layout report - School of Medicine - Trinity College Dublin

PEOPLE LIVING IN THE DUBLIN DOCKLANDSAND THEIR HEALTHThe health needs of people living in thePearse Street area, Ringsend and IrishtownSeptember 2002PART 1 A COMMUNITY BASED SURVEYFrances O’KeeffeJean LongTom O’DowdPART 2 THE HEALTH SERVICE PROVIDERS’ PERSPECTIVEFrances O’KeeffeJillian DeadyJean LongTom O’DowdREPORT PREPARED FOR THE ROYAL CITY OF DUBLIN HOSPITAL TRUST BY THE DEPARTMENTOF COMMUNITY HEALTH AND GENERAL PRACTICE, TRINITY COLLEGE, DUBLIN

TABLE OF CONTENTSPageAcknowledgementsForewordList of TablesList of FiguresList of AppendicesList of Abbreviations456888PART 1 - A community based survey9Summary10Introduction14Methods2.0 Introduction2.1 Study area2.2 Sampling2.3 Fieldwork2.4 Data collection instrument2.5 Statistical methods2.6 In depth interviews1515151616171818Results3.0 Introduction3.1 Response rate3.2 Demographic and socio-economic characteristics3.3 Health care issues and behaviours3.4 Chronic disease3.5 Disability3.6 Deaths3.7 Acute hospital services3.8 Health services for women3.9 Community health services3.10 Waiting for health care3.11 Primary carers’ suggested additional health needs3.12 Comparisons between the communities living in thePearse Street area and in Ringsend and Irishtown1920202226323436374044505154Discussion56References592

TABLE OF CONTENTSPagePART 2 - The health service providers’ perspective60Summary61Methods1.0 Introduction1.1 Aim1.2 Research design1.3 Study population1.4 Sampling1.5 Fieldwork1.6 Data analysis6465656565656666Results2.0 Introduction2.1 The health issues in the communityPhysical problemsMental health problemsSocial problemsLoneliness and isolationDrug and alcohol misuseSocial deprivationWhat occupies most of your time2.2 Services and resources in the communityMain barriers to effective delivery of servicesStaffing issuesPremises and local facilitiesSocial deprivationGeographical and administrative access to servicesBarriers within general practiceResources required to address the needs of the communityStaffHealth premisesResources for the elderlyLocally based servicesResources for family and childrenSuggestions on how to improve the service2.3 Co-ordination and teamwork in the areaLevel of co-ordination between service providers and teamwork in the areaThe primary care team676868686869697070707171717273737474747475757676777779Discussion82References84Appendices Parts 1 and 2853

ACKNOWLEDGEMENTSThe authors wish to thank the Royal City of Dublin Hospital Trust (Baggot Street Hospital) for commissioningand funding this study. A special thank you to Dr. John Ryan who gave of his time and knowledge freely.Thank you to the Chief Executive Officer and staff of the South Western Area Health Board for their support. Inparticular thank you to Mr. Brian Burke, General Manager, Dublin South City District (Community Care Area 3).Special thanks to the people who assisted with the fieldwork, in particular the data collectors from the localcommunity.Thanks to all the individuals in the community and the representatives of the different community groups whoshared their knowledge of the community and its needs.Thanks to all the service providers who shared their knowledge of and insights into the community.Thanks to John Fitzsimons and staff of St. Andrew’s Resource Centre for their support (including photographs),cooperation and use of the premises during the survey.Thanks to the staff of Ringsend Community Centre for the use of their premises during the survey.Thanks to Joe Grennell, Aileen Foran and staff of the Ringsend Action Project for their assistance and support(including photographs).Thanks to James Williams, Head of Survey Unit at the Economic and Social Research Institute, for selecting thesample, and to Mediscribe Ireland for transcribing the health service providers’ interviews.We also thank our colleagues Deirdre Handy, for administrative support and editing this report and ConorTeljeur, for providing population numbers and maps.And finally a very special thanks to all the people who agreed to participate in the survey.4

FOREWORDIn 2001 the Board of the Royal City of Dublin Hospital Trust commissioned and funded the Department ofCommunity Health and General Practice, Trinity College, to undertake a study of the health needs of peopleliving in the Pearse Street, Ringsend, and Irishtown areas, for the purpose of identifying health priorities whichare not currently addressed, or alternatively, are inadequately addressed.The Board of the Royal City of Dublin Trust is very pleased with the resulting report. This was produced by MsFrances O’Keeffe, Dr Jean Long and Professor Tom O’Dowd. We are indeed indebted to them and congratulatethe Department of Community Health and General Practice, Trinity College, on this excellent achievement. Weare happy that the report clearly fulfills its purpose.We are pleased to present this report to the communities of the areas involved. We hope it will generate apositive debate within the communities, among the local health service providers, and not least among thevarious statutory and voluntary agencies with roles to play in addressing the priorities identified. Most of all wehope it will lead to action.Bernard BreenChairman5

LIST OF TABLESPageTable 2.1Table 3.1Table 3.2Table 3.3Table 3.4Table 3.5Table 3.6Table 3.7Table 3.8Table 3.9Table 3.10Table 3.11Table 3.12Table 3.13Table 3.14Table 3.15Table 3.16Distribution of sample and population in both high and low deprivation districtelectoral divisions in the study areaPrimary carers’ reported characteristics of their householdsPrimary carers’ reported access to communication, house heating and health coverDemographic and socio-economic characteristics of the primary carersPrimary carers’ reported demographic, family and socio-economic informationfor individuals residing in the householdsPrimary carers’ reported tobacco use and drug dependency (alcohol or illicit)in the householdsPrimary carers’ reported number (%) of individuals (18 years or older) inthe households who smoke and the quantity smoked each day by these individualsPrimary carers’ reported number (%) of individuals in their households with adrug/alcohol problem and also their health service uptakePrimary carers’ reported experience of stressPrimary carers’ reported experience of intimidation and/or violence in thelast 12 monthsPrimary carers’ reported experience of coping with teenage children and the typeof assistance soughtPrimary carers’ reported types of chronic illness, the level of care required andhealth services used by individuals residing in their householdsLogistic regression model to identify factors associated with having a chronicillness in the population (187/699)Primary carers’ reported types of disability, the level of care required and thehealth services used by individuals residing in their householdsLogistic regression model to identify factors associated with having a disabilityin the population (21/699)Primary carers’ reported type of appointment for, channel of referral to and meansof transport used by individuals in their households to attend a hospital service inthe 12 months prior to the surveyLogistic regression model to identify the factors that influenced use of ahospital service in the year prior to the study among the population (176/699)1522232425262627283031333435363839Table 3.17 Primary carers’ reported current use of family planning, recent uptake of cervicalsmear tests and breast examination41Table 3.18Primary carers’ reported number of pregnancies in their households betweenJanuary 1997 and September 2001 and service uptake by pregnant womenduring each pregnancy42Table 3.19 Primary carers’ reported number (%) of individuals admitted to maternityhospital in the year prior to the survey, number (%) who used the hospital,and their level of satisfaction with services43Table 3.20Primary carers’ reported number (%) of individuals who visited their GP inthe year prior to the survey, their level of satisfaction with services and their reasonsfor satisfaction/dissatisfaction446

LIST OF TABLESPageTable 3.21Table 3.22Primary carers’ reported use of and satisfaction with out of hours medicalservices and their source of health informationLogistic regression model to identify factors associated with attending a generalpractitioner as one of the last three health services used in the year prior to the surveyamong the study population (327/699)4546Table 3.23 Primary carers’ reported vaccination uptake for children aged between two andfive years residing in their households47Table 3.24Table 3.25Table 3.26Primary carers’ reported number (%) of individuals using the communitynursing service in the year prior to the survey, their level of satisfaction with servicesand their reasons for satisfaction/dissatisfactionPrimary carers’ reported number (%) of individuals who visited their dentist inthe year prior to the survey, their level of satisfaction with services and their reasonsfor satisfaction/dissatisfactionPrimary carers’ reported number (%) of individuals residing in the householdswaiting for health care, length waiting for service, location of service and satisfactionwith waiting period484950Table 3.27 Logistic regression model to identify factors associated with waiting for health carein the population (53/699)51Table 3.28Additional health care services suggested by primary carers52Table 3.29 Primary carers’ suggestions for the location of a health centre that would serveboth communities53Table 3.30Summary of comparisons between the communities living in the Pearse street areaand Ringsend/Irishtown547

LIST OF FIGURESPageFigure 3.1Figure 3.2Figure 3.3Figure 3.4Figure 3.5Figure 3.6Figure 3.7Figure 3.8Figure 3.9Age profile of the population in 1996 census versus household membersin 2001 surveyGender profile of the population in 1996 census versus household membersin 2001 surveyKey characteristics of the households and primary carers (n=273)Primary carers’ reported sources of help to deal with stress (n=145)Primary carers’ reported sources of support to deal with the last incidentof intimidation or violence (n=30)Types of chronic illness reported by primary carers for the household members (n=187)Hospital facilities used by household members as reported by the primary carers (n=176)Household members reasons for attending hospital as reported by primary carers (n=176)Household members satisfaction with hospital services as reported by primary carer212123293032373739Figure 3.10 Practices of women during their most recent pregnancy (between January1997 and September 2001) as reported by primary carers (n=21)Figure 3.11 Type of treatment awaited by household members as reported by primary carers (n=26)4250LIST OF APPENDICESAppendix 1 Maps of the study areaAppendix 2 Information leaflets2a Letter to participants2b Poster2c Information sheet for interviewersAppendix 3 Survey teamAppendix 4 Procedures employed to ensure good ethical practiceAppendix 5 Satisfaction with hospital servicesAppendix 6 Topic guidelinesAppendix 7 Consent form for the service providers who participated in the studyAppendix 8 Silverman’s transcription symbols8687878889909091949596LIST OF ABBREVIATIONSCIDEDENTGMSGPnOROTSAHRUSWAHBConfidence IntervalDistrict Electoral DivisionEar, Nose and ThroatGeneral Medical ServiceGeneral PractitionerTotal number who answered the questionOdds RatioOccupational TherapistSmall Area Health Research UnitSouth Western Area Health Board8

PEOPLE LIVING IN THE DUBLIN DOCKLANDSAND THEIR HEALTHThe health needs of people living in thePearse Street area, Ringsend and IrishtownPART 1 A COMMUNITY BASED SURVEYFrances O’KeeffeJean LongTom O’Dowd

SUMMARY - PART 1SummaryWe have presented the main survey findings in this summary. More detailed findings are available in the resultssection for use by health planners employed by the area health boards. The information contained in thisdocument is also pertinent to those working in primary care or with a special interest in health care.What we set out to doWe set out to assess the health needs of households and their individual members residing in two geographicalcommunities: the Pearse Street area and the Ringsend/Irishtown area.How we conducted the assessmentInitially we contacted key individuals in the community to inform them of the proposed study and to ascertainwhat they felt were the key health and social issues in the area. We included these issues in the questionnaire.We then conducted a cross sectional study in the four district electoral divisions of the study area (excludingthe south-western corner of Pembroke West A). We interviewed primary or principal carers (defined as theperson in the household who manages the welfare and health of the family/household) in 273 of the selected360 households. We selected the households employing a cluster sampling methodology. We chose 30 clustersfrom both the two less deprived district electoral divisions and the two more deprived district electoral divisions.Each of the 60 clusters consisted of six adjacent households. We interviewed the primary carers in their homes,using an interviewer administered questionnaire.What we found in the surveyOf the 360 households selected to participate in the survey, over 75% participated, indicating a keen interestin health related issues. Data were also collected on 699 individuals residing in these houses.The people of the areaThe population in the area continues to grow and migrate with almost half of the households residing in the areafor less than ten years. This reflects the new private housing developments in the area over the last ten yearsand the movement of young families from flat complexes to houses. However this is generally an olderpopulation with almost one third over the age of 50 years and over half of these aged 65 years or over. Of noteis that 86 of the primary carers were aged between 65 and 95 years old, of whom 47 (55%) were living on theirown. Of those who stated that they were the primary carers, almost one quarter were men.Primary or principal carers reported that:• 51% of all household members are living in rented accommodationof these,• 37% live in government supported accommodation and 14% are renting privately.• 54% of households did not own a car,• almost 6% of households were occupied by non-nationals,• 45% of households had medical card cover,• 8% described themselves as lone parents,• 50% of primary carers had primary school education or less.Lifestyle and family issuesPrimary or principal carers reported that:• 53% had experienced stress in the year prior to the survey,of these,• 26% consulted their general practitioner because of their stress,• 12% had received prescribed medication,• 8% had visited a counsellor.• 11% experienced violence or intimidation in the previous year,of these,• 30% had experienced the incident in their own homes,• 37% had reported the violent incident to the police,• one third had sought medical assistance,10

SUMMARY - PART 1• 60% worried about their teenagers socialising,• 30% found their teenagers’ attitudes or behaviours upsetting,• 31% of household members, 18 years or over smoked,• 1% of household individuals, over 15 years old, had a problem with either alcohol or drugs.Chronic illness and disabilityPrimary carers reported that:• 27% of the 699 household members had a chronic illness;• the most common chronic illnesses were respiratory (25%), cardiovascular disease (24%) and arthritis (18%).• overall 3% of household members had a disability,of these,• 43% had their disability since birth,• Over three quarters had a physical disability.Hospital servicesPrimary or principal carers reported that:• 25% of household members used a hospital service in the 12 months prior to the survey,• the main reasons for attending were cardiovascular disease (18%), injury or an acute emergency (15%)and respiratory problems (10%),of those who used hospital services:• 63% were elective or planned attendances at the hospital,• 36% attended outpatients, 24% were seen in accident and emergency, 9% were day patientsand 31% were admitted to hospital,• 87% were satisfied with inpatient and outpatient services,• 82% were satisfied with the day care service and accident and emergency,• the main reasons for satisfaction and dissatisfaction were common to all hospital services,• their main reasons for satisfaction were that staff listened to their problem(s) and staff explainedtheir medical conditions,• their main reason for dissatisfaction was the long waiting periods encountered.• Hospital services were more likely to be used by those with chronic illness and those waiting forhealth care.Health services for womenFemale primary or principal carers (of child bearing age) reported that:• 46% (45/98) were using a method of family planning,• 54% of women aged 18 to 65 had a smear test in the last five years,• 43% of women aged 18 to 65 had a breast examination in the last five years,• only 29% of women aged 50 to 65 years had a mammogram in the last five years.Primary or principal carers reported that:• 52% of the women’s most recent pregnancies were planned,• only 30% opted for general practitioner and hospital shared care,• 29% of the women smoked during their last pregnancy,• 95% delivered their last child in the National Maternity hospital, Holles street.Community health servicesPrimary or principal carers reported that:• 47% of the household members had attended their general practitioner in the last year,of these,• 89% were satisfied with services provided by their general practitioners;• the main reasons for satisfaction were, the doctor listened to their problem(s) (74%), the doctorwas nearby (53%) and the doctor provided good treatment or care (52%),• the main cause of dissatisfaction was that the doctor did not listen to their problem(s) (6%).11

SUMMARY - PART 1• 21% of respondents were unhappy with the current ‘out of hours’ general practitioner service,• 5% of the individuals had consulted a community nurse in the last year,of these,• 80% were satisfied with the service provided,• the main reasons for satisfaction were the nurses were courteous and friendly (69%), the nurselistened to their problem(s) (59%) and the nurse provided good treatment (34%),• the main reason for dissatisfaction was that the nurse did not listen to their problem(s) (9%).• 96% of children aged between two and five years residing in their households had completed the routinechildhood vaccines,• 75% of children aged between two and five years had received the meningitis C vaccine,• the most common sources of health information were the staff at their general practice (59%) and healthinformation leaflets (27%),• just 12% of the population had visited a dentist in the 12 months prior to the survey.Waiting for health care• 4% of the household members were on a waiting list,of these,• 88% were waiting for hospital services,• 12% were waiting for dental services and other community services.Comparisons between the communities in the Pearse street area and in Ringsend/Irishtown• More householders in the Pearse Street area (52%) had moved into the area within the last 10 years than inRingsend/Irishtown (39%).• In the Pearse Street area 44% of individuals smoked more than ten cigarettes per day compared to 28% ofindividuals in Ringsend/Irishtown.• Primary carers living in Ringsend/Irishtown (59%) were more likely to use a method of family planning thanthose living in the Pearse Street area (33%).• A higher proportion of female primary carers living in Ringsend/Irishtown (50%) had a breast check withinthe last five years than the proportion living in the Pearse Street area (36%).• A slightly higher proportion of people living in Ringsend/Irishtown (29%) used a hospital service within thelast year than the proportion living in the Pearse Street area (22%).• A higher proportion of people living in the Pearse Street area (51%) attended their General Practitionerwithin the last year than the proportion living in Ringsend/Irishtown (42%).When the primary carer was asked where s/he preferred to attend a health centre the majority in both thePearse Street area (83%) and Ringsend/Irishtown (92%) wanted to attend a centre within their own area.Additional health services identified by the people in the area• 80% of the primary carers identified additional health needs in the area.For example:• 52% asked that ‘out of hours’ general practitioner services be reorganised and staffed by localgeneral practitioners,• 37% requested improved services for the elderly,these included,• day care (25%), long term care (18%), respite care (16%), and home visits (10%),• 25% requested a social work service to provide for all members of the community,• other services suggested included a local counselling service, a clinic to promote women’s health andservices for teenagers (which included contraceptive advice and psychological services).ConclusionThe people living in the area were keen to participate in the study and made valuable suggestions about theservices needed in the area. We hope that the information will be an important resource for health planners andservice providers in the area.12

