Journal of Gerontological Nursing

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Healthy People 2010 

Determinants of Preventive Services Utilization in Rural Older Women

Carol Pullen, EdD, RN; Kathryn Fiandt, DNS, ARNP; Susan Noble Walker, EdD, RN, FAAN

Abstract

A telephone questionnaire was administered to older women to assess what personal and contextual influences determined use of preventive services.

Abstract

A telephone questionnaire was administered to older women to assess what personal and contextual influences determined use of preventive services.

An emphasis on preventive health care has emerged as an essential strategy for containing health care costs, improving the quality of life, and decreasing the incidence of disability from chronic diseases among elderly individuals (Berg & Cassells, 1990; USDHHS, 1991). Preventive health care is especially important for people older than age 65, who currently account for one third of the nation's total personal health care expenditures (Melillo, 1996). For older women, the ability to maintain health and functional status is of critical concern because they have higher rates of morbidity and disability than men (Leveille, LaCroix, Hecht, Grothaus, & Wagner, 1992) and a life expectancy that exceeds that of men by more than 7 years (Friedan, 1993).

Rural older women are particularly vulnerable to disability associated with chronic illness as compared with their urban counterparts. Rural elderly individuals are in poorer health, have a greater incidence of chronic disease, and suffer more limitations in daily activities than urban older adults (Beck, Dijon, & Edwards, 1996; Dwyer, Lee & Coward, 1990). Most rural communities have a high proportion of elderly women (Bushy, 1993) and few formal health care services available (Dwyer, Lee, & Coward, 1990; Hassinger, Hicks, & Codino, 1993). Moreover, rural elderly individuals are less likely than urban to use health care services in general (Hiñes & Rutrough, 1994; Taylor, Puskin, Cooley & Braden, 1993) and preventive services in particular (Gluck, Wagner & Duffy, 1989; Lubben, Weiler, Chi & Dejong,1988; Van Nostrand, Fumer, Brunelle & Cohen, 1993).

Better use of clinical preventive services has been recognized as essential for the attainment of the year 2000 National Health Promotion and Disease Prevention Objectives (USDHHS, 1991). In 1989, the U-S. Preventive Services Task Force (USPSTF) first published recommendations for a core set of clinical preventive services - screening for early detection of disease or risk factors, immunizations, and counseling about lifestyle modification - specific to age, gender, and risk status of individuals. These included a set of recommendations for women age 65 and older. At the same time, an expert panel of the Institute of Medicine reported that older adults receive fewer cancer screenings than younger adults and that many are never counseled to modify lifestyle behaviors to improve their health, despite evidence that such measures would be beneficial (Berg & Cassels, 1990).

The purpose of this study was to: (a) describe the prevalence of preventive services utilization in compliance with the USPSTF recommendations for screening, counseling, and immunizations among rural older women in four Nebraska counties and (b) determine the extent to which personal influences (e.g., demographics, definition of health, and perceived health status) and contextual influences (e.g., access to care, sources of health information and provider recommendations) explain preventive services utilization among those women.

FRAMEWORK FOR DETERMINANTS OF PREVENTIVE SERVICES UTILIZATION

Utilization of most clinical preventive services requires interaction with the health care system. The two approaches used in the study of factors associated with elderly individuals* use of preventive services are emphasis on consumer behavior and emphasis on provider behavior (Gluck, Wagner & Duffy, 1989). Underlying the consumer behavior approach is the assumption that the decision to use a preventive health service is made by the individual. Likewise, the decision to follow a provider's advice about preventive health services is made by the individual. Therefore, the consumer behavior perspective was selected for this study of clinical preventive services utilization among rural older women.

The Figure depicts the framework of determinants of preventive services utilization used in this study. The determinants can be categorized broadly as personal, those specific to the individual, and contextual, those in the individual's environment. Effective strategies to increase use of preventive services with older women will require knowledge of both personal and contextual factors that influence behavior. With the exception of demographics, personal and contextual influences included in the framework are considered modifiable, an essential characteristic of variables to be targeted when structuring interventions to promote health behavior change.

