Socio Economic Status Chronic Morbidity and Health Services Utilization by Families

8/13/2019 Socio Economic Status Chronic Morbidity and Health Services Utilization by Families

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Family Practice Oxford University Press1998 Vol.13 No 4PrintedinGreat Britain

Socio-econom ic status, chronic m orbidity and healthservices utilization byfamiliesE Gomez Rodriguez,PMoreno Raymundo,MHernandez MonsalveandJ GervasG6mez Rodriguez E, Moreno Raymundo P, Hernandez Monsalve M and Gervas J.Socio-econom ic status, chronic m orbid ity and health services uti lizationbyfam ilies. amilyPractice 1996; 13:382-385.Background. This study deals wi th theperceptionof theburdenofchronic morbidi ty ingeneral practice.Ama rried coupleofgeneral practitioners wor k intwoprimary health centresin Mad rid (Spain), w ith popu lationsofdifferent socio-economic status: one de prived, anotherof medium and high class.Objective.The coupletry tounderstand their feelings about a higher prevalence and severityof chronic morbidi ty in the poor distr ict.Method.Atransversal observational study was designed.Atotalof119 patients aged 50 -70years were inte rview ed after the m edical encounter. Data were obtained ab out i)patients'sociodemographic condi t ions; ii)structureandeconom ic statusof thefamilies; and iii)chronic morbidi ty and health services utilization of family members.Results.Familiesin thedeprived distr ict included membersofmore thantwogenerationsin 76.5 of cases (18.8 in thecomparison distr ict); 70.3 of theheadsof thefamilies(main economic support) were pensionersin the poor district (23.7 in the comparisondistr ict); patients in the deprived distr ict have more contacts withthehealth systemandmore chronic m orbidi ty; fami l iesin thepoor area have less expressivenessandcohesionand more irr i tabil i ty andnegat ion.Conclusion.Perceived m orbidi ty ingeneral practiceisamix ofsocial and fam ily problemsas wel lasnumber and sever i tyofchronic health p roblems and health services uti l ization.Keywords.Socio-econo mic status, chronic mo rbidity, famil ies, health services uti l ization,general practice.

IntroductionGeneral practitioners (GPs) have impressionsandfeel-ings about the burden of chronic morbidity in their prac-tice populations,and it is notunusu al that marriedGPstalk about thisand other professional topics.1In thefollowing study two married GPs w orking in the SpanishNational Health Serviceas public employees triedtounderstand their feelings about differencesinthe burdenof chronic morbidityinthe populationsforwhich theycare. They agreed about the fact that familiesinthe poordistrict have m ore frequent and severe chronic morbid-ity, but they could not agree about w h at ' 'more frequentand severe chronic mo rbidity means. 2 Both worked

Received 7 November 1995;Accepted 29 March19 .Getafe, Area 10, INSA LUD , Madrid, *Alcobendas, Area 5,INSALUD, Madr id and *Equipo CESCA, Area5 , INSALUD,Madrid, Spain. Correspondence to Dr Gervas, Eqidpo CESCA,General Moscardo, 7, 28020 Madrid, Spain.

in public prim ary h ealth centres in two different districtsin Madrid.Thecentreshadsimilar structuresbut thepopulationshad quite different socio-economic status.The question was:isthereanyreal differencein mor-bidityor is itmerelythesocio-econom ic situationandits impact onhealth?The relationshipof socio-economic status(and theconcomitantandinseparable levelsofemployment andeducation)to thehealthof thepersonand the familyis well known. So, a physician perceivesin hisprac-tice nota clinical situation but this situation withina family in a socio-economic and cultural context.3Bu t in family/general practice as in other medicalspecialities,theindividual has rem ained the significantor exclusive focusofattention whilethefamily is vir-tually ignored.4-3 Ironically, it seems that family infamily medicineis fast becomingananachronismnotunlikethe royal family in theUnited K ingd om .3Our objectivewas to compare chronic morbidity,family functioningandhealth services utilizationin the382


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Chronic morbidity in families 383practices of two GPs working in different settings(medium/high class versus lower class district).