INTRODUCTIONAND METHODSPART 1

INTRODUCTION - PART 1IntroductionThe overall purpose of a health needs assessment is to gather the information required to bring about changebeneficial to the health of the target population. Needs assessments provide the basis for health care planningin a community. The assessment must incorporate the wider social and environmental determinants of health,such as deprivation, housing, education and employment. A combination of qualitative and quantitative researchmethods are required to collect the relevant information.Assessing the health needs of local communities is necessary for effective targeting, delivery and improvementof health and social services. Health needs assessments are of particular importance in view of the new primarycare strategy, which states that ‘health needs assessment is central to effective primary care’. 1 The new strategyemphasises the importance of including the community as partners in developing the health services. Identifyingand responding to the needs of the individuals in the community is an important element of this partnership.In April 2001, the Royal City of Dublin Hospital Trust (Baggot Street hospital) commissioned a study toinvestigate the health needs of the people living in the Pearse Street area, Irishtown and Ringsend. Where aclearly defined need is identified the Trust are interested in assisting in health projects within the local communityserved by the Royal City of Dublin Hospital.Study objectivesThe objectives of the study were to:• Describe the socio-economic status and demographic profileof the community.• Estimate proportions with chronic illness and disability in the community.• Measure current health service utilisation.• Measure satisfaction with current health service provision.• Establish areas of unmet needs.• Compare socio-economic characteristics, health status and health service utilisation of those living in thePearse Street area with those living in Ringsend/Irishtown.14

METHODS - PART 1MethodsThis chapter describes the methods employed to conduct and analyse the household survey and is presentedin six sections:2.0 Introduction2.1 Study area2.2 Sampling2.3 Fieldwork2.4 Data collection instrument2.5 Statistical methods2.6 In depth interviews2.0 INTRODUCTIONThe Department of Community Health and General Practice, based at the Trinity College Centre for HealthSciences, Adelaide and Meath Hospital, Dublin, incorporating The National Children’s Hospital, was requestedto undertake the health needs assessment in the Pearse Street area and in the Ringsend and Irishtown area.The South Western Area Health Board (SWAHB) fully endorsed the study. The study was approved by the StJames’s and Federated Dublin Voluntary Hospitals’ Joint Research Ethics Committee.2.1 STUDY AREAThe study area covered included three complete district electoral divisions, (Mansion House A, South Dock,Pembroke East A) and most of the fourth district electoral division Pembroke West A (excluding the southwestern corner). In the study, the area referred to as the Pearse Street area comprises the Mansion House Aand the South Dock district electoral divisions, and the Ringsend/Irishtown area includes the Pembroke East Aand the Pembroke West A district electoral divisions (DED).Health status and service uptake has been linked to deprivation 2 and therefore it was necessary to take accountof this factor when selecting the sample. The Small Area Health Research Unit (SAHRU) 2 provided a deprivationscore, based on parameters from the 1996 census, for each district electoral division in the country, including thefour district electoral divisions in the study area. The deprivation scores range from one to five, where one is leastdeprived and five is most deprived. In order to select the study population, the deprivation scores were collapsedinto two groups where district electoral divisions with scores of one to three were classified as less deprived anddistrict electoral divisions with scores of four and five were classified as more deprived.Table 2.1 presents the household numbers in each of the four district electoral divisions by level of deprivation. At thetime of the survey there were approximately 5,680 households in the area and half were classified as more deprived.Table 2.1 Distribution of sample and population in both the high and the low deprivation district electoral divisionsin the study areaDistrict electoral division Sample households Population householdsTotal Percent Total PercentLow Deprivation (1 to 3)South Dock 90 50 1396 49.3Pembroke West A 90 50 1433 50.7Total 180 100 2829 100.0High Deprivation (4 and 5)Mansion House A* 90 50 1343 47.1Pembroke East A** 90 50 1508 52.9Total 180 100 2851 100.0* excluding Trinity College ** excluding the south-western corner15

METHODS - PART 12.2 SAMPLINGWe estimated that the required sample size was 360 households based on the proportion of individualsreporting a chronic illness (22%) in a survey carried out in Tallaght in June 2001. 3 The sample was selectedusing a sampling methodology validated by the World Health Organization 4 and adapted by the Primary HealthCare Management Advancement Programme for assessing community health needs and health servicecoverage. 5 In this methodology cluster sampling rather than random sampling is employed, and for the survey30 clusters of 6 adjacent households were selected from each of the low and high deprivation areas, giving therequired number of 360 houses.The sample was supplied by Mr James Williams, Head of Survey Unit at the Economic and Social ResearchInstitute. The sample selection for each of the district electoral divisions within the high deprived areas andlow deprived areas was proportional to the number of households in each contributing district electoraldivision (Table 2.1).A portion of Pembroke West A was excluded because it was located in the East Coast Area Health Board.This was not clarified when the sampling strategy was devised but was later noted by the researchers inconversation with community members and was confirmed by the public health nurses. Therefore five of thefifteen selected clusters from Pembroke West A were replaced by five other clusters in the SWAHB withinthe district electoral division.Variation in the number of households listed in each district electoral division (Table 2.1) versus numbers ofhouseholds reported in the census arises due to under-registration of households (James Williams, personalcommunication 2001). The Department of the Environment has reported that 10% of households on theelectoral register are not listed or else not occupied by the person named on the electoral register as a resultof death or migration.The researcher adjusted each cluster of six adjacent houses and inserted those houses missing from thenumerical sequence (in order to include those not on the electoral register). The number of households inexcess of six was then removed from the end of the sequence. This was done in order to ensure a representativesample of the population actually living in the area rather than according to the electoral register. Of the 360houses in the Economic and Social Research Institute sample, 15 (4.2%) households were missing from theelectoral register and were therefore placed in their numerical sequence in their respective clusters asdescribed above.2.3 FIELDWORKPrior to the fieldwork the local newsletters informed the community about the survey. Posters were displayed inthe health centre, local community centres and local public premises. In October 2001, each of the 360selected households was sent a letter signed by a representative of the Royal City of Dublin Hospital and theacting General manager for the SWAHB in the area (Appendix 2).People living in the area were invited to participate as data collectors in the household survey. Those peoplewho expressed an interest attended a training programme prior to the survey. The data collection commencedin mid October 2001 and was collected initially each evening between 6 and 9 pm with the interviewers workingin pairs. Due to difficulty with access at night or feedback from the local community many houses were thenvisited during the day.16

METHODS - PART 1The questionnaire was administered by the interviewers to the primary carer (defined as the person in thehousehold who manages the welfare and health of the family/household) in each of the participating households.Flashcards were used to assist respondents identify the scale of an experience, identify the name of a chronicillness, as a prompt for a health service s/he may have used and the reasons for satisfaction/dissatisfaction withhealth services. When a household was not accessed, a note was left with a date for a return visit. Householdsthat were not accessed initially were revisited until access was gained up to a maximum of four return visits.Data collection was completed by mid December 2001.2.4 DATA COLLECTION INSTRUMENTDuring the months of July and August 2001 the researcher informed key individuals and community groupsabout the proposed survey and elicited their perceived needs. Several health and social services needs wereidentified.These were:• An increase in childcare facilities (including crèche facilities) that would have more flexible hours.• Strategies to address teenage health issues with particular reference to teenagers’ alcohol consumption.• Additional services for lone parents with particular reference to employment schemes and childcare facilities.• Specific services to address women’s health issues, including interventions to address domestic violenceand postnatal depression.• Expanded services for the elderly with specific reference to more accommodation with full time wardensupport and local bus transport to Baggot Street hospital.• Interventions to support drug users and their families in the community, in particular for the families in thePearse Street area.• A health centre located in the Pearse Street area.• Appointment of a community social worker to deal with all members within the family (not just children).Overall the main issues pertaining to health were found to be similar to the issues that had already been includedin the questionnaire, which was used in the health needs assessment carried out in the Tallaght area in 2001. 3Some minor revisions were included in the questionnaire used in this study in response to the discussions withthe community.The different sections of the questionnaire were designed to ascertain:• Demographic and socio-economic characteristics for each household and its individual members.• Experience of chronic illness and disability for households and individual household members.• Behaviours in relation to cigarette smoking and/or alcohol or drug misuse for households and individualhousehold members.• Primary carers’ experience of teenage children, violence and stress.• Uptake of cervical screening, breast examination, antenatal services and family planning by women.• Children’s (aged 24-59 months) uptake of vaccinations and developmental assessment.• Utilisation of and satisfaction with health services and the health care waiting lists.• Primary carers’ reported gaps in the service.17

METHODS - PART 12.5 STATISTICAL METHODSMedical undergraduates and graduate students at the Department of Community Health and General Practiceentered the data into two Excel spread sheets (one for the household and the other for household members).Data were cleaned and checked for accuracy by the principal researcher. This involved performing frequencydistributions for all variables to identify discordant values and ensure data followed logical checks. Statisticalanalysis was carried out using JMP IN, 6 and STATA. 7The frequency distribution for each variable was described in both the household and individual householdmembers’ datasets. Pearson χ2 test, and Fisher’s exact test were used to compare proportions inindependent groups of categorical data. Multiple logistic regression models were developed to determinewhich variables best predicted key outcomes (chronic disease, disability, service utilisation and waiting forhealth care) for the household members. Exact 95% confidence intervals (CI) were calculated for proportionsof binomial variables and for regression adjusted odds ratios.2.6 IN DEPTH INTERVIEWSDuring August and September 2001 the service providers were contacted and informed of the householdsurvey. They were also invited to participate in a study to ascertain the needs from the service providersperspective. Following completion of the household survey representatives from the different disciplines withinthe health services were interviewed. This study is presented as part two of this document.18

RESULTSPART 1

RESULTS - PART 1RESULTS3.0 INTRODUCTIONThe results of the survey are presented in twelve sections:3.1 Response rate.3.2 Demographic and socio-economic characteristics of the:• participating households• primary carers (respondents)• individual household members in each of the participating households.3.3 Health care issues (stress and violence) and health related behaviours (cigarette smokingand substance misuse).3.4 Chronic disease.3.5 Disability.3.6 Deaths.3.7 Acute hospital services.3.8 Health services for women.3.9 Community health services including general practice, community nursing, pharmacy servicesand dental services.3.10 Waiting for health care.3.11 Primary carers’ suggested additional health needs.3.12 Comparisons between the populations living in the Pearse Street area and in Ringsend/Irishtown.All findings that are presented are as reported by the primary carer (the person in the household who managesthe welfare and health of the family/household) in each household.3.1 RESPONSE RATEOf the 360 households invited to participate in the survey, 273 (76%) agreed to be interviewed. Forty threehouseholds (12%) did not wish to be interviewed while 41 (11%) households were not accessed (despite amaximum of four return visits). Nine of the clusters were in apartment blocks. The majority of the refusals andno access visits were in these apartment blocks, which are generally accessed through an intercom system.The response rate in the apartment blocks was much lower than in the wider community (15/54, 27% versus258/306, 84% p < 0.0001). The response rates were similar in the areas that were classified as more deprivedcompared with the areas classified as less deprived (139/180, 77% versus 134/180, 74%; p = 0.8).20

RESULTS - PART 1Figure 3.1 Age profile of the population in 1996 census versus household members in 2001 surveyCENSUS 1996 SURVEY 2001PERCENTAGE30252015105026.723.617.312.812.2 13.8 13.3 12.710.3 8.411.411.99.712.10 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 64 65 or moreAGE (IN YEARS)The age profile for the individual household members was significantly different from that reported in the 1996census, p < 0.0001 (Figure 3.1). There was a higher proportion of household members in the age groups 40to 49 years and 65 years or more in the survey population compared to the census population. There was alower number of household members aged 20 to 29 years in the survey population compared to the 1996survey. The gender profile was similar, p = 0.6 (Figure 3.2).Figure 3.2 Gender profile of the population in 1996 census versus household members in 2001 surveyCENSUS 1996 SURVEY 20015553.354.3PERCENTAGE50454046.7MALE45.6FEMALEAnalysis pertaining to households and primary carers refers to information ascertained from the 273 primarycarers who took part in the survey. The primary carers also provided information on the 699 individuals(including themselves) who resided in the participating households. Denominators vary because not allrespondents answered all questions.21

RESULTS - PART 13.2 DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICSDemographic and socio-economic characteristics at the household levelTable 3.1 presents the household characteristics as reported by the primary carers. On average, two individualslived in each house. Almost half of the households were living in the area for less than ten years and the majorityof these (94/122, 77%) had moved into the area within the last five years. One quarter of the households wereoutright owners while half of the households were either renting from the local authority (37%) or privately(14%). Non-nationals occupied almost six percent of households (Figure 3.3).Table 3.1 Primary carers’ reported characteristics of their householdsNo. %Number of people living in each house1 to 2 167 61.23 to 4 73 26.75 to 11 33 12.0n 273Average 2.5Median 2Range 1 to 8Year moved into house (grouped)1922 to 1940 15 5.71941 to 1960 24 9.01961 to 1980 45 17.01981 to 1990 59 22.21991 to 2001 122 46.0n 265DED deprivation score for area of residence(where 1 is least deprived and 5 is most deprived)1 69 25.22 70 25.63 04 60 22.05 74 27.1n 273Resides in an area classified as deprivedYes 134 49.1No 139 50.9n 273House occupancy statusOutright owner 68 25.1Mortgage 58 21.4Tenant purchasing plan 7 2.5Rent paid by health board or renting from local authority/housing association 99 36.5Renting privately 39 14.4n 271According to the primary carers, the majority (98%) of the households had access to a telephone (Table 3.2)and over half of the households (53%) did not own a car (Figure 3.3). Eighty seven percent of houses hadcentral heating, of these 78% used gas heating. Forty five percent of the households were medical card holderswhile four out of every ten households had private health insurance (Table 3.2). Five respondents had receivedthe medical card as a result of the new ‘over seventies scheme’.22

RESULTS - PART 1Table 3.2 Primary carers’ reported access to communication, house heating and health cover24 hour access to telephone by household memberYes 267 97.8No 6 2.2n 273Emergency phone access for those households with no phoneNeighbour 4 66.7Street 1 16.7Other 1 16.7n 6Central heating in the householdYes 236 87.1No 35 12.9nHealth cover for household occupantsMedical card 122 44.9VHI 83 30.5BUPA 11 4.0Other private 17 6.3None 39 14.3n 272Demographic and socio-economic characteristics for the primary carersThe primary carer is the person in the household who manages the welfare and health of the family/household.Table 3.3 presents the self-reported demographic and socio-economic characteristics of the primary carers. Ofthose who said that they were primary carers, almost a quarter (23%) were men (this included men who weresingle (42%), separated (12%) , widowed (17%) or those who shared the caring role with their partner (28%)).On average the primary carers were 50 years old and almost one third (32%) were between 65 and 95 yearsold. Of note, 86 of the primary carers were aged between 65 and 95 years old, and of those, 47 (55%) wereliving on their own. Over half (56%) of the primary carers were at home fulltime. Half of the primary carers hadeither no formal education or had completed primary school education only. Eight percent described themselvesas lone parents (Figure 3.3).Figure 3.3 Key characteristics of the households and primary carers (n=273)60504036.550.745.053.530PERCENTAGE201005.58.4GovernmentaccomodationPrimary educationor lessNon-national Lone parents Medical cardcoverNo carHOUSEHOLDS’ AND PRIMARY CARERS’ CHARACTERISTICS23

RESULTS - PART 1Table 3.3 Demographic and socio-economic characteristics of the primary carersNo. %GenderMale 64 23.4Female 209 76.5n 273Age in years19 to 34 64 23.935 to 49 66 24.650 to 64 52 19.465 to 95 86 32.1n 268Average 51.9Median 50Range 19-95Current employment statusWorking full time 91 33.3Working part time 28 10.3Always in the home 154 56.4n 273OccupationEmployers/managers, higher/lower professionals, self employed 64 55.2Non manual or manual skilled workers 14 12.1Semi skilled or unskilled workers 19 16.4Currently in education or community employment scheme 9 7.8Unknown 10 8.6n 116Educational attainmentPrimary education or none 138 50.7Junior group or intermediate certificate, technical or vocational training 35 12.9Leaving certificate, A levels, technical training 24 8.8Non degree qualification 16 5.9Degree, professional qualification or both, or postgraduate qualification 59 21.7n 272Attained highest qualification through an adult education schemeYes 7 5.5No 121 94.5n 128Marital statusSingle 104 38.1Married 107 39.2Separated, divorced, widowed 62 22.7n 273Demographic and socio-economic characteristics for individuals living in theparticipating householdsTable 3.4 presents the primary carers’ reported demographic, family and socio-economic information forindividuals residing in the participating households. There were slightly fewer men than women living in thesurveyed households. The household residents’ ages ranged from zero to 95 years and almost one third wereaged 50 years and over. Thirty nine percent of those living in the households were primary carers while justunder one third of them were the primary carers’ children. Almost 65% of household members aged between15 and 65 years were employed.24

RESULTS - PART 1Table 3.4 Primary carers’ reported demographic, family and socio-economic information for individuals residingin the householdsNo. %GenderMale 319 46.0Female 380 54.0n 699Age in years0 to 4 26 3.75 to 12 52 7.513 to 19 58 8.420 to 29 162 23.530 to 39 84 12.240 to 49 95 13.850 to 64 91 13.265 to 79 101 14.780 or more 20 2.9n 689Average 38.5Median 35.0Range 0 to 95Primary carers 273 39.2Other household members relationship with primary carerChild 203 29.1Partner or spouse 121 17.4Sibling 21 3.0Grandchild 12 1.7Parent 7 1.0Other relative 5 0.7Other 55 7.9n 697Members of the household in education, employment or at homeEmployed - full or part time 317 45.4Always in home 242 34.6School 99 14.1College or university 31 4.4Community employment or training scheme 10 1.4n 699Members aged 15 to 65 in education, employment or at homeEmployed - full or part time 308 64.6School 19 4.0College or university 31 6.5Community employment or training scheme 10 2.1Always in home 109 22.9n 477DED deprivation score for area of residence(where 1 is least deprived and 5 is most deprived)1 180 25.72 168 24.03 04 166 23.75 185 26.5n 69925