LITERATURE REVIEW

Preventive Services Utilization

For women older than age 65, the USPSTF (1989) recommends an annual visit to their health care provider during which specific screening, counseling, and immunization services are provided. Healthy People 2000 (USDHHS, 1991) sets a less ambitious objective:

to increase to at least 40% the proportion of people who had received, as a minimum within the appropriate interval, all of the screening and immunization services and at least one of the counseling services appropriate for their age and gender as recommended by the U.S. Preventive Services Task Force (p. 534).

The Office of Technology Assessment (OTA) analyzed available data sources concerning both the use and the determinants of use of preventive services. They concluded that few studies of consumer behaviors examined preventive service use among elderly individuals (Gluck, Wagner K Duffy, 1989). The OTA's analysis of data from the 1982 National Health Interview Survey (NHIS) revealed that the use of five preventive services (i.e., glaucoma screening, eye examinations, blood pressure measurement, breast examinations and Pap smears) by adults older than age 65 was consistently related to male gender (for the three relevant services), younger age, higher education and income, health insurance coverage beyond Medicare, and living in a metropolitan area. The NHIS, designated as the main tracking mechanism for Healthy People 2000 Objective 21.2, does not include data concerning many of the clinical preventive services (especially counseling) recommended for older women.

An analysis of data from the 1991 Health Promotion and Disease Prevention Supplement to the NHIS found that fewer than 1% of women older than age 65 reported receiving all of the recommended screening and counseling services for which data were available, and that only 5.3% were current with all recommended immunizations. As age increased, the number of preventive services received tended to decrease in all categories except immunizations (Bergman-Evans & Walker, 1996).

Rural people have been reported to use formal health services sparingly (Long & Weinert, 1989). Johnson (1991) found that only 49% of rural elderly individuals reported having a yearly physical examination. Van Nostrand et al. (1993) found that a lower percentage of rural than urban elderly women had a clinical breast examination or a mammogram. In contrast, Lubben et al. (1988) found that rural clients were more likely than urban clients to have received screening, including laboratory testing. However, they were much less likely to have received immunizations and comprehensive health counseling in areas such as weight control and medications.

Personal Influences

Demographic characteristics. Two demographic characteristics, age and marital status, have been shown to be determinants of preventive service utilization. Older age and single status of urban women were predictive of low mammogram utilization (Fullerton, Silverstein, Sadler & Connor, 1996; Miller & Champion, 1996), and older age and single status of both urban and rural women were predictive of not having a clinical breast examination (Sherman, Abel & Tavakoli, 1996).

In a study of rural older women who were socioeconomically disadvantaged Medicare Part B beneficiaries, older age, and single status were predictive of not having mammograms or Pap smears (Ives, Lave, Traven, Schulz & Kuller, 1996). Unmarried older women may or may not live alone; it is possible that those who do may lack the support of significant others to obtain preventive care. Rural areas tend to have higher proportions of widowed elderly women living alone than urban areas (Bushy, 1993). No literattire was found reporting a relationship between living arrangement and preventive services utilization.

Definition of health. Definition of health is the meaning or conception of health to which an individual subscribes and can range from defining health as the absence of illness to defining health as high level weilness (Smith, 1983). There is evidence that an individual's definition of health, particularly a weilness definition, strongly influences health-promoting lifestyle behaviors (Pender, Walker, Frank-Stromborg & Sechrist, 1990); however, no studies were found that explored the individual's definition of health as a determinant of preventive services utilization.

Perceived health status. Perceived health status has been shown to play a role in the utilization of preventive services among urban older adults. Zabalegui (1994) found a significant relationship between a positive health perception and cancer screening activities (including the mammogram, Pap smear, fecal occult blood test, sigmoidoscopy) in urban elderly individuals. Urban women who received a mammogram annually were more likely to rate their health as excellent or good and less likely to rate their health as fair or poor than women who never obtained a mammogram (Fullerton et al., 1996). It is not known how health perception influences the receipt of preventive services among rural elderly individuals, who have been found to perceive their health as significantly poorer than do urban dwellers (Eggebeen & Lichter, 1993).