Patients and methodsThis was a transversal observational study in twoprimary care facilities of the Spanish National HealthService. The Service has primary health centres wheresalaried GPs work with a patient list and act asgatekeepers.6Both practices are located in M adrid in two differenturban districts: district A has a wealthy population anddistrict B has a poor p opulation. T he practices are quitesimilar in structure and equipment.A pilot study gave the information needed to selectpatients aged 50- 70 years old, because this age-grouphas a greater chance of living with their families andis the biggest grou p of patients (we had only month'sworking days of tw o residents in psychiatry in their rota-tion in primary health care). The study lasted 1 monthand data collection took 16 working days.Data collection was carried out through standard-ized 15-minute personal interviews performed after themedical encounter (the interviewers we re two residentsin psychiatry: EGR and PMR). Complementary datawere obtained from patients' and families' medicalrecords. Information was recorded about (i) patients'sociodemographic conditions; (ii) structure andeconomic status of the families; and (iii) chronic mor-bidity and health services utilization of family members.In the interview, data we re gathered about patients'sociodemographic conditions (age, sex, occupation);family structure and functioning [family life eventsduring the last year,7 family unit environment (familyAP GA R), family environm ent scale (subscales ofcohesion, expressiveness and dispute),9 and illnessbehaviour questionnaire (subscales of irritability andnegation)10]; economic situation [occupation of thehead of the family (male/female main economic sup-port) and other members]; and the use of health ser-vices. From the medical records data were obtainedabout the use of the health services by family mem bers(number of contacts with the GP and number of refer-rals, laboratory tests, emergency consultations andhospitalizations); and about chronic morbidity with em-phasis on psychiatric morbidity (years of diseases andtheir severity). Family chronic morbidity and familypsychiatric m orbidity w ere rated from 1 to 7, 7 beingthe worst.

ResultsFrom a sample of 137 patients, eight were excludedbecause of living a lone, four refused to collaborate andsix provided incomplete information. The final number

of interviews was 119: 55 from district A and 64 fromDistrict B.The principal results are shown in Tables 1 ,2 ,3 and4. In district A, 23.6% of the heads of the familiesbelonged to class I and 23.7% were retired; in districtB , 3% belonged to class I and 70.3% were retired.The typical family in district A was a nuclear one(two generations, usually husband, wife and children)and had 3.8 members, 1.7 of whom were working(Table 1). Almost 50% of the members had chronicmorbidity (Table 2). Patients in A had a good u nder-standing of their family (expressiveness subscale), goodsupport between family members (cohesion subscale),and friendly expression of aggressiveness, anger andconflict (dispute subscale) (Table 3). Health servicesutilization was lower in A than in B (Table 4).The typical family in district B was multigenerational(more than two generations, usually grandparents,children and grandchildren), had lower education andhad 2.9 members, 1.0 of whom was working (Table1).A lmost 64% of the members had chronic morbidity(Table 2). Patients in B were older (Table 1), and hada greater level of interpersonal disputes related to ill-ness (irritability subscale), showed a greater tendencyto deny life conflicts which were presented as conse-quences of illness (negation subscale), and had a lowerunderstanding of their family (expressiveness subscale);differences were small but significant ( P < 0.01)(Table 3).

TABLE 1 haracteristics of the patients and their families

Patients sexFemale

Family structureNuclearMultigenerationalMonoparentalOther

Family membersPatients age (years)Occupation (members per family)

Employed with university degreeEmployed without university degreeStudentsHousewivesUnemployedRetiredDisabledOther (military service)

Group A(n = 55)

61.8%61.8%18.2%18.2%

1.8%3.8

560.51.10.940.380.120.580.10.12

Group B( n = 6 4 )

57%7.8%

76.5%15.6%-2.9

61.20.030.950.170.730.150.700.10.04

Group A, wealthy population; group B, deprived population.


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384 Family Practicean international journalT A B L E2 Family chronic morbidity

Group A Group BFamily global morbidity* 3.0 3.7Family global psychiatry morbidity* 2.2 2.7Members with chronic morbidity 49.7 63.8(per family) Rated from 1 to 7.Group A, wealthy population; group B , deprived population.

TABLE3 amily functioning

Family environment scaleE xpressiveness*Cohesion*Dispute*Illness behaviour questionnaireNegation**Irritability**

Group A

5. 86. 82.63. 21.1

Group B

5.06.42. 53.91.9

Rated from 0 to 9.* Rated from 0 to 5.Group A, wealthy population; group B , deprived population.