RESULTS - PART 13.3 HEALTH CARE ISSUES AND BEHAVIOURSSmoking and substance misuseAccording to the primary carers, at least one person in almost half of the households smoked cigarettes while3% of households had a person with an alcohol or drug problem (Table 3.5).Table 3.5 Primary carers’ reported tobacco use and drug dependency (alcohol or illicit) in the householdsNo. %Number of households with one or more smokersYes 133 49.1No 138 50.9n 271Numbers of households with a person with alcohol or drug dependencyYes 9 3.3No 262 96.6n 271Among those 18 years old or over, thirty one percent of household members smoked and of these, over onequarter smoked more than 20 cigarettes per day (Table 3.6).Table 3.6 Primary carers’ reported number (%) of individuals (18 years or older) in the households who smokeand quantity smoked each day by these individualsNo %Smoke (18 years or older)Yes 186 31.2No 410 68.8n 596For individuals who smoke, quantity smoked per dayLess than 10 62 34.210 to 20 69 36.5More than 20 53 29.3n 184The primary carers reported that 8 (1%) of the 596 individuals aged 15 years or over residing in the householdshad a problem with either alcohol or drugs at the time of the survey, all of whom had a serious problem (Table3.7). Six individuals out of the eight had a problem with heroin use. Five of the heroin users were attending adrug treatment centre and of these, four were on a methadone maintenance programme.26

RESULTS - PART 1Table 3.7 Primary carers’ reported number (%) of individuals in their households with a drug/alcohol problemand also their health service uptakeNo. %Scale of problem (1 not serious to 5 very serious)1234 3 37.55 5 62.5n 8Main drug usedHeroin 6 85.7Alcohol 1 14.3n 7Services used by allVisit general practitioner (GP) in relation to useYes 5 62.5No 3 37.5n 8Attend counsellingYes 4 57.1No 3 42.9n 7Attend a support groupYes 3 42.9No 4 57.1n 7Taking sedativesYes 1 14.3No 4 57.1Don’t know 2 28.6n 7Services accessed by heroin usersVisiting a needle exchange programmeYes 1 16.7No 5 83.3n 6On methadone maintenanceYes 4 66.6No 2 33.3n 6Attending a drug treatment centreYes 5 83.3No 1 16.7n 6Location of drug treatment centreIrishtown 1 20.0Baggot Street 3 60.0Trinity Court 1 20.0n 527

RESULTS - PART 1Primary carers’ experience of stressOver half of the primary carers reported that they had experienced stress in the year prior to the survey (Table3.8). Family issues (21%) and pressure at work (19%) were the most commonly cited causes of stress. Overone third of the primary carers said that they had experienced severe stress (Table 3.8). More than threequarters reported negative effects of stress. The most commonly reported negative effects of stress wereanxiety, feeling annoyed and depression.Table 3.8 Primary carers’ reported experience of stressNo. %Stress in the last 12 monthsYes 145 53.3No 127 46.6n 272Reason for stress (n=145)Family 30 20.7Pressure at work 28 19.3Everyday living 27 18.6Illness 15 10.3Bereavement 10 6.9Other 7 4.8Study 5 3.4Financial 5 3.4Moving house 5 3.4Related to alcohol or drug addiction 3 2.1Marital 3 2.1Bullying 2 1.4Loneliness 2 1.4Age related 2 1.4Unemployment 1 0.7Scale of stress 1(not serious) to 5 (very serious)1 22 15.22 31 21.43 38 26.24 26 17.95 28 19.3n 145Experienced negative effects of stressYes 113 77.9No 32 22.1n 145Negative effects (n = 113)Anxious 52 46.0Easily annoyed 36 31.9Depressed 31 27.4Smoke more 30 26.5Illness 11 9.7Eating too much or too little 11 9.7Sleeplessness 10 8.8Aggressive 9 8.0Other 5 4.4Take more alcohol/drugs 4 3.5Communication problems 2 1.828

RESULTS - PART 1The primary carers were asked what they did to help deal with their stress (Figure 3.4). Almost 60% soughthelp from close friends or family while a quarter attended their general practitioner. Over 10% said they wereon prescribed medication for stress.Figure 3.4 Primary carers’ reported sources of help to deal with stress (n=145)706059.35040PERCENTAGE3020100Consultedfriend/relative26.2VisitedGP7.6Visited counsellor12.4Prescriptionmedication3.4AlternativemedicationASSISTANCE TO DEAL WITH STRESSPrimary carers’ experience of violence and intimidationThirty (11%) primary carers reported that they had experienced violence or intimidation in the year prior to thesurvey, and of these, over half said that the scale of the violence or intimidation was very severe (Table 3.9).Of those who experienced violence, 18 (60%) said that it had occurred several times; nine (30%) respondentssaid that the incident had occurred in their homes; and 24 (80%) said that the incident was perpetrated bysomeone they knew (Table 3.9). Just under half of the episodes of violence or intimidation were as a result of aprevious disagreement.29

RESULTS - PART 1Table 3.9 Primary carers’ reported experience of intimidation and/or violence in the last 12 monthsNo. %Experienced intimidation and/or violence in last 12 monthsYes 30 11.1No 240 88.9n 270Scale of intimidation and/or violence 1 (not serious) to 5 (very serious)1 1 3.32 5 16.73 8 26.74 6 20.05 10 33.3n 30Frequency of intimidation and/or violenceOnce 5 16.6Few times 7 23.3Several times 18 60.0n 30Place where intimidation and/or violence occurredIn the home 9 30.0Outside the home 21 70.0n 30Perpetrators of intimidation and/or violenceSomeone they know 24 80.0Stranger 6 20.0n 30Reason for attackRandom attack 16 53.3Result of previous disagreement 14 46.7n 30The primary carers were asked where they had gone for help (Figure 3.5). Four (13%) primary carers said thatthey had moved to a safe place while ten (33%) said they had sought medical assistance. Eleven (37%) ofrespondents said they had reported the incident to the gardaí.Figure 3.5 Primary carers’ reported sources of support to deal with the last incident ofintimidation or violence (n=30)403536.730PERCENTAGE2520151013.323.310.050Safe place Visit GP Visit A&E Report to gardaiSOURCES OF SUPPORT TO DEAL WITH VIOLENT INCIDENT30

RESULTS - PART 1Primary carers’ experience of dealing with teenagersAccording to the primary carers with teenage children, three fifths worried about their teenagers’ socialising(Table 3.10). The most common reason for concern was that their teenager while socialising, would develop aproblem with or as a result of drug or alcohol use (43%). Forty percent of the respondents were also concernedthat their teenager would be assaulted (including sexual assault) or robbed.Table 3.10 Primary carers’ reported experience of coping with teenage children and the type of assistance soughtNo %Worried about teenagers’ socialisingYes 32 60.4No 18 33.9Sometimes 3 5.7n 53Incident primary carer would worry about mostDrug and drink related 15 42.9Sexually assaulted/robbed/attacked 14 40.0Pregnancy 3 8.6Car crash 2 5.7Commit assault 1 2.9n 35Happy with his/her friendsYes 48 90.6No 3 5.7Some of them 2 3.7n 53Found teenagers’ attitudes or behaviours upsettingYes 16 30.2No 37 69.8n 53Attitude, behaviour or action that is most upsettingDoes not listen to advice 8 50.0Mood swings 6 37.5Aggressive behaviour 1 6.2Takes and/or sells drugs or alcohol 1 6.2n 16Assistance or advice sought from others outside primary carers’ familyYes 5 31.3No 11 68.7n 16Where primary carer has gone for adviceTeacher 2 40.0GP 2 40.0Counsellor 1 20.0n 5The primary carers were asked if they found their teenagers’ behaviours upsetting and 30% said yes. Half ofthose who found their teenagers’ behaviours upsetting reported that the most upsetting behaviour was theirteenagers’ unmanageability (does not listen to advice, does not observe rules or boundaries, always wants tobe out with friends, etc.). A further 37% of respondents reported that their teenagers’ most upsetting behaviourwas their mood swings. Almost one third said that they had sought help to deal with their teenagers’ behaviour.The most common sources of help were teachers and general practitioners.31

RESULTS - PART 13.4 CHRONIC DISEASEProportion of individuals with a chronic disease in participating householdsAccording to the primary carers, over half (53%) of the households had at least one person who had a chronicillness. The primary carer reported that a total of 187 (26.8%, 95% CI 23.5 to 30.2) of the individuals residingin the surveyed households had a chronic illness. The most commonly reported chronic illnesses wererespiratory disease (25%), cardiovascular disease (24%) and arthritis (18%) (Figure 3.6).Figure 3.6 Types of chronic illness reported by primary carers for the household members (n=187)302524.623.52017.6PERCENTAGE1510508.64.8 3.2 2.71.61.611.9ArthritisCardiovascularRespiratoryCHRONIC ILLNESSPsychiatricDermatologyOrthopaedicEar, nose & throatCancerOther endocrineOtherOf those with a chronic illness, 30% required some degree of help at home (Table 3.11). One in ten hadassistance from a home help while a public health nurse had visited 13% in the three months prior to the survey.Almost three quarters had visited their general practitioner with over half of them attending for a repeatprescription. Almost 30% had attended a hospital in the three months prior to the survey.A slightly higher proportion of individuals (104/348, 30%) living in a less deprived area had a chronic illnesscompared to the proportion (83/351, 24%) living in a more deprived area (p=0.06).32

RESULTS - PART 1Table 3.11 Primary carers’ reported types of chronic illness, the level of care required and the health servicesused by individuals residing in their householdsNo. %Degree of care requiredNo assistance 130 69.5Housekeeping including medication 53 28.3Housekeeping including medication and help to sit out in chair 3 1.6Total nursing care as confined to bed 1 0.5n 187Have organised home-helpYes 19 10.2No 168 89.8n 187Visited by public health nurse in the past 3 monthsYes 24 12.9No 162 87.1n 186Attended GP in past 3 monthsYes 135 72.6No 51 27.4n 186Reasons for GP visit (n=150)Repeat prescription 77 51.3Medical check up 44 29.3Sudden illness 24 16.0Advice 5 3.3GP’s surgery within walking distanceYes 151 82.0No 29 15.8Not registered with a GP 4 2.2n 184Hospital visits due to this disease/illness in last 3 monthsYes 55 29.6No 131 70.4n 186Characteristics and practices associated with those who have a chronic illnessBi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics,disability, health related behaviours, health service utilisation and waiting for health care) indicated that severalfactors were significantly associated with having a chronic illness.Logistic regression models were constructed to clarify the independent associations between the significantvariables and the likelihood of having a chronic illness (Table 3.12). The relationships presented are those thatremained statistically significant or were deemed clinically important after taking account of confounding. Theassociations are expressed as odds ratios (OR) adjusted for confounding.33

RESULTS - PART 1Table 3.13 Primary carers’ reported types of disability, the level of care required and the health services usedby individuals residing in their householdsNo. %Types of disabilityPhysical 16 76.2Learning 3 14.3Combination of physical and learning 2 9.5n 21Time occurredBorn with or occurred at the time of birth 9 42.9Childhood 1 4.7Adolescence 0 0Adult 11 52.4n 21Degree of care requiredNo assistance 12 57.1Housekeeping including medication 5 23.8Housekeeping including medication and help to sit in chair 1 4.8Housekeeping including medication, help to sit out in chair, attend to personalhygiene and feeding 1 4.8Total nursing care as confined to bed 2 9.5n 21Special aids requiredYes 11 55.0No 9 45.0n 20Type of aids (n=11)Mobility aids 7 63.6Household aids 3 27.3Hearing aid 1 9.1Have home helpYes 2 10.0No 18 90.0n 20Visited by nurse in past 3 monthsYes 5 25.0No 15 75.0n 20Attended GP in past 3 monthsYes 9 45.0No 11 55.0n 20Attended hospital or specialist services in past 3 monthsYes 5 25.0No 15 75.0n 20A similar proportion of household members who had a disability were living in the less deprived areas and in themore deprived areas (14/351, 4% versus 7/348, 2%, p = 0.1).35

RESULTS - PART 1Characteristics and practices associated with those who have a disabilityBi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics,chronic illness, health related behaviours, health service utilisation and waiting for health care) indicated thatseveral factors were significantly associated with having a disability.Logistic regression models were constructed to clarify the independent associations between the significantvariables and the likelihood of having a disability (Table 3.14). The relationships presented are those thatremained statistically significant or were deemed clinically important after taking account of confounding. Theassociations are expressed as odds ratios adjusted for confounding.Household members who were at home full time were almost six times (adjusted OR 5.9, CI 2.1 to 21.4) morelikely to have a disability than those not at home full time. Those who attended their general practitioner (adjustedOR 4.8, CI 1.1 to 33.2) and or the hospital (adjusted OR 5.4, CI 1.3 to 35.9) in the year prior to the survey werealso five times more likely to suffer from a disability than those who attended neither in the same time period.Table 3.14 Logistic regression model to identify factors associated with having a disability in the population (21/699)Total Reported Prevalence % Adjusted Odds p-valuedisabilityratio (95% CI)At home full timeNo 457 4 0.9 1Yes 242 17 7.0 5.9 (2.1 to 21.4) 0.002Missing 0Attended GP and/or HospitalNo 339 2 0.5 1Either 223 10 4.5 5.4 (1.3 to 35.9) 0.03Both 137 9 6.6 4.8 (1.1 to 33.2) 0.05Missing 0Whole model χ 2 =32.3, p

RESULTS - PART 13.7 ACUTE HOSPITAL SERVICESProportion of individuals who used hospital services in participating householdsAccording to the primary carers, at least one person in 52% of the households used one or more of the hospitalservices in the year prior to the survey. The primary carers reported that 176 (25.2%, 95% CI 22.0 to 28.6) ofthe 699 individuals residing in the households used the hospital in the 12 months prior to the survey. Of thosewho used the hospital, 36% attended outpatients, 24% were seen in accident and emergency, 9% were daypatients and 31% were admitted as inpatients (Figure 3.7).Figure 3.7 Hospital facilities used by household members as reported by primary carers (n= 176)PERCENTAGE403530252015105036.430.723.9Outpatient Inpatient Accident &emergencyHOSPITAL FACILITY USED9.1Day caseAccording to the primary carers, of those who attended the hospital, 18% attended as a result of cardiovasculardisease, 15% as a result of injury or an acute emergency and 10% with a respiratory problem (Figure 3.8).Figure 3.8 Household members’ reasons for attending hospital as reported by primary carers (n=176)252017.6PERCENTAGE151050Cardiovascular14.7Emergency10.0Respiratory7.1Obstetrics &gynaecology5.9Orthopaedic5.9Psychiatric4.7Gastro-intestinal4.7ENT4.7Dermatology4.1 3.5Non cancertumours (lumps)Cancer2.9Renal2.9Other endocrine2.4Arthritis9.0OtherREASON FOR ATTENDINGThe primary carer reported that over three fifths had a planned appointment at the time they attended thehospital (Table 3.15). According to the primary carers, almost one third of those who used a hospital servicereferred themselves. The respondents reported that 20 of the 176 individuals who used the hospital servicewere transported by ambulance; of these only half were emergency cases.A higher proportion of household members (108/348, 31%) living in the less deprived areas reported using ahospital service in the year prior to the survey compared to the proportion (68/351, 19%) living in the moredeprived areas (p = 0.0004).37

RESULTS - PART 1Table 3.15 Primary carers’ reported type of appointment for, channel of referral to and means of transport usedby individuals in their households to attend a hospital service in the 12 months prior to the surveyNo. %Utilisation planned or emergencyPlanned 111 63.1Emergency 65 36.9n 176Referral to hospital by:Self 55 31.6GP 84 48.3Hospital doctor 34 19.5Police 1 0.5n 174Transport used to travel to hospitalPrivate 103 59.9Public 49 28.5Ambulance 20 11.6n 172Characteristics and factors associated with those using a hospital service in the last yearBi-variate analysis using seven groups of variables (demographic characteristics, socio-economiccharacteristics, chronic illness, disability, health related behaviours, other health services utilised and waiting forhealth care) indicated that several factors were significantly associated with using a hospital service in the yearprior to the survey.Logistic regression models were constructed to clarify the independent associations between the significantvariables and the likelihood of using a hospital service in the year prior to the survey (Table 3.16). Therelationships presented are those that remained statistically significant or were deemed clinically important aftertaking account of confounding. The associations are expressed as odds ratios adjusted for confounding.38

RESULTS - PART 1Table 3.16 Logistic regression model to identify the factors that influenced use of a hospital service in the yearprior to the study among the population (176/699)Total Attended Proportion % Adjusted p-valuehospitalOdds ratio(95% CI)Chronic diseaseNo 512 80 15.6 1Yes 187 96 51.3 3.3 (2.2 to 5.1)

