HEALTH CARE NEEDS FOR OLDER ADULTS.

• Author: Flett, Ross A.

INTRODUCTION

The increasing longevity of people in the industrialised world has generated a substantial body of new theoretical, policy-oriented and research writing, and there may well be a policy revolution required to deal with consequent societal changes (Markwick 1995, Banks and Fossel 1997, Wetle 1997). There is a call for a renewed vision of the roles and functions of people in what is referred to now as the "Third Age", a time in the life course when the basic work of parenting is done, when individuals leave paid, full-time employment, and when few positive roles are recognised (Cornman 1997). Certainly in the field of health the demands of this growing group are having a powerful impact on health professionals, "changing the mix of patients, conditions treated, and what the profession and society consider acceptable outcomes" (ibid: 856).

The research reported herein is a first step in the process of documenting the physical health, patterns of health service use, and related social policy implications in a population of New Zealand older adults. Issues of health care for older adults are an important research focus and health care providers need to be well informed about responses of this group to both general and specific health problems (Flett et al. 1994).

In reporting this data, we were conscious of the importance of avoiding the implicit view of older adults as a homogeneous group. Mizner and Strauss (1981: 462) point out a number of significant myths associated with older adults: the myth of ageing as a pathological process; the myth of progressive mental deterioration; the myth of inevitable physical deterioration; the myth of loss of sexuality and; the myth of social withdrawal and disengagement. They emphasise that "The aged [sic] are our future selves. If we continue to have discriminatory attitudes towards the aged, we ourselves are likely to become the victims of those prejudices."

BACKGROUND

The population of New Zealanders aged 65 and older has increased rapidly this century, with the number of older adults more than doubling between 1951 and 1996 (Statistics New Zealand 1998). The latest population projections (1996 base) indicate that the number of older adults is expected to grow by 150 per cent, from 422,667 in 1996 to 1.145 million in 2051. There is a great deal of debate about what such trends might mean for social policy makers and those involved in health service provision and planning.

Gordon and Singer (1995) note that most countries are looking at ways to reduce health care costs and the older adult population often becomes the focus or the target of such efforts at cost control. However, there are counter-arguments that question the inevitability of spending on health care for older people becoming an unsustainable economic burden.

Gordon and Singer (1995) review some data on health care spending as a percentage of GDP and its association with population ageing. The United States spends 14% of GDP on health care, but is among the lowest of 12 industrialised nations in its percentage of older adults. In contrast, 17.8% of the Swedish population is over 65 years old and that country spends 7.5% of GDP on health care (one third less than the United States). In Japan, the older adults population increased by 30% from 1980 to 1990 while there was only a 1.6% increase in the proportion of its GDP that went to general health care during that period. In the United States, the increase in the percentage of those aged 65 and over in the same period was about 10% (around one third that of Japan) and health care spending went up by 31.5%.

Most of the spending data reviewed above refers to the costs associated with acute care, and the issue is potentially very different in regard to the costs of long-term care. In order to place this economic data in perspective, we should emphasise that most older adults are relatively successful at remaining functional in the community. The majority report themselves to be in relatively good health despite frequently reporting the presence of chronic conditions and physical symptoms (Laird and Chamberlain 1990, Neville and Alpass 1999).

The Ministry of Health notes that less than one in 12 of the older disabled population are cared for in institutions and aged care facilities. The importance of appropriate and well-timed health service access cannot be underestimated in this context. In fact, Ministry of Health proposes that:

Timely access to health services is important in influencing the health of older people ... Early recognition and prompt assessment/referral and treatment is essential in promoting the health, independence and mobility of all older people. (1997: 28) HEALTH SERVICE UTILISATION

As Adler and Milstein (1979) note, health service planners' views of what people need are often not based on empirical data and there may be an inherent conflict between the planners "I know what you need" and the consumers "I know what I want" views of reality. Thus satisfaction with health service use is a variable that is important to understanding the overall health experience among older adults. Satisfaction is one element among many to be folded into the development of enlightened health care policy. In fact, Campbell et al. (1976: 503) argue that satisfaction must enter into public policy debate, a process that is best accomplished through the generation of empirical data.

While the research area of satisfaction with health care is an extensive one (Smith 1998), there is relatively limited New Zealand data available. Gribben (1992) reports some New Zealand data looking at satisfaction with general practitioner services in South Auckland and found that younger respondents (in the 18-29 age group) were most dissatisfied with these services.

The Ministry of Health identifies knowledge about the extent and nature of health experiences and health service use as an important research issue:

... research projects could better inform health service planning and purchase for older people ... we have little information about the health service needs of older [adults] ... or current levels and trends in disability among older people and kaumatua. (1997: 65) For example, the process of policy analysis, programme development and realistic health outcome target setting for older adults can be enhanced by additional knowledge about the types of health problems and ongoing levels of activity and disability with which older adults present when visiting their family physician.

Likewise, in terms of developing national policies that might underpin planning and purchase decisions in the area of mental health, there is clearly a need for additional information about the extent and nature of this type of health service use among older adults. While the need for mental health services for older adults and the efficacy of appropriate interventions have been well established in the literature, policies affecting access to services, service system coordination, financing of care, and the training of the professional health service professional have lagged behind need. As a consequence, a substantial proportion of older people whose mental and emotional problems are serious enough to warrant professional care do not receive services.

With the need for utilisation and satisfaction data in mind, and following on from previous research (Millar 1996, Millar et al. 1999), the present study sought to describe in a sample of New Zealand older adults:

1. the experience of health (conceptualised and measured in a variety of ways), and reported satisfaction with general practitioner health service provision;

2. problems in activities of daily living;

3. difficulties with upper and lower body functioning; and

4. the use of primary and secondary health care services (general practitioner visits, accident and emergency use, hospital admissions, outpatient service use), as well as other types of health services.

   METHOD

   Two hundred and fifty-two New Zealand older adult volunteers completed a structured one-hour interview administered by trained interviewers on behalf of the Massey University research team.(2) A cross-sectional survey was carried out, using a three-stage cluster design used for a survey of physical and mental health among community-dwelling New Zealanders in 1995 by the School of Psychology, Massey University. The first stage involved the random selection of 150 census enumeration districts (meshblocks) nation-wide,(3) the second involved a random selection of households, and the third involved sampling an eligible participant from each household. Of the 3,562 attempted contacts, 972 were not eligible, did not reply, or were otherwise unavailable for an interview. Of the remaining 2,590 contacts, 1,090 refused to be interviewed, giving a valid response rate of 58%. The overall response rate including those who were ineligible or unavailable was 42%. The sub-sample of 252 people examined in the present study represents those respondents who were aged 65 years or more at time of interview.

   In order to investigate reliably the experience of health and health service utilisation in particular subgroups of the population, such as Maori and rural respondents, it was necessary to ensure that the final sample included an adequate proportion of these groups. The sample design allowed for the deliberate oversampling of Maori and rural residents to ensure that the experiences of these groups could be documented with a greater degree of statistical reliability than would otherwise be the case had their proportions in the study sample reflected their proportions in the population of New Zealand as a whole. Readers interested in the differences between ethnic subgroups in this sample are strongly advised to read the report by Hirini et al. (1999), which includes a detailed analysis of ethnicity and the specific health issues for Maori elders. The Hirini et al. (1999) paper is...