Contextual Influences

Access to health care. Access to health care may be affected by distance to a primary health care provider and by having basic and preventive health insurance coverage. Many rural areas are federally designated Medically Underserved Areas and Health Professional Shortage Areas and are quite disadvantaged with regard to the availability of services (Dwyer et al., 1990; Hassinger, et al., 1993; U.S. Congress, Office of Technology Assessment, 1990). Traveling long distances to a health care provider is often cited as a barrier to receiving health care services in rural areas, particularly in frontier counties with an insufficient population to adequately support local services (U.S. Congress, Office of Technology Assessment, 1990). Non-metropolitan elderly individuals are almost twice as likely as metropolitan older adults to travel more than 30 minutes to a health care provider (Taylor et al., 1993).

Inadequate health insurance coverage is another barrier that may limit access to preventive services. For people older than age 65, Medicare and Medicaid account for the major source of health care payments. Medicare Part B pays only for limited preventive services such as mammogram, Pap smear, and immunizations (Melillo, 1996). There is some indication that Medicare coverage is predictive of preventive services utilization. Miller and Champion (1996) found that, for urban women, Medicare coverage was significantly associated with one-time mammography usage.

Rural elderly individuals with Medicare coverage only or private insurance were more likely to visit a physician than those with Medicaid (Kassab, Luloff, Kelsey & Smith, 1 996). Rural elderly individuals have been reported to be less likely than urban elderly individuals to have Medicare and private insurance coverage (Braden Oc Cooley, 1993). McCulloch (1991) reponed that fewer than one in three rural older women were covered by private insurance and were likely to postpone or eliminate health care of a preventive nature, waiting until they developed conditions requiring immediate medical attention.

Sources of health information. Rural elderly women use a wide variety of sources of health information, including health professionals, friends and family, written materials (e.g., newspapers, magazines) and media sources such as television and radio (Crockett, Heller, Merkel & Peterson, 1990). Media coverage was reported as a motivator for urban women to obtain mammography (Fullerton et al., 1996). However, it is not known how sources of health information influence rural women to receive recommended preventive services.

Provider recommendations. Provider recommendations, including professional advice and instruction or reminders, have been reported to be important influences among older adults on a variety of preventive services utilization, including mammography use (Skinner, Strecher & Hospers, 1 994; Sparks, Ragheb, Given & Swanson, 1996; Taplin, Anderman, Grothaus, Curry & Montano, 1994), blood pressure checks (McDowell, Newell & Rosser, 1989), and obtaining influenza vaccinations (Brimberry, 1988). The Institute of Medicine strongly recommends that primary care providers encourage elderly populations to use preventive services (Berg & Cassells, 1990).

Table

TABLE 1PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

TABLE 1

PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

Table

TABLE 1PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

TABLE 1

PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

METHODS

A descriptive correlational design was used to study the prevalence of utilization of USPSTF-recommended preventive services for rural older women and the extent to which personal and contextual influences explained such utilization. Institutional Review Board approval was obtained for the study.

Sample

A convenience sample consisted of 102 community-dwelling women age 65 and older from four rural southwestern Nebraska counties. They were recruited primarily through voter registration lists, with a few subjects agreeing to participate after hearing about the study in the community. All were White non-Hispanic, consistent with the population demographics of the area. They ranged from age 65 to 90 (mean = 74,2, SD = 5.99). The majority (54.9%) were not currently married and 53.9% lived alone. Twenty-seven (26.4%) lived on farms, ranches, or in the country; 60.7% lived in towns of fewer than 2,500 residents; and the remaining 12.7% lived in towns with populations between 2,500 and 9,999 people.

All of the women reported having basic health insurance coverage which included Medicare, Medicaid, and Medigap or other private health insurance. Almost half of the sample, (48%), stated they had health insurance coverage for preventive services; however, nearly one fourth (23.5%) did not know if they had preventive coverage.

Educational level varied, with 9.8% less than high school, 46.1% high school graduates, 32.4% attending some college, and 10.7% holding baccalaureate or advanced degrees. Incomes reflected the poverty of many rural elderly individuals; 18.6% reported yearly family incomes of less than $10,000; 34.3% between $10,000 and $19,999; 29.4% between $20,000 and $39,999; and only 6.8% $40,000 or over, with 10.7% declining to provide that information.

