Illness Prevention and Health Promotion Services Provided by Nurse Practitioners: Predicting Potential Consumers

Transcription

1 Illness Prevention and Health Promotion Services Provided by Nurse Practitioners: Predicting Potential Consumers NOLA J. PENDER, PHD, AND ALBERT R. PENDER, PHD Abstract: A cross-sectional survey of 388 residents of a northern Illinois county explored the relationships between psychosocial and behavioral characteristics of the population and intentions to use illness prevention and health promotion services provided by nurse practitioners. Results of the study indicated that 61 per cent of the respondents intended to use one or more of the nurse-provided services when they became available within the community. The best predictors of intention to use the services were: expressed interest in use of prevention and health promotion services for direct pay, education beyond high school, and a low level of life stress. Intentions to use the services did not differ significantly between individuals with a regular personal physician and those without a regular physician. These data were interpreted as indicating a need within the community for nurse practitioners to provide prevention and health promotion care. The findings also supported the complementary roles of nurses and physicians in providing health care to ambulatory populations. (Am J Public Health 1980; 70: ) Since it has been estimated that more than one-half of the deaths in this nation are due to unhealthy behavior or inappropriate life style, significant improvements in the health status of Americans can be made through illness prevention and health promotion efforts.' Major emphasis on health promotion has the potential long-term benefits of extending longevity, enhancing the quality of life, and reducing health care costs. Nurse practitioners as key health clinicians have a major responsibility for developing innovative prevention and health promotion programs.2 Decisions to offer new programs or services require a careful look at supply and demand factors: the supply of properly trained professional personnel to provide high quality care and public acceptance of the proposed services. While the preparation of nurse practitioners and their utilization in a variety of health care settings has received considerable attention in published research, little attention has been given to assessing the characteristics of consumers most likely to use health services provided by nurse practitioners. The purpose of this survey was to determine which subgroups within the population studied were most likely to use prevention and health promotion services of nurse practitioners when they became available within the community. Specifically, the purpose of the study was threefold: Address reprint requests to Nola J. Pender, PhD, School of Nursing, Northern Illinois University, DeKalb, IL Dr. Albert Pender is with the Department of Business Education at the University. This paper, submitted to the Journal October 26, 1979, was revised and accepted for publication February 9, To determine the level of interest in using prevention and health promotion services for direct pay; 2. To identify the extent to which the study population intended to use prevention and health promotion services provided by nurse practitioners; 3. To identify the linear combination of psychosocial and behavioral characteristics which best differentiated between individuals intending to use health promotion services provided by nurse practitioners and individuals with no intention of using nurse-provided services. Knowledge concerning the potential consumers of new programs or services is important to the success of innovations in health care delivery. In previous research, early adopters of new products or services have generally been younger, more highly educated, and more exposed to the mass media than late adopters or non-adopters.36 The above characteristics along with additional factors were selected as independent variables for this study to determine in what combination they might predict intentions to use prevention and health promotion services provided by nurse practitioners. Intentions to use other types of services provided by nurse practitioners were not surveyed in this study. Materials and Methods Data were collected between March and May of 1978 in a county in northern Illinois with a total population of approximately 80,000 people, consisting of both rural and suburban populations. The sample of 388 adults who participated in the survey resided in households that had been randomly selected for the study. Only one individual was AJPH August 1980, Vol. 70, No. 8

2 HEALTH PROMOTION SERVICES BY NURSES interviewed in each household. The average age of the sample was 42 years with a range from 20 to 90 years; 41 per cent were male and 59 per cent female; the mean level of formal education was 13 years. By job classification, 15 per cent of those employed were unskilled laborers, 30 per cent were skilled laborers, 30 per cent were in sales or clerical work, and 25 per cent held professional or managerial positions. A large majority of the study participants were of middle class socioeconomic status. The county was stratified by telephone exchange (geographic location) and a proportional sample of the population within each exchange was selected for participation in the structured telephone interviews. Since 96 per cent of the households in the county had telephones, this method of sampling was considered unbiased. The interviewers initially determined the number of individuals