PEOPLE LIVING IN THE DUBLIN DOCKLANDS AND THEIR HEALTH

Transcription

1 PEOPLE LIVING IN THE DUBLIN DOCKLANDS AND THEIR HEALTH The health needs of people living in the Pearse Street area, Ringsend and Irishtown September 2002 PART 1 A COMMUNITY BASED SURVEY Frances O Keeffe Jean Long Tom O Dowd PART 2 THE HEALTH SERVICE PROVIDERS PERSPECTIVE Frances O Keeffe Jillian Deady Jean Long Tom O Dowd REPORT PREPARED FOR THE ROYAL CITY OF DUBLIN HOSPITAL TRUST BY THE DEPARTMENT OF COMMUNITY HEALTH AND GENERAL PRACTICE, TRINITY COLLEGE, DUBLIN

2 TABLE OF CONTENTS Page Acknowledgements Foreword List of Tables List of Figures List of Appendices List of Abbreviations PART 1 - A community based survey 9 Summary 10 Introduction 14 Methods 2.0 Introduction 2.1 Study area 2.2 Sampling 2.3 Fieldwork 2.4 Data collection instrument 2.5 Statistical methods 2.6 In depth interviews Results 3.0 Introduction 3.1 Response rate 3.2 Demographic and socio-economic characteristics 3.3 Health care issues and behaviours 3.4 Chronic disease 3.5 Disability 3.6 Deaths 3.7 Acute hospital services 3.8 Health services for women 3.9 Community health services 3.10 Waiting for health care 3.11 Primary carers suggested additional health needs 3.12 Comparisons between the communities living in the Pearse Street area and in Ringsend and Irishtown Discussion 56 References 59 2

3 TABLE OF CONTENTS Page PART 2 - The health service providers perspective 60 Summary 61 Methods 1.0 Introduction 1.1 Aim 1.2 Research design 1.3 Study population 1.4 Sampling 1.5 Fieldwork 1.6 Data analysis Results 2.0 Introduction 2.1 The health issues in the community Physical problems Mental health problems Social problems Loneliness and isolation Drug and alcohol misuse Social deprivation What occupies most of your time 2.2 Services and resources in the community Main barriers to effective delivery of services Staffing issues Premises and local facilities Social deprivation Geographical and administrative access to services Barriers within general practice Resources required to address the needs of the community Staff Health premises Resources for the elderly Locally based services Resources for family and children Suggestions on how to improve the service 2.3 Co-ordination and teamwork in the area Level of co-ordination between service providers and teamwork in the area The primary care team Discussion 82 References 84 Appendices Parts 1 and

4 ACKNOWLEDGEMENTS The authors wish to thank the Royal City of Dublin Hospital Trust (Baggot Street Hospital) for commissioning and funding this study. A special thank you to Dr. John Ryan who gave of his time and knowledge freely. Thank you to the Chief Executive Officer and staff of the South Western Area Health Board for their support. In particular thank you to Mr. Brian Burke, General Manager, Dublin South City District (Community Care Area 3). Special thanks to the people who assisted with the fieldwork, in particular the data collectors from the local community. Thanks to all the individuals in the community and the representatives of the different community groups who shared their knowledge of the community and its needs. Thanks to all the service providers who shared their knowledge of and insights into the community. Thanks to John Fitzsimons and staff of St. Andrew s Resource Centre for their support (including photographs), cooperation and use of the premises during the survey. Thanks to the staff of Ringsend Community Centre for the use of their premises during the survey. Thanks to Joe Grennell, Aileen Foran and staff of the Ringsend Action Project for their assistance and support (including photographs). Thanks to James Williams, Head of Survey Unit at the Economic and Social Research Institute, for selecting the sample, and to Mediscribe Ireland for transcribing the health service providers interviews. We also thank our colleagues Deirdre Handy, for administrative support and editing this report and Conor Teljeur, for providing population numbers and maps. And finally a very special thanks to all the people who agreed to participate in the survey. 4

5 FOREWORD In 2001 the Board of the Royal City of Dublin Hospital Trust commissioned and funded the Department of Community Health and General Practice, Trinity College, to undertake a study of the health needs of people living in the Pearse Street, Ringsend, and Irishtown areas, for the purpose of identifying health priorities which are not currently addressed, or alternatively, are inadequately addressed. The Board of the Royal City of Dublin Trust is very pleased with the resulting report. This was produced by Ms Frances O Keeffe, Dr Jean Long and Professor Tom O Dowd. We are indeed indebted to them and congratulate the Department of Community Health and General Practice, Trinity College, on this excellent achievement. We are happy that the report clearly fulfills its purpose. We are pleased to present this report to the communities of the areas involved. We hope it will generate a positive debate within the communities, among the local health service providers, and not least among the various statutory and voluntary agencies with roles to play in addressing the priorities identified. Most of all we hope it will lead to action. Bernard Breen Chairman 5

6 LIST OF TABLES Page Table 2.1 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7 Table 3.8 Table 3.9 Table 3.10 Table 3.11 Table 3.12 Table 3.13 Table 3.14 Table 3.15 Table 3.16 Distribution of sample and population in both high and low deprivation district electoral divisions in the study area Primary carers reported characteristics of their households Primary carers reported access to communication, house heating and health cover Demographic and socio-economic characteristics of the primary carers Primary carers reported demographic, family and socio-economic information for individuals residing in the households Primary carers reported tobacco use and drug dependency (alcohol or illicit) in the households Primary carers reported number (%) of individuals (18 years or older) in the households who smoke and the quantity smoked each day by these individuals Primary carers reported number (%) of individuals in their households with a drug/alcohol problem and also their health service uptake Primary carers reported experience of stress Primary carers reported experience of intimidation and/or violence in the last 12 months Primary carers reported experience of coping with teenage children and the type of assistance sought Primary carers reported types of chronic illness, the level of care required and health services used by individuals residing in their households Logistic regression model to identify factors associated with having a chronic illness in the population (187/699) Primary carers reported types of disability, the level of care required and the health services used by individuals residing in their households Logistic regression model to identify factors associated with having a disability in the population (21/699) Primary carers reported type of appointment for, channel of referral to and means of transport used by individuals in their households to attend a hospital service in the 12 months prior to the survey Logistic regression model to identify the factors that influenced use of a hospital service in the year prior to the study among the population (176/699) Table 3.17 Primary carers reported current use of family planning, recent uptake of cervical smear tests and breast examination 41 Table 3.18 Primary carers reported number of pregnancies in their households between January 1997 and September 2001 and service uptake by pregnant women during each pregnancy 42 Table 3.19 Primary carers reported number (%) of individuals admitted to maternity hospital in the year prior to the survey, number (%) who used the hospital, and their level of satisfaction with services 43 Table 3.20 Primary carers reported number (%) of individuals who visited their GP in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction 44 6

7 LIST OF TABLES Page Table 3.21 Table 3.22 Primary carers reported use of and satisfaction with out of hours medical services and their source of health information Logistic regression model to identify factors associated with attending a general practitioner as one of the last three health services used in the year prior to the survey among the study population (327/699) Table 3.23 Primary carers reported vaccination uptake for children aged between two and five years residing in their households 47 Table 3.24 Table 3.25 Table 3.26 Primary carers reported number (%) of individuals using the community nursing service in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction Primary carers reported number (%) of individuals who visited their dentist in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction Primary carers reported number (%) of individuals residing in the households waiting for health care, length waiting for service, location of service and satisfaction with waiting period Table 3.27 Logistic regression model to identify factors associated with waiting for health care in the population (53/699) 51 Table 3.28 Additional health care services suggested by primary carers 52 Table 3.29 Primary carers suggestions for the location of a health centre that would serve both communities 53 Table 3.30 Summary of comparisons between the communities living in the Pearse street area and Ringsend/Irishtown 54 7

8 LIST OF FIGURES Page Figure 3.1 Figure 3.2 Figure 3.3 Figure 3.4 Figure 3.5 Figure 3.6 Figure 3.7 Figure 3.8 Figure 3.9 Age profile of the population in 1996 census versus household members in 2001 survey Gender profile of the population in 1996 census versus household members in 2001 survey Key characteristics of the households and primary carers (n=273) Primary carers reported sources of help to deal with stress (n=145) Primary carers reported sources of support to deal with the last incident of intimidation or violence (n=30) Types of chronic illness reported by primary carers for the household members (n=187) Hospital facilities used by household members as reported by the primary carers (n=176) Household members reasons for attending hospital as reported by primary carers (n=176) Household members satisfaction with hospital services as reported by primary carer Figure 3.10 Practices of women during their most recent pregnancy (between January 1997 and September 2001) as reported by primary carers (n=21) Figure 3.11 Type of treatment awaited by household members as reported by primary carers (n=26) LIST OF APPENDICES Appendix 1 Maps of the study area Appendix 2 Information leaflets 2a Letter to participants 2b Poster 2c Information sheet for interviewers Appendix 3 Survey team Appendix 4 Procedures employed to ensure good ethical practice Appendix 5 Satisfaction with hospital services Appendix 6 Topic guidelines Appendix 7 Consent form for the service providers who participated in the study Appendix 8 Silverman s transcription symbols LIST OF ABBREVIATIONS CI DED ENT GMS GP n OR OT SAHRU SWAHB Confidence Interval District Electoral Division Ear, Nose and Throat General Medical Service General Practitioner Total number who answered the question Odds Ratio Occupational Therapist Small Area Health Research Unit South Western Area Health Board 8

9 PEOPLE LIVING IN THE DUBLIN DOCKLANDS AND THEIR HEALTH The health needs of people living in the Pearse Street area, Ringsend and Irishtown PART 1 A COMMUNITY BASED SURVEY Frances O Keeffe Jean Long Tom O Dowd

10 SUMMARY - PART 1 Summary We have presented the main survey findings in this summary. More detailed findings are available in the results section for use by health planners employed by the area health boards. The information contained in this document is also pertinent to those working in primary care or with a special interest in health care. What we set out to do We set out to assess the health needs of households and their individual members residing in two geographical communities: the Pearse Street area and the Ringsend/Irishtown area. How we conducted the assessment Initially we contacted key individuals in the community to inform them of the proposed study and to ascertain what they felt were the key health and social issues in the area. We included these issues in the questionnaire. We then conducted a cross sectional study in the four district electoral divisions of the study area (excluding the south-western corner of Pembroke West A). We interviewed primary or principal carers (defined as the person in the household who manages the welfare and health of the family/household) in 273 of the selected 360 households. We selected the households employing a cluster sampling methodology. We chose 30 clusters from both the two less deprived district electoral divisions and the two more deprived district electoral divisions. Each of the 60 clusters consisted of six adjacent households. We interviewed the primary carers in their homes, using an interviewer administered questionnaire. What we found in the survey Of the 360 households selected to participate in the survey, over 75% participated, indicating a keen interest in health related issues. Data were also collected on 699 individuals residing in these houses. The people of the area The population in the area continues to grow and migrate with almost half of the households residing in the area for less than ten years. This reflects the new private housing developments in the area over the last ten years and the movement of young families from flat complexes to houses. However this is generally an older population with almost one third over the age of 50 years and over half of these aged 65 years or over. Of note is that 86 of the primary carers were aged between 65 and 95 years old, of whom 47 (55%) were living on their own. Of those who stated that they were the primary carers, almost one quarter were men. Primary or principal carers reported that: 51% of all household members are living in rented accommodation of these, 37% live in government supported accommodation and 14% are renting privately. 54% of households did not own a car, almost 6% of households were occupied by non-nationals, 45% of households had medical card cover, 8% described themselves as lone parents, 50% of primary carers had primary school education or less. Lifestyle and family issues Primary or principal carers reported that: 53% had experienced stress in the year prior to the survey, of these, 26% consulted their general practitioner because of their stress, 12% had received prescribed medication, 8% had visited a counsellor. 11% experienced violence or intimidation in the previous year, of these, 30% had experienced the incident in their own homes, 37% had reported the violent incident to the police, one third had sought medical assistance, 10

11 SUMMARY - PART 1 60% worried about their teenagers socialising, 30% found their teenagers attitudes or behaviours upsetting, 31% of household members, 18 years or over smoked, 1% of household individuals, over 15 years old, had a problem with either alcohol or drugs. Chronic illness and disability Primary carers reported that: 27% of the 699 household members had a chronic illness; the most common chronic illnesses were respiratory (25%), cardiovascular disease (24%) and arthritis (18%). overall 3% of household members had a disability, of these, 43% had their disability since birth, Over three quarters had a physical disability. Hospital services Primary or principal carers reported that: 25% of household members used a hospital service in the 12 months prior to the survey, the main reasons for attending were cardiovascular disease (18%), injury or an acute emergency (15%) and respiratory problems (10%), of those who used hospital services: 63% were elective or planned attendances at the hospital, 36% attended outpatients, 24% were seen in accident and emergency, 9% were day patients and 31% were admitted to hospital, 87% were satisfied with inpatient and outpatient services, 82% were satisfied with the day care service and accident and emergency, the main reasons for satisfaction and dissatisfaction were common to all hospital services, their main reasons for satisfaction were that staff listened to their problem(s) and staff explained their medical conditions, their main reason for dissatisfaction was the long waiting periods encountered. Hospital services were more likely to be used by those with chronic illness and those waiting for health care. Health services for women Female primary or principal carers (of child bearing age) reported that: 46% (45/98) were using a method of family planning, 54% of women aged 18 to 65 had a smear test in the last five years, 43% of women aged 18 to 65 had a breast examination in the last five years, only 29% of women aged 50 to 65 years had a mammogram in the last five years. Primary or principal carers reported that: 52% of the women s most recent pregnancies were planned, only 30% opted for general practitioner and hospital shared care, 29% of the women smoked during their last pregnancy, 95% delivered their last child in the National Maternity hospital, Holles street. Community health services Primary or principal carers reported that: 47% of the household members had attended their general practitioner in the last year, of these, 89% were satisfied with services provided by their general practitioners; the main reasons for satisfaction were, the doctor listened to their problem(s) (74%), the doctor was nearby (53%) and the doctor provided good treatment or care (52%), the main cause of dissatisfaction was that the doctor did not listen to their problem(s) (6%). 11

12 SUMMARY - PART 1 21% of respondents were unhappy with the current out of hours general practitioner service, 5% of the individuals had consulted a community nurse in the last year, of these, 80% were satisfied with the service provided, the main reasons for satisfaction were the nurses were courteous and friendly (69%), the nurse listened to their problem(s) (59%) and the nurse provided good treatment (34%), the main reason for dissatisfaction was that the nurse did not listen to their problem(s) (9%). 96% of children aged between two and five years residing in their households had completed the routine childhood vaccines, 75% of children aged between two and five years had received the meningitis C vaccine, the most common sources of health information were the staff at their general practice (59%) and health information leaflets (27%), just 12% of the population had visited a dentist in the 12 months prior to the survey. Waiting for health care 4% of the household members were on a waiting list, of these, 88% were waiting for hospital services, 12% were waiting for dental services and other community services. Comparisons between the communities in the Pearse street area and in Ringsend/Irishtown More householders in the Pearse Street area (52%) had moved into the area within the last 10 years than in Ringsend/Irishtown (39%). In the Pearse Street area 44% of individuals smoked more than ten cigarettes per day compared to 28% of individuals in Ringsend/Irishtown. Primary carers living in Ringsend/Irishtown (59%) were more likely to use a method of family planning than those living in the Pearse Street area (33%). A higher proportion of female primary carers living in Ringsend/Irishtown (50%) had a breast check within the last five years than the proportion living in the Pearse Street area (36%). A slightly higher proportion of people living in Ringsend/Irishtown (29%) used a hospital service within the last year than the proportion living in the Pearse Street area (22%). A higher proportion of people living in the Pearse Street area (51%) attended their General Practitioner within the last year than the proportion living in Ringsend/Irishtown (42%). When the primary carer was asked where s/he preferred to attend a health centre the majority in both the Pearse Street area (83%) and Ringsend/Irishtown (92%) wanted to attend a centre within their own area. Additional health services identified by the people in the area 80% of the primary carers identified additional health needs in the area. For example: 52% asked that out of hours general practitioner services be reorganised and staffed by local general practitioners, 37% requested improved services for the elderly, these included, day care (25%), long term care (18%), respite care (16%), and home visits (10%), 25% requested a social work service to provide for all members of the community, other services suggested included a local counselling service, a clinic to promote women s health and services for teenagers (which included contraceptive advice and psychological services). Conclusion The people living in the area were keen to participate in the study and made valuable suggestions about the services needed in the area. We hope that the information will be an important resource for health planners and service providers in the area. 12

