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| Journal of the New Zealand Medical Association,
15-July-2005, Vol 118 No 1218
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Teenage use of GP care for moderate to severe asthma in
Auckland, New Zealand
Stephen Buetow, Deborah Richards, Ed Mitchell, Barry
Gribben, Vivienne Adair, Gregor Coster, Makere Hight
As children move into their early and middle teenage years,
they begin to acquire the ability and permission to help make medical
care-seeking decisions. Enhancing the ability of adults to support teenagers is
the capacity and willingness of the teenager to recognise a particular health
problem or need, and disclose it to an adult.
Problem non-recognition by teenagers may reflect a lack of
both functional limitation and sensed danger.1
Non-disclosure, when there is recognition of health need, may result from
believing that continuing functional limitation is
inevitable2 or an expectation that the problem
will not be managed as the teenager wants. Negative teenager perceptions of the
organisation and delivery of general practitioner (GP)
services3–6 may help to account, in turn,
for teenagers’ under-use of these
services.7
Asthma is a common condition of rising
prevalence,8 which affects teenagers’
health status9 and can impair development into
independent, functional adulthood.10 In New
Zealand (NZ), GPs are responsible for the diagnosis and clinical management of
most asthma. Attendance patterns for GP asthma care vary widely in
NZ11 but are poorly understood for teenagers.
This paper focuses on 13–14 year olds with moderate to
severe asthma in the Auckland region. It aims to describe and understand from
their perspective the frequency with which they access GP asthma care. Reference
is made to teenagers’ perspectives on their need for this care; their
communication with parents and other guardians; and GP care.
MethodsStage 1 involved the random selection (in mid-2002) of
State secondary schools in Auckland City and Manukau City (south of Auckland
City). Schools were ineligible for selection if they had been invited to
participate in the concurrent, third phase of the International Study for Asthma
and Allergies in Childhood (ISAAC).12
Participation in our research was sought from 15 schools, first in writing to
the school principal and school nurse, and then through a follow-up phone call
to both. Site visits to interested schools established a working relationship as
well as the roles and responsibilities of each party.
In Stage 2, each participating school used its records
to identify all known 13–14 year-olds with breathing problems, and allowed
us to speak with this group about breathing, asthma, and our research. The
teenagers were invited to obtain from an adult guardian written informed consent
to self-complete a short questionnaire at a return visit. They were given a
supporting letter from the school principal; a coloured flyer about the project;
an information sheet; and a consent form. Our materials were available in
English, Maori, Mandarin, Samoan, and Tongan. The teenagers were told that all
participants would enter a draw for petrol vouchers. After approximately 2
weeks, a follow-up phone call was made to guardians of the teenagers who had not
returned consent forms. In late 2002, we administered the self-complete
questionnaire to the teenagers for whom written consent had been received.
Stage 3 identified the teenagers with moderate to
severe asthma from responses to the questionnaire (see below).
Sample
size—Power calculations had been performed for different sample
sizes. Without clustering by school, a sample of 107 students with moderate to
severe asthma was sufficient to estimate with 95% confidence any item response
reported with a prevalence of 75%±8%. For a regression model estimated by
maximum likelihood, we planned to allow approximately one parameter for each 10
observations.
Data
collection—The questionnaire had two parts. Part A focused on the
presence and severity of breathing problems during the previous 12 months. For
the teenagers reporting ‘wheezing or whistling in the chest’,
moderate to severe asthma was defined
by reports of at least one of the following: ≥4 wheezing attacks,
asthma-associated sleep disturbance on ≥1 night per week, and wheezing
severe enough to limit speech to one or two words at a time between breaths.
These definitions of asthma and severity of asthma were used by
ISAAC.12
Among other questions was one asking how many GP visits
the teenagers had made for their wheezing in the past
year. Part B covered issues not
discussed at our oral presentation and was required only if the asthma was
moderate to severe. The questions covered potential influences on the use of GP
care for wheezing. They were developed from published literature and our prior
qualitative interviews with families, including some teenagers, on child access
to GP care for moderate to severe
asthma.13–15 The questions were reduced
to six variables through additive scales. Two of the variables describe
perceived need. Three describe teenager communication and one describes beliefs
about GP care. Teenagers were assigned to each of the one or more ethnic groups
they specified.16
Data
analysis—Simple descriptive and inferential statistics were
produced to explore the dataset for teenagers with moderate to severe asthma.
The outcome of primary interest was a count of GP visits for asthma in the year
before completion of the questionnaire. A negative binomial regression model
(NBRM) was fitted using the software package,
Stata17 to account for this outcome. An
intraclass correlation of 0.000 suggested that no variation in GP attendance was
attributable to the clustering of students within the same schools.
Ethical approval for the study was obtained from the
Auckland Ethics Committee.
