Family Practice Vol. 16, No. 5, 522-527
© Oxford University Press 1999
Promoting medical self-care: evaluation of a family intervention implemented in the primary health care by pharmacies
a Primary Health Care Research and Development Unit, County Council Halland, Falkenberg,
b Department of Primary Health Care, Göteborg University, Göteborg,
c Atomen Pharmacy, Göteborg,
d Hospital Pharmacy, Varberg,
e Lövgärdet Child Care Clinic, Göteborg,
f Myran Pharmacy, Göteborg and
g Centre for Health Promotion Research, Halmstad University, Halmstad, Sweden.
Dr Bertil Marklund, Primary Health Care Research and Development Unit, County Council Halland, Box 113, 311 22 Falkenberg, Sweden.
Marklund B, Almroth B, Schaffrath A-M, Gunnarsson B, Höijer B and Fridlund B. Promoting medical self-care: evaluation of a family intervention implemented in the primary health care by pharmacies.Family Practice 1999; 16:522–527.
Received 24 November 1998; Revised 17 March 1999; Accepted 13 May 1999.
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Abstract |
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Background. Medical self-care is the range of behaviours undertaken by people to promote or restore health when dealing with a medical problem.
Objectives. The aim of the study was to evaluate medical self-care effects of a family intervention implemented in primary health care by pharmacies, in terms of non-professional and professional involvement.
Methods. The intervention was implemented in one of two primary health care areas during a 4-month period and involved consecutive families acting as an intervention (IG, n = 94) or a control (CG, n = 93) group. Eight telephone interviews were conducted with each family. The families were asked about complaints of illness, how long they prevailed and how they were treated.
Results. The results showed (P < 0.05–0.0001) that the IG had more medical problems (931 versus 621) compared with the CG, were less hospitalized (4 versus 10), stayed at home more to take care of sick children (84 versus 40), read more medical brochures (121 versus 31), tried more non-medical treatments (228 versus 116), and had fewer visits to the department of paediatrics but more visits to primary health care (69 and 98 versus 90 and 68).
Conclusions. Due to the non-randomization procedure, some caution with regard to generalization of the results must be taken, but they are in concordance with established knowledge of the usefulness of medical self-care. The results indicate that a brief intervention for families can change the use of health authorities. It therefore seems meaningful to implement the intervention in a more comprehensive way in the primary health care setting, while at the same time trying to implement it as a large-scale randomized experimental study, comprising aspects such as the individual's need for care, the use of the right organization level and the assessment of economic costs and savings.
Keywords. Evaluation, families, medical problems, medical self-care, primary health care.
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Introduction |
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Medical self-care comprises four areas: regulatory self-care (e.g. sleeping, eating), preventive self-care (e.g. dieting, exercising, brushing teeth), reactive self-care (responding to symptoms without professional involvement) and restorative self-care (behavioural changes as well as compliance with professional involvement).1 A simple definition is the range of behaviours undertaken by people to promote or restore health when dealing with a medical problem.2,3 It is documented that one-third of people with medical problems seek professional involvement and that most of the medical problems are managed through lay consultation and medical self-care.4,5 The effectiveness of medical self-care education in reducing health care utilization and improving safety has repeatedly been proved during the 1990s, which explains why the status of medical self-care has increased markedly.6 Furthermore, the behavioural and economic trends in Europe as well as in Sweden have enhanced people's concerns regarding health and life-style issues as well as demands to act as resource persons themselves.7–9 Until recently, the Health and Medical Care system in Sweden had been vague regarding what kind of medical problem requires which level of health and medical care, and had thereby allowed people to select a health authority more specialized than the medical problem demanded, i.e. special care in hospitals instead of primary health care.8 Consequently, consultation at primary health care centres and pharmacies in the form of supervision and counselling on common medical problems has come to play a significant role in how people can manage their medical self-care.10,11 In the long run, medical self-care is of economic interest from both a community and a personal perspective, as it effects a relief for the Health and Medical Care and results in changed contact habits with the pharmacies as well as out-patient and in-patient care. Two important review studies have shown the widespread use as well as the usefulness of medical self-care.12,13 However, no study with an experimental design seems to have been carried out in primary health care with a pharmaceutical involvement concerning families' medical problems, on why such knowledge about the impact of pharmacists' counselling on medical self-care management must be of interest. The aim of the study was therefore to evaluate the medical self-care effects of a family intervention implemented in primary health care by pharmacies in terms of non-professional and professional involvement.