13 INTRODUCTION AND METHODS PART 1

14 INTRODUCTION - PART 1 Introduction The overall purpose of a health needs assessment is to gather the information required to bring about change beneficial to the health of the target population. Needs assessments provide the basis for health care planning in a community. The assessment must incorporate the wider social and environmental determinants of health, such as deprivation, housing, education and employment. A combination of qualitative and quantitative research methods are required to collect the relevant information. Assessing the health needs of local communities is necessary for effective targeting, delivery and improvement of health and social services. Health needs assessments are of particular importance in view of the new primary care strategy, which states that health needs assessment is central to effective primary care. 1 The new strategy emphasises the importance of including the community as partners in developing the health services. Identifying and responding to the needs of the individuals in the community is an important element of this partnership. In April 2001, the Royal City of Dublin Hospital Trust (Baggot Street hospital) commissioned a study to investigate the health needs of the people living in the Pearse Street area, Irishtown and Ringsend. Where a clearly defined need is identified the Trust are interested in assisting in health projects within the local community served by the Royal City of Dublin Hospital. Study objectives The objectives of the study were to: Describe the socio-economic status and demographic profileof the community. Estimate proportions with chronic illness and disability in the community. Measure current health service utilisation. Measure satisfaction with current health service provision. Establish areas of unmet needs. Compare socio-economic characteristics, health status and health service utilisation of those living in the Pearse Street area with those living in Ringsend/Irishtown. 14

15 METHODS - PART 1 Methods This chapter describes the methods employed to conduct and analyse the household survey and is presented in six sections: 2.0 Introduction 2.1 Study area 2.2 Sampling 2.3 Fieldwork 2.4 Data collection instrument 2.5 Statistical methods 2.6 In depth interviews 2.0 INTRODUCTION The Department of Community Health and General Practice, based at the Trinity College Centre for Health Sciences, Adelaide and Meath Hospital, Dublin, incorporating The National Children s Hospital, was requested to undertake the health needs assessment in the Pearse Street area and in the Ringsend and Irishtown area. The South Western Area Health Board (SWAHB) fully endorsed the study. The study was approved by the St James s and Federated Dublin Voluntary Hospitals Joint Research Ethics Committee. 2.1 STUDY AREA The study area covered included three complete district electoral divisions, (Mansion House A, South Dock, Pembroke East A) and most of the fourth district electoral division Pembroke West A (excluding the south western corner). In the study, the area referred to as the Pearse Street area comprises the Mansion House A and the South Dock district electoral divisions, and the Ringsend/Irishtown area includes the Pembroke East A and the Pembroke West A district electoral divisions (DED). Health status and service uptake has been linked to deprivation 2 and therefore it was necessary to take account of this factor when selecting the sample. The Small Area Health Research Unit (SAHRU) 2 provided a deprivation score, based on parameters from the 1996 census, for each district electoral division in the country, including the four district electoral divisions in the study area. The deprivation scores range from one to five, where one is least deprived and five is most deprived. In order to select the study population, the deprivation scores were collapsed into two groups where district electoral divisions with scores of one to three were classified as less deprived and district electoral divisions with scores of four and five were classified as more deprived. Table 2.1 presents the household numbers in each of the four district electoral divisions by level of deprivation. At the time of the survey there were approximately 5,680 households in the area and half were classified as more deprived. Table 2.1 Distribution of sample and population in both the high and the low deprivation district electoral divisions in the study area District electoral division Sample households Population households Total Percent Total Percent Low Deprivation (1 to 3) South Dock Pembroke West A Total High Deprivation (4 and 5) Mansion House A* Pembroke East A** Total * excluding Trinity College ** excluding the south-western corner 15

16 METHODS - PART SAMPLING We estimated that the required sample size was 360 households based on the proportion of individuals reporting a chronic illness (22%) in a survey carried out in Tallaght in June The sample was selected using a sampling methodology validated by the World Health Organization 4 and adapted by the Primary Health Care Management Advancement Programme for assessing community health needs and health service coverage. 5 In this methodology cluster sampling rather than random sampling is employed, and for the survey 30 clusters of 6 adjacent households were selected from each of the low and high deprivation areas, giving the required number of 360 houses. The sample was supplied by Mr James Williams, Head of Survey Unit at the Economic and Social Research Institute. The sample selection for each of the district electoral divisions within the high deprived areas and low deprived areas was proportional to the number of households in each contributing district electoral division (Table 2.1). A portion of Pembroke West A was excluded because it was located in the East Coast Area Health Board. This was not clarified when the sampling strategy was devised but was later noted by the researchers in conversation with community members and was confirmed by the public health nurses. Therefore five of the fifteen selected clusters from Pembroke West A were replaced by five other clusters in the SWAHB within the district electoral division. Variation in the number of households listed in each district electoral division (Table 2.1) versus numbers of households reported in the census arises due to under-registration of households (James Williams, personal communication 2001). The Department of the Environment has reported that 10% of households on the electoral register are not listed or else not occupied by the person named on the electoral register as a result of death or migration. The researcher adjusted each cluster of six adjacent houses and inserted those houses missing from the numerical sequence (in order to include those not on the electoral register). The number of households in excess of six was then removed from the end of the sequence. This was done in order to ensure a representative sample of the population actually living in the area rather than according to the electoral register. Of the 360 houses in the Economic and Social Research Institute sample, 15 (4.2%) households were missing from the electoral register and were therefore placed in their numerical sequence in their respective clusters as described above. 2.3 FIELDWORK Prior to the fieldwork the local newsletters informed the community about the survey. Posters were displayed in the health centre, local community centres and local public premises. In October 2001, each of the 360 selected households was sent a letter signed by a representative of the Royal City of Dublin Hospital and the acting General manager for the SWAHB in the area (Appendix 2). People living in the area were invited to participate as data collectors in the household survey. Those people who expressed an interest attended a training programme prior to the survey. The data collection commenced in mid October 2001 and was collected initially each evening between 6 and 9 pm with the interviewers working in pairs. Due to difficulty with access at night or feedback from the local community many houses were then visited during the day. 16

17 METHODS - PART 1 The questionnaire was administered by the interviewers to the primary carer (defined as the person in the household who manages the welfare and health of the family/household) in each of the participating households. Flashcards were used to assist respondents identify the scale of an experience, identify the name of a chronic illness, as a prompt for a health service s/he may have used and the reasons for satisfaction/dissatisfaction with health services. When a household was not accessed, a note was left with a date for a return visit. Households that were not accessed initially were revisited until access was gained up to a maximum of four return visits. Data collection was completed by mid December DATA COLLECTION INSTRUMENT During the months of July and August 2001 the researcher informed key individuals and community groups about the proposed survey and elicited their perceived needs. Several health and social services needs were identified. These were: An increase in childcare facilities (including crèche facilities) that would have more flexible hours. Strategies to address teenage health issues with particular reference to teenagers alcohol consumption. Additional services for lone parents with particular reference to employment schemes and childcare facilities. Specific services to address women s health issues, including interventions to address domestic violence and postnatal depression. Expanded services for the elderly with specific reference to more accommodation with full time warden support and local bus transport to Baggot Street hospital. Interventions to support drug users and their families in the community, in particular for the families in the Pearse Street area. A health centre located in the Pearse Street area. Appointment of a community social worker to deal with all members within the family (not just children). Overall the main issues pertaining to health were found to be similar to the issues that had already been included in the questionnaire, which was used in the health needs assessment carried out in the Tallaght area in Some minor revisions were included in the questionnaire used in this study in response to the discussions with the community. The different sections of the questionnaire were designed to ascertain: Demographic and socio-economic characteristics for each household and its individual members. Experience of chronic illness and disability for households and individual household members. Behaviours in relation to cigarette smoking and/or alcohol or drug misuse for households and individual household members. Primary carers experience of teenage children, violence and stress. Uptake of cervical screening, breast examination, antenatal services and family planning by women. Children s (aged months) uptake of vaccinations and developmental assessment. Utilisation of and satisfaction with health services and the health care waiting lists. Primary carers reported gaps in the service. 17

18 METHODS - PART STATISTICAL METHODS Medical undergraduates and graduate students at the Department of Community Health and General Practice entered the data into two Excel spread sheets (one for the household and the other for household members). Data were cleaned and checked for accuracy by the principal researcher. This involved performing frequency distributions for all variables to identify discordant values and ensure data followed logical checks. Statistical analysis was carried out using JMP IN, 6 and STATA. 7 The frequency distribution for each variable was described in both the household and individual household members datasets. Pearson χ2 test, and Fisher s exact test were used to compare proportions in independent groups of categorical data. Multiple logistic regression models were developed to determine which variables best predicted key outcomes (chronic disease, disability, service utilisation and waiting for health care) for the household members. Exact 95% confidence intervals (CI) were calculated for proportions of binomial variables and for regression adjusted odds ratios. 2.6 IN DEPTH INTERVIEWS During August and September 2001 the service providers were contacted and informed of the household survey. They were also invited to participate in a study to ascertain the needs from the service providers perspective. Following completion of the household survey representatives from the different disciplines within the health services were interviewed. This study is presented as part two of this document. 18

19 RESULTS PART 1

20 RESULTS - PART 1 RESULTS 3.0 INTRODUCTION The results of the survey are presented in twelve sections: 3.1 Response rate. 3.2 Demographic and socio-economic characteristics of the: participating households primary carers (respondents) individual household members in each of the participating households. 3.3 Health care issues (stress and violence) and health related behaviours (cigarette smoking and substance misuse). 3.4 Chronic disease. 3.5 Disability. 3.6 Deaths. 3.7 Acute hospital services. 3.8 Health services for women. 3.9 Community health services including general practice, community nursing, pharmacy services and dental services Waiting for health care Primary carers suggested additional health needs Comparisons between the populations living in the Pearse Street area and in Ringsend/Irishtown. All findings that are presented are as reported by the primary carer (the person in the household who manages the welfare and health of the family/household) in each household. 3.1 RESPONSE RATE Of the 360 households invited to participate in the survey, 273 (76%) agreed to be interviewed. Forty three households (12%) did not wish to be interviewed while 41 (11%) households were not accessed (despite a maximum of four return visits). Nine of the clusters were in apartment blocks. The majority of the refusals and no access visits were in these apartment blocks, which are generally accessed through an intercom system. The response rate in the apartment blocks was much lower than in the wider community (15/54, 27% versus 258/306, 84% p < ). The response rates were similar in the areas that were classified as more deprived compared with the areas classified as less deprived (139/180, 77% versus 134/180, 74%; p = 0.8). 20

21 RESULTS - PART 1 Figure 3.1 Age profile of the population in 1996 census versus household members in 2001 survey CENSUS 1996 SURVEY 2001 PERCENTAGE to 9 10 to to to to to or more AGE (IN YEARS) The age profile for the individual household members was significantly different from that reported in the 1996 census, p < (Figure 3.1). There was a higher proportion of household members in the age groups 40 to 49 years and 65 years or more in the survey population compared to the census population. There was a lower number of household members aged 20 to 29 years in the survey population compared to the 1996 survey. The gender profile was similar, p = 0.6 (Figure 3.2). Figure 3.2 Gender profile of the population in 1996 census versus household members in 2001 survey CENSUS 1996 SURVEY PERCENTAGE MALE 45.6 FEMALE Analysis pertaining to households and primary carers refers to information ascertained from the 273 primary carers who took part in the survey. The primary carers also provided information on the 699 individuals (including themselves) who resided in the participating households. Denominators vary because not all respondents answered all questions. 21

22 RESULTS - PART DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS Demographic and socio-economic characteristics at the household level Table 3.1 presents the household characteristics as reported by the primary carers. On average, two individuals lived in each house. Almost half of the households were living in the area for less than ten years and the majority of these (94/122, 77%) had moved into the area within the last five years. One quarter of the households were outright owners while half of the households were either renting from the local authority (37%) or privately (14%). Non-nationals occupied almost six percent of households (Figure 3.3). Table 3.1 Primary carers reported characteristics of their households No. % Number of people living in each house 1 to to to n 273 Average 2.5 Median 2 Range 1 to 8 Year moved into house (grouped) 1922 to to to to to n 265 DED deprivation score for area of residence (where 1 is least deprived and 5 is most deprived) n 273 Resides in an area classified as deprived Yes No n 273 House occupancy status Outright owner Mortgage Tenant purchasing plan Rent paid by health board or renting from local authority/housing association Renting privately n 271 According to the primary carers, the majority (98%) of the households had access to a telephone (Table 3.2) and over half of the households (53%) did not own a car (Figure 3.3). Eighty seven percent of houses had central heating, of these 78% used gas heating. Forty five percent of the households were medical card holders while four out of every ten households had private health insurance (Table 3.2). Five respondents had received the medical card as a result of the new over seventies scheme. 22

23 RESULTS - PART 1 Table 3.2 Primary carers reported access to communication, house heating and health cover 24 hour access to telephone by household member Yes No n 273 Emergency phone access for those households with no phone Neighbour Street Other n 6 Central heating in the household Yes No n Health cover for household occupants Medical card VHI BUPA Other private None n 272 Demographic and socio-economic characteristics for the primary carers The primary carer is the person in the household who manages the welfare and health of the family/household. Table 3.3 presents the self-reported demographic and socio-economic characteristics of the primary carers. Of those who said that they were primary carers, almost a quarter (23%) were men (this included men who were single (42%), separated (12%), widowed (17%) or those who shared the caring role with their partner (28%)). On average the primary carers were 50 years old and almost one third (32%) were between 65 and 95 years old. Of note, 86 of the primary carers were aged between 65 and 95 years old, and of those, 47 (55%) were living on their own. Over half (56%) of the primary carers were at home fulltime. Half of the primary carers had either no formal education or had completed primary school education only. Eight percent described themselves as lone parents (Figure 3.3). Figure 3.3 Key characteristics of the households and primary carers (n=273) PERCENTAGE Government accomodation Primary education or less Non-national Lone parents Medical card cover No car HOUSEHOLDS AND PRIMARY CARERS CHARACTERISTICS 23