RESULTS - PART 1Accident and emergencyAccording to the primary carers, just over 6% of the household members had attended an accident andemergency service in the last year (Appendix 5). The primary carers reported that four fifths were satisfied withthe service. Among those who were satisfied, the main reasons given were: the staff listened to their problem(s)(50%), staff explained their medical condition (50%) and the hospital was nearby (45%). Among those whowere dissatisfied, the main causes were long waiting periods (42%), and staff were unfriendly (16%).Out patientsAmong the last three health services used, just over 9% of the individuals had attended an outpatients’department in the last year (Appendix 5). The primary carers reported that the majority (86%) were satisfied withthe service. Among those who were satisfied, the main reasons given were: staff listened to their problem(s)(54%), staff were friendly (51%) and staff explained their medical condition (46%). Among those who weredissatisfied, the main cause was long waiting periods (21%).InpatientsAccording to the primary carers, 7% of the individuals using hospital services in the last year were admitted tothe hospital (Appendix 5). The majority 89% were satisfied with the service. Among those who were satisfied,the main reasons given were: staff listened to their problem(s) (61%), the hospital was nearby (55%) and staffwere friendly (55%). Among those who were dissatisfied, the main cause was long waiting periods (9%).Day patientsAccording to the primary carers, 2% of the individuals were admitted as a day case. The majority (82%) weresatisfied with the service. Among those who were satisfied the main reasons for satisfaction were staff werefriendly (85%) and staff listened to their problem(s) (66%). The main reason for dissatisfaction was long waitingperiods (15%).3.8 HEALTH SERVICES FOR WOMENUptake of family planning, cervical smears and breast examinationThe women who described themselves as primary carers and were aged between 18 and 45 years were askedabout family planning practices (Table 3.17). Forty six percent reported that they were using a method of familyplanning. Of those who were currently using a method of family planning, nine percent of the women (or theirhusbands/partners) had been sterilised, 84% were using a temporary method of contraception while six percentwere using a natural method of family planning. Of those respondents who were not currently using a methodof family planning, almost one third said that they had no reason for not using a method of family planning.Fifty four percent of women, aged between 18 and 65 years, had a cervical smear in the last five years and43% within the same age group had a breast examination. Only 29% of women aged between 50 and 65 years(age group eligible for the National Breast Screening programme) had a mammogram within the last five years.40

RESULTS - PART 1Table 3.17 Primary carers’ reported current use of family planning, recent uptake of cervical smear tests andbreast examinationNo. %Use of family planning (women respondents 18 to 49 years)Yes 45 45.9No 53 54.1n 98Method of family planning usedNatural 3 6.7Temporary 38 84.4Permanent 4 8.9n 45Reason people do not use family planningNo reason 15 31.9Trying for a child, pregnant, postnatal 14 29.8Not currently sexually active 11 23.4History of hysterectomy 5 10.6On medication or fear of negative side effects 2 4.2n 47Cervical smear in last 5 years (women respondents 18 to 65 years)Yes 74 54.0No 63 46.0n 137Breast examination in last 5 years (women respondents 18 to 65 years)Yes 59 43.0No 78 56.9n 137Method of examinationBy a doctor 41 69.5Mammogram 18 30.5n 59Mammogram in last 5 years (women respondents 50 to 65 years)Yes 12 29.3No 29 70.7n 41Births and associated maternal health practices and servicesAccording to the primary carers, 22 children were born to 21 mothers, who currently reside in the area betweenJanuary 1997 and September 2001 (Table 3.18). Four (19%) of the women were between 16 and 19 years oldduring their most recent pregnancy.Primary carers reported ten (47%) of the women’s most recent pregnancies were unplanned. Eight of thewomen (38%) had taken folic acid prior to conception and six (29%) had smoked during their most recentpregnancy (Figure 3.10). Only one woman did not attend for antenatal care and similarly one woman did notattend for postnatal examination six weeks after delivery (Table 3.18). According to the primary carers, almosttwo thirds of the expectant women had antenatal care in a maternity hospital while only 30% had their careshared with the their general practitioner (Table 3.18). The vast majority had their youngest baby in the NationalMaternity Hospital, Holles Street.41

RESULTS - PART 1Table 3.18 Primary carers’ reported number of pregnancies in their households between January 1997 andSeptember 2001, and service uptake by pregnant women during each pregnancyNo %Women in household who have given birth in the last 4 yearsand number of births to each womanOne child 20 95.2Two children 1 4.8n 21Age when became pregnant on most recent occasion16 to 19 4 19.020 to 29 8 38.130 to 39 9 42.9n 21Antenatal care sought during pregnancyYes 20 95.2No 1 4.8n 21Place where antenatal care was receivedMaternity hospital 13 65.0Combined or shared care 6 30.0Consultant private clinic 1 5.0n 20Place of deliveryNational Maternity Hospital, Holles St 20 95.0Rotunda Hospital 1 5.0n 21Attended 6 week post natal check upYes 20 95.2No 1 4.8n 21Figure 3.10 Practices of women during their most recent pregnancy (between January 1997 andSeptember 2001) as reported by primary carers (n=21)PERCENTAGE100908070605040302010052.3Pregnancyplanned38.1Peri conceptualfolic acid28.6Smoked duringpregnancy95.2Antenatal carePRACTICES ASSOCIATED WITH PREGNANCY42

RESULTS - PART 1Satisfaction with maternity servicesAs one of the last three health services used, 11 women were admitted to a maternity hospital in the twelvemonths preceding the survey. Ten of them reported satisfaction levels; of these, five were satisfied with theirhealth care (Table 3.19). The main reason for satisfaction was that staff listened to their problem(s) and the mainreason for dissatisfaction was that the hospital did not provide adequate treatment or care.Table 3.19 Primary carers’ reported number (%) of individuals admitted to maternity hospital in the year priorto the survey, number (%) used the hospital, and the level of satisfaction with servicesNo %Admitted to maternity hospitalYes 11 5.5No 190 94.5n (women aged 15 to 49 years) 201Satisfied with care and treatment(1 very satisfied to 6 very dissatisfied)Yes (1 to 3) 5 50.0No (4 to 6) 5 50.0n 1043

RESULTS - PART 13.9 COMMUNITY HEALTH SERVICESGeneral PracticeAccording to the primary carers, 47% of the household members had attended their general practitioner as oneof the last three health services used in the year prior to the survey. Eighty nine percent were satisfied with theservice (Table 3.20). Among those who were satisfied, the main reasons were, the doctor listened to theproblem(s) (74%), the doctor was nearby (53%) and the doctor provided good treatment or care (52%).Among those who were dissatisfied, the main reason was that the doctor did not listen to the problem(s) (6%).Table 3.20 Primary carers’ reported number (%) of individuals who visited their GP in the year prior to thesurvey, their level of satisfaction with services and their reasons for satisfaction/dissatisfactionNo %Visited GPYes 327 46.8No 372 53.2n 699Satisfied with care and treatment from GPYes (1 - 3) 267 89.3No (4 - 6) 32 10.7n 299Level of satisfaction with care and treatment from GP(1 very satisfied to 6 very dissatisfied)1 199 66.52 54 18.13 14 4.74 19 6.45 3 1.06 10 3.3n 299Reason satisfied with care and treatment from GP (n = 299)Nearby 158 52.8Staff courteous and friendly 134 44.8Short waiting period 77 25.6Doctor listened to the problem 221 73.9Doctor explained the condition 139 46.5Doctor explained the treatment possibilities 105 35.1Doctor provided good treatment or care 184 51.5Service easily available on a 24 – hour basis 36 12.0Pleasant environment 35 11.7Affordable 20 6.7Organised appointments 20 6.7Reason dissatisfied with care and treatment from GP (n = 299)Too far 5 1.7Staff unfriendly 5 1.7Long waiting periods 12 4.0Doctor did not listen to the problem 19 6.4Doctor did not explain the condition 8 2.7Doctor did not explain the treatment possibilities 6 2.0Doctor provided inadequate or incorrect treatment 17 5.7Service difficult to access outside normal working hours 14 4.7Unpleasant environment 4 1.3Expensive 11 3.7No after care 11 3.744

RESULTS - PART 1A higher proportion of household members (181/348, 52%) living in the less deprived areas attended theirgeneral practitioner as one of the last three services used in the year prior to the survey compared to theproportion (146/351, 42%) living in the more deprived areas (p = 0.005).Table 3.21 Primary carers’ reported use of and satisfaction with ‘out of hours’ medical services and their sourceof health informationNo. %Services used for doctor out of hoursCall GP practice for radio doctor 171 62.9Go to hospital accident and emergency 23 8.4Depends on situation 36 13.2Never had to use the service 42 15.4n 272Satisfied with choice of out of hours serviceYes 138 60.0No 50 21.7Never thought about it 42 18.3n 230Source of information on health services (n=273)Staff at general practice 160 58.6Health information leaflet 73 26.7Family/friends 65 23.8Public broadcasting media 29 10.6Health centre staff 25 9.2Public health or community nurse 23 8.4Phone (includes directories and help lines) 19 6.9Internet 14 5.1At work 8 2.9Support groups 6 2.2Primary carers were asked what service they would access when seeking a doctor ‘out of hours’. Sixty threepercent would call a radio-doctor while less than 10% would go to an accident and emergency department.One fifth of respondents were unhappy with the current ‘out of hours’ general practitioner service (Table 3.21).Sources of health informationAccording to the respondents, the most important sources of health information were the general practice (includingthe receptionist, nurse and general practitioner), followed by health leaflets and then family/friends (Table 3.21).Characteristics and factors associated with those attending a general practitioner in the last yearBi-variate analysis using seven groups of variables (demographic characteristics, socio-economiccharacteristics, chronic illness, disability, health related behaviours, other health services utilised and waiting forhealth care) indicated that several factors were significantly associated with attending a general practitioner, asone of the last three health services used, in the year prior to the survey.Logistic regression models were constructed to clarify the independent associations between the significantvariables and the likelihood of attending a general practitioner in the year prior to the survey. Significant factorswere retained in the final model (Table 3.22). The relationships presented are those that remained statisticallysignificant or were deemed clinically important after taking account of confounding. The associations areexpressed as odds ratios adjusted for confounding.45

RESULTS - PART 1Table 3.22 Logistic regression model to identify factors associated with attending a general practitioner as oneof the last three health services used in the year prior to the survey among the study population (327/699)Total Attended Proportion Adjusted p-valueGP % Odds ratio(95% CI)GenderMale 319 118 36.1 1Female 380 209 63.9 2.3 (1.6 to 3.3)

RESULTS - PART 1Uptake of childhood vaccinesMotivation for childhood vaccines is done by public health nurses in the community and subsequently thevaccines are administered at general practice. Primary carers reported that 24 of the 25 children aged betweentwo and five years residing in their households had completed the routine childhood vaccines and of these, 18children had the meningitis C vaccine (Table 3.23).Table 3.23 Primary carers’ reported vaccination uptake for children aged between two and five years residingin their householdsNo. %Children’s vaccination statusStarted but incomplete 1 4.0Completed all vaccines 24 96.0n 25BCGYes 25 100No 0n 25DPT and Polio 3Yes 24 96.0No 1 4.0n 25HIB 3Yes 24 96.0No 1 4.0n 25MMRYes 24 96.0No 1 4.0n 25Meningitis CYes 18 75.0No 6 25.0n 24Community nursing serviceThe Area Health Boards notify mothers (in writing) and public health nurses remind mothers to bring theirinfants, when they are nine months old, for a developmental assessment by the area medical officers. Again 24of the 25 mothers reported that they had brought their infant for the developmental assessment.According to the primary carers, almost five percent of the household members were in contact with acommunity nurse, as one of the last three services used in the year preceding the survey (Table 3.24). Theprimary carers reported that over 80% were satisfied with the service. The main reasons for satisfaction werethat the nurse was courteous and friendly (69%), the nurse listened to their problem(s) (59%) and the nurseprovided good treatment (34%). The main reason for dissatisfaction was that the community nurse did not listento their problem(s) (9%).47

RESULTS - PART 1Table 3.24 Primary carers’ reported number (%) of individuals using the community nursing service in the yearprior to the survey, their level of satisfaction with services and their reasons for satisfaction/dissatisfactionNo %Used nursing serviceYes 32 4.6No 667 95.4n 669Satisfied with care and treatment from the nurseYes (1 - 3) 26 81.3No (4 - 6) 6 18.7n 32Level of satisfaction with care and treatment from the nurse(1 very satisfied to 6 very dissatisfied)1 22 68.82 4 12.53 0 04 2 6.25 0 06 4 12.5n 32Reason satisfied with care and treatment from the nurse (n = 32)Nearby 10 31.2Staff courteous and friendly 22 68.8Short waiting period 8 25.0Nurse listened to the problem 19 59.4Nurse explained the condition 9 28.1Nurse explained the treatment possibilities 10 31.2Nurse provided good treatment or care 11 34.4Service easily available on a 24 – hour basis 5 15.6Pleasant environment 4 12.5Affordable 2 6.3Organised appointments 2 6.3Reason dissatisfied with care and treatment from the nurse (n = 32)Too far 0 0.0Staff unfriendly 0 0.0Long waiting periods 2 6.3Nurse did not listen to the problem 3 9.4Nurse did not explain the condition 0 0.0Nurse did not explain the treatment possibilities 0 0.0Nurse provided inadequate or incorrect treatment 0 0.0Service difficult to access outside normal working hours 1 3.1Unpleasant environment 1 3.1Expensive 0 0.0No after care 1 3.148

RESULTS - PART 1Dental servicesThe primary carers reported that less than 12% of the population had visited a dentist, as one of the last threeservices used, in the 12 months prior to the survey (Table 3.25). The majority, 86% were satisfied with theservice. Among those who were satisfied, the main reason was the dentist listened to their problem(s) (64%).Among those who were dissatisfied, the main reason was that the treatment was expensive (14%).Table 3.25 Primary carers reported number (%) of individuals who visited their dentist in the year prior to thesurvey, their level of satisfaction with services and their reasons for satisfaction/dissatisfactionNo %Visited dentistYes 81 11.6No 618 88.4n 699Satisfied with care and treatment from the dentistYes (1 – 3) 60 85.7No (4 – 6) 10 14.3n 70Level of satisfaction with care and treatment from the dentist(1 very satisfied to 6 very dissatisfied)1 49 70.02 11 15.73 0 0.04 6 8.65 1 1.46 3 4.3n 70Reason satisfied with care and treatment from the dentist (n = 70)Nearby 19 27.1Staff courteous and friendly 43 61.4Short waiting period 20 28.6Dentist listened to the problem 45 64.3Dentist explained the condition 39 55.7Dentist explained the treatment possibilities 30 42.9Dentist provided good treatment or care 38 54.3Service easily available on a 24 – hour basis 11 15.7Pleasant environment 15 21.4Affordable 7 10.0Organised appointments 6 8.6Reason dissatisfied with care and treatment from the dentist (n = 70)Too far 2 2.9Staff unfriendly 4 5.7Long waiting periods 3 4.3Dentist did not listen to the problem 2 2.9Dentist did not explain the condition 1 1.4Dentist did not explain the treatment possibilities 0 0.0Dentist provided inadequate or incorrect treatment 1 1.4Service difficult to access outside normal working hours 3 4.3Unpleasant environment 1 1.4Expensive 10 14.3No after care 0 0.049

RESULTS - PART 13.10 WAITING FOR HEALTH CAREAccording to the primary carers, at least one person in every ten households was waiting for health care at thetime of the survey. Twenty six (3.7%, 95% CI 2.4 to 5.4) of the 699 individuals residing in the participatinghouseholds were waiting for health care at the time of the survey (Table 3.26).Figure 3.11 Type of treatment awaited by household members as reported by primary carers (n=26)PERCENTAGE403530252015105034.6Surgery26.9Outpatientconsultation11.511.57.7Dentist ENT Opthalmology Dermatology Longterm care3.83.8TYPE OF TREATMENTThe primary carer reported that, of those who were waiting for health care, 35% awaited surgery and 27%awaited an outpatient’s consultation (Figure 3.11). Three quarters were waiting for more than three months.Almost two thirds of primary carers thought that the waiting time was unacceptable. Over 40% were waiting forhealth care in St. Vincent’s University Hospital, Elm Park.Table 3.26 Primary carers’ reported number (%) of individuals residing in the households waiting for healthcare, length waiting for service, location of service and satisfaction with waiting periodNo %On a waiting listYes 26 3.7No 673 96.3n 699Length of wait in monthsLess than 3 6 23.14-6 11 42.37-12 7 26.9More than 12 2 7.7n 26Area in which the service being waited for is providedSt Vincent’s University Hospital 11 42.3Elsewhere 15 57.7n 26Opinion on waiting time(1 very reasonable to 5 very unreasonable)1 2 8.02 2 8.03 5 20.04 2 8.05 14 56.0n 2550

RESULTS - PART 1Factors associated with those waiting for health careBi-variate analysis using six groups of variables (demographic characteristics, socio-economic characteristics,chronic illness, disability, health related behaviours, and health services utilised) indicated that several factorswere significantly associated with reported waiting for health care at the time of the survey.Logistic regression models were constructed to clarify the independent associations between the significantvariables and the likelihood of reported waiting for health care at the time of the survey (Table 3.27). Therelationships presented are those that remained statistically significant or were deemed clinically important aftertaking account of confounding. The associations are expressed as odds ratios adjusted for confounding.Table 3.27 Logistic regression model to identify determinants of those waiting for health care in thepopulation (53/699)Total Awaiting Proportion Adjusted p-valuehealth care % Odds ratio(95% CI)DisabilityNo 678 22 3.2 1Yes 21 4 19.1 4.3 (1.1 to 13.7) 0.02Missing 0Attended both the GP andthe hospital within the last yearNo 562 11 2.0 1Yes 137 15 10.9 9.0 (3.1 to 32.3) 0.0002MissingWhole model χ 2 =26.3, p