Procedures

A computer-assisted interviewing system through the Bureau of Sociological Research at the University of Nebraska-Lincoln was used to conduct a telephone survey focused on various health behaviors. Trained interviewers called the subjects who had previously agreed to participate in the study and entered responses directly on the computer. The average length of the interview was 64 minutes, and only 1 1 women (10.8%) requested more than one session to complete it.

No problematic questions and no evidence of cognitive impairment among the subjects were identified by the interviewers. The interviewers evaluated the quality of the data obtained from each respondent. The experience of the Bureau has been that those who have cognitive impairment are unable to complete the interview. Informal feedback from the interviewers indicated that they and the subjects found the interview "interesting" and "enjoyable." Only the components of the survey concerned with preventive services utilization are reported in this article.

Measurement of Variables

Data were collected by the women's self-report, which was consistent with the consumer perspective of interest in this study.

Preventive services utiliation. Preventive services utilization was measured by three sections (i.e., screening, immunizations, counseling) of the Preventive Services Inventory (PSI) developed by the investigators to measure receipt of preventive services in the past year. Content validity was assured by the match of items within the screening, immunization, and counseling sections of the PSI with the age and gender-specific recommendations of the USPSTF (1989).

The screening section, which included history, physical examination, and laboratory/diagnostic tests information, contained 23 items such as "Have you had a mammogram in the past year?". The immunization section included 3 items such as "Have you received a flu shot in the past year?" , "Have you ever had the pneumovax?" and "Have you had the tetanus vaccine in the past ten years?" The counseling section, which focused on nutrition, physical activity, tobacco and alcohol use, injury prevention, dental health, mental health, cancer prevention, and hormone replacement, included 21 items such as "Has your primary care provider discussed reducing the cholesterol in your diet in the past year?". The items answered "yes" were counted and summed to yield a total score for each of the three sections.

Table

TABLE 2RANGES, MEANS, AND STANDARD DEVIATIONS FOR PREVENTIVE SERVICES UTILIZATION AND PERSONAL AND CONTEXTUAL VARIABLES (N = 99)

TABLE 2

RANGES, MEANS, AND STANDARD DEVIATIONS FOR PREVENTIVE SERVICES UTILIZATION AND PERSONAL AND CONTEXTUAL VARIABLES (N = 99)

Personal influences. Demographic characteristics were assessed by a Personal Data Form developed for use by the investigators. Definition of health was measured by the Laffrey Health Conception Scale (LHCS) (Laffrey, 1986). The LHCS is comprised of 28 Likert-response items with four scales of 7 items each to measure clinical, role performance, adaptive, and eudaimonistic dimensions of the definition of health. Walker (1990) recommended that the first three scales be combined to form a wellness definition scale. In the current study, the alphas for the wellness scale and the clinical scale were .930 and .843.

Perceived health status was measured by the general health perception scale from the Medical Outcomes Study Short-Form General Health Survey (MOS) (Stewart, Hays & Ware, 1988). Reliability and validity were established with a sample of 11,186 adults in the Medical Outcomes Study sponsored, in part, by the RAND Corporation, Santa Monica, California (Stewart et al., 1988). In the current study, the alpha was .884 for general health perception.

Contextual influences. Access to clinical preventive services was operationalized as distance to a health care provider and health insurance coverage for preventive health services, and measured by individual items. Sources of health information were operationalized as number of sources which included professional (e.g., family health care provider, office nurse) personal (e.g., friends, family) and media sources (e.g., newspapers, magazines, radio, television). Responses to the 8 items were counted and summed to provide a total score.

Provider recommendations were measured by items that asked the rural women to recall recommendations by their provider to obtain screening tests (8 items) and immunizations (3 items). An example of a question was "In the past year, has your provider recommended that you have a blood test for cholesterol?". Items answered "yes" were counted and summed to yield scores for each section.

RESULTS

There were 95 women (93.1%) who reported they had a primary care provider, of which 88 (92.6%) were physicians, 5 (5.3%) physician assistants, and 2 (2%) unspecified. None of these rural women reported having a nurse practitioner as their primary care provider. Ninetyfour of the women (92.2%) had seen a provider in the past year from 1 to 10 times (mean = 4.30, SD = 4.41). Only 14 (13.7%) of the women reported a serious illness in the past year. The women reported they used a variety of sources for their health information needs, including their health care provider (58%) office nurse (37%), family and friends (45%), and media sources. Media sources included magazines (94%), newspaper (87%), television (87%), and radio (42%).