24 RESULTS - PART 1 Table 3.3 Demographic and socio-economic characteristics of the primary carers No. % Gender Male Female n 273 Age in years 19 to to to to n 268 Average 51.9 Median 50 Range Current employment status Working full time Working part time Always in the home n 273 Occupation Employers/managers, higher/lower professionals, self employed Non manual or manual skilled workers Semi skilled or unskilled workers Currently in education or community employment scheme Unknown n 116 Educational attainment Primary education or none Junior group or intermediate certificate, technical or vocational training Leaving certificate, A levels, technical training Non degree qualification Degree, professional qualification or both, or postgraduate qualification n 272 Attained highest qualification through an adult education scheme Yes No n 128 Marital status Single Married Separated, divorced, widowed n 273 Demographic and socio-economic characteristics for individuals living in the participating households Table 3.4 presents the primary carers reported demographic, family and socio-economic information for individuals residing in the participating households. There were slightly fewer men than women living in the surveyed households. The household residents ages ranged from zero to 95 years and almost one third were aged 50 years and over. Thirty nine percent of those living in the households were primary carers while just under one third of them were the primary carers children. Almost 65% of household members aged between 15 and 65 years were employed. 24

25 RESULTS - PART 1 Table 3.4 Primary carers reported demographic, family and socio-economic information for individuals residing in the households No. % Gender Male Female n 699 Age in years 0 to to to to to to to to or more n 689 Average 38.5 Median 35.0 Range 0 to 95 Primary carers Other household members relationship with primary carer Child Partner or spouse Sibling Grandchild Parent Other relative Other n 697 Members of the household in education, employment or at home Employed - full or part time Always in home School College or university Community employment or training scheme n 699 Members aged 15 to 65 in education, employment or at home Employed - full or part time School College or university Community employment or training scheme Always in home n 477 DED deprivation score for area of residence (where 1 is least deprived and 5 is most deprived) n

26 RESULTS - PART HEALTH CARE ISSUES AND BEHAVIOURS Smoking and substance misuse According to the primary carers, at least one person in almost half of the households smoked cigarettes while 3% of households had a person with an alcohol or drug problem (Table 3.5). Table 3.5 Primary carers reported tobacco use and drug dependency (alcohol or illicit) in the households No. % Number of households with one or more smokers Yes No n 271 Numbers of households with a person with alcohol or drug dependency Yes No n 271 Among those 18 years old or over, thirty one percent of household members smoked and of these, over one quarter smoked more than 20 cigarettes per day (Table 3.6). Table 3.6 Primary carers reported number (%) of individuals (18 years or older) in the households who smoke and quantity smoked each day by these individuals No % Smoke (18 years or older) Yes No n 596 For individuals who smoke, quantity smoked per day Less than to More than n 184 The primary carers reported that 8 (1%) of the 596 individuals aged 15 years or over residing in the households had a problem with either alcohol or drugs at the time of the survey, all of whom had a serious problem (Table 3.7). Six individuals out of the eight had a problem with heroin use. Five of the heroin users were attending a drug treatment centre and of these, four were on a methadone maintenance programme. 26

27 RESULTS - PART 1 Table 3.7 Primary carers reported number (%) of individuals in their households with a drug/alcohol problem and also their health service uptake No. % Scale of problem (1 not serious to 5 very serious) n 8 Main drug used Heroin Alcohol n 7 Services used by all Visit general practitioner (GP) in relation to use Yes No n 8 Attend counselling Yes No n 7 Attend a support group Yes No n 7 Taking sedatives Yes No Don t know n 7 Services accessed by heroin users Visiting a needle exchange programme Yes No n 6 On methadone maintenance Yes No n 6 Attending a drug treatment centre Yes No n 6 Location of drug treatment centre Irishtown Baggot Street Trinity Court n 5 27

28 RESULTS - PART 1 Primary carers experience of stress Over half of the primary carers reported that they had experienced stress in the year prior to the survey (Table 3.8). Family issues (21%) and pressure at work (19%) were the most commonly cited causes of stress. Over one third of the primary carers said that they had experienced severe stress (Table 3.8). More than three quarters reported negative effects of stress. The most commonly reported negative effects of stress were anxiety, feeling annoyed and depression. Table 3.8 Primary carers reported experience of stress No. % Stress in the last 12 months Yes No n 272 Reason for stress (n=145) Family Pressure at work Everyday living Illness Bereavement Other Study Financial Moving house Related to alcohol or drug addiction Marital Bullying Loneliness Age related Unemployment Scale of stress 1(not serious) to 5 (very serious) n 145 Experienced negative effects of stress Yes No n 145 Negative effects (n = 113) Anxious Easily annoyed Depressed Smoke more Illness Eating too much or too little Sleeplessness Aggressive Other Take more alcohol/drugs Communication problems

29 RESULTS - PART 1 The primary carers were asked what they did to help deal with their stress (Figure 3.4). Almost 60% sought help from close friends or family while a quarter attended their general practitioner. Over 10% said they were on prescribed medication for stress. Figure 3.4 Primary carers reported sources of help to deal with stress (n=145) PERCENTAGE Consulted friend/relative 26.2 Visited GP 7.6 Visited counsellor 12.4 Prescription medication 3.4 Alternative medication ASSISTANCE TO DEAL WITH STRESS Primary carers experience of violence and intimidation Thirty (11%) primary carers reported that they had experienced violence or intimidation in the year prior to the survey, and of these, over half said that the scale of the violence or intimidation was very severe (Table 3.9). Of those who experienced violence, 18 (60%) said that it had occurred several times; nine (30%) respondents said that the incident had occurred in their homes; and 24 (80%) said that the incident was perpetrated by someone they knew (Table 3.9). Just under half of the episodes of violence or intimidation were as a result of a previous disagreement. 29

30 RESULTS - PART 1 Table 3.9 Primary carers reported experience of intimidation and/or violence in the last 12 months No. % Experienced intimidation and/or violence in last 12 months Yes No n 270 Scale of intimidation and/or violence 1 (not serious) to 5 (very serious) n 30 Frequency of intimidation and/or violence Once Few times Several times n 30 Place where intimidation and/or violence occurred In the home Outside the home n 30 Perpetrators of intimidation and/or violence Someone they know Stranger n 30 Reason for attack Random attack Result of previous disagreement n 30 The primary carers were asked where they had gone for help (Figure 3.5). Four (13%) primary carers said that they had moved to a safe place while ten (33%) said they had sought medical assistance. Eleven (37%) of respondents said they had reported the incident to the gardaí. Figure 3.5 Primary carers reported sources of support to deal with the last incident of intimidation or violence (n=30) PERCENTAGE Safe place Visit GP Visit A&E Report to gardai SOURCES OF SUPPORT TO DEAL WITH VIOLENT INCIDENT 30

31 RESULTS - PART 1 Primary carers experience of dealing with teenagers According to the primary carers with teenage children, three fifths worried about their teenagers socialising (Table 3.10). The most common reason for concern was that their teenager while socialising, would develop a problem with or as a result of drug or alcohol use (43%). Forty percent of the respondents were also concerned that their teenager would be assaulted (including sexual assault) or robbed. Table 3.10 Primary carers reported experience of coping with teenage children and the type of assistance sought No % Worried about teenagers socialising Yes No Sometimes n 53 Incident primary carer would worry about most Drug and drink related Sexually assaulted/robbed/attacked Pregnancy Car crash Commit assault n 35 Happy with his/her friends Yes No Some of them n 53 Found teenagers attitudes or behaviours upsetting Yes No n 53 Attitude, behaviour or action that is most upsetting Does not listen to advice Mood swings Aggressive behaviour Takes and/or sells drugs or alcohol n 16 Assistance or advice sought from others outside primary carers family Yes No n 16 Where primary carer has gone for advice Teacher GP Counsellor n 5 The primary carers were asked if they found their teenagers behaviours upsetting and 30% said yes. Half of those who found their teenagers behaviours upsetting reported that the most upsetting behaviour was their teenagers unmanageability (does not listen to advice, does not observe rules or boundaries, always wants to be out with friends, etc.). A further 37% of respondents reported that their teenagers most upsetting behaviour was their mood swings. Almost one third said that they had sought help to deal with their teenagers behaviour. The most common sources of help were teachers and general practitioners. 31

32 RESULTS - PART CHRONIC DISEASE Proportion of individuals with a chronic disease in participating households According to the primary carers, over half (53%) of the households had at least one person who had a chronic illness. The primary carer reported that a total of 187 (26.8%, 95% CI 23.5 to 30.2) of the individuals residing in the surveyed households had a chronic illness. The most commonly reported chronic illnesses were respiratory disease (25%), cardiovascular disease (24%) and arthritis (18%) (Figure 3.6). Figure 3.6 Types of chronic illness reported by primary carers for the household members (n=187) PERCENTAGE Arthritis Cardiovascular Respiratory CHRONIC ILLNESS Psychiatric Dermatology Orthopaedic Ear, nose & throat Cancer Other endocrine Other Of those with a chronic illness, 30% required some degree of help at home (Table 3.11). One in ten had assistance from a home help while a public health nurse had visited 13% in the three months prior to the survey. Almost three quarters had visited their general practitioner with over half of them attending for a repeat prescription. Almost 30% had attended a hospital in the three months prior to the survey. A slightly higher proportion of individuals (104/348, 30%) living in a less deprived area had a chronic illness compared to the proportion (83/351, 24%) living in a more deprived area (p=0.06). 32

33 RESULTS - PART 1 Table 3.11 Primary carers reported types of chronic illness, the level of care required and the health services used by individuals residing in their households No. % Degree of care required No assistance Housekeeping including medication Housekeeping including medication and help to sit out in chair Total nursing care as confined to bed n 187 Have organised home-help Yes No n 187 Visited by public health nurse in the past 3 months Yes No n 186 Attended GP in past 3 months Yes No n 186 Reasons for GP visit (n=150) Repeat prescription Medical check up Sudden illness Advice GP s surgery within walking distance Yes No Not registered with a GP n 184 Hospital visits due to this disease/illness in last 3 months Yes No n 186 Characteristics and practices associated with those who have a chronic illness Bi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics, disability, health related behaviours, health service utilisation and waiting for health care) indicated that several factors were significantly associated with having a chronic illness. Logistic regression models were constructed to clarify the independent associations between the significant variables and the likelihood of having a chronic illness (Table 3.12). The relationships presented are those that remained statistically significant or were deemed clinically important after taking account of confounding. The associations are expressed as odds ratios (OR) adjusted for confounding. 33

34 RESULTS - PART 1 Table 3.12 Logistic regression model to identify factors associated with having a chronic disease in the population (187/699) Total Reported Prevalence % Adjusted Odds p-value chronic illness ratio (95% CI) Age (in years) 0 to or over (3.6 to 8.4) Missing 10 Medical card No Yes (1.1 to 2.9) 0.04 Missing 4 Local authority housing No Yes (1.02 to 2.7) 0.04 Missing 6 Attended GP and/or hospital in the year prior to the survey No Yes (5.6 to 15.6) Missing 0 Whole model χ 2 =243, p< The initial model included variables significant at the 0.05 level and these were: age, time spent in the home, medical card status, house occupancy, disability status, used hospital in the last year, attended GP in the last year and waiting for health care at the time of the survey. Significant factors were retained in the final model. Household members aged 50 years or more were over five times (adjusted OR 5.5, CI 3.6 to 8.4) more likely to have a chronic illness than those less than 50 years old. Those who had a medical card were 60% more likely to have a chronic illness than those who had no medical card (adjusted OR 1.6, CI 1.1 to 2.9). Household members living in local authority housing were more likely to have a chronic illness than those who own or rent privately (adjusted OR 1.7, CI 1.02 to 2.7). Household members attending their general practitioner and or using a hospital service in the year prior to the survey were over nine times (adjusted OR 9.2, CI 5.6 to 15.6) more likely to have a chronic illness than those not attending their general practitioner and/or the hospital in the same time period. 3.5 DISABILITY Proportion of individuals with a disability in participating households According to the primary carers, eight percent of households had at least one person who had a disability. The primary carers reported that 21 (3.0%, 95% CI 1.9 to 4.6) of the 699 individuals residing in the surveyed households had a disability. Nine (43%) were born with a disability and 11 (52%) acquired their disability during adulthood. The most frequently reported type of disability was physical (Table 3.13). Of those with a disability nine (43%) required some degree of help at home and 11 (55%) required special aids to assist them with daily living. The majority did not have a home help and five (25%) were visited by a public health nurse in the three months prior to the survey. Nine (45%) had visited their general practitioner in the three months prior to the survey while five (25%) visited a hospital or special service in the same period. 34

35 RESULTS - PART 1 Table 3.13 Primary carers reported types of disability, the level of care required and the health services used by individuals residing in their households No. % Types of disability Physical Learning Combination of physical and learning n 21 Time occurred Born with or occurred at the time of birth Childhood Adolescence 0 0 Adult n 21 Degree of care required No assistance Housekeeping including medication Housekeeping including medication and help to sit in chair Housekeeping including medication, help to sit out in chair, attend to personal hygiene and feeding Total nursing care as confined to bed n 21 Special aids required Yes No n 20 Type of aids (n=11) Mobility aids Household aids Hearing aid Have home help Yes No n 20 Visited by nurse in past 3 months Yes No n 20 Attended GP in past 3 months Yes No n 20 Attended hospital or specialist services in past 3 months Yes No n 20 A similar proportion of household members who had a disability were living in the less deprived areas and in the more deprived areas (14/351, 4% versus 7/348, 2%, p = 0.1). 35

36 RESULTS - PART 1 Characteristics and practices associated with those who have a disability Bi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics, chronic illness, health related behaviours, health service utilisation and waiting for health care) indicated that several factors were significantly associated with having a disability. Logistic regression models were constructed to clarify the independent associations between the significant variables and the likelihood of having a disability (Table 3.14). The relationships presented are those that remained statistically significant or were deemed clinically important after taking account of confounding. The associations are expressed as odds ratios adjusted for confounding. Household members who were at home full time were almost six times (adjusted OR 5.9, CI 2.1 to 21.4) more likely to have a disability than those not at home full time. Those who attended their general practitioner (adjusted OR 4.8, CI 1.1 to 33.2) and or the hospital (adjusted OR 5.4, CI 1.3 to 35.9) in the year prior to the survey were also five times more likely to suffer from a disability than those who attended neither in the same time period. Table 3.14 Logistic regression model to identify factors associated with having a disability in the population (21/699) Total Reported Prevalence % Adjusted Odds p-value disability ratio (95% CI) At home full time No Yes (2.1 to 21.4) Missing 0 Attended GP and/or Hospital No Either (1.3 to 35.9) 0.03 Both (1.1 to 33.2) 0.05 Missing 0 Whole model χ 2 =32.3, p< The initial model included variables significant at the 0.05 level and these were: age, time spent in the home, chronic disease status, used hospital in the last year, attended GP in the last year and on a waiting list. 3.6 DEATHS Of the 193 households who were living in the area before 1997, 23 primary carers reported the death of a household member between January 1997 and October 2001 (23/193,12%). There were 521 household members living in the 193 households. According to the primary carers, 24 (5%) of the 521 individuals had died. The majority (71%) were over 70 years of age. 36