RESULTS - PART 1Table 3.28 Additional health care services suggested by primary carersNo. %Additional services neededYes 217 79.8No 26 9.5Do not know 29 10.7n 272Suggested additional services (n=217)Improved hospital services 47 21.6GP in accident and emergency 74 34.0Out of hours local GP service 80 36.9Clinic specially to promote women’s health 39 17.8Clinic specially to promote men’s health 18 8.3Clinic specially to promote child health 23 10.6Psychological services for adolescents 28 12.9Contraceptive advice for adolescents 36 16.6Counselling service 44 20.3Drug/alcohol services 34 15.7Free child health services 10 4.6Day care services for the elderly 55 25.3Respite services for the elderly 35 16.0Long term care for the elderly 39 18.0Home visits for the elderly 20 9.2Improved services for disabled (physical and intellectual) 11 5.1Local medical centre 15 6.9Social work service 55 25.3Improved student health services 3 1.4Speech therapy for children 2 0.9Community physiotherapist 1 0.5Dental services for children 15 6.9Bus services 7 3.2Information 5 2.352

RESULTS - PART 1Location of a health centreThe primary carers were asked to suggest a location for a health centre that would suit both communities. Manyof the respondents suggested a location in their own areas with the majority stating Pearse Street (36%) andover a quarter suggesting Ringsend or Irishtown (Table 3.29). Also a total of 48 (18%) respondents stated thatthey did not use services locally and therefore did not make any suggestions.Table 3.29 Primary carers’ suggestions for the location of a health centre that would serve both communitiesNo %Suggested location for health centre that would suitboth communities (n=155)Pearse Street 56 36.1Ringsend/Irishtown 27 17.4Irishtown Health Centre 12 7.7Somewhere in the middle 11 7.1Gas Company 9 5.8Trinity College car park 8 5.2Sir Patrick Dunn’s 8 5.2South Lotts Road 4 2.6Grand Canal Street 2 1.3Bath Avenue 2 1.3Community Centre Ringsend 2 1.3Individual centre for both areas 2 1.3St. Andrew’s Resource Centre 1 0.6Inner city 1 0.6College Green 1 0.6Cambridge Road 1 0.6Shelbourne Park 1 0.6Old bottle house 1 0.6Baggot Street 1 0.6Dork Street 1 0.6Macken Street 1 0.6Barrow Street 1 0.6Haddington Road 1 0.6Dockland development site 1 0.653

RESULTS - PART 13.12 COMPARISONS BETWEEN THE COMMUNITIES LIVING IN THE PEARSE STREETAREA AND RINGSEND/IRISHTOWNAll the variables were analysed comparing the characteristics, health status and service utilisation for the peopleliving in the Pearse Street area with those living in Ringsend/Irishtown. The results were similar for the majorityof the factors. The results presented are those that remained statistically significant or were deemed clinicallyimportant (Table 3.30).Table 3.30 Summary of comparisons between the communities living in the Pearse street area and Ringsend/IrishtownPearse Street Ringsend/ Test of associationIrishtownOccupationCollege 24 6.6 7 2.1 χ2 =10.6, df =4, p = 0.03Employed 170 46.6 147 44.0Home 116 31.7 126 37.7School 50 13.7 49 14.7Training 5 1.4 5 1.5n = 699 365 334Hospital useYes 79 21.6 97 29.0 χ2 =5.1, df =1, p = 0.02No 286 78.4 237 71.0n = 699 365 334No. of cigarettes smokedLess than 10 30 27.5 32 42.710-20 48 44.0 21 28.0 χ2 =9.2, df =3, p = 0.02More than 20 31 28.4 22 29.3n = 184 109 75Attend the GPYes 187 51.2 140 41.9 χ2 =6.1, df =1, p = 0.01No 178 48.7 197 58.1n = 699 365 334Primary carers’ use of familyplanning (age 18 to 49)Yes 16 32.6 29 59.2 χ2 =6.9, df =1, p = 0.008No 33 67.4 20 40.8n = 98 49 49Primary carers’ who had a breastcheck in the last 5 yearsYes 26 35.6 32 50.0 χ2 =2.9, df =1, p = 0.08No 47 64.4 32 50.0n = 137 73 64Year moved into the area1922 to 1940 3 2.1 12 9.61941 to 1960 8 5.7 16 12.81961 to 1980 16 11.4 29 23.2 χ2 =23.2, df =4, p >0.00011981 to 1990 40 28.6 19 15.21991 to 2001 73 52.1 49 39.2n = 265 125 140Choice of Health centrePearse street 93 83.8 7 6.1Ringsend/Irishtown 11 9.9 106 92.2 Fishers’ exact test, p > 0.0001Baggot Street 6 5.4 1 0.9Sandymount 1 0.9 1 0.9n = 226 111 11554

RESULTS - PART 1People living in the Pearse Street area (7%) were more likely to attend college than the people living inRingsend/Irishtown (2%). The residents living in Ringsend/Irishtown (38%) were more likely to be at home fulltime than those living in the Pearse Street area (32%). A slightly higher proportion of people living inRingsend/Irishtown (29%) used a hospital service within the last year than those residing in the Pearse Streetarea (21%). It is interesting to note that of the 10 people who used the psychiatric hospital services within thelast year, nine were living in the Pearse Street area. A higher proportion of people living in the Pearse Streetarea (51%) attended their general practitioner within the last year than those living in Ringsend/Irishtown (42%).Primary carers living in Ringsend/Irishtown (59%) were more likely to report using a method of family planningthan those living in the Pearse Street area (33%). A higher proportion of female primary carers living inRingsend/Irishtown (50%) said they had a breast check within the last five years compared to those living in thePearse Street area (36%). More householders in the Pearse Street area (52%) had moved into the area withinthe last 10 years than in Ringsend/Irishtown (39%). When the primary carer was asked where s/he preferredto attend a health centre the majority in both the Pearse Street area (83%) and Ringsend/Irishtown (92%)wanted to attend a centre in their own areas.55

DISCUSSIONPART 1

DISCUSSION - PART 1DISCUSSIONThe high response rate indicates a high level of interest in health in the Pearse Street area and inRingsend/Irishtown. The respondents were pleased to take part in the study and were keen to offer theiropinions about the health services and health needs in the area. In fact four out of every five respondents hadsuggestions for additional health or social services. There were similar response rates in areas classified as highdeprivation and low deprivation. Of note, the response rate for those living in the apartment blocks wassignificantly lower than for those living in houses or in local authority flat complexes (27% versus 84%).Therefore, the results of this study are to a large extent a reflection of the stable (longer term) community livingin the Pearse Street area and in Ringsend/Irishtown.This area, in common with all inner city areas of Dublin, has experienced significant change over the pastdecade and is certain to continue changing as documented in the Dublin Dockland development plan. 8The Pearse Street area and Ringsend/Irishtown have high levels of deprivation, 2 have very similar needs but aretwo distinct geographical communities. This was very apparent when people were asked "where would you liketo attend a health centre"? The majority in both the Pearse Street area and in Ringsend/Irishtown wanted toattend a health centre in their own area.Many factors influence and determine health including social and economic factors. A higher proportion ofhouseholds in this area live in government supported accommodation compared with the proportion ofhouseholds in the Tallaght area (37% versus 25%). 3 Almost 23% of individuals aged between 15 and 65 yearsold were not in employment which is higher than the national average (6%). 9 Half of the primary carers hadeither no formal education or had completed school at primary school level. In the study area, 45% ofhouseholds had a medical card which is much higher than the national coverage rate (32%) 10 and the coveragerate in the Eastern Regional Health Authority area (26%). 11 The medical card is means tested and therefore,regarded as a good indicator of poverty. The high levels of deprivation and the low levels of formal educationare major considerations when planning the health services and communicating with people in the area.Therefore, it is clear that a multi-disciplinary and inter-sectoral approach is required to address the social andhealth needs of this area.There is high service utilisation at both hospital and community level. A marginally higher proportion reportedchronic illnesses (27%) in the Pearse Street and the Ringsend/Irishtown areas compared to the proportion thatreported these illnesses (22%) in the Tallaght area, whereas the proportion with disability in both areas wassimilar. 3 These levels give an indication of the ongoing utilisation of both community and hospital services.Amongst the services requested by primary carers was an improved ‘out of hours’ general practitioner service.Respondents also suggested that it would be of benefit if people could have investigations (bloods and x-rays)done locally and a facility to deal with minor injuries.According to the primary carers, over half of households had at least one person who smoked cigarettes,indicating high levels of passive smoking. Among household members 18 years old or over, 31% smoked,which is similar to the national figure for cigarette smoking (31%). 12 Drug and alcohol problems appear to havebeen under reported by the respondents, as both these issues were raised as health care needs by bothcommunity organisations and the respondents in the surveyed households. Of particular concern to the peopleliving in both the Pearse Street and the Ringsend/Irishtown areas was the increased level of teenage drinking.The Pearse Street area and the Ringsend/Irishtown areas have a much larger proportion of individuals’ aged 65years and over than the overall proportion in the Eastern Regional Health Authority area (17% versus 10%). 11It is of interest to note that of the 86 primary carers aged between 65 and 95 years old, 47 (55%) were livingon their own. Of these 47 older respondents living alone, 38 reported a chronic illness and 21 reportedattending the hospital within the last year.57

DISCUSSION - PART 1The research team observed and commented on the loneliness and isolation of many of the older people livingin the Pearse Street and Ringsend/Irishtown areas. According to the respondents, in some cases this was asa result of recent bereavement, but in the majority of cases it was due to the change in house ownership overthe last five to ten years. Respondents said that there are people living in the area, who no longer know theirneighbours and there is little or no integration between old and new residents in the community. The number ofelderly living on their own and the change in the community support network has a direct impact on the healthneeds of the elderly and the workload of service providers.The majority of people commented on the very good service provided for the elderly in Baggot Street Hospitaland Sir Patrick Dunn’s Hospital but requested additional hospital and community services for the growing elderlypopulation. The challenge for the health and social services will be to provide a service that responds to theneeds of the elderly within a supportive environment.During consultation with community organisations and the household interviews, individuals commented on thedifficulties accessing services as a result of the restructuring of the Eastern Regional Health Authority. Manypeople felt the boundaries in the area were confusing and without logic. Residents were not sure which healthcentre they should attend or where to contact if they had queries.Almost half of the residents had moved into either the Pearse Street area or Ringsend/Irishtown within the lastten years. The level of migration was significantly higher in the Pearse Street area than in Ringsend/Irishtown(52% versus 39%). Local analysis attributes this in part to the growing number of private developments takingplace in the area. During the household survey, where possible, the researchers did ask the residents in theapartment blocks if they used local health services. In fact the main reason given by the residents of these blocksfor refusing to participate in the survey was that they did not know the location of nor use the health services.Of note, a further 48 of the 273 primary carers interviewed stated they did not use services locally. The fact thatthere is no health centre in the Pearse Street area may have contributed to their lack of awareness of localservices. Although people living in the Ringsend/Irishtown area also said that they did not know where the localhealth centre is situated. This indicates the need for the South Western Area Health Board to provide updatedinformation about the types of local health services available and where they are located.Stress has been identified as a major contributory factor to both mental and physical well being. 12 Highproportions of primary carers reported experiencing stress in the last year and subsequently suffering negativeconsequences of this stress. These findings are similar to the findings in the Tallaght survey. 3 As in the Tallaghtarea, many of the respondents relied on family or friends to help deal with stress. 3 In this survey and the Tallaghtsurvey, 3 there was little reported evidence of community based non-pharmacological support for stress. Thisindicates a lack of awareness of the health implications associated with stress and the need for serviceproviders to promote alternative methods of stress management.Similar proportions of primary carers in both this survey area and Tallaght 3 experienced intimidation or violencewithin the last year (11% versus 10%). In this survey (33%) and the Tallaght survey (23%), 3 high proportionsin both areas sought medical assistance as a result of the incident. This highlights two factors, first that theviolence experienced resulted in injury and secondly that violence is an important health care issue.Although numbers are small, vaccine uptake rates are higher in the study area than those quoted nationally fromthe Regional Interactive Child Health System’s data by Fitzgerald et al. 13The new primary care strategy emphasises that the health service should be available to all people within a givengeographical area, irrespective of who they are, where they live or their income. 1 The challenge will be to providea service that responds to the needs of all the community and is accessible to all, but particularly to those withthe greatest need.This report contains a wealth of information for people in the community and for health service planners andproviders. We hope it will be used by the community to advocate for additional services and that it will assist inthe planning of local health services.58

REFERENCES - PART 1REFERENCES1. Department of Health and Children. Primary Care A New Direction. Dublin: Stationery Office, 2001.2. Small Area Health Research Unit. A National Deprivation Index for Health and Health Services Research.Dublin: Department of Community Health and General Practice, Trinity College, 1997:49.3. People living in Tallaght and their Health, A community based cross-sectional study. Dublin. Department ofCommunity Health and General Practice, Trinity College, 2002.4. Lemeshow S, Robinson D. Surveys to measure programme coverage and impact: a review of the methodologyused by the expanded programme on immunization. World Health Statistics Quarterly 1985;38:65-75.5. Primary Health Care Management Advancement Programme. Assessing Community Health Needs andCoverage. 1st ed. Geneva: Aga Khan Foundation, 1993.6. Sall J, Lehman ASI. JMP Start Statistics: Version 3.2. Belmont New York: Duxbury Press, 1996.7. STATA Corporation. Reference manual-STATA release 3.1. 6th ed: College Station, 1993.8. Dublin Docklands Development Authority. City Quay and Westland Row, Area Action Plan. Dublin 2001.9. Central Statistics Office. Quarterly National Household survey. Cork: Central Statistics Office Office, 2001.10. Watson D, Williams J. Perceptions of the Quality of Health Care in the Public and Private Sectors in Ireland.Dublin: The Economic and Social Research Institute, 2001:91.11. Department of Public Health report, Eastern Health Board. Public Health at the turn of the century. Dublin 2000.12. Friel S, Nic Gabhainn S, Kelleher C. The National Health & Lifestyles Surveys. Dublin: Health PromotionUnit, Department of Health & Children, 1999:47.13. Fitzgerald M, O'Flanagan D. Immunisation uptake statistics for Ireland, Quarter 4. Dublin: National DiseaseSurveillance Centre, 2001.59

PEOPLE LIVING IN THE DUBLIN DOCKLANDSAND THEIR HEALTHThe health needs of people living in thePearse Street area, Ringsend and IrishtownPART 2 THE HEALTH SERVICE PROVIDERS’ PERSPECTIVEFrances O’KeeffeJillian DeadyJean LongTom O’Dowd

SUMMARY - PART 2SummaryThe main research findings are presented in this summary. More detailed findings are available in the results section.What we set out to doWe set out to gain a better understanding of the health needs and the current service provision in the area fromthe health and social service providers’ perspective. We also explored the participants’ perceptions of coordinationand teamwork amongst service providers and sought suggestions that would facilitate the primarycare team to work together effectively.How we conducted the studyWe obtained permission from the General Manager of the Dublin South City District to contact the seniormanager of each health service discipline within the Area Health Board. We contacted persons employed inprivate practice individually. We informed service providers about the study and asked them to discuss with theircolleagues the health needs in the area. We sent them a topic guide to assist with their discussion. We requestedthat they nominate a colleague from their discipline who would be willing to be interviewed on their behalf.Eighteen service providers agreed to participate. They represented a broad spectrum of health and socialservice providers in the community including doctors, nurses, therapists, home helps, social workers andcommunity workers. We collected the information through taped semi-structured interviews.What we foundThe results are presented under three broad categories: the health issues in the community, services andresources in the community, and co-ordination and teamwork in the area.The health issues in the communityThe health service providers were asked what were the main health issues in the area. The responses wereallocated into one of three categories: physical, mental or social.The respondents reported that:• The physical problems covered a broad spectrum of diseases affecting all age groups.• The problems associated with older people were the main problems. These included respiratory andcardiovascular diseases, arthritis, reduced mobility, physical frailty, incontinence, chronic leg ulcers andterminal illness.• Depression was the main mental health problem affecting both young and old.• The main factors associated with depression were, drug and alcohol misuse, the stress of daily living,loneliness and isolation, and social deprivation.• Overall the main social issues that had an impact on the health of the community were loneliness and isolationamong the elderly, the effects of alcohol and drug misuse, and factors associated with social deprivation(poor housing, poor education etc).Services and resources in the communityThe health service providers were asked to elicit the main barriers or difficulties they experienced in deliveringtheir service, to suggest methods that would improve existing services and to identify additional services required.The service providers interviewed worked in either the Pearse Street area or in Ringsend/Irishtown orboth. Respondents commented on the fact that these communities had separate identities, although bothneeded services.The main barriers discussed were related to insufficient staff, inadequate local health facilities and the difficultiesencountered promoting better health practices in a socially deprived area. The respondents also spoke aboutthe difficulties encountered for both service providers and service users since the restructuring of the healthboard. They spoke about the problems experienced by the elderly who have difficulties accessing the healthcentres because they are no longer within walking distance. Respondents also said that people living in thecommunity were unsure which health centre they should attend or where to contact if they have queries.61

