Getting Better Information from Country Consumers for Better Rural Health Service Responses

Getting Better Information from Country Consumers for Better Rural Health Service Responses Tony Woollacott, Anne Taylor, Kay Anastassiadis, Di Hetzel, Eleonora Dal Grande 5th National Rural Health Conference Adelaide, South Australia, 14-17th March 1999 Tony Woollacott Proceedings

Getting Better Information from Country Consumers for Better Rural Health Service Responses Tony Woollacott, Anne Taylor, Kay Anastassiadis, Di Hetzel, Eleonora Dal Grande INTRODUCTION SERCIS (Social, Environmental and Risk Context Information System) telephone interview surveys provide a unique, flexible and quality method of obtaining information from consumers on a range of health and wellbeing issues. The value of this approach is reflected by the fact that both quantitative and qualitative information can be obtained and analysed for a variety of purposes including policy development, strategic planning and operational planning at various levels. SERCIS surveys have been used as a primary method for obtaining baseline data on a range of health issues included in the SA Health Goals and Targets. The sample size used in some of these surveys is sufficient to obtain regional data on a number of health issues for all seven country health regions in South Australia (see attached map). This information supports the development of quality needs assessment processes at rural regional levels on an epidemiologically sound basis. S O UTH A US TRALIAN C O UNTRY H EALTH R EGIO NS Northern & Far Western N Eyre Wakefield Mid North Riverland Metropolitan Adelaide H ills, M allee & Southern South East

Example information will be presented highlighting the types of information that can be obtained from quality telephone surveys including consumer knowledge, satisfaction with services, service use, prevalence and incidence data, quality of life information, self-reported health impact. These types of information are quite broad and include maternal and child health, violence and abuse, diabetes, immunisation, risk factors, amongst others. The SERCIS survey has also been used to obtain information about sensitive issues and experiences such as domestic violence, rape and sexual assault and child abuse and neglect. These surveys have demonstrated that telephone interview surveys can provide information that is not available from other sources at a regional level and allow a better understanding of the diversity of health issues and concerns from a rural population health perspective. METHODOLOGY SERCIS is a telephone interview survey system designed to provide high quality health data on large samples of the South Australian population in a timely and flexible manner. The advantage of obtaining large samples lies in the opportunity to describe health problems and compare the health status and activities of different population or regional groups, either cross-sectionally or over time. All households in SA with a telephone connected and the telephone number listed in the Electronic White Pages (EWP) are eligible for selection in the sample. Telephone numbers are randomly selected from the Adelaide and country regions EWP telephone listings. A letter introducing the health survey is sent to the household of each selected telephone number shortly before telephone contact is made. SERCIS uses the CATI (Computer Assisted Telephone Interview) system in the interview process which automates many of the functions of the telephone interview. The CATI system administers questionnaires on the computer screen which allows direct entry of data, executes complex skip patterns, randomises response categories, and checks responses to see if they are within a specific range. Telephone surveys are cost-effective over other survey methods, such as faceto-face surveys, particularly for obtaining rural or remote data. Telephone surveys have the ability to reach people in rural or remote areas at any time of the day from a central office. Call backs can be easily scheduled by the CATI system if needed for respondent convenience. Also appointments can be made for interviews to be conducted in particular languages as needed. SERCIS interviews are normally offered in English, Italian, Greek and Vietnamese. This capability is more easily provided using the telephone method of interviewing. Another advantage of the telephone methodology compared to other survey methods, such as respondent completed questionnaires, is that respondents are not excluded because of illiteracy or poor literacy.