37 RESULTS - PART ACUTE HOSPITAL SERVICES Proportion of individuals who used hospital services in participating households According to the primary carers, at least one person in 52% of the households used one or more of the hospital services in the year prior to the survey. The primary carers reported that 176 (25.2%, 95% CI 22.0 to 28.6) of the 699 individuals residing in the households used the hospital in the 12 months prior to the survey. Of those who used the hospital, 36% attended outpatients, 24% were seen in accident and emergency, 9% were day patients and 31% were admitted as inpatients (Figure 3.7). Figure 3.7 Hospital facilities used by household members as reported by primary carers (n= 176) PERCENTAGE Outpatient Inpatient Accident & emergency HOSPITAL FACILITY USED 9.1 Day case According to the primary carers, of those who attended the hospital, 18% attended as a result of cardiovascular disease, 15% as a result of injury or an acute emergency and 10% with a respiratory problem (Figure 3.8). Figure 3.8 Household members reasons for attending hospital as reported by primary carers (n=176) PERCENTAGE Cardiovascular 14.7 Emergency 10.0 Respiratory 7.1 Obstetrics & gynaecology 5.9 Orthopaedic 5.9 Psychiatric 4.7 Gastro-intestinal 4.7 ENT 4.7 Dermatology Non cancer tumours (lumps) Cancer 2.9 Renal 2.9 Other endocrine 2.4 Arthritis 9.0 Other REASON FOR ATTENDING The primary carer reported that over three fifths had a planned appointment at the time they attended the hospital (Table 3.15). According to the primary carers, almost one third of those who used a hospital service referred themselves. The respondents reported that 20 of the 176 individuals who used the hospital service were transported by ambulance; of these only half were emergency cases. A higher proportion of household members (108/348, 31%) living in the less deprived areas reported using a hospital service in the year prior to the survey compared to the proportion (68/351, 19%) living in the more deprived areas (p = ). 37

38 RESULTS - PART 1 Table 3.15 Primary carers reported type of appointment for, channel of referral to and means of transport used by individuals in their households to attend a hospital service in the 12 months prior to the survey No. % Utilisation planned or emergency Planned Emergency n 176 Referral to hospital by: Self GP Hospital doctor Police n 174 Transport used to travel to hospital Private Public Ambulance n 172 Characteristics and factors associated with those using a hospital service in the last year Bi-variate analysis using seven groups of variables (demographic characteristics, socio-economic characteristics, chronic illness, disability, health related behaviours, other health services utilised and waiting for health care) indicated that several factors were significantly associated with using a hospital service in the year prior to the survey. Logistic regression models were constructed to clarify the independent associations between the significant variables and the likelihood of using a hospital service in the year prior to the survey (Table 3.16). The relationships presented are those that remained statistically significant or were deemed clinically important after taking account of confounding. The associations are expressed as odds ratios adjusted for confounding. 38

39 RESULTS - PART 1 Table 3.16 Logistic regression model to identify the factors that influenced use of a hospital service in the year prior to the study among the population (176/699) Total Attended Proportion % Adjusted p-value hospital Odds ratio (95% CI) Chronic disease No Yes (2.2 to 5.1) < Missing 0 Attended GP in the year prior to the survey No Yes (2.8 to 7.1) < Missing 0 Waiting for health care at the time of the survey No Yes (1.3 to 8.2) < Missing 0 Whole model χ2=147, p< The initial model included variables significant at the 0.05 level and these were: age, house occupancy, time spent in the home, chronic illness status, disability status, attended GP in the last year and waiting for health care at the time of the survey. Significant factors were retained in the final model. Household members reporting a chronic illness were over three times (adjusted OR 3.3, CI 2.2 to 5.1) more likely to have used a hospital service in the last year than those not reporting a chronic illness. Individuals attending their general practitioner in the year prior to the survey were over four times (adjusted OR 4.4, CI 2.8 to 7.1) more likely to have also used a hospital service than those not attending their general practitioner in the same time period. Household members reporting waiting for health care were over 3 times (adjusted OR 3.2, CI 1.3 to 8.2) more likely to have used a hospital service than those not reporting waiting for health care. Satisfaction with hospital services Primary carers were asked to recall the last three health services used by themselves and by the other household members in the year prior to the survey. If they had used a service or accompanied the household member, they were also asked to recall their level of satisfaction with the service, and reasons for satisfaction or dissatisfaction. Appendix 5 presents detailed tables on satisfaction with hospital services and Figure 3.9 presents the proportion satisfied with each hospital service. Figure 3.9 Household members satisfaction with hospital services as reported by primary carers PERCENTAGE Outpatients Accident and emergecy Inpatients Day patient SATISFIED WITH HOSPITAL SERVICES 39

40 RESULTS - PART 1 Accident and emergency According to the primary carers, just over 6% of the household members had attended an accident and emergency service in the last year (Appendix 5). The primary carers reported that four fifths were satisfied with the service. Among those who were satisfied, the main reasons given were: the staff listened to their problem(s) (50%), staff explained their medical condition (50%) and the hospital was nearby (45%). Among those who were dissatisfied, the main causes were long waiting periods (42%), and staff were unfriendly (16%). Out patients Among the last three health services used, just over 9% of the individuals had attended an outpatients department in the last year (Appendix 5). The primary carers reported that the majority (86%) were satisfied with the service. Among those who were satisfied, the main reasons given were: staff listened to their problem(s) (54%), staff were friendly (51%) and staff explained their medical condition (46%). Among those who were dissatisfied, the main cause was long waiting periods (21%). Inpatients According to the primary carers, 7% of the individuals using hospital services in the last year were admitted to the hospital (Appendix 5). The majority 89% were satisfied with the service. Among those who were satisfied, the main reasons given were: staff listened to their problem(s) (61%), the hospital was nearby (55%) and staff were friendly (55%). Among those who were dissatisfied, the main cause was long waiting periods (9%). Day patients According to the primary carers, 2% of the individuals were admitted as a day case. The majority (82%) were satisfied with the service. Among those who were satisfied the main reasons for satisfaction were staff were friendly (85%) and staff listened to their problem(s) (66%). The main reason for dissatisfaction was long waiting periods (15%). 3.8 HEALTH SERVICES FOR WOMEN Uptake of family planning, cervical smears and breast examination The women who described themselves as primary carers and were aged between 18 and 45 years were asked about family planning practices (Table 3.17). Forty six percent reported that they were using a method of family planning. Of those who were currently using a method of family planning, nine percent of the women (or their husbands/partners) had been sterilised, 84% were using a temporary method of contraception while six percent were using a natural method of family planning. Of those respondents who were not currently using a method of family planning, almost one third said that they had no reason for not using a method of family planning. Fifty four percent of women, aged between 18 and 65 years, had a cervical smear in the last five years and 43% within the same age group had a breast examination. Only 29% of women aged between 50 and 65 years (age group eligible for the National Breast Screening programme) had a mammogram within the last five years. 40

41 RESULTS - PART 1 Table 3.17 Primary carers reported current use of family planning, recent uptake of cervical smear tests and breast examination No. % Use of family planning (women respondents 18 to 49 years) Yes No n 98 Method of family planning used Natural Temporary Permanent n 45 Reason people do not use family planning No reason Trying for a child, pregnant, postnatal Not currently sexually active History of hysterectomy On medication or fear of negative side effects n 47 Cervical smear in last 5 years (women respondents 18 to 65 years) Yes No n 137 Breast examination in last 5 years (women respondents 18 to 65 years) Yes No n 137 Method of examination By a doctor Mammogram n 59 Mammogram in last 5 years (women respondents 50 to 65 years) Yes No n 41 Births and associated maternal health practices and services According to the primary carers, 22 children were born to 21 mothers, who currently reside in the area between January 1997 and September 2001 (Table 3.18). Four (19%) of the women were between 16 and 19 years old during their most recent pregnancy. Primary carers reported ten (47%) of the women s most recent pregnancies were unplanned. Eight of the women (38%) had taken folic acid prior to conception and six (29%) had smoked during their most recent pregnancy (Figure 3.10). Only one woman did not attend for antenatal care and similarly one woman did not attend for postnatal examination six weeks after delivery (Table 3.18). According to the primary carers, almost two thirds of the expectant women had antenatal care in a maternity hospital while only 30% had their care shared with the their general practitioner (Table 3.18). The vast majority had their youngest baby in the National Maternity Hospital, Holles Street. 41

42 RESULTS - PART 1 Table 3.18 Primary carers reported number of pregnancies in their households between January 1997 and September 2001, and service uptake by pregnant women during each pregnancy No % Women in household who have given birth in the last 4 years and number of births to each woman One child Two children n 21 Age when became pregnant on most recent occasion 16 to to to n 21 Antenatal care sought during pregnancy Yes No n 21 Place where antenatal care was received Maternity hospital Combined or shared care Consultant private clinic n 20 Place of delivery National Maternity Hospital, Holles St Rotunda Hospital n 21 Attended 6 week post natal check up Yes No n 21 Figure 3.10 Practices of women during their most recent pregnancy (between January 1997 and September 2001) as reported by primary carers (n=21) PERCENTAGE Pregnancy planned 38.1 Peri conceptual folic acid 28.6 Smoked during pregnancy 95.2 Antenatal care PRACTICES ASSOCIATED WITH PREGNANCY 42

43 RESULTS - PART 1 Satisfaction with maternity services As one of the last three health services used, 11 women were admitted to a maternity hospital in the twelve months preceding the survey. Ten of them reported satisfaction levels; of these, five were satisfied with their health care (Table 3.19). The main reason for satisfaction was that staff listened to their problem(s) and the main reason for dissatisfaction was that the hospital did not provide adequate treatment or care. Table 3.19 Primary carers reported number (%) of individuals admitted to maternity hospital in the year prior to the survey, number (%) used the hospital, and the level of satisfaction with services No % Admitted to maternity hospital Yes No n (women aged 15 to 49 years) 201 Satisfied with care and treatment (1 very satisfied to 6 very dissatisfied) Yes (1 to 3) No (4 to 6) n 10 43

44 RESULTS - PART COMMUNITY HEALTH SERVICES General Practice According to the primary carers, 47% of the household members had attended their general practitioner as one of the last three health services used in the year prior to the survey. Eighty nine percent were satisfied with the service (Table 3.20). Among those who were satisfied, the main reasons were, the doctor listened to the problem(s) (74%), the doctor was nearby (53%) and the doctor provided good treatment or care (52%). Among those who were dissatisfied, the main reason was that the doctor did not listen to the problem(s) (6%). Table 3.20 Primary carers reported number (%) of individuals who visited their GP in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction No % Visited GP Yes No n 699 Satisfied with care and treatment from GP Yes (1-3) No (4-6) n 299 Level of satisfaction with care and treatment from GP (1 very satisfied to 6 very dissatisfied) n 299 Reason satisfied with care and treatment from GP (n = 299) Nearby Staff courteous and friendly Short waiting period Doctor listened to the problem Doctor explained the condition Doctor explained the treatment possibilities Doctor provided good treatment or care Service easily available on a 24 hour basis Pleasant environment Affordable Organised appointments Reason dissatisfied with care and treatment from GP (n = 299) Too far Staff unfriendly Long waiting periods Doctor did not listen to the problem Doctor did not explain the condition Doctor did not explain the treatment possibilities Doctor provided inadequate or incorrect treatment Service difficult to access outside normal working hours Unpleasant environment Expensive No after care

45 RESULTS - PART 1 A higher proportion of household members (181/348, 52%) living in the less deprived areas attended their general practitioner as one of the last three services used in the year prior to the survey compared to the proportion (146/351, 42%) living in the more deprived areas (p = 0.005). Table 3.21 Primary carers reported use of and satisfaction with out of hours medical services and their source of health information No. % Services used for doctor out of hours Call GP practice for radio doctor Go to hospital accident and emergency Depends on situation Never had to use the service n 272 Satisfied with choice of out of hours service Yes No Never thought about it n 230 Source of information on health services (n=273) Staff at general practice Health information leaflet Family/friends Public broadcasting media Health centre staff Public health or community nurse Phone (includes directories and help lines) Internet At work Support groups Primary carers were asked what service they would access when seeking a doctor out of hours. Sixty three percent would call a radio-doctor while less than 10% would go to an accident and emergency department. One fifth of respondents were unhappy with the current out of hours general practitioner service (Table 3.21). Sources of health information According to the respondents, the most important sources of health information were the general practice (including the receptionist, nurse and general practitioner), followed by health leaflets and then family/friends (Table 3.21). Characteristics and factors associated with those attending a general practitioner in the last year Bi-variate analysis using seven groups of variables (demographic characteristics, socio-economic characteristics, chronic illness, disability, health related behaviours, other health services utilised and waiting for health care) indicated that several factors were significantly associated with attending a general practitioner, as one of the last three health services used, in the year prior to the survey. Logistic regression models were constructed to clarify the independent associations between the significant variables and the likelihood of attending a general practitioner in the year prior to the survey. Significant factors were retained in the final model (Table 3.22). The relationships presented are those that remained statistically significant or were deemed clinically important after taking account of confounding. The associations are expressed as odds ratios adjusted for confounding. 45

46 RESULTS - PART 1 Table 3.22 Logistic regression model to identify factors associated with attending a general practitioner as one of the last three health services used in the year prior to the survey among the study population (327/699) Total Attended Proportion Adjusted p-value GP % Odds ratio (95% CI) Gender Male Female (1.6 to 3.3) < Missing 0 Chronic disease No Yes (4.9 to 14.4) < Missing 0 Used a hospital service in the year prior to the survey No Yes (3.0 to 8.7) < Missing 0 Whole model χ 2 =223, p< The initial model included variables significant at the 0.05 level and these were gender, age, time spent in the home, house occupancy status, medical card status, chronic illness status, disability status, used a hospital service within the last year and waiting for health care at the time of the survey. Significant factors were retained in the final model. Female household members were over two times more likely to have attended their general practitioner in the year prior to the survey than their male counterparts (adjusted OR 2.3, CI 1.6 to 3.3). Household members reporting a chronic illness were over eight times (adjusted OR 8.3, CI 4.9 to 14.4) more likely to have attended their general practitioner in the year prior to the survey than those without a chronic illness. Those using a hospital service in the last year were just over five times (adjusted OR 5.1, CI 3.0 to 8.7) more likely to have attended their general practitioner in the year prior to the survey than those not using a hospital service in the same time period. 46

47 RESULTS - PART 1 Uptake of childhood vaccines Motivation for childhood vaccines is done by public health nurses in the community and subsequently the vaccines are administered at general practice. Primary carers reported that 24 of the 25 children aged between two and five years residing in their households had completed the routine childhood vaccines and of these, 18 children had the meningitis C vaccine (Table 3.23). Table 3.23 Primary carers reported vaccination uptake for children aged between two and five years residing in their households No. % Children s vaccination status Started but incomplete Completed all vaccines n 25 BCG Yes No 0 n 25 DPT and Polio 3 Yes No n 25 HIB 3 Yes No n 25 MMR Yes No n 25 Meningitis C Yes No n 24 Community nursing service The Area Health Boards notify mothers (in writing) and public health nurses remind mothers to bring their infants, when they are nine months old, for a developmental assessment by the area medical officers. Again 24 of the 25 mothers reported that they had brought their infant for the developmental assessment. According to the primary carers, almost five percent of the household members were in contact with a community nurse, as one of the last three services used in the year preceding the survey (Table 3.24). The primary carers reported that over 80% were satisfied with the service. The main reasons for satisfaction were that the nurse was courteous and friendly (69%), the nurse listened to their problem(s) (59%) and the nurse provided good treatment (34%). The main reason for dissatisfaction was that the community nurse did not listen to their problem(s) (9%). 47

48 RESULTS - PART 1 Table 3.24 Primary carers reported number (%) of individuals using the community nursing service in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction No % Used nursing service Yes No n 669 Satisfied with care and treatment from the nurse Yes (1-3) No (4-6) n 32 Level of satisfaction with care and treatment from the nurse (1 very satisfied to 6 very dissatisfied) n 32 Reason satisfied with care and treatment from the nurse (n = 32) Nearby Staff courteous and friendly Short waiting period Nurse listened to the problem Nurse explained the condition Nurse explained the treatment possibilities Nurse provided good treatment or care Service easily available on a 24 hour basis Pleasant environment Affordable Organised appointments Reason dissatisfied with care and treatment from the nurse (n = 32) Too far Staff unfriendly Long waiting periods Nurse did not listen to the problem Nurse did not explain the condition Nurse did not explain the treatment possibilities Nurse provided inadequate or incorrect treatment Service difficult to access outside normal working hours Unpleasant environment Expensive No after care