living in a given household and the ages of each. A matrix of random numbers was used to select the specific member of the household to be interviewed. The telephone interview required approximately minutes to complete. Out of a total of 430 households contacted, complete data were obtained from 388 individuals for a response rate of 90 per cent. Sample questions from the survey appear in Appendix 1. The ten independent variables selected as possible predictors of intention to use prevention and health promotion services provided by nurse practitioners (described more fully in Appendix 2) were: age, years of formal education, number in household, major life change score,7 attentiveness to current health issues, interest in using prevention and health promotion services, number of physician visits within last 12 months, number of dental visits within last 24 months, use of existing prevention and early detection services, and use of existing health education and health counseling services. The dependent variable of intention to use prevention and health promotion services of nurse practitioners was measured by asking respondents if they would use the proposed services for direct pay if they were offered by nurse practitioners with master's level preparation. From this response, the two groups to be tested for maximal differentiation on alternative linear combinations of the independent variables were created:8 1) individuals intending to use nurse practitioner services, and 2) individuals not intending to use nurse practitioner services. Results Descriptive Data on Independent Variables A profile of the study sample on each of the independent variables used in the discriminant analysis is presented below. While a number of the characteristics were not normally distributed in the sample, those variables that were significantly skewed were all in the positive direction making transformation of the data prior to analysis unnecessary. By age categories, 55 per cent of the individuals interviewed were between 20 and 40 years of age, 27 per cent between 41 and 60 years of age, and 18 per cent over 61 years of age. The mean age of the total group was 41 years. Sixty- TABLE 1-Expressed Interest in Using Illness Prevention and Health Promotion Services for Direct Pay Service Percentage of Sample Expressing Interest Physical examination 66 Screening services for detection of illness 64 Rehabilitation and support services for individuals with a chronic illness 55 Periodic breast examination and instruction in self-examination (women only) 53 Counseling services for high risk individuals 45 Health education 40 Assistance in preparation for the death of a family member 33 Stress management and relaxation techniques 30 Family and marriage counseling services 28 Counseling for retirement 27 one per cent of the group were high school graduates while 39 per cent had graduated from college. Fifteen per cent of the group lived alone, 36 per cent lived in two-member households, 42 per cent lived in three- to five-member households, and 7 per cent reported six or more household members. The mean household size was 3.5 members. The extent of major life change within the sample as measured by the abbreviated social readjustment scale ranged from 0 to 255 life change units with an overall mean of 32. Death of a close family member was the life change reported most frequently. When the interviewees were queried regarding the extent to which they followed the mass media coverage of alternative plans for national health insurance, 10 per cent stated they followed coverage closely, 51 per cent followed coverage occasionally, and 39 per cent did not follow related mass media at all. Regarding attentiveness to the laetrile controversy, 21 per cent followed it closely, 57 per cent occasionally, and 22 per cent did not follow mass media coverage of the controversy. Interest in using prevention and health promotion services for direct pay once they became available within the community was measured prior to determining whether the respondents would use the services if provided by nurse practitioners. Table 1 presents these data. Physical examination and screening services for detection of illness resulted in the highest levels of expressed interest. When interviewees were questioned about physician visits within the last 12 months, 21 per cent had not seen a physician, 27 per cent had visited a physician once, and 52 per cent twice or more. The three most frequent reasons for visits to physicians' offices were for a routine check up, musculoskeletal problem, or upper respiratory infection. Of the individuals interviewed, 33.5 per cent had not visited the dentist within the last two years, while 66.5 per cent reported at least one dental visit during that time. The most frequent AJPH August 1980, Vol. 70, No

