Physical Health Status: Effect of Physical Health Components on Utilization of Health Services and Community Aged Care Services among The Iranian Elderly in the Sydney Metropolitan Area

1): Faculty of Health Sciences, University of Sydney, Australia
2): Ministry of Health and Medical Education, Iran
3): Research center on aging, university of social welfare & rehabilitation sciences

Correspondence:

Mahtab Alizadeh-Khoei, MPH, PhD,
Associated Professor,
Department of Elderly Health, Ministry of Health and Medical Education,
4th floor, corner of Jomhori St. and Hafez Ave.,
Tehran, Post Code 1134845764, Iran
Tel: +9821 66700402
Fax : +9821 6670 7547
Email: alizadeh@health.gov.ir

A.Akbari kamrani, MD.
Associated Professor of Iranian Research Center on Aging,
University of Social Welfare & Rehabilitation Sciences, Daneshjoo Boulevard, Ewin,
Tehran, Post Code 1985713834, Iran
Tel: +9821 22180077
Email: akbarikamrani@uswr.ac.ir

Soheila Koshbin, Social medicine (MD),
Head of department of elderly health,
Ministry of Health and Medical Education,
4th floor, corner of Jomhori St. and Hafez Ave.,
Tehran, Post Code 1134845764, Iran
Tel: +9821 66700402
Fax : +9821 66707547
Email: sokhoshbin@yahoo.com

INTRODUCTION

Ageing is associated with an increase in functional limitation and in the occurrence of chronic conditions^[14]. As people age, they tend to use more hospital services and prescription medicines. Chronic diseases, and long-term illnesses that are rarely cured, are the cause of disabilities and diminished quality of life, and are a major contributor to the need for health care services^[11,14].

Studies of the physical health in the Australian population reveals that the ethnic elderly who have spent a considerable part of their lives in Australia and have adapted to Australian culture exhibit risk behaviours common to native Australians. Therefore, elderly migrants are as much at risk of obesity, heart disease, cancer and diabetes^[16].

Physical functioning

One measure of health status is physical functioning. The incidence of core activity restriction increases significantly after the age of 65 years^[4]. For those aged 65+ who have a disability, 54% live alone of which 16% have a severe disability^[9]. The 1999 Older People's Health Survey^[13] covered several areas of physical functioning, including the SF-36 measure of physical functioning, questions on sight and hearing, experience of pain, ability to carry out Activities of Daily Living, and whether any changes had been made to the home to make it easier to live in. Although the SF-36 measures eight different aspects of health, using different scales, only the physical functioning scale was used in the Older People's Health Survey. The scale comprises questions concerning a person's ability to do various moderate and vigorous activities. Physical functioning, as measured by the SF-36, was better among males than females of all ages. 55% of elderly respondents were able to carry out all ADL independently. Two-thirds of Australians 75+ years old reported having activity restriction in communication, mobility or self-care, and for 50% these people the core activity restriction was classed as severe or profound^[9]. Assistance has been documented as being required with at least one ADL for 77% of people 75+^[4]. A significant proportion (40%) of people aged 75+ have reported their health as fair or poor due to conditions that affected their lifestyle, independence and health status, such as arthritis (for about 50% of the older population), deteriorating eyesight and hearing loss (36%), hypertension (40%), and 18% heart disease^[9].

Chronic illness

Physical activity is difficult for elderly with chronic diseases. Evidence from the National Health and Nutrition Examination Survey and other population studies conducted in the USA suggests that the prevalence of inactivity is considerable among adults, increasing substantially among those aged 65+^[17]. For individuals with chronic health conditions such as arthritis, other forms of ADL such as performing household duties may promote wellbeing more effectively than physical activity. Arthritis is the nation's leading cause of disability, limiting activity and resulting in hospitalisation and outpatient visits^[12].

Chronic disease and getting old often lead to disabilities and becoming increasingly limited in being able to walk, climb stairs, and stoop. As such, chronic diseases without doubt lead to limitations in ADL, forcing people to rely on home care and/or rehabilitation care, and, in many cases, to be institutionalised in assisted living facilities or nursing homes^[18]. Thus as the elderly with chronic diseases and disabilities become even older, they usually require long-term care^[7].

According to^[1] responses to the need for "required assistance in everyday activities" indicated that those 55+, born overseas and having a lower command of English were more likely to need assistance than their Australian-born counterparts^[6].

A random sample health care study in Australia showed that among those aged 75+, of which 6.4% were from a non-English speaking background, chronic conditions were the most frequent reason for using health care services. These chronic conditions included psychological problems (dementia and Alzheimer's disease), circulatory problems (stroke, heart failure and arterial fibrillation) and osteoarthritis, while hypertension was the second most common reason^[15].