Telephone surveys overcome safety issues for the interviewer visiting households at different times of the day and night and safety issues for the respondent letting unknown people into their house. The data are weighted to the Australian Bureau of Statistics, Estimated Residential Population by age, sex, area (country & metropolitan Adelaide) and the probability of selection within the household. Weighting is done to remove non-response to make the data reflective of the South Australian population. SERCIS is a flexible system and can be used not only in direct self-report surveys, but also in recruiting for postal or other surveys requiring more detailed or complex information than can be obtained in telephone surveys (such as clinical information). TYPES OF INFORMATION OBTAINED A wide variety of types of information has been obtained from SERCIS surveys in South Australia. This information has been found to be of much value in strategic planning processes such as the development of the Strategic Plan for Diabetes in South Australia, particularly because it has provided regional level data. In many instances information has been collected which has never before been available in South Australia, for example population prevalence data on various forms of interpersonal violence and abuse and the consequent effects and service use. This information will be of major benefit in reviewing service provision and needs, and in strategic development of services. SERCIS provides an ability to monitor change over time by repeating survey questions, this can be of particular use in assessing the impact of strategies and interventions. Some examples of the types of information that have been obtained are presented below. PREVALENCE AND INCIDENCE DATA A wide range of self-reported prevalence and incidence data has been collected including for diabetes (by type), asthma, heart attack/angina, stroke, cancer, arthritis, osteoporosis and hearing loss. This data is obtained from a question which asks Have you ever been told by a doctor that you have. Prevalence of Type 2 Diabetes Regional Proportions 95 Confidence Interval Metropolitan Regions 3.3 2.9-3.8 SA Country Regions 3.9 3.4-4.4 Hills Mallee Southern 2.9 1.9-3.8 Wakefield 3.8 2.6-5.0

Mid North 6.5 4.7-8.4 Riverland 1.6 0.7-2.7 South East 4.5 3.2-5.9 Eyre 3.2 1.9-4.6 Northern & Far Western 5.1 3.5-6.5 STATE 3.5 3.1-3.8 Source: SERCIS SA Health Goals and Targets Health Priority Areas Surveys 1997 & 1998 SERVICE USE Questions regarding service use have been asked in relation to a wide variety of health services including hospital services (by type), general practitioner, dentist, community health services, podiatrist, specialist doctor, etc. Proportion of women, aged 50 years or less, who have given birth in the last three years in South Australia who attended at least one antenatal education session [excluding those who attended with previous pregnancies] Women who attended at least one antenatal education session Metropolitan Regions 72.8 Country Regions 68.5 Hills Mallee Southern 78.3 Wakefield 81.8 Mid North 68.8 Riverland 64.3 South East 84.6 Eyre 64.7 Northern & Far Western 45.5 STATE 71.4 Statistically significantly higher or lower (p < 0.05) than state figure Source: SERCIS SA Health Goals and Targets Health Priority Areas Survey 1997

SATISFACTION WITH SERVICES Questions regarding satisfaction with services used have usually been asked in conjunction with questions on service use. When interpreting the results of subjective questions such as levels of satisfaction and self-assessed quality of life, it is important to bear in mind issues such as the extent to which satisfaction levels etc. relate to levels of expectation. The levels of expectation of people resident in metropolitan areas may be significantly higher than for people in country areas and higher levels of satisfaction amongst country residents does not necessarily mean that better services are provided in country areas. Instead it may only mean that metropolitan residents have higher expectations of services. Proportion of women, aged 50 years or less, who have given birth in the last 3 years in South Australia who were satisfied/very satisfied with health care received at stages of the birth event Women who were satisfied/very satisfied with health care received: before birth during birth after birth after leaving the hospital Metropolitan Regions 92.5 91.7 82.2 74.0 Country Regions 97.2 95.8 87.7 85.4 Hills Mallee Southern 97.6 92.5 92.5 87.5 Wakefield 90.6 96.8 96.8 83.9 Mid North 100.0 100.0 80.8 84.6 Riverland 100.0 95.5 87.0 95.5 South East 96.2 92.5 85.2 76.9 Eyre 96.8 100.0 90.3 77.4 Northern & Far Western 97.1 97.1 77.1 94.3 STATE 93.9 92.9 84.1 77.5 Statistically significantly higher or lower (p < 0.05) than state figure Statistically significantly higher or lower (χ 2 test, p < 0.05) than other comparison group Source: SERCIS SA Health Goals and Targets Health Priority Areas Survey 1997