TABLE 4 Fam ily health services utilization per mon th)Group A Group B

Contacts with the GPReferralsL aboratory testsHospitalizationsE mergency consultations

1.340.120.210.020.04

2.120.130.300.030.08

Group A, wealthy population; group B , deprived population.

DiscussionPerception of chronic d iseases severity in patients andtheir families by GPs is not a family problem identifiedin family research.4-3 In fact, almost the whole topic ofthe family is neglected in family/general medicineresearch.3 In clinical practice the family is alive andwell, because if you care for patients you will end upcaring for their families;11 but the family is sufferingfrom neglect in the scientific arena both in research andteaching.31 2Our findings support the concept of patients deeplyinvolved with their environment and show how a clinicalproblem or consulting pattern may reflect a familydysfunction. Lower class families have not only morechronic morbidity and frequent use of public health ser-vices but a higher number of pensioners as head of the

family (70.3% ), lower education, multigeneration com-position, and a lower num ber of employed persons (oneper family).In our study we have explored GPs' perception ofchronic morbidity in the popu lation for which they care.Our findings suggest that GPs' perception is a mix ofnumber and severity of chronic health problems, higherrate of health services utilization, low education,unemployment and family dysfunction. These findingshelp to clarify wh at a m or e frequent and severe chronicmo rbidity means in general practice. They are con-sistent with previous evidence that low socio-economicstatus is related to both higher morbidity and poorhealth. The suggestion is that low socio-economic statussomehow has the effect of increasing disease suscep-tibility in general, with stress as the pathway. 4GPs should emphasize the imp ortance of social classand family issues in the evolution of chronicdiseases;3-31112 social class is more important than pa-tient gender.

13Patients want their GP to address theirpsychosocial problems, including family concerns, andto directly involve other family members in the treat-ment of medical problems.14Our study show s the differences in the way in whicheach class utilizes health services . Th is is consistent withprevious studies that show a relation between frequentattenders and lowest social class, poor family support,low income, marital breakdown and psychiatricproblems.1317Several strengths and limitations ofthisstudy deservecomments. Differences found in health services utiliza-tion between families in A and B districts can be in-fluenced by easy access to private health care for groupA (6 % of the Spanish population ha s private and publiccoverage, mainly high/medium class) but families indistrict A have more m embers than in district B whichincreases the probability of contacting the health ser-vices. Age may be a confounding factor but an olderpopulation is a characteristic of district B and we havenot designed the study to avoid the ecological fallacy.Both GPs have21 years of experience and have a com-mon research interest but preconceived ideas and per-sonal style may have influenced their way of working.It is evident that a small sample and two practices donot comprise a large enough population to generalizeour findings to other populations.Additional research would further clarify the extentto which perceived morbidity by GPs is a mix of socialand family problems as well as number and severity ofchronic health prob lems and health services utilization.

AcknowledgementThe authors would like to thank Mercedes PeYezFernandez, G P in district B (and wife of Juan Geiv as,GP in district A).


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Chronic morbidity in families 385References1 Iipsky MS. Night of the iguana.J F am Pract 1995; 40: 229.2 B os G AMV . T he burden of chronic diseases in terms ofdisability, use of health care and healthy life expectancies.Eur J Publ Health 1995; 5: 29-34.3 Dowrick C . Why do die O'Sheas consult so often? An explora-tion of complex family illness behaviour.Soc Sci Med1992;

34: 4 9 1 ^ 9 7 .4 Schwenk T L , Hughes CC. T he family in family medicine.Rhetoric or reality? Soc Sci Med 1983; 17: 1-16.3 Smilkstein G. T he family in family medicine revisited, again.J Fam Pract 1994; 39: 527-531.6 G&vas J, Perez Fernandez M M, Starfield B . Primary care,financing and gatekeeping in Western E urope. Fam Pract1994; 11: 307-317.7 Gonzalez Rivera JL , Morera A. L a valoracion de los sucesosvitales: adaptation espanola de la escala de Ho mes y Rake.Psiquis 1983; 4: 7-11.8 Smilkstein G. T he family APG AR: a proposal for a familyfunctioning test and its use by ph ysicians. / FamPract 1978;6: 12-31.9 Moosrh A. Escala de clima social . Madrid: Tea E diciones;1984.10 LJor B , N ieto J, Godoy C, M orales JM. B aremo del custionarioIB Q en poblaci

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Socio Economic Status Chronic Morbidity and Health Services Utilization by Families