49 RESULTS - PART 1 Dental services The primary carers reported that less than 12% of the population had visited a dentist, as one of the last three services used, in the 12 months prior to the survey (Table 3.25). The majority, 86% were satisfied with the service. Among those who were satisfied, the main reason was the dentist listened to their problem(s) (64%). Among those who were dissatisfied, the main reason was that the treatment was expensive (14%). Table 3.25 Primary carers reported number (%) of individuals who visited their dentist in the year prior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfaction No % Visited dentist Yes No n 699 Satisfied with care and treatment from the dentist Yes (1 3) No (4 6) n 70 Level of satisfaction with care and treatment from the dentist (1 very satisfied to 6 very dissatisfied) n 70 Reason satisfied with care and treatment from the dentist (n = 70) Nearby Staff courteous and friendly Short waiting period Dentist listened to the problem Dentist explained the condition Dentist explained the treatment possibilities Dentist provided good treatment or care Service easily available on a 24 hour basis Pleasant environment Affordable Organised appointments Reason dissatisfied with care and treatment from the dentist (n = 70) Too far Staff unfriendly Long waiting periods Dentist did not listen to the problem Dentist did not explain the condition Dentist did not explain the treatment possibilities Dentist provided inadequate or incorrect treatment Service difficult to access outside normal working hours Unpleasant environment Expensive No after care

50 RESULTS - PART WAITING FOR HEALTH CARE According to the primary carers, at least one person in every ten households was waiting for health care at the time of the survey. Twenty six (3.7%, 95% CI 2.4 to 5.4) of the 699 individuals residing in the participating households were waiting for health care at the time of the survey (Table 3.26). Figure 3.11 Type of treatment awaited by household members as reported by primary carers (n=26) PERCENTAGE Surgery 26.9 Outpatient consultation Dentist ENT Opthalmology Dermatology Long term care TYPE OF TREATMENT The primary carer reported that, of those who were waiting for health care, 35% awaited surgery and 27% awaited an outpatient s consultation (Figure 3.11). Three quarters were waiting for more than three months. Almost two thirds of primary carers thought that the waiting time was unacceptable. Over 40% were waiting for health care in St. Vincent s University Hospital, Elm Park. Table 3.26 Primary carers reported number (%) of individuals residing in the households waiting for health care, length waiting for service, location of service and satisfaction with waiting period No % On a waiting list Yes No n 699 Length of wait in months Less than More than n 26 Area in which the service being waited for is provided St Vincent s University Hospital Elsewhere n 26 Opinion on waiting time (1 very reasonable to 5 very unreasonable) n 25 50

51 RESULTS - PART 1 Factors associated with those waiting for health care Bi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics, chronic illness, disability, health related behaviours, and health services utilised) indicated that several factors were significantly associated with reported waiting for health care at the time of the survey. Logistic regression models were constructed to clarify the independent associations between the significant variables and the likelihood of reported waiting for health care at the time of the survey (Table 3.27). The relationships presented are those that remained statistically significant or were deemed clinically important after taking account of confounding. The associations are expressed as odds ratios adjusted for confounding. Table 3.27 Logistic regression model to identify determinants of those waiting for health care in the population (53/699) Total Awaiting Proportion Adjusted p-value health care % Odds ratio (95% CI) Disability No Yes (1.1 to 13.7) 0.02 Missing 0 Attended both the GP and the hospital within the last year No Yes (3.1 to 32.3) Missing Whole model χ 2 =26.3, p< The initial model included variables significant at the 0.05 level and these were: age, gender, access to private health care, chronic illness status, disability status, used a hospital service in the 12 months prior to the survey and attended a GP in the 12 months prior to the survey. Significant factors were retained in the final model. Household members reporting a disability were over four times (adjusted OR 4.3, CI 1.1 to 13.7) more likely to be waiting for health care at the time of the survey than those who did not have a disability. Individuals who attended both their general practitioner and the hospital in the year prior to the survey were nine times (adjusted OR 9.0, CI 3.1 to 32.3) more likely to report waiting for health care than those who did not attend the two services in the same time period PRIMARY CARERS SUGGESTED ADDITIONAL HEALTH NEEDS Eighty percent of carers identified additional health needs in the area. Table 3.28 presents the suggested services and facilities required. Fifty two percent of the respondents asked that out of hours general practitioner services be reorganised. They suggested that this service be located either in accident and emergency (34%) or attended by a general practitioner from a group practice in the area (37%) (rather than the current radio-doctor facility). Over one third of the respondents (37%) requested one or more services for the elderly. These included day care services (25%), respite services (16%), long term care facilities (18%), and almost 10% requested home visits for the elderly. Over a quarter of respondents requested a community social work service and 20% asked for a local counselling service. Fifty three primary carers had teenage children in this study and it is of interest to note that 36 of the carers requested contraceptive advice for their teenagers and 28 requested psychological services. 51

52 RESULTS - PART 1 Table 3.28 Additional health care services suggested by primary carers No. % Additional services needed Yes No Do not know n 272 Suggested additional services (n=217) Improved hospital services GP in accident and emergency Out of hours local GP service Clinic specially to promote women s health Clinic specially to promote men s health Clinic specially to promote child health Psychological services for adolescents Contraceptive advice for adolescents Counselling service Drug/alcohol services Free child health services Day care services for the elderly Respite services for the elderly Long term care for the elderly Home visits for the elderly Improved services for disabled (physical and intellectual) Local medical centre Social work service Improved student health services Speech therapy for children Community physiotherapist Dental services for children Bus services Information

53 RESULTS - PART 1 Location of a health centre The primary carers were asked to suggest a location for a health centre that would suit both communities. Many of the respondents suggested a location in their own areas with the majority stating Pearse Street (36%) and over a quarter suggesting Ringsend or Irishtown (Table 3.29). Also a total of 48 (18%) respondents stated that they did not use services locally and therefore did not make any suggestions. Table 3.29 Primary carers suggestions for the location of a health centre that would serve both communities No % Suggested location for health centre that would suit both communities (n=155) Pearse Street Ringsend/Irishtown Irishtown Health Centre Somewhere in the middle Gas Company Trinity College car park Sir Patrick Dunn s South Lotts Road Grand Canal Street Bath Avenue Community Centre Ringsend Individual centre for both areas St. Andrew s Resource Centre Inner city College Green Cambridge Road Shelbourne Park Old bottle house Baggot Street Dork Street Macken Street Barrow Street Haddington Road Dockland development site

54 RESULTS - PART COMPARISONS BETWEEN THE COMMUNITIES LIVING IN THE PEARSE STREET AREA AND RINGSEND/IRISHTOWN All the variables were analysed comparing the characteristics, health status and service utilisation for the people living in the Pearse Street area with those living in Ringsend/Irishtown. The results were similar for the majority of the factors. The results presented are those that remained statistically significant or were deemed clinically important (Table 3.30). Table 3.30 Summary of comparisons between the communities living in the Pearse street area and Ringsend/Irishtown Pearse Street Ringsend/ Test of association Irishtown Occupation College χ2 =10.6, df =4, p = 0.03 Employed Home School Training n = Hospital use Yes χ2 =5.1, df =1, p = 0.02 No n = No. of cigarettes smoked Less than χ2 =9.2, df =3, p = 0.02 More than n = Attend the GP Yes χ2 =6.1, df =1, p = 0.01 No n = Primary carers use of family planning (age 18 to 49) Yes χ2 =6.9, df =1, p = No n = Primary carers who had a breast check in the last 5 years Yes χ2 =2.9, df =1, p = 0.08 No n = Year moved into the area 1922 to to to χ2 =23.2, df =4, p > to to n = Choice of Health centre Pearse street Ringsend/Irishtown Fishers exact test, p > Baggot Street Sandymount n =

55 RESULTS - PART 1 People living in the Pearse Street area (7%) were more likely to attend college than the people living in Ringsend/Irishtown (2%). The residents living in Ringsend/Irishtown (38%) were more likely to be at home full time than those living in the Pearse Street area (32%). A slightly higher proportion of people living in Ringsend/Irishtown (29%) used a hospital service within the last year than those residing in the Pearse Street area (21%). It is interesting to note that of the 10 people who used the psychiatric hospital services within the last year, nine were living in the Pearse Street area. A higher proportion of people living in the Pearse Street area (51%) attended their general practitioner within the last year than those living in Ringsend/Irishtown (42%). Primary carers living in Ringsend/Irishtown (59%) were more likely to report using a method of family planning than those living in the Pearse Street area (33%). A higher proportion of female primary carers living in Ringsend/Irishtown (50%) said they had a breast check within the last five years compared to those living in the Pearse Street area (36%). More householders in the Pearse Street area (52%) had moved into the area within the last 10 years than in Ringsend/Irishtown (39%). When the primary carer was asked where s/he preferred to attend a health centre the majority in both the Pearse Street area (83%) and Ringsend/Irishtown (92%) wanted to attend a centre in their own areas. 55

56 DISCUSSION PART 1

57 DISCUSSION - PART 1 DISCUSSION The high response rate indicates a high level of interest in health in the Pearse Street area and in Ringsend/Irishtown. The respondents were pleased to take part in the study and were keen to offer their opinions about the health services and health needs in the area. In fact four out of every five respondents had suggestions for additional health or social services. There were similar response rates in areas classified as high deprivation and low deprivation. Of note, the response rate for those living in the apartment blocks was significantly lower than for those living in houses or in local authority flat complexes (27% versus 84%). Therefore, the results of this study are to a large extent a reflection of the stable (longer term) community living in the Pearse Street area and in Ringsend/Irishtown. This area, in common with all inner city areas of Dublin, has experienced significant change over the past decade and is certain to continue changing as documented in the Dublin Dockland development plan. 8 The Pearse Street area and Ringsend/Irishtown have high levels of deprivation, 2 have very similar needs but are two distinct geographical communities. This was very apparent when people were asked "where would you like to attend a health centre"? The majority in both the Pearse Street area and in Ringsend/Irishtown wanted to attend a health centre in their own area. Many factors influence and determine health including social and economic factors. A higher proportion of households in this area live in government supported accommodation compared with the proportion of households in the Tallaght area (37% versus 25%). 3 Almost 23% of individuals aged between 15 and 65 years old were not in employment which is higher than the national average (6%). 9 Half of the primary carers had either no formal education or had completed school at primary school level. In the study area, 45% of households had a medical card which is much higher than the national coverage rate (32%) 10 and the coverage rate in the Eastern Regional Health Authority area (26%). 11 The medical card is means tested and therefore, regarded as a good indicator of poverty. The high levels of deprivation and the low levels of formal education are major considerations when planning the health services and communicating with people in the area. Therefore, it is clear that a multi-disciplinary and inter-sectoral approach is required to address the social and health needs of this area. There is high service utilisation at both hospital and community level. A marginally higher proportion reported chronic illnesses (27%) in the Pearse Street and the Ringsend/Irishtown areas compared to the proportion that reported these illnesses (22%) in the Tallaght area, whereas the proportion with disability in both areas was similar. 3 These levels give an indication of the ongoing utilisation of both community and hospital services. Amongst the services requested by primary carers was an improved out of hours general practitioner service. Respondents also suggested that it would be of benefit if people could have investigations (bloods and x-rays) done locally and a facility to deal with minor injuries. According to the primary carers, over half of households had at least one person who smoked cigarettes, indicating high levels of passive smoking. Among household members 18 years old or over, 31% smoked, which is similar to the national figure for cigarette smoking (31%). 12 Drug and alcohol problems appear to have been under reported by the respondents, as both these issues were raised as health care needs by both community organisations and the respondents in the surveyed households. Of particular concern to the people living in both the Pearse Street and the Ringsend/Irishtown areas was the increased level of teenage drinking. The Pearse Street area and the Ringsend/Irishtown areas have a much larger proportion of individuals aged 65 years and over than the overall proportion in the Eastern Regional Health Authority area (17% versus 10%). 11 It is of interest to note that of the 86 primary carers aged between 65 and 95 years old, 47 (55%) were living on their own. Of these 47 older respondents living alone, 38 reported a chronic illness and 21 reported attending the hospital within the last year. 57

58 DISCUSSION - PART 1 The research team observed and commented on the loneliness and isolation of many of the older people living in the Pearse Street and Ringsend/Irishtown areas. According to the respondents, in some cases this was as a result of recent bereavement, but in the majority of cases it was due to the change in house ownership over the last five to ten years. Respondents said that there are people living in the area, who no longer know their neighbours and there is little or no integration between old and new residents in the community. The number of elderly living on their own and the change in the community support network has a direct impact on the health needs of the elderly and the workload of service providers. The majority of people commented on the very good service provided for the elderly in Baggot Street Hospital and Sir Patrick Dunn s Hospital but requested additional hospital and community services for the growing elderly population. The challenge for the health and social services will be to provide a service that responds to the needs of the elderly within a supportive environment. During consultation with community organisations and the household interviews, individuals commented on the difficulties accessing services as a result of the restructuring of the Eastern Regional Health Authority. Many people felt the boundaries in the area were confusing and without logic. Residents were not sure which health centre they should attend or where to contact if they had queries. Almost half of the residents had moved into either the Pearse Street area or Ringsend/Irishtown within the last ten years. The level of migration was significantly higher in the Pearse Street area than in Ringsend/Irishtown (52% versus 39%). Local analysis attributes this in part to the growing number of private developments taking place in the area. During the household survey, where possible, the researchers did ask the residents in the apartment blocks if they used local health services. In fact the main reason given by the residents of these blocks for refusing to participate in the survey was that they did not know the location of nor use the health services. Of note, a further 48 of the 273 primary carers interviewed stated they did not use services locally. The fact that there is no health centre in the Pearse Street area may have contributed to their lack of awareness of local services. Although people living in the Ringsend/Irishtown area also said that they did not know where the local health centre is situated. This indicates the need for the South Western Area Health Board to provide updated information about the types of local health services available and where they are located. Stress has been identified as a major contributory factor to both mental and physical well being. 12 High proportions of primary carers reported experiencing stress in the last year and subsequently suffering negative consequences of this stress. These findings are similar to the findings in the Tallaght survey. 3 As in the Tallaght area, many of the respondents relied on family or friends to help deal with stress. 3 In this survey and the Tallaght survey, 3 there was little reported evidence of community based non-pharmacological support for stress. This indicates a lack of awareness of the health implications associated with stress and the need for service providers to promote alternative methods of stress management. Similar proportions of primary carers in both this survey area and Tallaght 3 experienced intimidation or violence within the last year (11% versus 10%). In this survey (33%) and the Tallaght survey (23%), 3 high proportions in both areas sought medical assistance as a result of the incident. This highlights two factors, first that the violence experienced resulted in injury and secondly that violence is an important health care issue. Although numbers are small, vaccine uptake rates are higher in the study area than those quoted nationally from the Regional Interactive Child Health System s data by Fitzgerald et al. 13 The new primary care strategy emphasises that the health service should be available to all people within a given geographical area, irrespective of who they are, where they live or their income. 1 The challenge will be to provide a service that responds to the needs of all the community and is accessible to all, but particularly to those with the greatest need. This report contains a wealth of information for people in the community and for health service planners and providers. We hope it will be used by the community to advocate for additional services and that it will assist in the planning of local health services. 58