CONSUMER KNOWLEDGE 5 th NATIONAL RURAL HEALTH CONFERENCE A range of consumer knowledge questions has been asked including aspects of knowledge of diabetes, and knowledge of components of a well balanced diet. Proportion of people with a correct knowledge of the recommended number of serves of fruit adults should eat per day for a well balanced diet Males Females Metropolitan Regions 30.9 46.6 Country Regions 21.9 42.2 STATE 28.4 45.5 Statistically significantly higher or lower (χ 2 test, p < 0.05) than overall figure Source: SERCIS SA Health Goals and Targets Health Monitoring Indicators Survey 1998 RISK FACTORS Extensive investigation of common health risk factors has been undertake in SERCIS surveys e.g. smoking, alcohol use, physical inactivity, high blood pressure and weight. Proportion of people who reported currently being smokers Males Females People Metropolitan Regions 23.1 18.5 20.7 Country Regions 26.8 21.9 24.4 Hills Mallee Southern 22.7 22.3 22.6 Wakefield 23.6 17.8 20.7 Mid North 26.7 17.6 22.1 Riverland 25.0 22.0 23.5 South East 30.2 22.0 26.1 Eyre 31.6 22.3 26.9 Northern & Far Western 30.3 30.2 30.1 STATE 24.1 19.4 21.7 Statistically significantly higher or lower (p < 0.05) than state figure Statistically significantly higher or lower (χ 2 test, p < 0.05) than other comparison group Note: The weighting of the data can result in rounding discrepancies. Source: SERCIS SA Health Goals and Targets Health Priority Areas Survey 1997

QUALITY OF LIFE INFORMATION Quality of life measures have been included in SERCIS surveys particularly for cross tabulation with results from other questions in these surveys, in relation to issues such as mental health and interpersonal violence and abuse. The Short Form 12 (SF-12) Health Status measure has been used in a number of surveys and the General Health Questionnaire (GHQ-28) in the Mental Health Status of South Australians survey. The SF-12 consists of 12 questions addressing quality of life issues, which are aggregated into two summary scales: the physical component summary scale (PCS), in which a higher score indicates better physical health; and the mental component summary scale (MCS), in which a higher score indicates better mental health. The two scores range between 0 and 100. SF-12 scores for adults (aged 18 years or more) PCS MCS Males Females Males Females Metropolitan Regions 49.7 48.0 52.8 51.6 Country Regions 49.2 48.5 52.8 52.3 Hills Mallee Southern 49.8 47.1 52.0 51.6 Wakefield 48.0 49.0 53.0 53.4 Mid North 50.3 50.0 55.5 49.9 Riverland 49.8 47.6 54.2 55.1 South East 50.9 49.0 53.0 51.5 Eyre 48.9 47.5 53.8 52.7 Northern & Far Western 45.9 50.7 50.2 51.7 STATE 49.5 48.1 52.8 51.8 Source: SERCIS SA Health Goals and Targets Violence and Abuse Health Priority Area Survey 1998

SF-12 scores for adults (aged 18 years or more) who reported experiencing one or more forms of interpersonal violence PCS MCS Males Females Males Females Metropolitan Regions 49.8 47.9 50.9 48.7 Country Regions 50.2 48.5 50.8 49.4 Source: SERCIS SA Health Goals and Targets Violence and Abuse Health Priority Area Survey 1998 SELF-REPORTED HEALTH AND OTHER IMPACTS In a SERCIS survey on interpersonal violence and abuse open ended questions about the health and other life effects of interpersonal violence and abuse were asked of people who had had these experiences. These questions provided a large amount of qualitative information on these impacts. This is a useful approach in relation to issues where response categories are not obvious. COMMUNITY ATTITUDES SERCIS surveys have also been used to investigate attitudes at the population level, for example community attitudes to people with mental illnesses have been assessed. Proportion of respondents who agree or strongly agree with the statement If they are not a danger to themselves or others, people with mental illness are better off out of institutions, and living in the community. Males Females Metropolitan Regions 77.9 80.7 Country Regions 80.1 84.0 STATE 78.5 81.5 Statistically significantly higher or lower (χ 2 test, p < 0.05) than other comparison group Source: SERCIS SA Health Goals and Targets Health Monitoring Indicators Survey 1998 COMMUNITY PRIORITIES People have been asked in SERCIS surveys to indicate their preferences regarding the allocation of resources and provision of services.