Further understanding of the relationships between physical health, and utilization of health and aged care services may inform the design of effective intervention programs for older immigrants.

METHODS

Participants and Procedure

Census data estimates that 1,209 Iranian-born immigrants aged 65+ live in the Sydney Metropolitan area^[3]; 302 elderly who had lived in this area for at least six months participated. This sample size (with power approaching 0.5) was considered adequate for the purpose of the study. Questions used in the study were drawn from the NSW Older People's Health Survey 1999, a state-wide telephone survey with questions designed and validated for telephone data collection^[13]. That state-wide survey included a variety of demographic measures in addition to closed-ended and multiple-choice questions about mental and physical health and the use of health and aged care services. The questions selected for use in this study were translated into Farsi (the native language of most Iranians) in line with guidelines for cross-cultural adaptation of self-report measures^[5].

Two people, fluent in Farsi and English, independently translated the questionnaire from English to Farsi. The two versions were compared at a consensus meeting during which differences were discussed and a consensus version was developed.

Data for the present study were collected through a variety of methods: telephone interviews, face-to-face interviews, and a written survey instrument returned by mail. The research project was publicized in weekly Iranian newspapers and on radio stations that broadcast in Farsi. In an attempt to reach as many elderly Iranian immigrants as possible, surveys were distributed at places and events that were likely to be frequented by the target population.

Measures
The questionnaire used in the present study asked about demographic variables (age, gender, education, marital status, living arrangements, number of children living in Australia, financial status, government benefits, home ownership) and acculturation (language spoken at home, self-assessed English proficiency, and duration of residence in Australia). The survey also included questions to identify participants' physical functioning, ability to perform ADL, utilizationh of health services, and use of aged care services.

Physical functioning was measured using 10 items from the SF-36 (short form 36) Health Survey^[19]. Participants were asked the extent to which their health limited them in their ability to engage in various activities (e.g., climbing one flight of stairs) on a 3-point scale (a lot, a little, not at all). Scores were summed for each participant and classified as: no limitations (24 to 30), some limitations (17 to 23), or limited physical function (10 to 16).
Participants' ability to perform ADL was assessed with five "yes" or "no" questions^[10].

Three questions asked whether respondents could perform various activities on their own (e.g., household duties) and two asked whether respondents needed help or supervision to perform personal care activities (e.g., bathing). Scores were summed for each participant, yielding an ADL score. ADL scores were classified as high (4 or 5), moderate (2 or 3), or low (0 or 1).

Participants were asked if they had received any of three basic aged care services (assistance with household duties, personal care, and meal preparation or delivery) in the last week and any of five supportive aged care services (e.g. transportation for errands or medical appointments) in the past four weeks. A total score for basic and supportive aged care services was derived by summing across the three and five items respectively.

Participants were also asked to respond "yes" or "no" to six questions about their use of health services during the preceding 12 months (e.g. seen by a GP or local doctor, spent at least one night in hospital) and a total score for health service use was derived by adding the scores for those six services.

Data Analysis
The data were analysed using SPSS V15.0 for windows. T tests and one-way ANOVAs were used to identify significant variables.

RESULTS

A total of 302 participants completed the survey. Nearly equal numbers of men (49%) and women (51%) participated. The largest age category comprised participants aged 65 to 69 (46%); 21% were 70-74; 16% were 75-79; and 17% were 80 or older. Most (65%) were married; 24% were widowed; and 10% were separated or divorced. Many (45%) lived with a spouse or partner; 28% lived in the home of one of their children; 7% lived with other family or friends; and 21% lived alone.

The majority of participants (74%) had difficulty communicating in English: 28% could not communicate at all in English, and 46% could not communicate well in English.

Length of stay in Australia more than 10 years was 71.5% and recent migration to Australia less than 10 years, was 28.5%. Among those who had reached the retirement age, only 7% respondents were employed. With respect to financial situation, 17% of the Iranian elderly respondents reported they were living comfortably. A similar proportion (16%) claimed financial difficulty and the majority (67%) stated that they were able to manage. A great majority (78.5%) rely on Medicare and/or health concession card while less than a quarter (21.5%) of elderly who participated in this survey had private health insurance.

The greater part of the Iranian elderly respondents (71%) suffered from one or more chronic disorders/diseases. The most common problems were arthritis (21.9%), incontinence (17.9%), and high blood pressure (11.9%).