Table

TABLE 3DETERMINANTS OF SCREENING SERVICES RECEIVED (N = 99)

TABLE 3

DETERMINANTS OF SCREENING SERVICES RECEIVED (N = 99)

Preventive Services Utilization

The prevalence of each of the USPSTF-recommended preventive services (e.g., screening, immunizations, counseling) are shown in Table 1.

Screening. Recommended screening services included history, physical examination, and laboratory /diagnostic procedures received in the past year. Weight and blood pressure were the physical examination components, and cholesterol was the laboratory test most frequently reported as received. Only 1% of these rural women recalled receiving all of the recommended screenings (excluding high risk screenings) for women older than age 65 in the past year.

Immunizations. Recommended immunizations included influenza, pneumonia, and tetanus. Only 17.6% of these rural women reported receiving all three of the immunizations within the recommended time frames.

The topical area in which the most women reported receiving counseling in the past year was cancer prevention; 55.3% recalled receiving some counseling in the last year. The fewest women reponed receiving counseling in the areas of alcohol use (2%), dental health (4.9%), tobacco use (6.9%), and injury prevention (10.8 %). Tobacco and alcohol counseling were rarely reponed, but few women in the sample reported that they currently smoked (2.9%) or drank any alcohol (17.6%). Overall, 65.6% of the women recalled receiving counseling in at least one recommended area during the past year.

Determinants of Preventive Services Utilization

Three hierarchical regression analyses were used to assess the relationship of the personal influences (e.g., demographics, definition of health, perceived health status) and contextual influences (e.g., access to care, sources of health information, provider recommendations) to preventive services utilization. Descriptive statistics for all criterion and predictor variables entered in regression analyses appear in Table 2 or in the sample description.

Table

TABLE 4DETERMINANTS OF IMMUNIZATION SERVICES RECEIVED (N = 99)

TABLE 4

DETERMINANTS OF IMMUNIZATION SERVICES RECEIVED (N = 99)

Counseling services, screening services, and immunization services were used as separate criterion variables. For each of the three regression analyses, subsets of personal and contextual influences were entered in separate blocks. Personal influences were entered in the first three blocks, followed by the contextual influences in the next three blocks. Missing data for distance to primary care provider reduced the sample size to 99 for these analyses.

As shown In Table 3, all influences accounted for 67% of the variance in screening services received. Personal influences in the first three blocks explained 10% of the variance in screening services. Perceived health status was the only personal influence block to significantly increase the variance explained (as indicated by the significance of change in R2), and no personal influence variables made statistically significant independent contributions to the regression equation (as indicated by the significance of the Beta values). Beyond that accounted for by personal influences, contextual influences further explained 57% of the variance in screening services. The access, sources of health information, and provider recommendations blocks all significantly increased the variance explained, but only provider recommendations made a statistically significant independent contribution to the regression, with a large beta weight of 0.69.

It was noted that having health insurance coverage for preventive services and the number of sources of health information had moderate simple correlations with screening services, but that their effect was eliminated in the multiple regression by the powerful influence of provider recommendations. Because the influence of provider recommendations on screening services utilization was so great, separate correlation analyses were run to determine whether that influence held true across all laboratory and diagnostic tests. Correlations between provider recommendations for participating in specific screenings and women obtaining that screening ranged from .607 to 949 for cholesterol, thyroid, mammogram, Pap Smear, and stool hematest.

Table

TABLE 5DETERMINANTS OF COUNSELING SERVICES RECEIVED (N = 99)

TABLE 5

DETERMINANTS OF COUNSELING SERVICES RECEIVED (N = 99)

As shown In Table 4, all influences accounted for 31% of the variance in immunization services received. Personal influences explained only 7% of the variance in immunization services, and none of the personal influences significantly increased the variance explained or made independent contributions to the regression equation. Contextual influences further explained 24% of the variance. Provider recommendations was the only variable to significantly increase the variance explained and make a statistically significant independent contribution to the regression equation.

