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Ageing in Place: Community FIRST and Home Support Client Perspectives

Background

There is an increasing need to change the way services and support is provided to older people as the New Zealand population ages.  Three key documents, The Disability Strategy (2001), The New Zealand Positive Ageing Strategy (2001) and the Health of Older People Strategy (2002) provide a powerful base from which innovative home-based alternatives could be developed.  Community FIRST under Presbyterian Support Otago is one of these home-based support services currently available as a pilot scheme.  Community FIRST provides a wide range of home based services for people eligible for rest home care.  This study examines the strengths and weaknesses of Community FIRST and the standard Home Support services, both provided by Presbyterian Support Otago, as perceived by clients, their family, staff and co-ordinators of each service; and makes recommendations for future provision of these services.

Methods

We interviewed a small sample of clients, their family, staff and co-ordinators from each service.  They were chosen to represent a range of home situations for Community FIRST, and the Home Support clients were chosen to match this group.  Five clients from Community FIRST and five clients from CareLink Home Support who had level of need consistent with rest home level care were selected and interviewed, preferably in the presence of their family.  Clients’ primary caregivers were then identified and interviewed.  Two coordinators from each service were interviewed.  Themes from the interviews were then analysed.  Questionnaires were developed from the recent strategy documents.  The interviews took place between 14 March and 02 April 2005, and ethical approval was obtained.

Results

The two groups of clients were similar in level of need.  For Community FIRST this group was fairly representative of all clients.  For Home Support clients this represented the clients with the very highest level of need.  We identified four strong themes from our interviews: Living at home and in the community; Nature and quality of care; Programme funding, Carer wages and training; and Communication.

  1. Living at home and in the community
    All clients interviewed expressed a strong desire of staying at home, and this was a major source of job satisfaction for the caregivers.
  2. Nature and quality of care
    Clients of both groups generally appreciated their caregivers.  Clients of Community FIRST felt the programme was flexible and rehabilitative and was highly valued.  Despite this, the caregivers and co-ordinators of this service expressed concerns about maintaining the flexibilityin the future.  Client unease with frequent staff changes was noted in the Home Support group.  Home Support caregivers and co-ordinators found that strict time allotments restrict the provision of care to the clients.
  3. Programme funding, carer wages and training
    Staff changes were infrequent in Community FIRST.  Clients and families of both groups felt that caregiver pay should be improved and more training offered to caregivers.  Caregivers of both group expressed dissatisfaction with pay.  In addition, they desire more practical training sessions.  Co-ordinators indicated the funding structure of Community FIRST enables flexibility.  Clients and families of Home Support commented on staff shortages.  Co-ordinators of Home Support recognised the effect of low caregiver pay has on their services.
  4. Communication
    Community FIRST clients and caregivers felt communication was adequate and the co-ordinators were easily accessible.  Co-ordinators met regularly with their caregivers to create a service plan for clients, however overwork was a barrier to provide adequate care and communication.  Clients and caregivers of Home Support felt overworked co-ordinators impacted on communication and in turn, client care.  Co-ordinators would like to communicate more effectively, and provide better client care, however, these are precluded by barriers such as time pressures and limited funding.

Conclusion

Older people desire and enjoy staying at home with the support of their informal carers, as well as the professional and friendly caregivers from CareLink Home Support or Community FIRST.  Community FIRST appeared to be much better suited to cater for clients assessed as being in higher (rest home) level care.  This appears to be due to the flexible framework and structure within which Community FIRST operates, that enables the high level of co-ordination of care.  A higher level and more flexibility of funding, staffing (in the office and in the community) and programming, adequate and continuing staff training, more secure employment of caregivers, and slightly more adequate pay are likely to be the major contributors to the observed difference.

Recommendations

Our study has highlighted several important aspects of the Community FIRST model of care that were particularly valued by the clients and their family, caregivers and coordinators.  We believe that these aspects are critical for provision of services to the care of the elderly.  Home care services should include these aspects and be more available to the older population at large.

Authors of Report

Kate Fairbrother, Melissa Horsfall, Adeline Lo, Arapera Salter, Ming Chang Yu

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Are People Trained in Smoking Cessation Offering a Support Service? If Not, Why Not?

Background

Cigarette smoking is an issue raising controversy in New Zealand and worldwide, medically, socially and politically. The intensely highlighted health-related consequences of smoking and recent anti-smoking legislation have raised awareness in the smoking cessation process.

Aim

To establish how many people who have undertaken training in smoking cessation are offering cessation support for their client group, and if not, why not.