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Methods |
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Design and setting
During a 4-month period, a study with an evaluative experimental design was performed in the city of Göteborg, Sweden, involving two primary health care areas including 10 000 inhabitants each, one acting as the intervention area and the other as the control area. The study was approved by the Committee for Ethics in Medical Investigations, Göteborg University, Sweden.
Sample and criteria
In each of the intervention and the control areas, 100 consecutive families with children were invited to participate during a routine visit to the child-care clinic. The inclusion criteria were that they could speak and understand Swedish, were registered at the child-care clinic and were reachable by telephone during the period of study. Parents and all siblings under 18 years of age of the child registered at the child-care clinic were included in the study.
Intervention
The intervention's primary objective was ‘ease of access' regarding information and support of medical problems in the participating families. Therefore the families were informed both orally and in writing about telephone and visiting opening hours at the primary health care centre, as well as at the child-care clinic and pharmacy. The message to the families was that they should not hesitate to contact these primary health care authorities if they were at a loss as to what to do, i.e. the primary health care should normally be the first choice of Health and Medical Care authority. Another message to the families was that they should acquire knowledge regarding the simplest and most common medical problems in the family. Within a week they were also contacted by the local pharmacy to make an appointment with a pharmacist, which was aimed at creating awareness of medical problems and medical self-care management, i.e. what it is and what they should do. The target of the intervention was that the families should gain basic knowledge as well as understanding of medical problems of families and thereby select the most adequate Health and Medical Care authority for the actual medical problem. At the meeting, which took place at the local pharmacy and lasted 30–60 minutes, the pharmacist used two booklets containing information about medical self-care and children's diseases. The pharmacist also pointed out the family's personal responsibility for medical self-care and that the role of the pharmacist was that of a medical counsellor who could support them. The personal service was emphasized, and much effort was put into creating good relations, which is why the concept of ‘the family pharmacist' was coined. Personnel both at the primary health care centre and the local pharmacy attended a 9-hour course in medical self-care encompassing three occasions. The areas treated included medical and pharmacological as well as pedagogical and responsibility issues for the purpose of strengthening the personnel's decisions regarding recommendations for medical self-care or professional involvement.
Instruments
Background interview. .
A structured interview based on a questionnaire, created by a health care team consisting of nurses, pharmacists and GPs, was conducted by one person in both the intervention and the control area with all the families. Socio-economic questions were asked regarding the families' composition, education and working situation, education in health and medical care, and established diseases. The families also received an ‘illness diary’ with which to keep the medical problems up to date. A medical problem consisted of symptoms or complaints, and a medical problem was defined as new when the symptoms or complaints had been gone for at least 2 days but than recurred as before or in a new form.
Telephone interviews. . The same person conducted all the structured telephone interviews. The questions asked pertaining to the last week concerned the whole family. They were: in case of symptoms or complaints of illness, what were the symptoms or complaints, how long did they prevail and how were they treated?
Data collection
Families in both the intervention and the control areas received information about the study aim at the child-care clinic visit, orally as well as in writing. If the families agreed to participate, the interview was conducted on the same day, before they left the child-care clinic. The first telephone interview was performed 2 weeks later and continued every second week for up to 4 months after the visit at the child-care clinic, i.e. a total of eight telephone interviews.
Data analysis
The statistical package of social sciences (SPSS)14 was used in the analysis procedure. Descriptive statistics (frequency tables and cross-tabulations) were applied to illustrate the preliminary information as well as inferential statistics (Mann–Whitney test, t-test) to compare differences between independent groups.15 The level of significance was set at P < 0.05.