ResultsTen of the 15 invited schools took
part. Their mean decile was 5.1 (s=3.1). Their mean total roll was 1386 students
(s=935) with, on average, 12.9% Maori and 22.3% Pacific Islanders. Of the five
other schools, all cited workload as their reason for not participating. Their
mean decile was 3.8 (s=3.8) and they averaged 1312 students (s=654) of whom
15.1% and 42.5% (on average) were Maori and Pacific Island students
respectively.
Participant schools identified 510 13–14 year-olds as
having breathing problems or asthma, of whom 271 (53.1%) returned written
consent from a guardian to complete our questionnaire. Of the 85.2% (231/271)
students reporting ‘wheezing or whistling in the chest in the last 12
months,’ almost half (114/231) fulfilled the criteria for moderate to
severe asthma.
The students’ mean age was 13.5 (s=0.5) with a sex
ratio of 40.7 (33 boys and 81 girls). Almost three-quarters (84/114) identified
as NZ European. Maori and Pacific teenagers numbered 15.8% (18/114) and 13.6%
(15/114) respectively; 22.8% (26/114) identified as Maori and/or Pacific
Islander. Fourteen teenagers (12.3%) identified as Asian.
Approximately four in every ten (39/100) of the teenagers
had made 0 or 1 visit to a GP for asthma in the year before completing the
questionnaire; 17% (17/100) had made ≥5 visits. Low attendees (0 or 1
visit) were disproportionately NZ European, and high attendees (≥5 visits)
tended to be Maori and/or Pacific Islanders.
However, no statistically significant differences were
detected between the mean numbers of visits reported by Maori and Pacific
teenagers (4.5 visits) compared with other teenagers (2.5 visits) (t = -1.673, p
> | t | = 0.108), or by the boys (3.9 visits) and girls (2.5 visits)
respectively (t = 1.4, p > | t | = 0.189). A statistically significant
relationship was found between the number of GP visits for asthma and the
severity of moderate to severe asthma (F = 19.6, p > F = 0.000).
Table 1 reports the distribution of responses to statements
about need, communication, and GP care. Among key findings was that only half of
the teenagers received GP care as often as these teenagers wished. Almost
one-third reported having to pay for their GP care. Table 2 summarises findings
from the NBRM. Expected attendance was increased for Maori and Pacific students
compared with other students, and by asthma of increased severity. No
interactions were detected.
Table 2. General Practitioner (GP) visits by
13–14 year olds with moderate to severe asthma: negative binomial
regression model (N=92)
DiscussionAuckland 13–14 year-old
students with moderate to severe asthma described a variable frequency for
accessing GP asthma care. Low attendees were disproportionately NZ European.
High attendees tended to be Maori and/or Pacific Islanders (groups that have
traditionally experienced barriers to accessing GP
care12,18–20). Our survey of the parents
of 6–9 year olds with moderate to severe asthma replicated this
finding.21
Teenage beliefs influencing this utilisation pattern were
identified. About half the sample reported ‘needing’ GP asthma care.
A similar proportion receives such care as often as it wants, independently of
ethnicity. With only 36% agreeing that this care is ‘important,’
these results indicate an unmet desire for GP asthma care that teenagers
consider appropriate rather than necessary.
Most teenagers reported telling their parents when they
wheeze (or much less frequently, school staff) and when their inhaler runs out.
Only three in every five said they tell their parents when they cannot manage
their wheeze themselves, and only half ask to see a GP about their wheeze. This
highlights a need to explain to teenagers the circumstances under which growing
autonomy does not preclude asking for help.
Almost one in every four teenagers indicated sometimes
resisting GP attendance for asthma care. That 29% reported having to pay for
their GP care indicates that GP use has frequently depended on the financial
resources of teenagers, which presumably are low, and not merely the motivation
to attend, which our results suggest is generally also not high.
The NBRM estimated that perceived need for GP asthma care
increases the expected number of visits for asthma by 25%. Teenagers’
resistance to this care reduces the expected number of visits by a similar
proportion. So too, to a lesser extent, does teenagers telling a guardian about
their asthma and its management. However, low attendance could promote
information giving-rather than vice versa,
and attendance could be reduced less by information-giving
per se than unwillingness by teenagers
to advocate for attendance requiring dependence on parents. Also, GP care is
frequently considered unimportant by teenagers, who may see it to interfere with
their ability to minimise differences from peers.
Expected attendance was increased for the Maori and/or
Pacific teenagers by 77% and by asthma of increased severity by 26%, given all
the values in the model. This challenges the persistence of barriers to Maori
and Pacific peoples accessing GP services, at least for acute
asthma.12,18–20 None of the six
predictors relating to need, communication, and GP care characterised
disproportionately the Maori and Pacific teenagers. However, although we asked
solely about total visits, our findings could be explained by barriers to these
teenagers accessing only routine preventative care. Asthma exacerbations could
then have prompted GP visits for acute care, explaining the higher total number
of Maori and Pacific visits for asthma.