Objectives

  1. To identify what is available in Otago in terms of smoking cessation support.
  2. Current best practice: effectiveness according to literature.
  3. Identify barriers to practical implementation of the skills learnt in smoking cessation training programs.
  4. Identify improvements that could be made to increase the efficacy of smoking cessation programs.

Methods

A short answer qualitative pilot questionnaire was sent to 8 people in Dunedin identified as experts in smoking cessation. From this we formulated a 22-question multi-choice and 4-question short answer questionnaire, and forwarded it to those who had attended a smoking cessation course run by National Heart Foundation in the previous 3 years. The poor response (n=3) led us to enlist via telephone a practice nurse from most Dunedin General Practice listed in the blue pages. Those who consented (n=25) were interviewed face-to-face with a similar survey.

Results

The results could not be statistically analysed due to the small study population. Half of the respondents had attended a cessation course. There was a link between positive attitudes to providing smoking cessation, support and having a personal smoking history as well as having previously attended a smoking cessation program. Only 1 out of 25 respondents could prescribe NRT. Face-to-face counselling was thought to be more effective than telephone support and brief intervention strategies (<5min), but with an increase in cost. Barriers identified were limited resources in terms of time and money, the topic not being taken seriously amongst the public and health professionals, a lack of awareness of courses on offer and a lack of co-ordination between health services.

Discussion

Despite some encouraging results regarding smoking cessation, there were areas that required attention. Using a larger study population, a more definitive study needs to be conducted to identify barriers to practical implementation of the skills learnt in smoking cessation training programs, and to identify improvements that could be made to increase the efficacy of smoking cessation programs.

Authors of Report

Laura Vercoe, Kimberley Shaw, Jade McCurdie, Jordan Baker, Natalie Durup, Hwee Sin Chong, Hana Pak, Yukio Flinte

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Community Attitudes to Mental Illness: A Survey of the Dunedin Area

Introduction

Mental illness has historically suffered from a poor public perception, with deleterious consequences for community-based patients. Previous work has found that attitudes to mental illness vary between particular demographic groups in the population. Over the past few years in NZ, the Like Minds Like Mine campaign has been attempting to destigmatise mental illness. This study aimed to assess current attitudes to mental illness amongst the Dunedin community, and to compare these findings to those of local and overseas studies. In addition, an attempt was made to identify sources of influence on attitudes, and to correlate different sources with particular attitudes.

Methods

A standardised tool for assessing community attitudes to mental illness was incorporated into a questionnaire, along with questions regarding influences on respondents’ opinions. The questionnaire was then mailed to four hundred randomly selected Dunedin residents. Responses were analysed to obtain scores for four specific attitude dimensions (Authoritarianism, Benevolence, Community Mental Health Ideology, and Social Restrictiveness), along with a “social distance score”. Scores were then compared between various demographic subgroups, and correlated with specific sources of influence.

Results

The majority of respondents scored highly in favour of Benevolence and Community Mental Health Ideology, whilst being relatively non-Authoritarian and non-Socially Restrictive. Personal experience with mental illness was reported as being the most common source of influence on respondents’ opinions. Talking to friends, personal experience and the Like Minds Like Mine campaign were all associated with favourable attitudes, while TV news and newspaper stories were associated with reduced comfort with social relationships with the mentally ill.

Discussion

Overall, the Dunedin population holds tolerant views regarding mental illness and its treatment. Attitudes become less tolerant with increasing age and decreasing educational level. The findings replicate those of previous Dunedin and overseas studies. Personal experience with mental illness, along with most other sources of influence, were associated with holding tolerant views, with only TV news and newspaper stories being associated with reduced comfort levels.

Authors of Report

Hermione Binnie, James Clark, George Downward, Andrew Irving, Aik Lyn Tan

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Gout in the Community

This study is a cross-sectional, observational study looking at the prevalence and management of gout in a single GP practice in Dunedin. The aim was to establish baseline data for the initial assessment of gout, a growing health problem in New Zealand.  The study was carried out in a similar way to a recent Auckland study of gout by Gow et al (2004).

Information was taken from the GP database using Medtech32. This data included basic information including, height, weight, ethnicity, number of attacks, uric acid levels, number of uric acid estimations and age and sex.  The data were analysed using the statistical programme SPSS.

The results showed the estimated prevalence of gout in Dunedin is half that of gout in Auckland and has a similar prevalence to gout elsewhere in the Western world.