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Results |
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Participation and demographics
Of the 100 families consecutively selected to each of the intervention and the control groups, 94 families in the intervention (IG) and 93 families in the control (CG) group participated. The drop-outs were due to moving out of the area (IG, n = 3 and CG, n = 3) or refusal to participate (IG, n = 3 and CG, n = 4). The distribution among the family members was 94 mothers (mean age 31 years), 79 fathers (mean age 33 years) and 193 children (mean age 4 years, range 0–15 and 2.05 children per family, range 1–8) in the IG and 93 mothers (mean age 31 years), 78 fathers (mean age 33 years) and 208 children (mean age 4 years, range 0–15 and 2.2 children per family, range 1–8) in the CG. The most common educational background among the mothers was high school (48% IG, n = 46 and 36% CG, n = 33) and among fathers comprehensive school (23% IG, n = 21 and 25% CG, n = 23). Of the mothers, 26% (n = 25) in the IG and 21% (n = 20) in the CG were working, 57% (n = 54) in the IG and 24% (n = 22) in the CG were on parental leave and 4% (n = 4) in the IG and 14% (n = 13) in the CG were unemployed. The corresponding figures for the fathers were 72% (n = 57) in the IG and 59% (n = 46) in the CG working, 2% (n = 2) in the IG and 6% (n = 6) in the CG on parental leave and 5% (n = 5) in the IG and 11% (n = 10) in the CG unemployed. An educational background in the health and medical area was found among 26% (n = 24) in the IG and 27% (n = 25) in the CG. The backgrounds varied from nursing assistant to registered nurse or physiotherapist in both groups. In all comparisons between the IG and CG, non-statistically significant differences were found concerning the demographic data, with the exception of mothers' parental leave, which showed a statistically significant difference between groups.
Medical problems
As Table 1
shows, the medical problems were clustered into 10 fields, where the three most prominent fields were problems with the ear–nose–throat, the gastricintestinal channel, and the central nervous system, showing no statistically significant changes between groups; see Table 2. In total, 931 medical problems were reported in the IG, compared with 621 in the CG, a statistically significant difference between groups (P < 0.001). Twenty-five per cent of the IG (n = 93) and of the CG (n = 95) stated that they had no medical problems during the period of study. Thirty-five per cent (n = 33) of the IG reported that they had suffered from a long-term medical problem, while this figure in the CG was 19% (n = 18), a statistically significant difference between groups (P < 0.02). The most prominent medical problems were asthma and allergy, diabetes, fibromyalgia and chronic pain.
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During the period of study, four persons in the IG and 10 persons in the CG were hospitalized, a statistically significant difference between groups (P < 0.048), comprising 9 days in the IG and 48 days in the CG. Sixty-two in the IG (mothers and fathers) and 59 in the CG (mothers and fathers) were on sick leave, a non-statistically significant difference between groups. The sick leave in the IG included 15 persons at home for one day, 36 for 2 days to a week and 11 for more than a week. The corresponding figures for the CG were four persons at home for one day, 26 for 2 days to a week and 29 for more than a week. Eighty-five in the IG (mothers and fathers) and 40 in the CG (mothers and fathers) had cared for a sick child, a statistically significant difference between groups (P < 0.006), comprising 257 days in the IG and 114 days in the CG. In the IG, 184 children had been away from pre-school or school, and the corresponding figure for the CG was 143, a non-statistically significant difference between groups, comprising 508 days in the IG and 399 days in the CG. Drugs were used in 785 cases in the IG and 558 cases in the CG, a statistically significant difference between groups (P < 0.012).
Medical self-care management with non-professional involvement
In 13% (n = 121) of all medical problems in the IG and 5% (n = 31) in the CG, the families had read medical books, pharmacy brochures, etc. to manage their medical problems, a statistically significant difference between groups (P < 0.0001). As Table 3 shows, the IG had tried 228 non-medical treatments, while the comparable figure for the CG was 116, a statistically significant difference between groups (P < 0.0001). The most common non-medical treatment for both IG and CG was rest followed by different external applications, internal fluid applications and internal solid applications. The IG also reported back gymnastics and emergency splints regarding external applications, stale cola, sodium bicarbonate, bilberry soup, rose-hip cream and processed sour milk regarding internal fluid applications, and carrot purée, ice-cream and diet regarding internal solid application.
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Medical self-care management with professional involvement
In 10% of all medical problems (n = 95) in the IG and 8% (n = 54) in the CG, telephone advice was received, a non-statistically significant difference between groups. The main health care advice in the IG was from the child-care clinic, while the CG received the advice from the department of paediatrics, as shown in Table 4
. The corresponding figures for visits to the health care authorities were 25% (n = 241) in the IG and 37% (n = 232) in the CG, a statistically significant difference between groups (P < 0.014). The main health care visit in the IG was to the primary health care centre, while the CG mainly visited the department of paediatrics, as shown in Table 5. In five cases in the IG and one case in the CG, primary health care personnel visited the family in their homes.
