i n the health or behaviour of a family member? 180. Have you changed your place of residence? 181. Have you been found g u i l t y of 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 , etc.)? 182. Have you had a l o t more or a l o t les s contact with your spouse? 

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