The study also showed that gout patients in Dunedin are having fewer numbers of acute attacks of gout than patients in Auckland.  The study found a higher prevalence of gout in Polynesians.  It also found that once a patient has the diagnosis of gout, factors such as their age, ethnicity, weight and sex are not associated with the severity of their gout.

Authors of Report

Nusrat Zahan, Carl Harmer, Sanjeeva Herath, Louisa Metcalf, Bridget Watson

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The Great Otago Sugar Rush: A Survey of Dunedin High School Student Sugary Drink Consumption

Background

Childhood and adolescence obesity is a growing concern in New Zealand. Worldwide,  the prevalence of obesity in children and adolescence is increasing.  Sugar-containing drinks (SCD’s) represents an important modifiable risk factor in childhood and adolescence obesity.  Alongside childhood and adolescence obesity prevalence, sugary drink consumption, as part of daily total caloric intake, has risen dramatically over the last couple of decades.  This study looks at SCD’s in high schools, in these areas:  policy in schools, attitudes and consumption in students, and attitudes of parents.

Method

The study design was a cross-sectional observational study of Dunedin high school students.  Three questionnaires were used: a student questionnaire which compared intake and attitudes to SCD’s; a school questionnaire to assess the provision of SCD’s in high-schools, and whether they have policies on sugary drink consumption; and a parent questionnaire to assess factors in the home environment that may affect overall consumption. 

Results

Six of twelve secondary schools in Dunedin took part in the study, 437 in a “full” data set, and because some students estimated consumption at 3-4 times the mean (up to 18.5 litres a day)  342  students are in a “restricted” data set (fluid intake of  3.5L or less).  Form 3 students consumed a significantly larger amount of sugar from SCD’s than form 6 students (full data set, p=0.0237, Ratio1.54, CI 1.06 - 2.24). Females consume significantly less sugar from SCD’s than males (full p=0.00098, Ratio 0.49, CI 0.32 - 0.75; restricted p=0.0082, Ratio 0.54, CI 0.35 - 0.85).  Restricted availability at home was predictive of reduced consumption (Ratio of never to usually available at home 0.41, CI 0.22-0.77, p<0.0001).  Dental fillings significantly predicted sugar consumption from SCD’s.  Students with no fillings at all or one filling have half the consumption of sugar compared with students with greater than three fillings (p=0.0242). Increased TV viewing is also associated with consumption.  Students with 0-1 hours viewing have a quarter of the consumption of students with 5+ hours of viewing (p<0.0001). 

Discussion

The study shows that targeting education programmes at male form 3 students may have the highest utility in reducing SCD consumption.  Restriction on the availability of  SCD at home may have the greatest effect on high-school students consumption.  The effect of television viewing should be the subject of further investigation.  The effect of school policy on consumption of SCD’s may be important but will require a larger number of schools to be studied.

Authors of Report

Chih-Ching Choong, Chris Gray, Jonathan Graham, Nicholas Johnston, Yehwon Yoo

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The Meningitis B Immunization Programme:  Opinions From Parents of Year 8 Students

Background

New Zealand has an epidemic of meningococcal B disease.  Following the development of a vaccine specific for the New Zealand strain of the disease (MeNZBTM), free immunization is being offered to all young New Zealanders aged 6 months to 19 years.

This is a mass immunization programme.  School children (30 000 in Otago) will be offered the immunization at school.  This is a novel approach in the South Island.  The MeNZB immunization campaign has resulted in an uptake that is postulated to be higher than the uptake of the polio/tetanus booster immunization.

The aims of this study were to assess the acceptability of the MeNZB immunization programme in Otago.  The secondary aims were (1) to assess the effectiveness of the MeNZB information pack in helping parents make an informed decision about immunising their child, and (2) to determine whether the implementation of a ‘school based’ immunization approach is more acceptable for parents compared with a primary care based approach.

Methods

Ethical approval for this study was obtained from the Lower South Ethics Committee and ODHB.  A questionnaire was developed following review of relevant literature.  A random sample of 500 parents/guardians of Year 8 (12 year old) children was selected from a sampling frame of 2644 Year 8 children in Otago.  Responses were returned anonymously using a prepaid envelope, and entered onto a database.  Statistical analysis was undertaken using SPSSv10.5.

Results

The response rate was 34%.  There was a high uptake of both the MeNZBTM immunization (94%) and of the age 11 polio/tetanus immunization (90%).  Overall parents found the consent form easy to understand and thought it provided enough information, though if they did not they were less likely to consent.  Significant differences in opinions between those who consented to their child being immunised with MeNZBTM and those who did not existed, specifically with regard to safety and efficacy of the vaccine, perceived risk of their child being affected by the disease, and preference for alternative methods.  Parents with university degrees were significantly less likely to immunise their children.  Most parents had no preference for where their child was immunised, though there was a trend for highly educated parents to prefer the GP setting and those with no qualifications to prefer a school based setting. 