SUMMARY - PART 2Respondents were asked what resources were required in the area. Most of the respondents stated they didnot have enough resources and reported the need for:• More staff within their own specific service and within the other services.• Regardless of their own discipline most respondents reported a shortage of physiotherapists,occupational therapists, speech and language therapists and social workers.• A health centre in the Pearse Street area and the need for the existing health centre in Irishtown to berenovated and upgraded.• Facilities available at local level for area medical officers, occupational therapists, speech and languagetherapists and other services not currently based in the area, to provide a more effective service.• An expanded service for the elderly including a full time social worker, suitably adapted local transport,and emergency respite beds in the local area.• Crèche facilities in the area and an expanded social work service to support families.Respondents were asked for suggestions on how to improve services. Apart from the many resources alreadymentioned the main suggestions were:• Improve formal communication between disciplines so as to improve teamwork.• Incorporate more health promotion and prevention activities in their daily work.• Place more emphasis on a client centred service.• Collate information on the different services available in the area and disseminate the information toboth service providers and service users.• Provide ongoing training and further education for service providers to ensure they continue to providea good service.Co-ordination and Teamwork in the areaThe respondents were asked to discuss the level of co-ordination amongst service providers in the area. Mostof the respondents said that there was some level of co-ordination (ranging from poor to good) in the area.They reported that:• There was no formal structure for communicating within the health services and most co-ordinating wasdone on an informal basis.• Communication was mainly by telephone with very little ‘face to face’ meetings with the other disciplines.• The level of co-ordination depended on the personalities of the individuals working within the differentdisciplines and how long they had worked in the area.• The service providers worked in isolation and this negatively affected the delivery of the service.• There was good co-ordination and communication between the community services and the local hospitalsand vice versa. On the other hand respondents said that there was poor co-ordination between the acutehospital services and the community health services.• The level of co-ordination between the health services and other government sectors, the voluntary servicesand the community itself, varied.• Co-ordination was generally much better if the services were in the same premises or in close proximity toeach other.62

SUMMARY - PART 2Respondents were asked to give suggestions as to how the primary care team could work better for thecommunity. The majority of the participants made very positive suggestions and displayed a great willingness towork together.The respondents suggested that:• The service providers needed to be based within a geographical area, and ideally based within the samehealth facility.• It was important to have structured team meetings and good communication between the different services.• Knowing the individuals in the team and using information technology would improve communication.• Potentially the primary care team could work together in the area of health promotion and advocacy on behalfof the community.• The area being surveyed would be ideal for a primary care pilot project.ConclusionThe health service providers displayed a vast knowledge of the area and showed a keen interest to worktogether to improve the overall service for the community.63

METHODSPART 2

METHODS - PART 2METHODS1.0 IntroductionIn April 2001, the Royal City of Dublin Hospital Trust (Baggot Street Hospital) commissioned a study toinvestigate the health needs of the people living in the Pearse Street area, Irishtown and Ringsend. TheDepartment of Community Health and General Practice, based at the Trinity College Centre for HealthSciences, Adelaide and Meath Hospital, Dublin, incorporating The National Children’s Hospital, was requestedto undertake the study. The South Western Area Health Board (SWAHB) fully endorsed the study.The first part of the study consisted of a household survey in the community and the results are presented inPart 1 of this report. During August and September 2001 the service providers were contacted and informedof the household survey. They were also invited to participate in a study to ascertain the needs from the serviceproviders’ perspective. Following completion of the household survey representatives from the differentdisciplines within the health services were interviewed.1.1 AimThe study set out to gain a better understanding of the health needs and the current service provision in thearea, from the health service providers’ perspective. The research also sought to explore the participants’perceptions of co-ordination and teamwork amongst service providers and sought suggestions that wouldfacilitate the primary care team to work together effectively.1.2 Research DesignGiven the importance of exploring the service providers understanding and experiences from their ownperspectives, this study employed a qualitative methodology, using a grounded theory approach.Grounded theory is a method of collecting and analysing qualitative data with the aim of developing theories thatare grounded in real world observations. The goal of grounded theory is to provide a description or anexplanation of events as they occur in reality, and not just as they have been perceived anecdotally.The information was collected through a semi-structured, in-depth taped interview. The semi structuredinterview is used when the researcher knows the type of questions to be asked but cannot predict the answers.This approach was chosen as it ensures that the researcher obtains the information required while at the sametime permitting the participants’ freedom to describe their experiences and understandings in their own words.1.3 Study PopulationIn grounded theory individuals are chosen based on their knowledge and expertise of the research topic. In thisstudy the population consisted of the health service providers within the Pearse Street area and the Ringsendand Irishtown areas.1.4 SamplingThe selection of an appropriate and adequate sample is crucial in qualitative research. 1 Purposeful samplingselects individuals for study participation based on their knowledge of the research topic. For this study apurposeful sample of health service providers within the study area was chosen. Approximately 15-20 interviewswere deemed necessary to achieve maximum saturation. 2 65

METHODS - PART 21.5 FieldworkPermission was obtained through the General Manager of the Dublin South City District (CCA3) to contact thesenior manager of each health service discipline within the area. Persons employed in private practice werecontacted individually. All the personnel contacted were informed about the study and asked to discuss withtheir colleagues the health needs in the area. A topic guide was sent to assist in the discussion (Appendix 6).They were asked to nominate a colleague who would be willing to be interviewed on behalf of their discipline.The participants who agreed to be interviewed were contacted by phone to arrange the interview. Theresearcher allowed full flexibility regarding the time and place of the interview.The interviews took place between the 29th of November and the 11th of December 2001. A total of 18 healthservice providers were interviewed. Each interview lasted approximately 30 minutes, ranging form 20 to 45minutes. Prior to commencing each interview a full explanation of the research was given to each individualparticipant. The researcher reassured the participants about confidentiality and anonymity. Participants werethen invited to sign a consent form, indicating their voluntary participation in the study (Appendix 7). Participantswere also made aware of their freedom to withdraw from the interview at any time.Each interview started with a general introductory question. The topic guidelines were used to probe the areasof interest (Appendix 6). As the interview progressed the researcher asked the participants to clarify issues thatemerged during the interview process. In order to ensure that the researcher would not influence emerging data,the interviewer refrained from offering opinions or answering questions during the course of the interview. Noteswere taken at the end of the interview in which the researcher recorded personal reflections on the interview.1.6 Data AnalysisAll interviews were transcribed verbatim. Transcription included information on pauses and gaps, as well ascomments in brackets using Silverman’s transcription symbols (Appendix 8). The researcher read thetranscripts while listening to the tapes. This served to improve familiarity with the data collected and helped toverify accuracy of transcriptions.Five interviews were analysed manually through detailed scrutiny of the transcripts to identify common conceptsand these were coded. The coded transcripts were reviewed by two experienced reserchers to ensure theinterviews were coded correctly. All the interviews were then coded using a qualitative research softwareprogramme ‘Ethnograph’ and subjected to analysis. Similar concepts or codes were then grouped together. Anumber of categories and sub categories were identified in the study.A copy of the findings was sent to five of the participants. They were asked to read through the report and tocomment on whether they felt it accurately represented their views. This was done to enhance the credibility ofthe study.66

SUMMARYRESULTSPART 2

RESULTS - PART 2RESULTS2.0 INTRODUCTIONEighteen service providers were interviewed, five of whom were male. They represented a broad spectrum ofhealth and social service providers in the community including doctors, nurses, therapists, home help serviceand social workers. Four service providers worked mainly with children, three worked with older people and theremainder worked with people in all age groups.The results are presented under three broad categories: the main health issues for people living in thecommunity, services and resources needed to respond to the people’s needs, and the level of co-ordination andteamwork among health providers in the area including insights on how best to facilitate the primary care teamto work.Participants were asked how long they had worked in the area. On average the health service providers hadworked for seven and a half years in the area (ranging from 10 weeks to 30 years). Half of the respondents hadworked in the area for 10 years or more. Some of the participants said that they had worked longer in thecommunity care area but the area being surveyed had only become part of their catchment area since theintroduction of the three Area Health Boards.2.1 THE HEALTH ISSUES IN THE COMMUNITYThe health service providers were asked what were the main health issues in the area. The responses wereallocated into one of three categories: physical, mental or social.Physical problemsThe physical problems covered a broad spectrum of diseases. Many of the respondents (11) spoke about theproblems associated with the older people. These included arthritis, reduced mobility, physical frailty,incontinence, chronic leg ulcers and terminal illness.Respondents also talked about chronic illnesses including respiratory problems (young and old), cardiovascularproblems (including hypertension), arthritis, diabetes (young and old), neurological problems (Parkinson’sdisease, cerebral palsy, multiple sclerosis and motor neurone disease), physical disability and problemsassociated with care of patients with cancer and other terminal illnesses.Women’s health related issues also presented as health problems for people living in the area. These includedissues associated with pregnancy, antenatal and postnatal care, family planning and contraceptive advice (adultsand teenagers). For young children the main problems mentioned were related to hearing and speech, dentalcaries and orthodontics. Respondents said that the physical complications associated with lifestyle issues (suchas smoking, drug and alcohol misuse) added to the burden of ill health in the community.Mental health problemsOver half of the respondents (10) spoke about depression as the main mental health problem. Respondentsreported that depression affects both young and old. According to the respondents the main mental health issuefor younger people was depression associated with drug and alcohol misuse.‘…depression….You know as a result of being on the drugs as well as being kinda off the drugs…. there’s alot of hopelessness and depression around’ (HSP14)‘We would see an abuse of alcohol, maybe leading to depression’ (HSP16)With reference to families the respondents highlighted that postnatal depression and depression associatedwith the stress of day-to-day living were the main mental health problems.68

RESULTS - PART 2‘The depression that some of our mothers are suffering from for various reasons, from their, maybe their familybackground, or from their families that they are trying to cope in difficult situations so depression would be oneof the most underlying themes that we’re working with very vulnerable families’ (HSP16)Respondents reported that depression among older people was mainly associated with loneliness and isolation.‘…all ageing process problems, just getting older….and the loneliness and the related depression thatbecomes more apparent as time goes on’ (HSP3)‘…and with the elderly, often times they have no backup and they’re isolated and so on, and they becomedepressed’ (HSP13)Many of the respondents said that mental health issues and social deprivation were interlinked. Peopleexperiencing deprivation were more likely to have mental health problems.‘…because we are a very deprived area there is the social phenomenon of people with mental health problems….we have an inordinate amount of people with mental health problems….many of them in poor livingconditions, poor housing etc.’ (HSP18)According to the respondents a small proportion of people living in the community also suffer from other mentalhealth problems such as anxiety, schizophrenia, psychosis, manic depression, Alzheimer’s and senile dementia.Respondents reported that autism, attention deficit disorder and intellectual disability were mental health issuesaffecting children living in the area. One respondent who works specifically with children noted that the numberof children with these disorders had increased over the last few years (HSP10).Social problemsAll the respondents spoke about the different social issues that impact on the health of the community. The threemain issues discussed were loneliness and isolation among the elderly, the effects of alcohol and drug misuse,not only on the individuals but also on their families, and the link between social deprivation and health.Loneliness and isolationThe most common issue discussed (10) was the loneliness and isolation of the elderly in the community. Accordingto the respondents, in some cases this was as a result of recent bereavement but for the majority of cases it wasas a result of the changing social support network in the area. The respondents said that the social network hadchanged because the children of the older population could no longer afford accommodation in the area. Thosewho are now buying houses in the area do not necessarily mix with the local community, and this has resulted inan older unsupported population. Many new residents have moved into the area over the last five to ten years. Themajority are young and are out at work and as a result older people no longer know their neighbours.‘I mean years ago everybody knew everybody else. Everyone knew their neighbours but nowadays there’s alot of younger people moved in and there isn’t the same kind of neighbourhood’ (HSP1)The health service providers noted the valuable assistance provided by the facilities in the area for their olderclients, for example, the day centre in St. Andrews Resource Centre, Cambridge Court in Ringsend, Sir PatrickDunn’s hospital and Day Care Unit and Baggot Street Hospital. Respondents also highlighted the loneliness andisolation experienced by the elderly who are housebound or living alone but do not attend local facilities and donot have regular visits from family and friends.‘In the elderly population you have quite a few older people who are quite isolated, don’t go out, don’t meetother people….can be left at home with very little in the way of services and not seeing people, you know.They go to Mass up there in the morning and that’s often the highlight of their day, there’s nothing else youknow’ (HSP13)69

RESULTS - PART 2‘Em, another problem I’ve encountered is loneliness. A lot of people are very lonely, a lot of old people…. it’slack of someone to talk to….A lot of these people are housebound’ (HSP1)Drug and alcohol misuseMany of the respondents (7) spoke about the effects of alcohol and drug addiction on the health of individualsin the community. Apart from the physical and mental health problems associated with these habits, respondentscommented on the social and economic impact. The main social and economic issues highlighted were thefinancial implications for individuals and for their families, long-term unemployment, the disruption to family lifeand issues around childcare and parenting.‘In my job, I think the main theme would be addiction and alcohol problems….alcohol problems would be alarge part of our work and some addiction….we’re working with very vulnerable families….families in crisis,families that are stressed’ (HSP16)Respondents said that there was drug misuse in the area and acknowledged that the drug services in the areahad responded and had improved the situation. However it was suggested that alcohol misuse was still a hiddenproblem that needs to be addressed.‘…alcohol is quite a problem and I think in general practice, it still remains quite hidden in the sense that youare often not aware of it and it’s difficult for you to (---) sometimes it comes up as the issue after you’ve beenseeing someone for a long time, the penny suddenly drops.’ (HSP13)Social deprivationRespondents (7) spoke about working in a ‘disadvantaged’ area. In the respondents’ opinion, the effects ofpoverty, poor housing and low levels of education all impact on how individuals address their health needs.Some respondents spoke about how women who lived in deprived areas neglected their health and did not seeit as a priority.‘…the influence that housing has on people’s health in this area is very very significant’ (HSP18)‘Women’s health would be an issue which often, I suppose they leave their own medical needs to the verylast, you know’ (HSP16)Similarly men do not access services as, it is not ‘a man ((ly)) thing to do’ (HSP4).Respondents said that certain lifestyle factors were associated with deprivation and they spoke about thenegative impact of these factors on their health.‘…if they have medical cards, they tend to be poor, unemployed, older folk and living in corporation housing….they smoke and they drink more and eh (---) they don’t look after their own health’ (HSP4)Respondents said that research indicates that behavioural disorders and speech and language difficultiesamong children are more common in areas of deprivation, as are psychiatric illnesses.‘…in terms of psychiatric morbidity, all the studies would show that the more deprived the area is the higher((the proportion with)) psychiatric illnesses, and the higher the use of the service’ (HSP15)What occupies most of your time?Respondents were asked what occupied most of their time. A small number of respondents (4) said it was theirroutine workload. Many respondents highlighted particular aspects of their workload, for example, care of theelderly (6), dealing with people who have mental health problems (5), in particular those with chronic problemsand care of children (3) at risk or follow up of those referred for specialist treatment.70

RESULTS - PART 2Respondents also reported that some issues, which consumed their time, were not necessarily part of their job.Many of the health service providers (12) said that they had to deal with social issues on a regular basis.‘Well a lot of the care of the elderly…. there would be a lot of social problems involved….Example, eh, elderlyliving alone and perhaps the time when they get sick, if family are living outside the area….obviously theyrequire a lot of input and we don’t really have the resources’ (HSP12)‘…an area that takes an enormous amount of time, people looking for medical backup for housingproblems….we seem to spend an inordinate amount of time writing letters on people’s behalf to the localauthorities for various housing issues’ (HSP18)Some of the respondents (4) reported that clerical/administration duties occupied too much of their time.2.2 SERVICES AND RESOURCES IN THE COMMUNITYThe health service providers were asked about the adequacy of services in the area, to suggest methods toimprove existing services and to identify additional services required.Main barriers to effective delivery of servicesRespondents were asked what were the main barriers or difficulties they experienced in delivering their service.The main issue raised were related to staffing levels, local health facilities and social deprivation.Staffing issuesThe majority of the participants (12) said that the staffing issues both within their own service and in otherservices was the main barrier to providing an adequate health service. Respondents said that as a result of staffshortages within their own specific service they were unable to provide an adequate service, they found itdifficult to reduce waiting lists and in some cases they had no cover for sick leave or annual leave.‘…again down to staffing resources, we have to prioritise and see the most needy first, you know, in terms ofseverity….but that’s not acceptable, you know, sort of in terms, professionally you feel, like kind of a tug there’(HSP7)‘…effective delivery, eh I suppose staffing is one, our waiting list in comparison to others would be verylong….So that’s a problem to effective service for the clients and other professionals see it as a difficulty’(HSP8)‘I mean I can’t get a day off for love nor money. And it’s very, very bad….And that does affect the way wedeliver the service as well because I mean you are under pressure’ (HSP2)Respondents also said that delays in recruiting and difficulty in retaining staff affect the quality and the continuitywithin the service.‘…we’re having difficulties in recruitment, there’s a kind of a nationwide shortage, say for adults withdisabilities or who might suffer a stroke or whatever, there is no service for them in the community, the postshaven’t been filled and the same with the post for older people’ (HSP7)‘…it’s difficult to get staff because there’s not enough people qualified in the country, that’s literally the bottomline so it’s people are always moving so therefore continuity is a problem’ (HSP8)‘…they change so often it’s hard to build a good relationship with somebody. Now I’ve heard numerous womensaying you know another social worker….So their history is being lost all the time, and history on paper doesn’treflect history in somebody’s head’ (HSP5)71