As shown In Table 5, all influences accounted for 13% of the variance in counseling services received. Personal influences explained 8% of the variance in counseling services. The only personal variable and, in fact, the only variable to significantly increase the variance explained and to make a statistically significant independent contribution to the regression equation was perceived health status. Contextual influences accounted for only an additional 5% of the variance in counseling services. Provider recommendations were not included in this analysis because counseling is essentially a provider recommendation for health behavior changes.

DISCUSSION

This study demonstrated that it was feasible to administer a complex questionnaire to rural older women over the telephone. These women were able to successfully complete the interview, and 89.2% were able and willing to complete it in a single session. All measurement instruments were successfully used over the telephone and had sufficient reliability (internal consistency) to support continued use via that mode. It was possible to assess recommended clinical preventive services utilization, as well as selected personal and contextual influences on such utilization, without undue burden to the older women.

The results concerning contact with health care providers differed from those of Johnson (1991) and Long and Weinert (1989), who found that rural populations used formal health services sparingly. Although three of the four counties in this study were in federally designated Health Professional Shortage Areas, 92.2% of these rural women had seen a health care provider an average of four times in the past year. Despite regular visits to a health care provider, utilization of preventive services by rural older women in this study was quite low. These findings were consistent with previous studies that examined partial sets of the USPSTF-recommended preventive services for older women (BergmanEvans & Walker, 1996; Gluck, Wagner & Duffy, 1989).

Prevalence of preventive services utilization fell far short of the USPSTF recommendation that 100% of women older than age 65 should receive ail of the screening, counseling, and immunization services. The less ambitious Healthy People 2000 objective for people 65 and older, that 40% would receive all of the USPSTF-recommended screening and immunization services, also was not met. Only 1% of the women received all of the recommended screening services, and only 17.6% received the immunization services. The Healthy People 2000 objective that 40% would receive at least one counseling service (which is a very minimal expectation) was exceeded in that 65.6% of the women received counseling in at least one of the nine areas. Nevertheless, the low rate of counseling about women's behaviors essential to the prevention of disability, such as physical activity (25.4%) and injury prevention (10.8%), are of great concern.

Because counseling services typically are time consuming and not reimbursable, it is conceivable that busy providers in health professional shortage areas may not allocate sufficient time to offer these very important preventive services. In view of Bergman-Evans' and Walker's (1996) findings that women received fewer counseling services with increasing age, the results instead may suggest that providers did not attach sufficient importance to counseling older women about their preventive behaviors.

Because the data in the study were self-reported, the women may not have remembered if they received some of the history-taking or counseling services. It is reasonable to assume that most people would remember the receipt of a physical examination or laboratory/diagnostic test. However, in some cases the women may not have understood the purpose of the examination or test and therefore not reported receiving it. For example, the physician could have examined the skin or performed carotid auscultation without the awareness of the woman.

In addition, the providers may not have included some of the counseling components if they were already familiar with the women's history. For example, few women were asked about tobacco or alcohol use; because few women smoked or used alcohol, the providers may have already been aware of their abstention from these. Even with these possible explanations, the preponderance of the data strongly suggests that rural providers may not be complying with all of the USPSTF recommendations.

Other recognized limitations of this study include the nonrandom sample and the time frames for the collection of the information. Each woman was asked if she had received a service in the past year. It is conceivable that for some components (e.g., mammogram, Pap smear) that these tests had been received within the recommended time frames of 1 to 2 or 1 to 3 years. Because the primary care providers for these women were physicians or physician assistants, it is not known how the results might have differed if any of the providers were nurse practitioners. At the time of this study, there were only 77 nurse practitioners in Nebraska - more than half of these were concentrated m an urban area.

The results supported some relationships proposed in the framework. Both personal and contextual influences were determinants of receipt of preventive services for these older rural women; however, the contextual influences made a more significant contribution. Provider recommendations were strongly associated with the receipt of both screening and immunization services. It is consistent with the extensive literature that provider recommendations are important determinants of preventive services utilization. This cohort of older women may have been socialized to follow a health care provider's recommendations rather than take more responsibility for their health and request preventive services.