Health services for elderly people in their homes as a high priority: Regional Proportions * Age and sex standardised to the South Australian country population Statistically significantly higher or lower (p < 0.05) than country overall Source: SERCIS SA Country Health Survey 1996 Regional Proportions Age and Sex standardised* SA Country Regions 80.6 80.6 Hills Mallee Southern 79.9 79.8 Wakefield 78.9 78.6 Mid North 83.7 83.6 Riverland 83.2 83.2 South East 77.8 78.1 Eyre 78.4 78.5 Northern & Far Western 83.9 84.8 SENSITIVE ISSUES A strength of the telephone interview methodology is that it facilitates addressing sensitive issues both from the perspective of the respondent, the interviewer and the commissioning agency. For the respondent there is the relative anonymity of the telephone and for the interviewer there is also the safety of not having to ask sensitive questions in face to face household interviews. For the commissioning agency there is the likelihood that the quality of responses is improved by respondents feeling more comfortable in talking about sensitive issues and experiences. One of the particular benefits of the telephone methodology in country areas is that respondents are not put in the situation of being asked sensitive questions by someone they may know. Many survey research practitioners employ interviewers in country areas to conduct interviews in their own communities as it is often logistically difficult and expensive for interviewers to be brought into country areas from cities or other country areas sufficiently removed to ensure anonymity. Sensitive issues were explored in South Australia in the SERCIS Violence and Abuse Survey. This survey investigated different forms of interpersonal violence - physical, sexual, emotional and economic violence in a domestic situation, physical and sexual violence experienced by people in a non-domestic situation, child abuse and/or neglect, and elder abuse.

SERCIS LIMITATIONS 5 th NATIONAL RURAL HEALTH CONFERENCE Telephone surveys are a powerful and flexible means of obtaining epidemiologically sound population health and other information. They are also much cheaper than face to face surveys. However, there are some limitations which must be considered when deciding how to collect particular types of data. A small proportion of the population do not have telephone connections (3 in SA). This proportion is disproportionately concentrated in the Aboriginal population and amongst unemployed people. Also, a proportion of the population have silent phone numbers (17 in SA, 12.5 in major SA country towns). Telephone numbers for SERCIS surveys are derived from the electronic white pages and, consequently, people with silent numbers are excluded from the sampling frame. In SA we have used face to face surveys to ascertain the population characteristics of people without telephone connections and with silent numbers. Silent numbers are generally more prevalent amongst males, younger people, people who are separated or divorced and people who never married. It is important to be aware of the population groups who may be underrepresented in survey samples in relation to the particular issues being surveyed. Prior to the SERCIS Violence and Abuse Survey we ascertained that of people with a telephone connection, 4.2 reported having a silent number because of fear of interpersonal violence. SUMMARY SERCIS surveys have been conducted for the SA health system over the last four years and a powerful collection of data has been created, which informs policy, planning, service delivery and evaluation. The ability to obtain data on a wide range of issues, of varying types and in relation to highly sensitive issues has demonstrated the value of this tool particularly in an environment that is increasingly focussed on health outcomes and evidence based service delivery. The wide range of information that can be collected, the ability to obtain regional data cost-effectively and the logistical and confidentiality advantages of telephone interviewing have made SERCIS an indispensable part of the South Australian health system, particularly in relation to rural communities.