3 PENDER AND PENDER TABLE 2-Existing Prevention and Early Detection Services Received during the Previous Two Years Service Per Cent of Sample Receiving Service Blood pressure check 82 Physical examination 75 Breast examination (women only) 74 Pap smear (women only) 73 Check for diabetes (urine or blood) 53 Check for glaucoma 45 Rectal examination 40 Electrocardiogram 29 reasons for dental visits were routine check up, filling cavity, cleaning, and extraction. Existing prevention and early detection services received during the last two years are presented in Table 2; blood pressure check was the service received most frequently. The study participants were also asked to report the extent to which they had received health education, health counseling, anticipatory guidance, and stress management services from their physician or another source within the community during the previous two years. Table 3 presents these results. Only a small proportion of the individuals interviewed had received any health education or health counseling services. Instruction in breast self-examination, which one-half of the women in the study received, was the service most often reported. Prediction of the Dependent Variable Of the individuals interviewed, 61 per cent indicated that they would use the prevention and health promotion services identified in Table 2 if they were provided at a clinic staffed by nurse practitioners prepared at the graduate level. Thirty-five per cent of the interviewees stated that they would not use the proposed services if provided by nurse practitioners.* Four per cent were undecided. Using discriminant analysis, alternative linear combinations of the independent variables were tested to select the combination of variables that would maximally differentiate between individuals intending to use nurse practitioner services and those with no intention of using such services. The order of the independent variables as they were entered in the analysis and the significance of the subsequent change in Rao's V appear in Table 4. The variables significant beyond the.05 level in predicting intentions to use prevention and health promotion services provided by nurse practitioners were: interest in use of prevention and health promotion services for direct pay, years of formal education, and major life change score (MLCS). Individuals intending to use nurse practitioner services expressed greater interest in prevention *Means and standard deviations on each of the independent variables for the two levels of the dependent variable appear in Appendix TABLE 3-Existing Health Education and Health Counseling Services Received during the Previous Two Years Service Per Cent of Sample Receiving Services Instruction in breast self-examination (women only) 50.0 Health education concerning cancer danger signals 23.8 Information about proper nutrition or weight control 19.0 Information regarding how to modify your life style to decrease the chances of illness 18.2 Guidance in coping with personal or environmental stress 9.4 Assistance to quit smoking 5.8 Assistance in dealing with the death of a close family member 5.5 Marital counseling 2.3 and health promotion services, had a higher level of formal education, and had a lower MLCS than individuals who did not intend to use nurse practitioner services. Using the derived discriminant function, 77.4 per cent of the study participants were correctly classified into the two categories of the dependent variable. The value of Wilks' Lambda indicated that the three significant independent variables explained 35 per cent of the variance in the dependent variable. A high level of interest in using prevention and health promotion services for direct pay was the best predictor of intention to use these types of services when provided by nurse practitioners. Age, number in household, attentiveness to current health issues, and reported use of various types of health services were not significant in predicting intentions to use nurse practitioner services. Non-parametric statistics were used to determine whether four additional qualitative characteristics of the study sample were related to intentions to use nurse practitioner services. The characteristics were: sex of respondent, having a regular personal physician, a positive attitude toward use of health services in the absence of illness, and third party pay for nurse practitioner services. Sex of the respondent was unrelated to intentions to use the services of nurse practitioners (X2 =.016, 1 df, p >.05). Males and females in the study showed comparable levels of intention. Of the individuals interviewed, 87 per cent reported having a regular personal physician. Chi square analysis indicated that the existence of a personal physician did not affect intentions to use the services of nurse practitioners (X2 =.214, 1 df, p >.05). Individuals with and without a regular physician were equally interested in nurse practitioner services. Individuals who believed that it was a good idea to have a periodic health check in the absence of illness were significantly more accepting of nurse practitioner services for health promotion than were individuals who considered such a check up unnecessary (X2 = 12.20, 1 df, p <.001). Coverage of nurse practitioner services by health insurance or other sources of third party pay significantly increased willingness to use the services (X2 = , 1 df, p <.001). AJPH August 1980, Vol. 70, No. 8

4 HEALTH PROMOTION SERVICES BY NURSES TABLE 4-Discriminant Analysis of Independent Variables as Predictors of Intention to Use Health Promotion Services Provided by Nurse Practitioners Variables Entered Rao's V Change in Rao's V Significance of Change Discriminant Function Coeffcient Interest in using prevention and health promotion services Years of formal education Major life change score Age Use of existing health education and health counseling services Number in household Use of existing prevention and early detection services Number of physician visits within last 12 months Attentiveness to current health issues Number of dental visits within last 24 months *.004*.018** *p <.01 **p <.05 Discussion AJPH August 1980, Vol. 70, No. 8 The results of this study support the high level of acceptance of nurse practitioners reported by Spitzer9 and Batchelor.'0 A majority of the