Access to health care, composed of distance to a primary health care provider and insurance coverage for preventive care, was associated with the receipt of screening services. Preventive coverage under Medicare Part B has been shown to be a significant determinant of screening services (Miller & Champion, 1996). Preventive coverage was the most important component of access for these women. It is noteworthy that screening services (e.g., stool hematest, cholesterol, thyroid), not covered by Part B Medicare but included in this study, may have reduced the strength of the association between preventive coverage and screenings obtained.

It is understandable that distance was not a stronger influence, because most of the women (71.7%) in this study traveled no more than 25 miles to a primary care provider. Previous literature indicates that rural elderly women use a variety of sources of health information. These findings suggest that those who use more different sources are likely to obtain more screening services.

Only one personal influence, the perception of poorer health, was a significant determinant of the receipt of both screening and counseling services. This finding was in contrast with Zabalegui (1994) and Fullerton et al. (1996), who found a positive health perception was associated with greater participation in screening by urban elderly individuals. It is conceivable that clients in poorer health may present to providers as more likely candidates to benefit from screening and counseling services. This may be particularly true of physician providers who have an illness orientation to health care. Unfortunately, this may mean that more healthy older women are not obtaining recommended screenings to detect disease early, or counseling concerning lifestyle behavior that can prevent disease and decline in function as they age. Neither of the other two personal influences, demographic characteristics and definition of health, were significantly associated with the receipt of any of the preventive services.

RECOMMENDATIONS

It is important that all providers be educated in regard to the impact of their recommendations or lack thereof on receipt of preventive services and to the importance of these services for older women. While this is particularly important for gerontological nurse practitioners who are primary health care providers, it also is relevant for gerontological nurses who encounter older clients in various rural settings. Such content therefore should be included in all undergraduate and graduate gerontological nursing curricula.

Gerontological nurses in rural areas should work closely with each other and with community groups to provide access to preventive services. Health screening events can be held in churches, senior centers, or other locations accessible to older women. It is important for health screenings to be tailored to meet the needs and expectations of the older client.

Gerontological nurses can increase the availability of sources of health information through many avenues including articles in the newspaper, and pamphlets available in the office and other sites such as the grocery store, senior centers, and churches. Materials should be specifically targeted to the special needs of older women. All health education literature should encourage women to take responsibility for their health and to talk to their health care provider about receipt of preventive services. Because the women in this study indicated that friends and family were important sources of information, nurses should consider strategies to involve family and friends as a way to increase receipt of preventive services.

It is equally relevant that rural older women receive preventive services education recommended for their age and be empowered to obtain the services independently or, for those needing provider intervention, to request the provider perform or order the services. Further research is warranted to study interventions that would empower rural older women to be more knowledgeable about recommended preventive services for their age group and to participate in decision-making about their health care. There is a need for research to evaluate the outcomes of various interventions designed to influence rural older women to use recommended preventive services.

Women also must be educated regarding the preventive services benefits provided by their health insurance coverage and encouraged to use these benefits. Policy groups should be educated in regard to the importance of expanding the preventive coverage available under Medicare Part B to include all of the preventive services recommended by the USPSTF. Expanded coverage should include reimbursement to the provider for counseling services on preventive health behavior. Cost barriers continue to block achievement of the Healthy People 2000 goals. Expanded coverage for preventive services could aid in reducing morbidity and result in greater cost containment.

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TABLE 1

PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

TABLE 1

PREVALENCE OF WOMEN RECEIVING RECOMMENDED SCREENINGS, IMMUNIZATIONS, AND COUNSELING (N= 102)

TABLE 2

RANGES, MEANS, AND STANDARD DEVIATIONS FOR PREVENTIVE SERVICES UTILIZATION AND PERSONAL AND CONTEXTUAL VARIABLES (N = 99)

TABLE 3

DETERMINANTS OF SCREENING SERVICES RECEIVED (N = 99)

TABLE 4

DETERMINANTS OF IMMUNIZATION SERVICES RECEIVED (N = 99)

TABLE 5

DETERMINANTS OF COUNSELING SERVICES RECEIVED (N = 99)

10.3928/0098-9134-20010101-12

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