59 REFERENCES - PART 1 REFERENCES 1. Department of Health and Children. Primary Care A New Direction. Dublin: Stationery Office, Small Area Health Research Unit. A National Deprivation Index for Health and Health Services Research. Dublin: Department of Community Health and General Practice, Trinity College, 1997: People living in Tallaght and their Health, A community based cross-sectional study. Dublin. Department of Community Health and General Practice, Trinity College, Lemeshow S, Robinson D. Surveys to measure programme coverage and impact: a review of the methodology used by the expanded programme on immunization. World Health Statistics Quarterly 1985;38: Primary Health Care Management Advancement Programme. Assessing Community Health Needs and Coverage. 1st ed. Geneva: Aga Khan Foundation, Sall J, Lehman ASI. JMP Start Statistics: Version 3.2. Belmont New York: Duxbury Press, STATA Corporation. Reference manual-stata release th ed: College Station, Dublin Docklands Development Authority. City Quay and Westland Row, Area Action Plan. Dublin Central Statistics Office. Quarterly National Household survey. Cork: Central Statistics Office Office, Watson D, Williams J. Perceptions of the Quality of Health Care in the Public and Private Sectors in Ireland. Dublin: The Economic and Social Research Institute, 2001: Department of Public Health report, Eastern Health Board. Public Health at the turn of the century. Dublin Friel S, Nic Gabhainn S, Kelleher C. The National Health & Lifestyles Surveys. Dublin: Health Promotion Unit, Department of Health & Children, 1999: Fitzgerald M, O'Flanagan D. Immunisation uptake statistics for Ireland, Quarter 4. Dublin: National Disease Surveillance Centre,

60 PEOPLE LIVING IN THE DUBLIN DOCKLANDS AND THEIR HEALTH The health needs of people living in the Pearse Street area, Ringsend and Irishtown PART 2 THE HEALTH SERVICE PROVIDERS PERSPECTIVE Frances O Keeffe Jillian Deady Jean Long Tom O Dowd

61 SUMMARY - PART 2 Summary The main research findings are presented in this summary. More detailed findings are available in the results section. What we set out to do We set out to gain a better understanding of the health needs and the current service provision in the area from the health and social service providers perspective. We also explored the participants perceptions of coordination and teamwork amongst service providers and sought suggestions that would facilitate the primary care team to work together effectively. How we conducted the study We obtained permission from the General Manager of the Dublin South City District to contact the senior manager of each health service discipline within the Area Health Board. We contacted persons employed in private practice individually. We informed service providers about the study and asked them to discuss with their colleagues the health needs in the area. We sent them a topic guide to assist with their discussion. We requested that they nominate a colleague from their discipline who would be willing to be interviewed on their behalf. Eighteen service providers agreed to participate. They represented a broad spectrum of health and social service providers in the community including doctors, nurses, therapists, home helps, social workers and community workers. We collected the information through taped semi-structured interviews. What we found The results are presented under three broad categories: the health issues in the community, services and resources in the community, and co-ordination and teamwork in the area. The health issues in the community The health service providers were asked what were the main health issues in the area. The responses were allocated into one of three categories: physical, mental or social. The respondents reported that: The physical problems covered a broad spectrum of diseases affecting all age groups. The problems associated with older people were the main problems. These included respiratory and cardiovascular diseases, arthritis, reduced mobility, physical frailty, incontinence, chronic leg ulcers and terminal illness. Depression was the main mental health problem affecting both young and old. The main factors associated with depression were, drug and alcohol misuse, the stress of daily living, loneliness and isolation, and social deprivation. Overall the main social issues that had an impact on the health of the community were loneliness and isolation among the elderly, the effects of alcohol and drug misuse, and factors associated with social deprivation (poor housing, poor education etc). Services and resources in the community The health service providers were asked to elicit the main barriers or difficulties they experienced in delivering their service, to suggest methods that would improve existing services and to identify additional services required. The service providers interviewed worked in either the Pearse Street area or in Ringsend/Irishtown or both. Respondents commented on the fact that these communities had separate identities, although both needed services. The main barriers discussed were related to insufficient staff, inadequate local health facilities and the difficulties encountered promoting better health practices in a socially deprived area. The respondents also spoke about the difficulties encountered for both service providers and service users since the restructuring of the health board. They spoke about the problems experienced by the elderly who have difficulties accessing the health centres because they are no longer within walking distance. Respondents also said that people living in the community were unsure which health centre they should attend or where to contact if they have queries. 61

62 SUMMARY - PART 2 Respondents were asked what resources were required in the area. Most of the respondents stated they did not have enough resources and reported the need for: More staff within their own specific service and within the other services. Regardless of their own discipline most respondents reported a shortage of physiotherapists, occupational therapists, speech and language therapists and social workers. A health centre in the Pearse Street area and the need for the existing health centre in Irishtown to be renovated and upgraded. Facilities available at local level for area medical officers, occupational therapists, speech and language therapists and other services not currently based in the area, to provide a more effective service. An expanded service for the elderly including a full time social worker, suitably adapted local transport, and emergency respite beds in the local area. Crèche facilities in the area and an expanded social work service to support families. Respondents were asked for suggestions on how to improve services. Apart from the many resources already mentioned the main suggestions were: Improve formal communication between disciplines so as to improve teamwork. Incorporate more health promotion and prevention activities in their daily work. Place more emphasis on a client centred service. Collate information on the different services available in the area and disseminate the information to both service providers and service users. Provide ongoing training and further education for service providers to ensure they continue to provide a good service. Co-ordination and Teamwork in the area The respondents were asked to discuss the level of co-ordination amongst service providers in the area. Most of the respondents said that there was some level of co-ordination (ranging from poor to good) in the area. They reported that: There was no formal structure for communicating within the health services and most co-ordinating was done on an informal basis. Communication was mainly by telephone with very little face to face meetings with the other disciplines. The level of co-ordination depended on the personalities of the individuals working within the different disciplines and how long they had worked in the area. The service providers worked in isolation and this negatively affected the delivery of the service. There was good co-ordination and communication between the community services and the local hospitals and vice versa. On the other hand respondents said that there was poor co-ordination between the acute hospital services and the community health services. The level of co-ordination between the health services and other government sectors, the voluntary services and the community itself, varied. Co-ordination was generally much better if the services were in the same premises or in close proximity to each other. 62

63 SUMMARY - PART 2 Respondents were asked to give suggestions as to how the primary care team could work better for the community. The majority of the participants made very positive suggestions and displayed a great willingness to work together. The respondents suggested that: The service providers needed to be based within a geographical area, and ideally based within the same health facility. It was important to have structured team meetings and good communication between the different services. Knowing the individuals in the team and using information technology would improve communication. Potentially the primary care team could work together in the area of health promotion and advocacy on behalf of the community. The area being surveyed would be ideal for a primary care pilot project. Conclusion The health service providers displayed a vast knowledge of the area and showed a keen interest to work together to improve the overall service for the community. 63

64 METHODS PART 2

65 METHODS - PART 2 METHODS 1.0 Introduction In April 2001, the Royal City of Dublin Hospital Trust (Baggot Street Hospital) commissioned a study to investigate the health needs of the people living in the Pearse Street area, Irishtown and Ringsend. The Department of Community Health and General Practice, based at the Trinity College Centre for Health Sciences, Adelaide and Meath Hospital, Dublin, incorporating The National Children s Hospital, was requested to undertake the study. The South Western Area Health Board (SWAHB) fully endorsed the study. The first part of the study consisted of a household survey in the community and the results are presented in Part 1 of this report. During August and September 2001 the service providers were contacted and informed of the household survey. They were also invited to participate in a study to ascertain the needs from the service providers perspective. Following completion of the household survey representatives from the different disciplines within the health services were interviewed. 1.1 Aim The study set out to gain a better understanding of the health needs and the current service provision in the area, from the health service providers perspective. The research also sought to explore the participants perceptions of co-ordination and teamwork amongst service providers and sought suggestions that would facilitate the primary care team to work together effectively. 1.2 Research Design Given the importance of exploring the service providers understanding and experiences from their own perspectives, this study employed a qualitative methodology, using a grounded theory approach. Grounded theory is a method of collecting and analysing qualitative data with the aim of developing theories that are grounded in real world observations. The goal of grounded theory is to provide a description or an explanation of events as they occur in reality, and not just as they have been perceived anecdotally. The information was collected through a semi-structured, in-depth taped interview. The semi structured interview is used when the researcher knows the type of questions to be asked but cannot predict the answers. This approach was chosen as it ensures that the researcher obtains the information required while at the same time permitting the participants freedom to describe their experiences and understandings in their own words. 1.3 Study Population In grounded theory individuals are chosen based on their knowledge and expertise of the research topic. In this study the population consisted of the health service providers within the Pearse Street area and the Ringsend and Irishtown areas. 1.4 Sampling The selection of an appropriate and adequate sample is crucial in qualitative research. 1 Purposeful sampling selects individuals for study participation based on their knowledge of the research topic. For this study a purposeful sample of health service providers within the study area was chosen. Approximately interviews were deemed necessary to achieve maximum saturation. 2 65

66 METHODS - PART Fieldwork Permission was obtained through the General Manager of the Dublin South City District (CCA3) to contact the senior manager of each health service discipline within the area. Persons employed in private practice were contacted individually. All the personnel contacted were informed about the study and asked to discuss with their colleagues the health needs in the area. A topic guide was sent to assist in the discussion (Appendix 6). They were asked to nominate a colleague who would be willing to be interviewed on behalf of their discipline. The participants who agreed to be interviewed were contacted by phone to arrange the interview. The researcher allowed full flexibility regarding the time and place of the interview. The interviews took place between the 29th of November and the 11th of December A total of 18 health service providers were interviewed. Each interview lasted approximately 30 minutes, ranging form 20 to 45 minutes. Prior to commencing each interview a full explanation of the research was given to each individual participant. The researcher reassured the participants about confidentiality and anonymity. Participants were then invited to sign a consent form, indicating their voluntary participation in the study (Appendix 7). Participants were also made aware of their freedom to withdraw from the interview at any time. Each interview started with a general introductory question. The topic guidelines were used to probe the areas of interest (Appendix 6). As the interview progressed the researcher asked the participants to clarify issues that emerged during the interview process. In order to ensure that the researcher would not influence emerging data, the interviewer refrained from offering opinions or answering questions during the course of the interview. Notes were taken at the end of the interview in which the researcher recorded personal reflections on the interview. 1.6 Data Analysis All interviews were transcribed verbatim. Transcription included information on pauses and gaps, as well as comments in brackets using Silverman s transcription symbols (Appendix 8). The researcher read the transcripts while listening to the tapes. This served to improve familiarity with the data collected and helped to verify accuracy of transcriptions. Five interviews were analysed manually through detailed scrutiny of the transcripts to identify common concepts and these were coded. The coded transcripts were reviewed by two experienced reserchers to ensure the interviews were coded correctly. All the interviews were then coded using a qualitative research software programme Ethnograph and subjected to analysis. Similar concepts or codes were then grouped together. A number of categories and sub categories were identified in the study. A copy of the findings was sent to five of the participants. They were asked to read through the report and to comment on whether they felt it accurately represented their views. This was done to enhance the credibility of the study. 66

67 SUMMARY RESULTS PART 2

68 RESULTS - PART 2 RESULTS 2.0 INTRODUCTION Eighteen service providers were interviewed, five of whom were male. They represented a broad spectrum of health and social service providers in the community including doctors, nurses, therapists, home help service and social workers. Four service providers worked mainly with children, three worked with older people and the remainder worked with people in all age groups. The results are presented under three broad categories: the main health issues for people living in the community, services and resources needed to respond to the people s needs, and the level of co-ordination and teamwork among health providers in the area including insights on how best to facilitate the primary care team to work. Participants were asked how long they had worked in the area. On average the health service providers had worked for seven and a half years in the area (ranging from 10 weeks to 30 years). Half of the respondents had worked in the area for 10 years or more. Some of the participants said that they had worked longer in the community care area but the area being surveyed had only become part of their catchment area since the introduction of the three Area Health Boards. 2.1 THE HEALTH ISSUES IN THE COMMUNITY The health service providers were asked what were the main health issues in the area. The responses were allocated into one of three categories: physical, mental or social. Physical problems The physical problems covered a broad spectrum of diseases. Many of the respondents (11) spoke about the problems associated with the older people. These included arthritis, reduced mobility, physical frailty, incontinence, chronic leg ulcers and terminal illness. Respondents also talked about chronic illnesses including respiratory problems (young and old), cardiovascular problems (including hypertension), arthritis, diabetes (young and old), neurological problems (Parkinson s disease, cerebral palsy, multiple sclerosis and motor neurone disease), physical disability and problems associated with care of patients with cancer and other terminal illnesses. Women s health related issues also presented as health problems for people living in the area. These included issues associated with pregnancy, antenatal and postnatal care, family planning and contraceptive advice (adults and teenagers). For young children the main problems mentioned were related to hearing and speech, dental caries and orthodontics. Respondents said that the physical complications associated with lifestyle issues (such as smoking, drug and alcohol misuse) added to the burden of ill health in the community. Mental health problems Over half of the respondents (10) spoke about depression as the main mental health problem. Respondents reported that depression affects both young and old. According to the respondents the main mental health issue for younger people was depression associated with drug and alcohol misuse. depression.you know as a result of being on the drugs as well as being kinda off the drugs. there s a lot of hopelessness and depression around (HSP14) We would see an abuse of alcohol, maybe leading to depression (HSP16) With reference to families the respondents highlighted that postnatal depression and depression associated with the stress of day-to-day living were the main mental health problems. 68

69 RESULTS - PART 2 The depression that some of our mothers are suffering from for various reasons, from their, maybe their family background, or from their families that they are trying to cope in difficult situations so depression would be one of the most underlying themes that we re working with very vulnerable families (HSP16) Respondents reported that depression among older people was mainly associated with loneliness and isolation. all ageing process problems, just getting older.and the loneliness and the related depression that becomes more apparent as time goes on (HSP3) and with the elderly, often times they have no backup and they re isolated and so on, and they become depressed (HSP13) Many of the respondents said that mental health issues and social deprivation were interlinked. People experiencing deprivation were more likely to have mental health problems. because we are a very deprived area there is the social phenomenon of people with mental health problems.we have an inordinate amount of people with mental health problems.many of them in poor living conditions, poor housing etc. (HSP18) According to the respondents a small proportion of people living in the community also suffer from other mental health problems such as anxiety, schizophrenia, psychosis, manic depression, Alzheimer s and senile dementia. Respondents reported that autism, attention deficit disorder and intellectual disability were mental health issues affecting children living in the area. One respondent who works specifically with children noted that the number of children with these disorders had increased over the last few years (HSP10). Social problems All the respondents spoke about the different social issues that impact on the health of the community. The three main issues discussed were loneliness and isolation among the elderly, the effects of alcohol and drug misuse, not only on the individuals but also on their families, and the link between social deprivation and health. Loneliness and isolation The most common issue discussed (10) was the loneliness and isolation of the elderly in the community. According to the respondents, in some cases this was as a result of recent bereavement but for the majority of cases it was as a result of the changing social support network in the area. The respondents said that the social network had changed because the children of the older population could no longer afford accommodation in the area. Those who are now buying houses in the area do not necessarily mix with the local community, and this has resulted in an older unsupported population. Many new residents have moved into the area over the last five to ten years. The majority are young and are out at work and as a result older people no longer know their neighbours. I mean years ago everybody knew everybody else. Everyone knew their neighbours but nowadays there s a lot of younger people moved in and there isn t the same kind of neighbourhood (HSP1) The health service providers noted the valuable assistance provided by the facilities in the area for their older clients, for example, the day centre in St. Andrews Resource Centre, Cambridge Court in Ringsend, Sir Patrick Dunn s hospital and Day Care Unit and Baggot Street Hospital. Respondents also highlighted the loneliness and isolation experienced by the elderly who are housebound or living alone but do not attend local facilities and do not have regular visits from family and friends. In the elderly population you have quite a few older people who are quite isolated, don t go out, don t meet other people.can be left at home with very little in the way of services and not seeing people, you know. They go to Mass up there in the morning and that s often the highlight of their day, there s nothing else you know (HSP13) 69