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Discussion |
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Methodological issues
This study aims to evaluate the effects of a medical self-care intervention for families when faced with a medical problem. A weakness in such an evaluative study design is that the sample procedure lacks randomization,15 but from a clinical point of view randomization was not possible due to the involvement of personnel from the pharmacies as well as from primary health care centres. Using consecutive families at two different child-care clinics is appropriate from the viewpoint of applicability involving feasible samples, even if the use of matched samples had been methodologically stronger.15 Furthermore, telephone interviews as a data collection technique are also relevant due to the facts that families answered questions regarding their illness diaries and that the interviews were structured following pre-determined questions, a statement in line with both Paunamäki and Aschan's16 and Rapley's reasoning.17 Another viewpoint is that interviews are time-consuming, which was, however, reduced due to the use of the telephone. In addition, interviews were acceptable to both parties as well as for scientific scrutiny.10,11 The validity and reliability are deemed sufficient, as the questions asked were constructed by health care professionals with a good knowledge of medical self-care and medical problems and were continuously responded to by the families during the 4 months. Another important factor in the scrutiny of the study is the educational level of the parents; their general skills as well as their health and medical skills are on average high, especially among mothers in the IG, which is assumed to have influenced their medical self-care activities in a positive way.13 Furthermore, in both groups, few families declined to participate, which also strengthened the reliability of as well as the scope for generalizing the findings.
Medical problems and medical self-care management effects
In general this study shows that the dominating medical problem representing half of them all was from the ear–nose–throat region, which is quite in line with other studies.16,18 Of additional interest is that 25% of the families in both the IG and CG reported no medical problems during such a long period of study, which may indicate a good knowledge of means of health maintenance and medical self-care in both groups. However, looking more specifically at the intervention effects, the IG reported fewer hospital days than the CG, as well as shorter sick leaves, which should underline the effectiveness of the medical self-care education.6 These positive intervention benefits are to some extent shrouded by the high number of medical problems as well as the high number of days of caring for sick children among the IG compared with the CG. However, from a sound family perspective this might be a possible intervention effect of being aware of the medical problems and taking care of them in order to prevent long-term as well as chronic diseases.7,8 The greater use of drugs in the IG compared with the CG can also be an effect of such reasoning. It is obvious that the intervention has benefited the medical self-care management regarding non-professional involvement in that more families in the IG had read medical books and pharmacy brochures in order to manage the medical problems themselves as well as having tried non-medical treatments with respect to usefulness, such as stale cola, bilberry soup and carrot purée. However, the percentage of 13 in the IG makes it plain that more efforts must be made to pull down the old authoritarian health care system where families avoid involving themselves in medical self-care.6 Positive intervention effects are also found regarding medical self-care management with professional involvement, where established knowledge says that one-third seek professional involvement,4 which is in line with the 37% in the CG of this study, while the IG showed only 25%. Furthermore, the use of health care advice showed the exclusive use of out-patient care in the IG compared with the use of both in-patient and out-patient care for the CG regarding medical problems coming mainly from the ear–nose–throat region and suffered mostly by the children. The same assertion must be made regarding the health care visits when it comes to the nature of the medical problems, which in most cases should be handled by the primary health care.4,10 This was the case in the IG, while the CG more often visited the department of paediatrics. Therefore, the main effect of such an intervention might be to help people with medical problems to search for the correct health authority level and not to believe that the effects will be fewer visits to the Health and Medical Care.19
Conclusions and implications
The aim of the study was to evaluate medical self-care effects of a family intervention implemented in the primary health care by pharmacies, in terms of non-professional and professional involvement. Due to a non-randomization procedure, some caution with regard to generalization of the result must be taken, but it is in concordance with the established knowledge of the usefulness of medical self-care. The results showed how a brief intervention for families could improve their medical self-care management, thereby changing their use of health authorities, to a level more adapted to the real medical problems. Another important statement is the positive outcome of using pharmacy personnel for launching the intervention. It seems therefore meaningful to implement the intervention in a more comprehensive way in primary health care while at the same time trying to implement it as a large randomized experimental study comprising aspects such as the individual's need for care, the use of the right organization level and the assessment of economic costs and savings.
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Moore SH, LeGerfo J, Inu TS. Effects of a self-care book on physician visits. A randomized trial. JAMA 1980; 243(22): 2317–2320.
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