Conclusion

The generalisability of this study is limited by the response rate and small numbers.  In future studies, follow up of non-respondents should be considered if there is adequate time.  Future studies could aim to over-sample parents of Maori and Pacific ethnicity within the Otago region, particularly given these groups are most at risk of meningococcal disease.  Including information in consent forms may be an effective way to inform parents when they are deciding to immunise their children, especially about vaccine safety and efficacy.  Even though our study indicated most parents had no preference about the preferred immunization setting they may prefer to have the choice, and school based settings may more effective when targeting families from lower socioeconomic areas for immunization. 

Postscript

After the results were presented by the group, an additional 38 survey forms had been received (by 18.10.05), taking the response rate from 34.2% to 42.0%.  Using all 206 responses, 99.5% had received the information pack, 98.5% found it easy to understand, 88.1% said it contained sufficient information, and 10.3% had used the phone helpline or website.  95.6% had or planned to have their child receive the MeNZB immunization and 91.9% had received the Polio/Tetanus booster.  Preferred settings for immunization were 25.4% school, 25.9% GP, and 48.8% with no preference.

Respondents were broken down into 161 prompt respondents (completed survey received 10.06.05 to 20.06.05) and 45 late respondents (22.06.05 onwards).  Looking for associations between timeliness of reply and answers to survey questions showed that late respondents were more likely to be parents of older children (aged 13 and over, compared to 10-12 years old) (p=0.034) and to be in agreement with or uncertain about the use of homeopathy instead of a vaccine (p=0.026). There was evidence that late respondents were less likely to have known someone with Polio/Tetanus (p=0.042).  For those respondents who had not vaccinated their child against Polio/Tetanus, late respondents were less likely to be planning to do so (p=0.006).  Late respondents were less likely to agree that they had received sufficient information about the Polio/Tetanus boosters (p=0.040).  No other differences were found between prompt and late respondents, providing no evidence that non-respondents would have differed from respondents in ways other than those already mentioned.

These final results provide more assurance about the basic findings presented in the report.

Authors of Report

Maartje O’Brien, Patricia Boyd, Matthew Dalman, Hannah Kim, Kate Mullin, George Stephenson, Nathan Watkins

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Walking to Primary School or Being Driven: How Many Children and Why?

Childhood obesity is a growing public health concern nationally and internationally.   The burden to both the individual and the health care system is significant and addressing this problem, in terms of both prevention and treatment, has become the focus of many public health strategies. Although the aetiology of the upward trend in childhood obesity is likely to be multifactorial, the contribution of declining activity levels cannot be ignored.  Walking to and from school provides children with a convenient and regular means for energy expenditure.  This study seeks to estimate the prevalence of walking to school amongst Dunedin primary school children.  It also seeks to identify the major barriers to walking that may exist for this population. 

Results

1157 completed questionnaires were returned, giving a response rate of 67.9%. On the study day, 34.5% of Dunedin primary school children walked to school and 36.8% walked home. 28.9% of children were frequent walkers, while 40.8% of children living within 2km of school walk frequently. Factors rated most important in influencing parents’ decision to let their child walk to school were crossing roads, traffic speed, health benefits of walking and stranger danger. The proportion of children walking reduces with increasing distance from school (<1km OR 1.00, 1-2km OR 0.27, 2-3km OR 0.11, >3km OR 0.03). Females were less likely to walk than males (OR 0.73) and their parents were more concerned about stranger danger and the availability of a walking companion. Children in year 1-3 were less likely to walk than those in year 4-6 (OR 0.59) and parents of younger children thought road safety issues were more important. Children at decile 2-4 schools had 2.39 the odds of walking compared to decile 5-7. Maori and Pacific Island children were more likely to walk to school than NZ European children (OR 1.57 and 2.69 respectively).

Conclusions

This study has established a baseline for the proportion of primary school children walking to school and also identifying the major barriers and predictors influencing the decision to walk to school. The biggest barrier to walking to school as identified by parents is road safety. The strongest positive predictor of walking to school is the proximity of the school. These results may have ramifications for local, regional and national health and transport policies.

Authors of Report

Richard Burt, Kent Chow, Roana Donohue, Haji Satry Haji Sani, Keryn Taylor, Cindy Towns, Sofie Yelavich

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