70 RESULTS - PART 2 Em, another problem I ve encountered is loneliness. A lot of people are very lonely, a lot of old people. it s lack of someone to talk to.a lot of these people are housebound (HSP1) Drug and alcohol misuse Many of the respondents (7) spoke about the effects of alcohol and drug addiction on the health of individuals in the community. Apart from the physical and mental health problems associated with these habits, respondents commented on the social and economic impact. The main social and economic issues highlighted were the financial implications for individuals and for their families, long-term unemployment, the disruption to family life and issues around childcare and parenting. In my job, I think the main theme would be addiction and alcohol problems.alcohol problems would be a large part of our work and some addiction.we re working with very vulnerable families.families in crisis, families that are stressed (HSP16) Respondents said that there was drug misuse in the area and acknowledged that the drug services in the area had responded and had improved the situation. However it was suggested that alcohol misuse was still a hidden problem that needs to be addressed. alcohol is quite a problem and I think in general practice, it still remains quite hidden in the sense that you are often not aware of it and it s difficult for you to (---) sometimes it comes up as the issue after you ve been seeing someone for a long time, the penny suddenly drops. (HSP13) Social deprivation Respondents (7) spoke about working in a disadvantaged area. In the respondents opinion, the effects of poverty, poor housing and low levels of education all impact on how individuals address their health needs. Some respondents spoke about how women who lived in deprived areas neglected their health and did not see it as a priority. the influence that housing has on people s health in this area is very very significant (HSP18) Women s health would be an issue which often, I suppose they leave their own medical needs to the very last, you know (HSP16) Similarly men do not access services as, it is not a man ((ly)) thing to do (HSP4). Respondents said that certain lifestyle factors were associated with deprivation and they spoke about the negative impact of these factors on their health. if they have medical cards, they tend to be poor, unemployed, older folk and living in corporation housing.they smoke and they drink more and eh (---) they don t look after their own health (HSP4) Respondents said that research indicates that behavioural disorders and speech and language difficulties among children are more common in areas of deprivation, as are psychiatric illnesses. in terms of psychiatric morbidity, all the studies would show that the more deprived the area is the higher ((the proportion with)) psychiatric illnesses, and the higher the use of the service (HSP15) What occupies most of your time? Respondents were asked what occupied most of their time. A small number of respondents (4) said it was their routine workload. Many respondents highlighted particular aspects of their workload, for example, care of the elderly (6), dealing with people who have mental health problems (5), in particular those with chronic problems and care of children (3) at risk or follow up of those referred for specialist treatment. 70

71 RESULTS - PART 2 Respondents also reported that some issues, which consumed their time, were not necessarily part of their job. Many of the health service providers (12) said that they had to deal with social issues on a regular basis. Well a lot of the care of the elderly. there would be a lot of social problems involved.example, eh, elderly living alone and perhaps the time when they get sick, if family are living outside the area.obviously they require a lot of input and we don t really have the resources (HSP12) an area that takes an enormous amount of time, people looking for medical backup for housing problems.we seem to spend an inordinate amount of time writing letters on people s behalf to the local authorities for various housing issues (HSP18) Some of the respondents (4) reported that clerical/administration duties occupied too much of their time. 2.2 SERVICES AND RESOURCES IN THE COMMUNITY The health service providers were asked about the adequacy of services in the area, to suggest methods to improve existing services and to identify additional services required. Main barriers to effective delivery of services Respondents were asked what were the main barriers or difficulties they experienced in delivering their service. The main issue raised were related to staffing levels, local health facilities and social deprivation. Staffing issues The majority of the participants (12) said that the staffing issues both within their own service and in other services was the main barrier to providing an adequate health service. Respondents said that as a result of staff shortages within their own specific service they were unable to provide an adequate service, they found it difficult to reduce waiting lists and in some cases they had no cover for sick leave or annual leave. again down to staffing resources, we have to prioritise and see the most needy first, you know, in terms of severity.but that s not acceptable, you know, sort of in terms, professionally you feel, like kind of a tug there (HSP7) effective delivery, eh I suppose staffing is one, our waiting list in comparison to others would be very long.so that s a problem to effective service for the clients and other professionals see it as a difficulty (HSP8) I mean I can t get a day off for love nor money. And it s very, very bad.and that does affect the way we deliver the service as well because I mean you are under pressure (HSP2) Respondents also said that delays in recruiting and difficulty in retaining staff affect the quality and the continuity within the service. we re having difficulties in recruitment, there s a kind of a nationwide shortage, say for adults with disabilities or who might suffer a stroke or whatever, there is no service for them in the community, the posts haven t been filled and the same with the post for older people (HSP7) it s difficult to get staff because there s not enough people qualified in the country, that s literally the bottom line so it s people are always moving so therefore continuity is a problem (HSP8) they change so often it s hard to build a good relationship with somebody. Now I ve heard numerous women saying you know another social worker.so their history is being lost all the time, and history on paper doesn t reflect history in somebody s head (HSP5) 71

72 RESULTS - PART 2 Participants commented on how the staff shortages in other professional disciplines affected the delivery of their service. For example, respondents said that the shortage of occupational therapists, speech and language therapists and in particular physiotherapists, resulted in long waiting lists and a curtailed or inadequate service. We have a point five (0.5) physiotherapist in the area.so for some of our clients.that would be a very big help if we had a physio (HSP8) unfortunately we have no physiotherapist, we have no occupational therapist at the moment we did have up to a year ago but now due to the problems with recruitment (HSP3) Speech and language forget it.i mean I know of people I referred and maybe were told yes, you know, we re looking at a year ahead now (HSP6) Participants said that they had difficulties accessing hospital services. They said that as a result of staff shortages within the hospital service, in some cases specific hospital services were not available to the community and for other services there were long waiting lists. Backup, we have no Radiology for instance in this area. Vincent s Hospital have closed their X-ray machines to GP s (HSP4) There is a problems in, say managing patients in cardiac failure because you can t get ECHOs ((cardiac ultrasound)) (HSP13) waiting lists for specialist services, neurology, orthopaedic, ENT, they would be the main difficulties or barriers to delivering a proper service to the patients (HSP4) I refer a squint, but I have no knowledge of how many months that might take.but the uncertainty of it, you have to tell a mother "well I m going to refer you now but I really can t say when you ll get your appointment" this is so delayed, it s really ineffective (HSP10) Premises and local facilities Respondents (5) reported that the facilities in the health centre in Irishtown were not adequate and that the centre is not easy for the public to locate. The respondents said that having no health centre in the Pearse Street area added to their difficulties. there are rooms alright but there is nowhere to store records or that sort of stuff, apart from in your own room, and then they want to dump other services in on top of you.i was asked to let them in to my room, well I knew I had no choice, so I did, but then they re putting in their filing cabinets and their presses and stuff in on top of you and you re trying to use the room for that (HSP13) And you know this building which is a huge building has only got two things on the surface of the building that tell you what it is. A small blue sign hidden well behind the railings that says it is a health centre and dispensary is still firmly written into the sort of granite on the gatepost. And that s very frustrating for people who want to provide a lot more on the inside (HSP6) we don t have a health centre actually in the area. I just feel we are actually removed from the area we are working in and it causes all sorts of problems, in for instance for patients (HSP12) 72

73 RESULTS - PART 2 Respondents (5) who provide a service in the area but are based in an office outside the area reported that it was very difficult to provide an effective service. Well I suppose effective delivery of service would mean that we are getting to our clients.that we would have access to physical resources that are near the client group. Here it isn t the easiest to get to. It is quite awkward to get to, and in particular if you are trying to bring a couple of children with you (HSP16) another factor affecting the service is that our clinic, the clinic isn t based in the area.they have to travel up to this centre.so that I think is a drawback (HSP7) Social deprivation Respondents (5) said that it was difficult to promote better health practices in an area that is socially deprived. I have fourteen hundred GMS ((General Medical Service)) patients in the inner city.they don t look after their health. eating health diets and not smoking or drinking does not go down very well (HSP4) and despite giving them oral hygiene messages every time they come and somebody being out to the school, it s not really changing their attitude towards dental health. They don t put it on a high priority (HSP11) One respondent said that non-compliance with treatment was a barrier to effective delivery of the service. The difficulties are multi-factorial and they stem around again a lot of the indices of deprivation, the poor education of the parents with regards to children s health, the poor compliance and the lack of importance they would apply to preventive measures.it s actually getting people to attend and to follow up on actions that would be beneficial to their health (HSP18) Geographical and administrative access to services Respondents (5) did speak about some of the difficulties experienced by the community since the new health boards were introduced. In particular they spoke about the difficulties experienced by the elderly. Patients are quite confused about where they are to go for this that and the other.the health centre in Irishtown there, looked after patients from here.for dressings and other services and suddenly patients are being told down there that they are not allowed go there anymore, they have to go to Baggot Street, which on a map is not very far.the distance for somebody who s elderly and can t walk very far.it s going to take them three quarters of an hour or so. there s no bus you have to go into town and out again (HSP13) Since we moved areas I find that the health centre is removed from the actual people.we were based in Baggot street and for a number of elderly who lived around they could walk over, which they can t now.it s such a long walk for the elderly down here, we end up visiting them and that s defeating the whole purpose of making people independent (HSP12) Other issues mentioned by the respondents were the lack of clerical support, the inefficient postal service within the health board, and the fact that there is no means of receiving feed back from the clients as to the effectiveness of the service. 73

74 RESULTS - PART 2 Barriers within general practice Respondents within general practice (4) said that the new health board division affected their service and they experienced some difficulties communicating with the health board. the other thing that has happened is that the area has been divided in, well three.i have a lot of patients who come from the North Strand and that area across the bridge, because you know it is only a minute away. So in local terms it is not very far but in Health Board terms it is a foreign country. I m trying to deal with the Northern Area Health Board, the South Western Area Health Board and the East Coast Area Health Board. And it is very difficult to actually try and find out whom you are supposed to be dealing with (HSP13) I ve been writing reports and, you know requests for, sort of, support for over the years. So amongst the things that I wanted to do early on was to have say, a reception area, to have a nurse and to be able to work at night and to be visible in the area. So these are some of the things I ve been focussing on continuously since I ve started here. And I had zero success (HSP6) Another thing I wrote to the health board six months ago looking for a grant to build.and I still haven t heard, you know I wrote again, still haven t heard (HSP4) We have significant difficulties at the health board interface with regards to medical card eligibility, medical card application forms etcetera. I think it is fair to say that the single biggest area that we apply energy to is trying to keep people s medical cards up to date (HSP18) Resources required to address the needs of the community Respondents were asked if they had adequate resources to address the needs of the community. Most of the respondents (14) stated they did not have enough resources. Some respondents (6) said that they had sufficient facilities within their own service but if other support services were better resourced the quality of their own service would improve. Staff Respondents were asked what resources were required in the area and for suggestions on how to improve services. The majority of the respondents (15) spoke about the need to improve staffing levels within their own service. List 1 details the type of additional staff (by designation) required in the area and also the frequency with which each cadre of staff were mentioned by respondants. List 1 Frequency with which respondents mentioned that additional service providers were required in the area. Occupational therapists (9) Physiotherapist (9) Speech and Language therapist (7) Social worker for the elderly (6) Generic social worker (5) Clerical/administration staff (5) Counsellors (5) Specialist in hospitals (e.g. ENT, Ophthalmic, Orthopaedics, Neurology) (5) Community ophthalmologist (1) Health premises According to the respondents the other main resource needed was in relation to the health premises in the area. The respondents said that a health centre was required in the Pearse Street area and that the existing health centre in Irishtown required renovation and upgrading. Respondents (9) said that both health centres need to have the capacity to accommodate several different services in the area and be client centred. The term one stop shop or poly-centre was used by many of the respondents. 74

75 RESULTS - PART 2 if the physical surroundings are not conducive to people feeling we value them, that they re not thought well of, that s what the surroundings sometimes implies.whereas if a place has been tailor made like a poly-centre or whatever, that can meet their needs in a very client friendly, appropriate way, that the physical surroundings are conducive to working with professionals, then I think you are half way there (HSP16) Well you have got to have a good building, you have to have the right rooms, a satisfactory waiting area, playthings in the waiting area, it should be warm, it should be clean, I mean these things are important to make people want to come and use the services, people have to feel that it is something they wish to do because it is pleasant (HSP10) Resources for the elderly Respondents (7) spoke highly of the facilities for the elderly already available in the area, but spoke about the need to increase resources for the elderly. In particular participants said that there was a need for urgent respite beds in the area. At present if an urgent respite bed is required the person has to be admitted to an acute hospital. there s very little you can do if you walk in on an elderly person who is in dire straits. They don t have any clinical reason to go to a hospital and at the moment I see that there is very little places that can deal with this. You have to send them to an acute hospital, it only exacerbates the problem cos they re sitting in casualty for hours (HSP1) Other services requested included a social worker to work specifically with the elderly, twilight service for the elderly (home helps, care attendants), more day centres particularly in the Ringsend/Irishtown area. Respondents (5) spoke about the need for transport that is purpose built for the elderly. They said that older people had difficulty travelling to shops and health and community facilities (such as Baggot Street Hospital, Sir Patrick Dunn s and St. Andrew s Resource Centre). Respondents also suggested that loneliness and isolation among the elderly should be addressed. The service providers made some innovative suggestions including a home visitation service, a friendship centre and more day centres. there is a need for more places locally that people can go, in terms of say day centres that would provide meals, entertainment, some nursing care, I think people always value that (HSP13) The day centres are usually orientated towards activity, and eh, interaction, social interaction.a friendship centre is maybe more a drop in centre where you d maybe have a cup of tea between eleven and twelve or, after mass or something like that where people can just meet and it s warm for half an hour.a shorter thing, and where they network themselves (HSP8) Locally based services Respondents (5) who are not based in the area e.g. area medical officers, occupational therapists; speech and language therapists etc. spoke about the difficulties of not having facilities available at local level. and if we had an office I would consider basing people down here, because we use other health centres in that way and so you have a better opportunity to liase and get to know people coming and going as well as the staff that use the health centre (HSP8) The respondent within the drug services said that there was a need for the drug counsellors and outreach workers to be based at local level and highlighted the need for rehabilitation facilities to be based within the local geographical area. I mean all the drug clinics are based on very strict geographical lines and while if you re going for rehab, you ve got to go to Dun Laoghaire, seems like a non starter (HSP14) 75