individuals surveyed indicated that they would use prevention and health promotion services provided by nurse practitioners for direct pay once they became available within the community. The lack of actual experience with nurse practitioners on the part of most respondents is a limitation of the study. However, such a positive response with little direct experience may indicate a high level of motivation among study participants to seek services oriented toward maintaining wellness as a complement to existing medical services. The significance of both interest in using prevention and health promotion services afid level of formal education as predictors of intentions to tise nurse practitioner services support findings from othef Innovation studies. Previous studies have found that early Adopters of new services were more readily accepting of new Ideas and more highly educated than late adopters or non-adopters. Interestingly, major life change also emerged as a significant predictor of intention to use nurse practitioner services. The fact that individuals with a low MLCS were more accepting of nurseprovided services than individuals with a high MLCS supports findings of Chenoy, Spitzer, and Anderson.I' They found that clients who were under stress, experiencing physical symptoms, or confronting worry-inducing medical situations preferred to see a physician rather than a nurse practitioner for care. While the rate of correct classification of the sample on the dependent variable using the discriminant function was 77.4 per cent with 35 per cent of the variance in the dependent variable explained, additional studies need to be conducted to determine the applicability of these predictor variables to other populations. Also, other variables in combination with those used in this study should be tested to determine if greater power of prediction can be attained. Although age and use of existing health education and health counseling services failed to achieve the.05 level of significance in the discriminant analysis, their significance at the.07 level suggests that these two variables ought to be reconsidered in other studies. The trend of the current data was toward younger individuals being more receptive to health ptomotion services offered by nurse practitioners than older persons. The data also suggested that individuals already using existing health education and health counseling services may be more receptive to using prevention and health promotion services provided by nurse practitioners than individuals with no previous exposure to health promotion care. The focus of this study on behavioral intentions rather than behavior can be viewed as another limitation. While behavioral intentions have been shown to correlate with overt behavior in a majority of studies, the correlation can range from.34 to.89 depending on the stability of the intention, the specificity of the intention, and the ability and opportunity for follow through with the intended behavior. 12 The nature of the behavioral intention-behavior relationship for use of nurse practitioner services needs to be empirically determined through additional investigative work. Systematic identification of the characteristics of consumers already using nurse practitioner services could provide additional information about potential consumers for the same services in other settings. An important finding of this study was that having a regular personal physician did not significantly affect intentions 801

5 PENDER AND PENDER to use the services offered by nurse practitioners. One possible interpretation of this result is that the study population did not view the prevention and health promotion services to be provided by nurse practitioners as duplicating the traditional medical functions of physicians. The fact that interviewees indicated that they would be even more likely to use the health promotion services provided by nurse practitioners if they were covered by health insurance rather than direct pay provides support for third party reimbursement for health promotion services comparable to medical treatment services. REFERENCES 1. Healthy people: The Surgeon General's Report on Health Promotion and Disease Prevention (U.S. Public Health Service Pub. No ). Washington, DC: U.S. Govt Printing Office, Ford LC: A nurse for all settings: The nurse practitioner. Nursing Outlook 27: , Robertson TS: Innovative Behavior and Communication. New York: Holt, Rinehart and Winston, Rogers EM and Cartano DG: Methods of measuring opinion leadership. Public Opinion Quarterly 26: , Meyers JH and Robertson TS: Dimensions of opinion leadership. Journal of Marketing Research 19:41-46, Armstrong GM and Feldman LP: Exposure and sources of opinion leaders. Journal of Advertising Research 16:21-27, Holmes TH and Rahe RH: The social readjustment rating scale. Journal of Psychosomatic Research 11: , Kleinbaum DC and Kupper LL: Applied Regression Analysis and Other Multivariable Methods. North Scituate, MA: Duxbury Press, Spitzer WO, et al: The Burlington randomized trial of the nurse practitioner. N Engl J Med 290: , Batchelor GM, et al: Nurse practitioners in primary care II: Impact of an interdisciplinary team on attitudes of a rural population. Canadian Medical Association Journal 112: , Chenoy NC, Spitzer WO and Anderson GD: Nurse practitioners in primary care II: Prior attitudes of a rural population. Canadian Medical Journal 108: , Fishbein M and Ajzen I: Belief, Attitude, Intention and Behavior. Reading, MA: Addison-Wesley Publishing Company, ACKNOWLEDGMENTS This survey was conducted