RESULTS - PART 2Participants commented on how the staff shortages in other professional disciplines affected the delivery of theirservice. For example, respondents said that the shortage of occupational therapists, speech and languagetherapists and in particular physiotherapists, resulted in long waiting lists and a curtailed or inadequate service.‘We have a point five (0.5) physiotherapist in the area….so for some of our clients….that would be a very bighelp if we had a physio’ (HSP8)‘…unfortunately we have no physiotherapist, we have no occupational therapist at the moment we did haveup to a year ago but now due to the problems with recruitment’ (HSP3)‘Speech and language forget it….I mean I know of people I referred and maybe were told yes, you know, we’relooking at a year ahead now’ (HSP6)Participants said that they had difficulties accessing hospital services. They said that as a result of staffshortages within the hospital service, in some cases specific hospital services were not available to thecommunity and for other services there were long waiting lists.‘Backup, we have no Radiology for instance in this area. Vincent’s Hospital have closed their X-ray machinesto GP’s’ (HSP4)‘There is a problems in, say managing patients in cardiac failure because you can’t get ECHOs ((cardiacultrasound))’ (HSP13)‘…waiting lists for specialist services, neurology, orthopaedic, ENT, they would be the main difficulties orbarriers to delivering a proper service to the patients’ (HSP4)‘I refer a squint, but I have no knowledge of how many months that might take….But the uncertainty of it, youhave to tell a mother "well I’m going to refer you now but I really can’t say when you’ll get yourappointment"…this is so delayed, it’s really ineffective’ (HSP10)Premises and local facilitiesRespondents (5) reported that the facilities in the health centre in Irishtown were not adequate and that thecentre is not easy for the public to locate. The respondents said that having no health centre in the Pearse Streetarea added to their difficulties.‘…there are rooms alright but there is nowhere to store records or that sort of stuff, apart from in your ownroom, and then they want to dump other services in on top of you….I was asked to let them in to my room,well I knew I had no choice, so I did, but then they’re putting in their filing cabinets and their presses and stuffin on top of you and you’re trying to use the room for that’ (HSP13)‘And you know this building which is a huge building has only got two things on the surface of the buildingthat tell you what it is. A small blue sign hidden well behind the railings that says it is a health centre anddispensary is still firmly written into the sort of granite on the gatepost. And that’s very frustrating for peoplewho want to provide a lot more on the inside’ (HSP6)‘…we don’t have a health centre actually in the area. I just feel we are actually removed from the area we areworking in and it causes all sorts of problems, in for instance for patients’ (HSP12)72

RESULTS - PART 2Respondents (5) who provide a service in the area but are based in an office outside the area reported that itwas very difficult to provide an effective service.‘Well I suppose effective delivery of service would mean that we are getting to our clients….that we wouldhave access to physical resources that are near the client group. Here it isn’t the easiest to get to. It is quiteawkward to get to, and in particular if you are trying to bring a couple of children with you’ (HSP16)‘…another factor affecting the service is that our clinic, the clinic isn’t based in the area….they have to travelup to this centre….So that I think is a drawback’ (HSP7)Social deprivationRespondents (5) said that it was difficult to promote better health practices in an area that is socially deprived.‘I have fourteen hundred GMS ((General Medical Service)) patients in the inner city….they don’t look aftertheir health.…eating health diets and not smoking or drinking does not go down very well’ (HSP4)‘…and despite giving them oral hygiene messages every time they come and somebody being out to theschool, it’s not really changing their attitude towards dental health. They don’t put it on a high priority’ (HSP11)One respondent said that non-compliance with treatment was a barrier to effective delivery of the service.‘The difficulties are multi-factorial and they stem around again a lot of the indices of deprivation, the pooreducation of the parents with regards to children’s health, the poor compliance and the lack of importance theywould apply to preventive measures….it’s actually getting people to attend and to follow up on actions thatwould be beneficial to their health’ (HSP18)Geographical and administrative access to servicesRespondents (5) did speak about some of the difficulties experienced by the community since the new healthboards were introduced. In particular they spoke about the difficulties experienced by the elderly.‘Patients are quite confused about where they are to go for this that and the other….the health centre inIrishtown there, looked after patients from here….for dressings and other services and suddenly patients arebeing told down there that they are not allowed go there anymore, they have to go to Baggot Street, which ona map is not very far….the distance for somebody who’s elderly and can’t walk very far….it’s going to takethem three quarters of an hour or so…. there’s no bus you have to go into town and out again’ (HSP13)‘Since we moved areas I find that the health centre is removed from the actual people….we were based inBaggot street and for a number of elderly who lived around they could walk over, which they can’t now….it’ssuch a long walk for the elderly down here, we end up visiting them and that’s defeating the whole purposeof making people independent’ (HSP12)Other issues mentioned by the respondents were the lack of clerical support, the inefficient postal service withinthe health board, and the fact that there is no means of receiving feed back from the clients as to theeffectiveness of the service.73

RESULTS - PART 2Barriers within general practiceRespondents within general practice (4) said that the new health board division affected their service and theyexperienced some difficulties communicating with the health board.‘…the other thing that has happened is that the area has been divided in, well three….I have a lot of patientswho come from the North Strand and that area across the bridge, because you know it is only a minute away.So in local terms it is not very far but in Health Board terms it is a foreign country. I’m trying to deal with theNorthern Area Health Board, the South Western Area Health Board and the East Coast Area Health Board.And it is very difficult to actually try and find out whom you are supposed to be dealing with’ (HSP13)‘I’ve been writing reports and, you know requests for, sort of, support for over the years. So amongst the thingsthat I wanted to do early on was to have say, a reception area, to have a nurse and to be able to work at nightand to be visible in the area. So these are some of the things I’ve been focussing on continuously since I’vestarted here. And I had zero success’ (HSP6)‘Another thing I wrote to the health board six months ago looking for a grant to build….and I still haven’t heard,you know I wrote again, still haven’t heard’ (HSP4)‘We have significant difficulties at the health board interface with regards to medical card eligibility, medicalcard application forms etcetera. I think it is fair to say that the single biggest area that we apply energy to istrying to keep people’s medical cards up to date’ (HSP18)Resources required to address the needs of the communityRespondents were asked if they had adequate resources to address the needs of the community. Most of therespondents (14) stated they did not have enough resources.Some respondents (6) said that they had sufficient facilities within their own service but if other support serviceswere better resourced the quality of their own service would improve.StaffRespondents were asked what resources were required in the area and for suggestions on how to improveservices. The majority of the respondents (15) spoke about the need to improve staffing levels within their ownservice. List 1 details the type of additional staff (by designation) required in the area and also the frequency withwhich each cadre of staff were mentioned by respondants.List 1 Frequency with which respondents mentioned that additional service providers were required in the area.• Occupational therapists (9)• Physiotherapist (9)• Speech and Language therapist (7)• Social worker for the elderly (6)• Generic social worker (5)• Clerical/administration staff (5)• Counsellors (5)• Specialist in hospitals(e.g. ENT, Ophthalmic, Orthopaedics, Neurology) (5)• Community ophthalmologist (1)Health premisesAccording to the respondents the other main resource needed was in relation to the health premises in the area.The respondents said that a health centre was required in the Pearse Street area and that the existing healthcentre in Irishtown required renovation and upgrading. Respondents (9) said that both health centres need tohave the capacity to accommodate several different services in the area and be client centred. The term ‘onestop shop’ or ‘poly-centre’ was used by many of the respondents.74

RESULTS - PART 2‘…if the physical surroundings are not conducive to people feeling we value them, that they’re not thoughtwell of, that’s what the surroundings sometimes implies….whereas if a place has been tailor made like apoly-centre or whatever, that can meet their needs in a very client friendly, appropriate way, that the physicalsurroundings are conducive to working with professionals, then I think you are half way there’ (HSP16)‘Well you have got to have a good building, you have to have the right rooms, a satisfactory waiting area,playthings in the waiting area, it should be warm, it should be clean, I mean these things are important to makepeople want to come and use the services, people have to feel that it is something they wish to do becauseit is pleasant’ (HSP10)Resources for the elderlyRespondents (7) spoke highly of the facilities for the elderly already available in the area, but spoke about theneed to increase resources for the elderly. In particular participants said that there was a need for urgent respitebeds in the area. At present if an urgent respite bed is required the person has to be admitted to an acute hospital.‘…there’s very little you can do if you walk in on an elderly person who is in dire straits. They don’t have anyclinical reason to go to a hospital and at the moment I see that there is very little places that can deal with this.You have to send them to an acute hospital, it only exacerbates the problem cos they’re sitting in casualty forhours’ (HSP1)Other services requested included a social worker to work specifically with the elderly, twilight service for theelderly (home helps, care attendants), more day centres particularly in the Ringsend/Irishtown area.Respondents (5) spoke about the need for transport that is purpose built for the elderly. They said that olderpeople had difficulty travelling to shops and health and community facilities (such as Baggot Street Hospital, SirPatrick Dunn’s and St. Andrew’s Resource Centre).Respondents also suggested that loneliness and isolation among the elderly should be addressed. The serviceproviders made some innovative suggestions including a home visitation service, a friendship centre and moreday centres.‘…there is a need for more places locally that people can go, in terms of say day centres that would providemeals, entertainment, some nursing care, I think people always value that’ (HSP13)‘The day centres are usually orientated towards activity, and eh, interaction, social interaction….a friendshipcentre is maybe more a drop in centre where you’d maybe have a cup of tea between eleven and twelve or,after mass or something like that where people can just meet and it’s warm for half an hour….a shorter thing,and where they network themselves’ (HSP8)Locally based servicesRespondents (5) who are not based in the area e.g. area medical officers, occupational therapists; speech andlanguage therapists etc. spoke about the difficulties of not having facilities available at local level.‘…and if we had an office I would consider basing people down here, because we use other health centresin that way and so you have a better opportunity to liase and get to know people coming and going as well asthe staff that use the health centre’ (HSP8)The respondent within the drug services said that there was a need for the drug counsellors and outreachworkers to be based at local level and highlighted the need for rehabilitation facilities to be based within the localgeographical area.‘I mean all the drug clinics are based on very strict geographical lines and while if you’re going for rehab,you’ve got to go to Dun Laoghaire, seems like a non starter’ (HSP14)75

RESULTS - PART 2The respondent within the psychiatric service said that there was a need to expand community-based services.‘Certainly if we had more community based services within the area, I think we could reduce the admissionrate considerably and improve the quality of life for the people in the area….for example we have a day centrein the Ringsend area it has made a big difference and then there was supposed to be one for Pearse Streetbut that funding money ran out and we still only have one’ (HSP15)Respondents also said that x-ray facilities and a minor surgery facility were required in the area.Resources for families and childrenIn relation to family support, the respondents (6) said that the following were required; crèche facilities in thearea, services for children with behavioural problems and/or autism, parenting classes and health servicesspecifically for adolescents. Once again the respondents said that the social work service needed to beexpanded to support families in the area.‘So I mean we would deal with a lot of young people who have misinformation relating to their health and thatwould often be the case….how their bodies work may not be not known to them’ (HSP16)‘…social workers, I think could be a bit more on the ground with us locally, with the families who have problemchildren, who have drug problems, all that sort of area, it’s very difficult for people to get help’ (HSP13)Suggestions on how to improve the serviceApart from the many resource requirements already mentioned, when asked how the service could be improved,the majority of respondents (12) said that there was a need to improve communication between disciplines soas to improve teamwork. These issues will be discussed in the final section. Some respondents reported thattheir workload tended to deal mostly with problems and crises. They said there was a need to incorporate morehealth promotion and prevention activities in their work. Respondents also said that there was a need to providea more client centred service.‘I think in areas of disadvantage in particular, you really need sort of you know, more of an emphasis oneducation and prevention of health problems, you know, I feel strongly that there isn’t…. funds seem to begeared towards dealing with the problems and coping with crisis. I think that would be very useful and moneywell spent and I mean around lots of different areas….from you know diet, exercise, parenting skills,behavioural management, all sorts of areas’ (HSP7)‘There would be a need to develop the service in a more friendly client based, to be more mindful of the needsof that particular, you know, client group’ (HSP16)According to the respondents (4), the health board needs to collate information on the different servicesavailable in the area and what exactly they provide. This information should be disseminated to both serviceproviders and people in the community. Respondents also said there was need for a health informationresource centre in the area.‘I don’t think the Boards are running a service if they’re not prepared to tell people in the area what the serviceis and who it is for’ (HSP6)‘I don’t think that there is enough awareness out there in the community from the clients’ point of view, I don’tthink they know enough about us or actually to what our limitations are’ (HSP5)‘Now we could have a much more fundamental health information resource here in a properly managed centre,with everything from the web to CD ROM’s to books. I think if you are going to change peoples habits theseare some of the kind of things that will work’ (HSP6)76

RESULTS - PART 2Respondents said that there was a need for ongoing training and further education for service providers toensure they continue to provide a good service.‘I think if we are looking at services, then we have to be up-skilled and continue our training and have accessto continued education, and you are going to give a better service, that’s really important’ (HSP8)2.3 CO-ORDINATION AND TEAMWORK IN THE AREAThis section presents the respondents perceived level of co-ordination between services in the area andsuggestions on how best to facilitate the primary care team to work effectively.Level of co-ordination between service providers and teamwork in the areaThree of the respondents were happy with the level of co-ordination between services in the area. Only onerespondent said that there was no co-ordination between services in the area. The other respondents (17)said that there was some level of co-ordination (ranging from poor to good) in the area but that it was mostlyon an informal basis. The respondents reported that they experienced good co-ordination between differentservices but this was done through the efforts of the individuals within the services rather than through anyformal structure.Many respondents (10) said there was no formal structure for communicating within the health services and thatmost co-ordinating was done on an informal basis.‘I don’t think there’s particular organised co-ordination, I mean you have to kinda chase up on people.…there’sno formal structure for us to meet and it is very informal’ (HSP1)‘Eh, there is a certain amount of co-ordination but there are no clear channels of communication….there is verylittle in the line of ‘face to face’ consultation between the health care providers’ (HSP18)Respondents (6) said that communication was mainly by telephone.‘Yeah there is co-ordination, obviously we have but if you are not in the same building it isn’t always easy….youare working with very antiquated telephone services that is not built for speed….it is often more difficult to getsomebody down the road, you know, in another profession’ (HSP16)‘…sometimes it is frustrating, it’s difficult, because you are ringing people and most people are out doing theircalls, it’s difficult to contact people’ (HSP3)‘…we speak over the phone yeah, we don’t meet up at team meetings’ (HSP5)Some respondents (6) reported that the level of co-ordination depended on the personalities of the individualsworking within the different disciplines and how long they had worked in the area.‘…we made a point of meeting each other….but that was only because we were the type of people that wewould socialise easily. But it is just if you were anyway shy at all and you came to work in this place youmightn’t get to meet somebody from one end of the day to the next….it’s only through our own effort, kindamaking an effort’ (HSP2)‘…there is and there isn’t co-ordination I think some of it is personality and some of it is how long you’rearound’ (HSP15)77

RESULTS - PART 2Respondents (5) said that the services were not integrated. They said that service providers worked in isolationand this negatively affects the delivery of the service. Different service providers can be seeing the same clientbut there is often no sharing of information.‘If something changes in the time that I have seen somebody I would expect to be informed. Likewise I wouldinform somebody. It’s just a complete lack of communication really, you know. People are doing stuff and nottelling the next person’ (HSP1)‘…services in the community are not integrated. And I think we all do our own thing in the community inisolation’ (HSP13)‘…everybody is so busy with what they do. But they are all working in isolation, you know, except if they haveto make contact about somebody or other but I don’t think you are serving the community well by working inisolation because health is a very broad thing’ (HSP5)Respondents (10) reported that co-ordination was generally much better if the services were in the samepremises or in close proximity to each other.‘The public health nurses, I’m very lucky, I work from a health centre….so that I’d see them every day. And itcertainly makes a big difference in terms of that they know you and you can go in and say….‘hi did you seeMrs. So and so’ and she’ll come down and say ‘so and so is back from hospital’ or what not. And it does help,it gives you a sense of kind of teamwork’ (HSP13)‘…the services they’re all so localised, the nurses are here on a weekly basis, we’ve the chiropodist in and thedoctor is across the road, and we’ve so much contact with them’ (HSP17)‘I mean the issue of not being based in the area with some of the other service providers is something of anobstacle in terms of, you know people, you have to make a special effort to make communication’ (HSP7)Co-ordination between community services and hospital services was also discussed. The majority of theservices providers who liase with both Sir Patrick Dunn’s hospital and/or Baggot Street reported that there wasgood co-ordination and communication between the community services and these hospitals and vice versa.‘…we’re very lucky here we have Patrick Dunn’s down the road ( ) run’s an absolutely fantastic service thereand has been a fantastic back-up for me, I speak to ( ) about three times a week about people going in andout, and that’s my back-up’ (HSP9)‘What we link with quite a bit, I suppose in the community at the moment, would be the GP and the publichealth nurse, we have good communication with both of them, and also the home help organiser….we wouldhave quite a lot of links with the CPN‘s ((Community Psychiatric Nurse)) in the community and they wouldrefer here to the unit as well’ (HSP3)On the other hand respondents (4) said that there was poor co-ordination between the acute hospital servicesand the community health services.‘…so you are kinda in the dark, relying on patients to tell you what happened, if there’s a daughter or son theymight say "oh they were in such a place yesterday for geriatric assessment" and where you might havesuggested this six weeks ago, you never knew anything happened about it’ (HSP1)‘A patient was sent home from ( ), I think about two weeks ago, the district care unit was supposed to beinvolved, but I never heard anything about the patient being sent home. Nobody rang me or nobody told me’(HSP13)78