76 RESULTS - PART 2 The respondent within the psychiatric service said that there was a need to expand community-based services. Certainly if we had more community based services within the area, I think we could reduce the admission rate considerably and improve the quality of life for the people in the area.for example we have a day centre in the Ringsend area it has made a big difference and then there was supposed to be one for Pearse Street but that funding money ran out and we still only have one (HSP15) Respondents also said that x-ray facilities and a minor surgery facility were required in the area. Resources for families and children In relation to family support, the respondents (6) said that the following were required; crèche facilities in the area, services for children with behavioural problems and/or autism, parenting classes and health services specifically for adolescents. Once again the respondents said that the social work service needed to be expanded to support families in the area. So I mean we would deal with a lot of young people who have misinformation relating to their health and that would often be the case.how their bodies work may not be not known to them (HSP16) social workers, I think could be a bit more on the ground with us locally, with the families who have problem children, who have drug problems, all that sort of area, it s very difficult for people to get help (HSP13) Suggestions on how to improve the service Apart from the many resource requirements already mentioned, when asked how the service could be improved, the majority of respondents (12) said that there was a need to improve communication between disciplines so as to improve teamwork. These issues will be discussed in the final section. Some respondents reported that their workload tended to deal mostly with problems and crises. They said there was a need to incorporate more health promotion and prevention activities in their work. Respondents also said that there was a need to provide a more client centred service. I think in areas of disadvantage in particular, you really need sort of you know, more of an emphasis on education and prevention of health problems, you know, I feel strongly that there isn t. funds seem to be geared towards dealing with the problems and coping with crisis. I think that would be very useful and money well spent and I mean around lots of different areas.from you know diet, exercise, parenting skills, behavioural management, all sorts of areas (HSP7) There would be a need to develop the service in a more friendly client based, to be more mindful of the needs of that particular, you know, client group (HSP16) According to the respondents (4), the health board needs to collate information on the different services available in the area and what exactly they provide. This information should be disseminated to both service providers and people in the community. Respondents also said there was need for a health information resource centre in the area. I don t think the Boards are running a service if they re not prepared to tell people in the area what the service is and who it is for (HSP6) I don t think that there is enough awareness out there in the community from the clients point of view, I don t think they know enough about us or actually to what our limitations are (HSP5) Now we could have a much more fundamental health information resource here in a properly managed centre, with everything from the web to CD ROM s to books. I think if you are going to change peoples habits these are some of the kind of things that will work (HSP6) 76

77 RESULTS - PART 2 Respondents said that there was a need for ongoing training and further education for service providers to ensure they continue to provide a good service. I think if we are looking at services, then we have to be up-skilled and continue our training and have access to continued education, and you are going to give a better service, that s really important (HSP8) 2.3 CO-ORDINATION AND TEAMWORK IN THE AREA This section presents the respondents perceived level of co-ordination between services in the area and suggestions on how best to facilitate the primary care team to work effectively. Level of co-ordination between service providers and teamwork in the area Three of the respondents were happy with the level of co-ordination between services in the area. Only one respondent said that there was no co-ordination between services in the area. The other respondents (17) said that there was some level of co-ordination (ranging from poor to good) in the area but that it was mostly on an informal basis. The respondents reported that they experienced good co-ordination between different services but this was done through the efforts of the individuals within the services rather than through any formal structure. Many respondents (10) said there was no formal structure for communicating within the health services and that most co-ordinating was done on an informal basis. I don t think there s particular organised co-ordination, I mean you have to kinda chase up on people. there s no formal structure for us to meet and it is very informal (HSP1) Eh, there is a certain amount of co-ordination but there are no clear channels of communication.there is very little in the line of face to face consultation between the health care providers (HSP18) Respondents (6) said that communication was mainly by telephone. Yeah there is co-ordination, obviously we have but if you are not in the same building it isn t always easy.you are working with very antiquated telephone services that is not built for speed.it is often more difficult to get somebody down the road, you know, in another profession (HSP16) sometimes it is frustrating, it s difficult, because you are ringing people and most people are out doing their calls, it s difficult to contact people (HSP3) we speak over the phone yeah, we don t meet up at team meetings (HSP5) Some respondents (6) reported that the level of co-ordination depended on the personalities of the individuals working within the different disciplines and how long they had worked in the area. we made a point of meeting each other.but that was only because we were the type of people that we would socialise easily. But it is just if you were anyway shy at all and you came to work in this place you mightn t get to meet somebody from one end of the day to the next.it s only through our own effort, kinda making an effort (HSP2) there is and there isn t co-ordination I think some of it is personality and some of it is how long you re around (HSP15) 77

78 RESULTS - PART 2 Respondents (5) said that the services were not integrated. They said that service providers worked in isolation and this negatively affects the delivery of the service. Different service providers can be seeing the same client but there is often no sharing of information. If something changes in the time that I have seen somebody I would expect to be informed. Likewise I would inform somebody. It s just a complete lack of communication really, you know. People are doing stuff and not telling the next person (HSP1) services in the community are not integrated. And I think we all do our own thing in the community in isolation (HSP13) everybody is so busy with what they do. But they are all working in isolation, you know, except if they have to make contact about somebody or other but I don t think you are serving the community well by working in isolation because health is a very broad thing (HSP5) Respondents (10) reported that co-ordination was generally much better if the services were in the same premises or in close proximity to each other. The public health nurses, I m very lucky, I work from a health centre.so that I d see them every day. And it certainly makes a big difference in terms of that they know you and you can go in and say. hi did you see Mrs. So and so and she ll come down and say so and so is back from hospital or what not. And it does help, it gives you a sense of kind of teamwork (HSP13) the services they re all so localised, the nurses are here on a weekly basis, we ve the chiropodist in and the doctor is across the road, and we ve so much contact with them (HSP17) I mean the issue of not being based in the area with some of the other service providers is something of an obstacle in terms of, you know people, you have to make a special effort to make communication (HSP7) Co-ordination between community services and hospital services was also discussed. The majority of the services providers who liase with both Sir Patrick Dunn s hospital and/or Baggot Street reported that there was good co-ordination and communication between the community services and these hospitals and vice versa. we re very lucky here we have Patrick Dunn s down the road ( ) run s an absolutely fantastic service there and has been a fantastic back-up for me, I speak to ( ) about three times a week about people going in and out, and that s my back-up (HSP9) What we link with quite a bit, I suppose in the community at the moment, would be the GP and the public health nurse, we have good communication with both of them, and also the home help organiser.we would have quite a lot of links with the CPN s ((Community Psychiatric Nurse)) in the community and they would refer here to the unit as well (HSP3) On the other hand respondents (4) said that there was poor co-ordination between the acute hospital services and the community health services. so you are kinda in the dark, relying on patients to tell you what happened, if there s a daughter or son they might say "oh they were in such a place yesterday for geriatric assessment" and where you might have suggested this six weeks ago, you never knew anything happened about it (HSP1) A patient was sent home from ( ), I think about two weeks ago, the district care unit was supposed to be involved, but I never heard anything about the patient being sent home. Nobody rang me or nobody told me (HSP13) 78

79 RESULTS - PART 2 Hospital service do their own thing. They close their out patients, they close their x-ray or ultrasound or physio, there is no co-ordination at all (HSP4) Participants (5) spoke about the varying level of co-ordination with other government sectors, with voluntary services in the community and the community itself. when you are in an area you get to know the corporation people, who you should contact for different processes, so we know if it s a disabled persons grant, you contact Joe Soap in the corporation, you do that informally, you develop these networks yourself (HSP8) it works quite well with the community, we ve good relations with the community from St. Andrew s resource centre, they would come here and that so, we have a lot of contact here for liaison, with the priests and the parish here and with the local schools. There s quite a lot of community networking going on (HSP3) now we are not very good at utilising voluntary services, not good at liasing with the voluntary agencies.there is a myriad of agencies that are doing a lot of good work and I think we tend to be a bit isolationist (HSP15) The primary care team Respondents did have some concerns about the concept of the primary care team. Some respondents wondered about who and how the team would be managed. Issues relating to role clarity and job descriptions were raised and that perhaps some professionals may feel that other professionals were interfering with their role. The respondents also questioned who would be entitled to primary care services, with the two-tier system in Ireland, of public and private patients. The respondents queried if the services would be available for all the clients or just those in the public system. There was some discussion as to who would be part of the primary care team. Suggestions varied from the core team consisting of the service providers who are active in the day-to-day care of the clients in the community e.g. the general practitioner service, the nursing service, the home help service, psychiatric service, the community welfare service, supported by other services like the physiotherapist, occupational therapist etc. Others suggested the team should be broader and include voluntary agencies and representatives from the community, representatives from the local hospital services and from the drug services. The primary care team was considered as an important link between primary and secondary care. Respondents were asked to give suggestions as to how the primary care team might work better for the community. The majority of the participants (17) made very positive suggestions and displayed a great willingness to work together to improve the overall service. The service providers interviewed worked in either the Pearse Street area or in Ringsend/Irishtown or both. Respondents commented on the fact that they were two separate communities both needing services. we need a presence in each area, I find a bridge between the two is a huge physical and psychological barrier, it s absolutely amazing because the distance is not very far (HSP15) the people in Pearse Street would think of themselves as different from Irishtown and Ringsend, Irishtown and Ringsend see themselves as one entity and Pearse Street as a separate one (HSP16) Respondents (14) said that service providers needed to be based within a geographical area, and ideally based within the same health facility. This would benefit the client and the service providers. I think that people need to be in close proximity need to be in the same building as each other.once you have a premises and once you have adequate facilities then you can attract the services. So really there are limitless possibilities once you have the adequate facilities and adequate staffing back-up (HSP18) 79

80 RESULTS - PART 2 the whole kind of one stop shop idea has great potential really, in terms of having people able to go to one place that they can identify with, and you know access a number of services there and then.and I also think when a team like that work well there s a great synergy develops and they collaborate and work very well together because they are in proximity, they are dealing with the same groups of people, they get a better idea of the kind of issues that are there for the people of the area and what their priorities are (HSP7) Respondents (12) spoke about the importance of structured team meetings and good communication between the different services. Respondents spoke about the need for meetings about general issues within the services and then the need for meetings about individual clients (case conference type meetings) or a specific client group. The need for training to facilitate team building was also raised. I also think we need, not just do we need to be in the same building but we need a formal communication structure and I m thinking of protected time for team meetings etc. with very formal structures in place rather than the kind ad hoc situation that we have at the moment. those type of approaches would be very helpful (HSP18) I think we can all, in the primary care team do with training, training on working together, not hiving off in our own little corner (HSP14) I mean I think there is a huge need to develop full multi disciplinary teams and to empower people on the teams to do what they are best at (HSP15) I think meeting, well depending what the situation is, sometimes it can involve a group of clients (HSP3) occasionally we have case conferences, I hope they re going to become more regular. I d anticipate they would, as we d build more teams in the near future (HSP7) Communication is central to good teamwork. Respondents (6) spoke about the value of knowing the individuals in the team and the importance of using information technology to improve communication. I think all people involved in the primary care team should know who the other people are in the team. Like not just know there is a social worker or a GP. You need to have a face and know the person (HSP1) I suppose to facilitate the primary care team to work better, I guess IT ((Information Technology)) is a huge issue. Yeah I think that s very important that we can communicate, because I don t know when or who has seen that client and if we were all tuned into the same system.if you could look at your computer as a health care worker and say well an OT was there on so-and so date, or the last episode was so long ago you could make the referral. It would make an awful lot of sense and obviously we d be using the same system, inputting and using the common information (HSP8) I mean teamwork at some level would even be just a matter of communication. If I had a file here that I could open up and say right the physio is such and such and, you know by just `ringing them or faxing something to them that I knew at least they were in their system and they would be able to get back to me and say well I ll see this person in three months time (HSP6) 80

81 RESULTS - PART 2 Respondents gave good examples of how the primary care team could work together to address the needs of the community. Respondents (5) spoke about the primary care team working together in the area of health promotion and advocacy on behalf of the community. lots of people could identify with kind of a preventative role, we could get involved with maybe working with parents, or working with new parents, nurses, dentists, area medical officers and whoever, I just know from my own profession that certainly we would like to get more involved in preventative work, I would imagine other professionals would be similar (HSP7) Another example given was the health professionals liasing with other relevant groups and agencies to advocate for a safer environment for older people. Some suggestions given were to lobby for more pedestrian crossings in the area, footpaths that are wide enough for wheelchair access, benches in parks that are suitable for the elderly, better lighting in the stairs and in the lifts in the local flat complexes. The possibility of providing out of hours service was discussed. One suggestion was to have late evening surgeries to provide a service for the many clients who are working and can only avail of the services in the evening. if we move towards a purpose built health centre with a number of doctors involved in it, that improves your ability to provide, I m thinking of, late evening surgeries, that type of facility (HSP18) The majority of the service providers were very positive about working as part of a team. Respondents (4) did suggest that the area being surveyed would be ideal for a primary care pilot project. I mean the primary care team that they envisage in the Health Strategy, as far as I am concerned this is a ready made one of these.i mean what more do you need but willing participants who work close to each other. So it would be a good place to start (HSP6) 81

82 DISCUSSION PART 2

83 DISCUSSION - PART 2 DISCUSSION This study was undertaken, as part of the health needs assessment in the area. Most of the issues discussed by the service providers support the findings of the household survey conducted in the area. The service providers reported that the care of older people was one of the main health issues in the area and similarly in the household survey it was reported that one third of the surveyed population was aged over 50 years and of these, more than half were over 65 years. In the household survey the most commonly reported chronic illnesses were respiratory disease, cardiovascular disease, arthritis and psychiatric illnesses, which were similar to the main health problems reported by the service providers. A number of studies have been conducted which establish a relationship between loneliness and ill health (physical and mental). 3,4 In this study the service providers spoke about the loneliness and isolation of the elderly and the impact on their health. In the household survey over half of the primary carers, who were over 65 years old, were living on their own. Research shows that deprivation is strongly linked to poor health. 5,6 The service providers spoke about the link between health and social deprivation. They spoke about the effects of poverty, poor housing and low levels of education on the health of individuals. The results of the household survey indicates that this is a deprived area with 45% of households having medical card cover, 37% of the households living in government supported accommodation and 50% of primary carers having primary school education or less. The survey reported that those who had medical card cover and those who lived in government-supported accommodation were more likely to have a chronic illness than those with private health cover or those who own or rent private accomodation. These facts support the issues as identified by the service providers. In the household survey, drug and alcohol problems appear to have been under reported as only one percent of primary carers reported that the household members have a problem with substance misuse. In contrast the service providers spoke about the physical, mental and social implications of drug and alcohol misuse and stated that drug and alcohol misuse was one of the main health issues in the area. In the household survey, the primary carers reported that there was a need for a health centre in the Pearse Street area and the service providers endorsed this. Some of the main services requested by the service providers were also requested by the primary carers, for example, more day care and respite facilities for the elderly, generic social work service (to work with young and old) and a local counselling service. Human resources, physical infrastructure and information and communication technology were highlighted by the service providers as central to the effective functioning of the primary care team. These strategies are in line with the new primary care strategy. 7 The service providers were very positive about working with the other disciplines and displayed a willingness to work together to improve the health of the community. 83

84 REFERENCES - PART 2 REFERENCES 1. Morse J M, and Field P A. Nursing Research The application of Qualitative approaches: 2ed. Cheltenham, England: Stanley Thornes Publishers Ltd, Treacy M P, Hyde A. Nursing Research Design and Practice. Dublin: University College, Prince M.J, Harwood R.H, Thomas A. Social Support Deficits, Loneliness and Life events as Risk factors for Depression in Old Age. The Gospel Oak Project VI. Psychological Medicine 1997; 27(2): Brenda W, Penninx J H, Theo van Tilburg et al, Effects of social support and Personal Coping resources on Mortality in Older age: The longitudinal Aging Study Amsterdam. American Journal of Epidemiology 1997; 146: White I.R, Blane D, Morris J.N, Educational attainment, deprivation-affluence and self reported health in Britain: a cross sectional study. Journal of Epidemiology and Community Health 1999; 53: Eachus J, Williams M, Chan P. Deprivation and cause specific morbidity: evidence from Somerset and Avon survey of health. British Medical Journal 1996; 312: Department of Health and Children. Primary Care A New Direction. Dublin: Stationery Office,

85 APPENDICES