Physical functioning distribution in Iranian elderly reveals that the majority of respondents (84.4%) had a health limitation in doing vigorous activities (such as running, lifting heavy objects or participating in strenuous sport); many (69.9%) had moderate limitations in doing activities such as moving a table, pushing a vacuum cleaner, playing lawn bowls or golf or bushwalking; 68.5% respondents had a health limit in lifting or carrying groceries; and about three quarters (73.2%) of elderly respondents had a health limit in climbing several flights of stairs. 69.2% respondents had physical functioning limitation in walking more than one kilometre or about half a mile, followed by a limitation in bending, kneeling or stooping (68.5%). However, only a fifth (20.9%) of respondents had physical functioning limitation in bathing or clothing independently.

Not quite half of respondents were rated no limitation in their physical functioning (40.7%). About the same (41.1%) experienced moderate limit in their physical functioning conditions to do moderate and vigorous activities and only one fifth of respondents (18.2%) claimed to suffer from a high level of limitation in their physical functioning.

Distribution of ADL confirms that 64.2% of elderly respondents were capable of doing their household duties like laundry, vacuuming or dusting by themselves; also 76.5% said that they could prepare their meals, and 43.7% of respondents could do their home maintenance or gardening. However, 16.9% of them claimed to need help or supervision with personal care such as showering or bathing, clothing or getting to the toilet. In the meantime, 25.5% reported the need for help with cutting their toenails.
Rating outcomes of ADL demonstrate that 56.0% of respondents were rated as in the less need for supervision level in their ADL. About 29.8% rated in the moderate need supervision level, followed by 14.2% who had high need of supervision.

Table 1 provides an association between categorical community aged care services data and physical functioning limitation in the Iranian elderly respondents. For respondents who cannot do their household duties, home maintenance or personal care on their own, the result shows that there are significant differences between the three types of tasks for which respondents need help (F = 23.64, P = .000). This shows that respondents who need help for community basic maintenance services were more likely to have a high limitation in their physical functioning (M = 19.20), followed by elderly who need help for community supportive services (M = 22.00). Additionally, there were significant differences between utilisation of interpreter services and organised community aged care services, (F = 9.66, P = .003). This shows that individuals who continually used any kind of aged care services or an organised community aged care services (such as community nursing, home care, respite care, day care services, meals on wheels, home visiting, home maintenance and transportation), were more likely to have a more limited physical functioning (M = 16.63) in comparison to elderly who used only interpreter services (M = 19.95).

Table 1 ANOVA for comparing use of community aged care services with physical functioning in the Iranian elderly respondents

1) Basic maintenance services included: household duties, personal care, meals at home.
2) Supportive services included: home maintenance, day care service, respite services, special transport.

Findings also show that Iranian elderly who need help from community basic maintenance aged care services were more likely to need high supervision in their ADL (F = 33.31, P = .000). Furthermore there were significant differences between utilisation of interpreter services and organised community aged care services, (F = 9.63, P = .003). This shows that individuals who continually use any kind of aged care services or an organised community aged care service, were more likely to need a higher level of supervision in their ADL (M =1.76) in comparison to elderly who used only interpreter services (M = 2.77)
A series of univariate analyses was carried out, followed by linear and multiple regression analyses. Table 2 shows that use of health services was predicted by four health variables: psychological distress/ K6 (ß = -.293); wellbeing (ß = -.289); physical function/SF-36 (ß= -.546); ADL (ß = -.482). This shows that elderly, who had a lower level of physical functioning and a lower level of ADL, were less likely to use health services.

Table 2 multiple regression analysis of health services utilised and health predictors' variables

DISCUSSION

These results show that most participants suffered from at least one chronic medical condition. These findings support those^[16] on the general Australian population who suggests that elderly migrants are at risk of heart disease and diabetes - conditions associated with high blood pressure.

Participants with chronic medical problems are more likely to utilise health services. This finding is supported by^[15] study that among migrant people aged 75+, chronic conditions like hypertension and osteoarthritis were the most frequent reason for using health care services.

The results suggest that elderly with more limited physical function, and unable to perform ADL, were more likely to use health services. This finding is supported by studies conducted in other immigrant communities, for example, in the USA where older Mexican immigrants are more likely to present to an emergency room than use mental clinic services^[8].

Utilisation of aged care services too is predicted by mental and physical health status. The results suggest that Iranian elderly, who were more limited in physical function, and in greater need of help or assistance with ADL, were less likely to use aged care services. This finding is confirmed by the report of^[2] stating that elderly migrants with physical problems or other disabilities were under-utilising a range of community services such as nursing homes or hostels.

CONCLUSION

Generally, elderly respondents with chronic medical problems were more likely to use different types of health services than those with acute medical problems.

Findings show that those who had a lower level of physical functioning and ADL were more likely to use health services. Elderly unable to do household duties/home maintenance on their own or who needed help with personal care were more likely to suffer from greater limitations to their physical functioning (were more likely to need higher supervision in their ADL).

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