Other reasons are needed for why almost 40% of the
teenagers, who were mainly NZ European, under-used GP care for their moderate to
severe asthma. Compared with Maori and Pacific teenagers, they were perhaps more
likely to have previously received and redeemed repeat prescriptions for asthma,
and to receive acute care out-of-hours from relatively high-cost,
community-based Accident and Medical Services.
It is also unclear why boys were more likely than girls to
report obtaining GP asthma care. The finding is not due to differences in asthma
severity.
Strengths and
limitations—Complementing our other
quantitative21 and qualitative
research13–15,22 on factors influencing
child access to GP care for moderate to severe asthma, this study responds to
lack of knowledge regarding how frequently 13–14 year olds attend for GP
care of moderate to severe asthma, and why. The high attendance by Maori and
Pacific teenagers highlights a need to question whether barriers to GP
attendance persist for this group (at least for acute asthma), compared with NZ
Europeans. The study raises the possibility that barriers to accessing
preventative care can account for increased total numbers of visits among Maori
and Pacific teenagers.
Nevertheless, the findings have limitations. One-third of
the schools did not participate, but characteristics of these schools did not
differ from those that did. A more major limitation is that the response rate by
guardians of children with breathing problems was only 53%, which may limit the
generalisability of the findings to all asthmatic teenagers. We do not know how
non-participating teenagers differed from the teenage participants. A further
limitation is that the final sample size for the teenagers was also small,
reflecting difficulty in accessing this group.
Use of a school-wide screening questionnaire was
unacceptable to the schools, thus requiring school nurse records to identify
asthmatic teenagers. This is unlikely to have produced a large selection bias
because nurses were most likely to know the teenagers with moderate to severe
asthma. In our companion study,21 prevalences
of moderate to severe asthma among 6–9 year-olds (based on parents’
questionnaire responses) were independent of how schools identified children
with breathing problems.
Over-representation of girls in the study most likely
reflects our sample, which included two girls-only schools but no boys-only
schools. Self-enumeration of GP visits for asthma in the previous year was
subject to misclassification. It was not validated against GP claims for patient
subsidies because this would have breached participants’ anonymity. GP
records of visits could not be checked because of the large number of GPs and
the potential for each patient to attend more than one practice. However,
self-reports have been shown not to impact systematically on estimates of ethnic
differences in health care use,23 and these
differences show the same pattern as reported by the parents of similar
6–9 year-olds.21 Furthermore,
non-systematic misclassification would tend to reduce our ability to find
significant associations.
No distinction was made between routine visits and visits
for acute care. Exposure time was not measured at the interval level, and use of
school records might not have identified some eligible students. Reports of
wheezing were not validated against a diagnosis from a doctor, although our
focus on moderate to severe asthma most likely minimised this problem. The
questions defining moderate to severe asthma came from
ISAAC,12 but we developed our own questions on
factors influencing access to GP care in the absence of any standardised and
validated tool. Qualitative interviews with teenagers might have yielded
different insights and concerns.
Implications—There
is a need to respond to an unmet preference by teenagers for improved access to
GP care of moderate to severe asthma—despite a high level of self-reported
attendance for GP asthma care by Maori and Pacific teenagers. Research is needed
to test whether or not this utilisation pattern is specifically for acute care
of poorly controlled asthma in the face of barriers to accessing routine,
preventative care.
If barriers to accessing preventative care persist and
increase both acute visits and hence total visits among Maori and Pacific
teenagers, this challenges the assumption that access can be defined simply in
terms of barriers that must be overcome to obtain healthcare.
A concurrent need exists to understand the widespread
under-use of GP care for moderate to severe asthma, especially among NZ European
teenagers. In the meantime, health policy should educate teenagers with moderate
to severe asthma, and their guardians, on the importance of preventative care
for asthma (as part of integrated strategies for addressing known barriers to
teenage use of GP services). This would complement previous research
highlighting a need to improve knowledge about asthma and its management among
parents, teachers and teenagers.12,18–20
Health policy must also respond to concerns that teenagers
and guardians express about the acceptability of GP services, while promoting
teenage-guardian communication about health issues associated with teenage
asthma. An indicator of success will be whether teenagers are taken to a doctor
when requested.
Author information:
Stephen Buetow, Senior Research Fellow; Deborah Richards, Research Nurse; Ed A
Mitchell, Professor; Barry Gribben, Honorary Senior Research Fellow; Vivienne
Adair, Honorary Senior Lecturer; Gregor Coster, Dean of Graduate Studies; Makere
Hight, Maori consultant; Department of General Practice and Primary Health Care,
University of Auckland, Auckland
Acknowledgements:
This research was made possible by a project grant from the Health
Research Council of New Zealand, and more recently by salary support from
ProCare Health Ltd. Professor Ed A Mitchell is supported by the Child Health
Research Foundation.
Correspondence: Dr
Stephen Buetow, Senior Research Fellow, Department of General Practice and
Primary Health Care, University of Auckland, Private Bag 92019, Auckland. Fax:
(09) 373 7006; email: s.buetow@auckland.ac.nz
References:
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