by the Public Opinion Laboratory, Northern Illinois University, DeKalb, IL, Jon D. Miller, PhD, Director. Sample Questions from the Community Survey on Intentions to Use Prevention and Health Promotion Services Provided by Nurse Practitioners During the past two years have you utilized any of the following services for the prevention or early detection of illness? A. physical examination B. electrocardiogram (electrical recording of heart activity) C. blood pressure check D. rectal examination for cancer E. urine checked for diabetes F. eyes checked for glaucoma WOMEN ONLY G. pap smear for cervical or uterine cancer H. breast examination by physician or nurse Do you have a regular physician? During the past two years have you received any of the following health promotion services from your physician or another community source? A. health education, concerning cancer danger signals B. weight control C. guidance in how to reduce health hazards and increase your chances of living a long life D. assistance with marital problems E. help in dealing with the death of a family member F. assistance in coping with personal stress or anxiety G. help to quit smoking WOMEN ONLY H. instruction in how to examine your breasts How many times during the last 12 months have you seen your physician? APPENDIX I At present, do you pay for physician visits directly or are they covered by some form of health insurance? A. direct pay B. insurance C. mixed D. not sure In some cities, there are clinics that specialize in health promotion, prevention and the early detection of illness. If County had a clinic for this purpose, which of the following services would you be interested in using assuming that you had to pay for the service directly? 1. Would be interested in using 2. Would not be interested in using A. physical examination B. screening services for the detection of illness; for example, high blood pressure, hearing loss, diabetes C. counseling services for persons who are high risk cases due to age, family background, or personal habits D. health education regarding promotion of personal or family health E. counseling in preparation for retirement F. assistance and support in preparing for the death of a person close to you G. stress management and relaxation techniques H. family and marriage counseling I. rehabilitation and support services for individuals with a chronic illness such as arthritis or diabetes WOMEN ONLY J. periodic breast examination and instruction in self examination Would you use the above services for direct pay if they were offered in a clinic staffed by nurse practitioners instead 802 AJPH August 1980, Vol. 70, No. 8

6 HEALTH PROMOTION SERVICES BY NURSES of physicians? Let me explain, the nurse practitioners would have master's degrees and be prepared to function independently in providing care to clients. A. Would use B. Would not use Would you be more interested in using these services if the cost were covered by health insurance? A. Yes B. No APPENDIX 2 Variables Used as Predictors of Intention to Use Health Promotion Services Provided by Nurse Practitioners * Interest in using prevention and health promotion services-expressed interest in illness screening, health education, health counseling, anticipatory guidance, and stress management services for direct pay. * Years offormal education * Major Life Change Score (MLCS) -the number of life events that had occurred during the last two years out of the ten most stressful life events identified in the Social Readjustment Rating Scale developed by T. H. Holmes.7 Life change units for the events reported by each individual were summed as a measure of life stress. * Age * Use of existing health education and health counseling services-receipt of the following assistance during the last two years: information concerning the early warning signs and symptoms of cancer, counseling regarding proper nutrition and weight control, assistance in managing personal or environmental stress, risk appraisal, information concerning modification of life style to decrease chances of illness, and instruction in breast self-examination (women only). * Number in household * Use of existing prevention and early detection services -use of the following services for early detection of disease during the previous two years: physical examination, blood pressure check, urine or blood check for diabetes, check for glaucoma, electrocardiogram, rectal examination, breast examination (women only), and pap smear (women only). * Number of physician visits within the last 12 months * Attentiveness to current health issues-extent to which respondent had followed mass media coverage of 1) laetrile controversy, and 2) proposed plans for national health insurance: closely, occasionally, or not at all. An attentiveness score was obtained by weighting and summing responses to both questions. * Number of dental visits within the last 24 months Means and Standard Deviations of Variables Used as Predictors of Intention to Use Prevention and Health Promotion Services Provided by Nurse Practitioners Intention to Use Services Intend to Use Do Not Intend to Use Independent Variables Mean SD Mean SD Interest in using prevention and health promotion services c Years of formal education Major life change score Age Use of existing health education and health counseling services Number in household Use of existing prevention and early detection services Number of physician visits within last 12 months Attentiveness to current health issues Number of dental visits within last 24 months AJPH August 1980, Vol. 70, No