RESULTS - PART 2‘Hospital service do their own thing. They close their out patients, they close their x-ray or ultrasound or physio,there is no co-ordination at all’ (HSP4)Participants (5) spoke about the varying level of co-ordination with other government sectors, with voluntaryservices in the community and the community itself.‘…when you are in an area you get to know the corporation people, who you should contact for differentprocesses, so we know if it’s a disabled persons grant, you contact Joe Soap in the corporation, you do thatinformally, you develop these networks yourself’ (HSP8)‘…it works quite well with the community, we’ve good relations with the community from St. Andrew’sresource centre, they would come here and that so, we have a lot of contact here for liaison, with the priestsand the parish here and with the local schools. There’s quite a lot of community networking going on’ (HSP3)‘…now we are not very good at utilising voluntary services, not good at liasing with the voluntaryagencies….there is a myriad of agencies that are doing a lot of good work and I think we tend to be a bitisolationist’ (HSP15)The primary care teamRespondents did have some concerns about the concept of the primary care team. Some respondentswondered about who and how the team would be managed. Issues relating to role clarity and job descriptionswere raised and that perhaps some professionals may feel that other professionals were interfering with theirrole. The respondents also questioned who would be entitled to primary care services, with the two-tier systemin Ireland, of public and private patients. The respondents queried if the services would be available for all theclients or just those in the public system.There was some discussion as to who would be part of the primary care team. Suggestions varied from thecore team consisting of the service providers who are active in the day-to-day care of the clients in thecommunity e.g. the general practitioner service, the nursing service, the home help service, psychiatric service,the community welfare service, supported by other services like the physiotherapist, occupational therapist etc.Others suggested the team should be broader and include voluntary agencies and representatives from thecommunity, representatives from the local hospital services and from the drug services. The primary care teamwas considered as an important link between primary and secondary care.Respondents were asked to give suggestions as to how the primary care team might work better for thecommunity. The majority of the participants (17) made very positive suggestions and displayed a greatwillingness to work together to improve the overall service.The service providers interviewed worked in either the Pearse Street area or in Ringsend/Irishtown or both.Respondents commented on the fact that they were two separate communities both needing services.‘…we need a presence in each area, I find a bridge between the two is a huge physical and psychologicalbarrier, it’s absolutely amazing because the distance is not very far’ (HSP15)‘…the people in Pearse Street would think of themselves as different from Irishtown and Ringsend, Irishtownand Ringsend see themselves as one entity and Pearse Street as a separate one’ (HSP16)Respondents (14) said that service providers needed to be based within a geographical area, and ideally basedwithin the same health facility. This would benefit the client and the service providers.‘I think that people need to be in close proximity need to be in the same building as each other….once youhave a premises and once you have adequate facilities then you can attract the services. So really there arelimitless possibilities once you have the adequate facilities and adequate staffing back-up’ (HSP18)79

RESULTS - PART 2‘…the whole kind of ‘one stop shop’ idea has great potential really, in terms of having people able to go to oneplace that they can identify with, and you know access a number of services there and then….and I also thinkwhen a team like that work well there’s a great synergy develops and they collaborate and work very welltogether because they are in proximity, they are dealing with the same groups of people, they get a better ideaof the kind of issues that are there for the people of the area and what their priorities are’ (HSP7)Respondents (12) spoke about the importance of structured team meetings and good communication betweenthe different services. Respondents spoke about the need for meetings about general issues within the servicesand then the need for meetings about individual clients (case conference type meetings) or a specific clientgroup. The need for training to facilitate team building was also raised.‘I also think we need, not just do we need to be in the same building but we need a formal communicationstructure and I’m thinking of protected time for team meetings etc. with very formal structures in place ratherthan the kind ad hoc situation that we have at the moment…. those type of approaches would be very helpful’(HSP18)‘I think we can all, in the primary care team do with training, training on working together, not hiving off in ourown little corner’ (HSP14)‘I mean I think there is a huge need to develop full multi disciplinary teams and to empower people on theteams to do what they are best at’ (HSP15)‘I think meeting, well depending what the situation is, sometimes it can involve a group of clients’ (HSP3)‘…occasionally we have case conferences, I hope they’re going to become more regular. I’d anticipate theywould, as we’d build more teams in the near future’ (HSP7)Communication is central to good teamwork. Respondents (6) spoke about the value of knowing the individualsin the team and the importance of using information technology to improve communication.‘I think all people involved in the primary care team should know who the other people are in the team. Likenot just know there is a social worker or a GP. You need to have a face and know the person’ (HSP1)‘I suppose to facilitate the primary care team to work better, I guess IT ((Information Technology)) is a hugeissue. Yeah I think that’s very important that we can communicate, because I don’t know when or who hasseen that client and if we were all tuned into the same system….if you could look at your computer as a healthcare worker and say well an OT was there on so-and so date, or the last episode was so long ago you couldmake the referral. It would make an awful lot of sense and obviously we’d be using the same system, inputtingand using the common information’ (HSP8)‘I mean teamwork at some level would even be just a matter of communication. If I had a file here that I couldopen up and say right the physio is such and such and, you know by just `ringing them or faxing somethingto them that I knew at least they were in their system and they would be able to get back to me and say wellI’ll see this person in three months time’ (HSP6)80

RESULTS - PART 2Respondents gave good examples of how the primary care team could work together to address the needs ofthe community. Respondents (5) spoke about the primary care team working together in the area of healthpromotion and advocacy on behalf of the community.‘…lots of people could identify with kind of a preventative role, we could get involved with maybe working withparents, or working with new parents, nurses, dentists, area medical officers and whoever, I just know from myown profession that certainly we would like to get more involved in preventative work , I would imagine otherprofessionals would be similar’ (HSP7)Another example given was the health professionals liasing with other relevant groups and agencies to advocatefor a safer environment for older people. Some suggestions given were to lobby for more pedestrian crossingsin the area, footpaths that are wide enough for wheelchair access, benches in parks that are suitable for theelderly, better lighting in the stairs and in the lifts in the local flat complexes.The possibility of providing ‘out of hours service’ was discussed. One suggestion was to have late eveningsurgeries to provide a service for the many clients who are working and can only avail of the services inthe evening.‘…if we move towards a purpose built health centre with a number of doctors involved in it, that improves yourability to provide, I’m thinking of, late evening surgeries, that type of facility’ (HSP18)The majority of the service providers were very positive about working as part of a team. Respondents (4) didsuggest that the area being surveyed would be ideal for a primary care pilot project.‘I mean the primary care team that they envisage in the Health Strategy, as far as I am concerned this is a readymade one of these….I mean what more do you need but willing participants who work close to each other.So it would be a good place to start’ (HSP6)81

DISCUSSIONPART 2

DISCUSSION - PART 2DISCUSSIONThis study was undertaken, as part of the health needs assessment in the area. Most of the issues discussedby the service providers support the findings of the household survey conducted in the area.The service providers reported that the care of older people was one of the main health issues in the area andsimilarly in the household survey it was reported that one third of the surveyed population was aged over 50years and of these, more than half were over 65 years. In the household survey the most commonly reportedchronic illnesses were respiratory disease, cardiovascular disease, arthritis and psychiatric illnesses, whichwere similar to the main health problems reported by the service providers.A number of studies have been conducted which establish a relationship between loneliness and ill health(physical and mental). 3,4 In this study the service providers spoke about the loneliness and isolation of the elderlyand the impact on their health. In the household survey over half of the primary carers, who were over 65 yearsold, were living on their own.Research shows that deprivation is strongly linked to poor health. 5,6 The service providers spoke about the linkbetween health and social deprivation. They spoke about the effects of poverty, poor housing and low levels ofeducation on the health of individuals. The results of the household survey indicates that this is a deprived areawith 45% of households having medical card cover, 37% of the households living in government supportedaccommodation and 50% of primary carers having primary school education or less. The survey reported thatthose who had medical card cover and those who lived in government-supported accommodation were morelikely to have a chronic illness than those with private health cover or those who own or rent privateaccomodation. These facts support the issues as identified by the service providers.In the household survey, drug and alcohol problems appear to have been under reported as only one percentof primary carers reported that the household members have a problem with substance misuse. In contrast theservice providers spoke about the physical, mental and social implications of drug and alcohol misuse andstated that drug and alcohol misuse was one of the main health issues in the area.In the household survey, the primary carers reported that there was a need for a health centre in the PearseStreet area and the service providers endorsed this. Some of the main services requested by the serviceproviders were also requested by the primary carers, for example, more day care and respite facilities for theelderly, generic social work service (to work with young and old) and a local counselling service.Human resources, physical infrastructure and information and communication technology were highlighted bythe service providers as central to the effective functioning of the primary care team. These strategies are in linewith the new primary care strategy. 7 The service providers were very positive about working with the otherdisciplines and displayed a willingness to work together to improve the health of the community.83

REFERENCES - PART 2REFERENCES1. Morse J M, and Field P A. Nursing Research The application of Qualitative approaches: 2ed. Cheltenham,England: Stanley Thornes Publishers Ltd, 19982. Treacy M P, Hyde A. Nursing Research Design and Practice. Dublin: University College, 19993. Prince M.J, Harwood R.H, Thomas A. Social Support Deficits, Loneliness and Life events as Risk factorsfor Depression in Old Age. The Gospel Oak Project VI. Psychological Medicine 1997; 27(2): 323-3324. Brenda W, Penninx J H, Theo van Tilburg et al, Effects of social support and Personal Coping resources onMortality in Older age: The longitudinal Aging Study Amsterdam. American Journal of Epidemiology 1997;146:510-5195. White I.R, Blane D, Morris J.N, Educational attainment, deprivation-affluence and self reported health inBritain: a cross sectional study. Journal of Epidemiology and Community Health 1999; 53:535-5416. Eachus J, Williams M, Chan P. Deprivation and cause specific morbidity: evidence from Somerset and Avonsurvey of health. British Medical Journal 1996; 312:287-2927. Department of Health and Children. Primary Care A New Direction. Dublin: Stationery Office, 2001.84

APPENDICES

APPENDIX 1MAPS OF THE STUDY AREACLONTARFPHIBSBOROUGHGPOEAST WALLLIFFEYPEARSE STREETRINGSENDIRISHTOWNBALLSBRIDGESANDYMOUNTSTUDY AREASTUDY AREA, THE PEARSE STREET AREA AND THE RINGSEND - IRISHTOWN AREACLUSTERS BY LEVEL OF DEPRIVATIONAREA STATUSLESS DEPRIVEDMORE DEPRIVEDMORE DEPRIVEDLESS DEPRIVEDNON RESIDENTIALOUTSIDE STUDY AREA86

APPENDIX 2INFORMATION LEAFLETSAppendix 2a Letter to participantsThe Householder16 October 2001Dear HouseholderThe Baggot Street Hospital Trust in cooperation with the South Western Area Health Board are interestedin responding to the health needs of the people in your area. We have asked the Trinity College Centrefor Health Sciences to carry out a survey on our behalf.In the next two or three weeks one of our researchers will call on you to ask you to take part in ahousehold survey. We would like to interview the person who looks after the health of the people in thehouse. We will ask about the health of the household members and satisfaction with the servicesprovided. We want to find out what other health services you think are needed in the area.We hope you will be willing to complete the interview, which will take between 20 and 30 minutes. Weplan to conduct the interviews between 6 and 9 each evening. If this time does not suit you the researcherwill arrange a more suitable time for you to be interviewed.You are of course free to refuse to take part in the survey, but this is a good opportunity for you to ensurethat you have a say in the planning of the health care services in your area. All the information collectedwill be treated in the strictest confidence and will not be disclosed to anyone outside the research team.Thank you for reading this letter and looking forward to obtaining your views. If you have any querieswhatsoever, please contact Ailbhe at 6081087 or Deirdre at 6082293.Yours sincerelyDr. John RyanBaggot Street Hospital TrustMs. Rachel DevlinActing General Manager,SWAHB87

APPENDIX 2INFORMATION LEAFLETSAppendix 2b Poster88

APPENDIX 2INFORMATION LEAFLETSAppendix 2c Information sheet for interviewersHello, I am show IDWe are research assistants employed by the Baggot Street Trust and are carrying out the survey on their behalf.Did you receive a letter in the post?If yes, as you are aware the Trust and the South Western Area Health Board are interested in responding to thehealth needs of the people in the area.If no, apologise and explain……… ‘they are interested in responding to the health needs of the people in thearea’We would like to interview the person in the household who manages the health of the people in the house.We will ask questions about your background, health status, health services used, satisfaction with them andother health services you need.The interview will take 20 to 30 minutes .You are of course free to refuse to take part in the survey but this is a good opportunity to ensure youhave a say in the planning of health services in this area.All the information will be treated in the strictest confidence and will not be disclosed to anyone outside theresearch team.Is this a convenient time to talk to you?If yes, can I come inside?If no , can you give me an alternative time?Once inside ask if you can sit side by side, preferably at a tablePlace the flashcards in front of the respondentEnsure the respondent can see the questionnaireRemind the respondent that if there is any question you do not wish to answer please say pass.Go through the questionnaire following the instructions provided in the questionnaireWhen finished recheck the questionnaire to ensure it is completeThank the respondent for his/her timeTell them the health centre number for enquiries about public health services such as vaccination, childhealth and cervical screening. All other enquiries to their own general practitioner.Before handing in the questionnaire ensure all coding is completed and correct.89

APPENDIX 3 & 4APPENDIX 3 - Survey TeamMs Katriona BolandMs Jillian DeadyMs Mary EganMs Olive FaulknerMs Aishling HeveyMs. Malebogo Lebbo KebabonyeDr Jean LongMs Mary MurphyMs Edosa OdaroProf Tom O’DowdMs Frances O’KeeffeMs Rosalyn O’LoughlinMs Tracey PetersonMs Nicola SweeneyData collector from the communityResearch FellowData collector from the communityData collector from the communityData collector from the communityMedical StudentLecturer in International HealthData collector from the communityMedical StudentGeneral PractitionerResearch FellowResearch FellowData collector from the communityResearch AssistantAPPENDIX 4 - Procedures Employed to Ensure Good Ethical PracticeThe main ethical problems associated with the research project are as follows:• The need to ensure informed consent from the primary carer• The need to ensure confidentialityThe following measures were taken to deal with these issues:Informed ConsentEach household was sent a letter detailing the purpose of each survey, the data collection methodsand the proposed dates.Information leaflets describing the purpose of each study, the data collection methods, thestudy population, and the use of results were provided to guide the interviewers when visitingthe households.The respondents were then asked if they wished to take part. No inducements were offered. Thosewho agreed completed the questionnaire. Agreement to complete the questionnaire was taken asconsent for the survey.Those respondents who did not fully comprehend the explanation, e.g. those with languagedifficulties, were excluded from the survey.Maintaining ConfidentialityConfidentiality was assured as no household members’ surnames were recorded on thequestionnaires. Each questionnaire was assigned a number for data entry purposes.90

APPENDIX 5SATISFACTION WITH HOSPITAL SERVICESTable 5a Primary carers’ reported number (%) of individuals who used accident and emergency services in theyear prior to the survey, level of satisfaction with services and their reasons for satisfaction/dissatisfaction.No %Attended accident and emergency departmentYes 46 6.6No 653 93.4n 699Satisfied with accident and emergency serviceYes 31 81.6No 7 18.4n 38Level of satisfaction with accident and emergency service(1 very satisfied to 6 very dissatisfied)1 18 47.42 7 18.43 6 15.84 3 7.95 2 5.36 2 5.3n 38Reason satisfied with accident and emergency (n = 38)Nearby 17 44.7Staff courteous and friendly 16 42.1Short waiting period 8 21.1Doctor/health professional listened to the problem 19 50.0Doctor/health professional explained the condition 19 50.0Doctor/health professional explained the treatment possibilities 16 42.1Doctor/health professional provided good treatment or care 15 39.5Service easily available on a 24 – hour basis 5 13.2Pleasant environment 4 10.5Affordable 4 10.5Organised appointments 2 5.3Reason dissatisfied with accident and emergency (n = 38)Too far 0 0.0Staff unfriendly 6 15.8Long waiting periods 16 42.1Doctor/health professional did not listen to the problem 2 5.3Doctor/health professional did not explain the condition 3 7.9Doctor/health professional did not explain the treatment possibilities 3 7.9Doctor/health professional provided inadequate or incorrect treatment 3 7.9Service difficult to access outside normal working hours 0 0.0Unpleasant environment 1 2.6Expensive 0 0.0No after care 2 2.691

APPENDIX 5Table 5b Primary carers’ reported number (%) of the individuals attended the outpatients department in the yearprior to the survey, level of satisfaction with services and their reasons for satisfaction/dissatisfaction.No %Attended outpatients departmentYes 63 9.1No 636 90.9n 699Satisfied with service in the outpatients departmentYes 49 86.0No 8 14.0n 57Level of satisfaction with service in the outpatients department(1 very satisfied to 6 very dissatisfied)1 31 54.32 14 24.63 4 7.14 2 3.55 1 1.86 5 8.8n 57Reason satisfied with outpatients’ service (n = 57)Nearby 10 17.5Staff courteous and friendly 29 50.9Short waiting period 15 17.3Doctor/health professional listened to the problem 31 54.4Doctor/health professional explained the condition 26 45.6Doctor/health professional explained the treatment possibilities 22 38.6Doctor/health professional provided good treatment or care 31 54.4Service easily available on a 24 – hour basis 7 12.3Pleasant environment 8 14.0Affordable 2 3.5Organised appointments 8 14.0Reason dissatisfied with outpatients service (n = 57)Too far 0 0.0Staff unfriendly 0 0.0Long waiting periods 12 21.1Doctor/health professional did not listen to the problem 5 8.8Doctor/health professional did not explain the condition 1 1.8Doctor/health professional did not explain the treatment possibilities 1 10.8Doctor/health professional provided inadequate or incorrect treatment 3 5.3Service difficult to access outside normal working hours 1 1.8Unpleasant environment 1 1.8Expensive 0 0.0No after care 2 3.592

APPENDIX 5Table 5c Primary carers’ reported number (%) of the individuals admitted to hospital in the year prior to thesurvey, level of satisfaction with services and their reasons for satisfaction/dissatisfaction.No %Admitted to hospitalYes 46 6.6No 653 93.4n 699Satisfied with inpatient care and treatmentYes 39 88.6No 5 11.4n 44Level of satisfaction with care and treatment as an inpatient(1 very satisfied to 6 very dissatisfied)1 31 70.42 7 15.93 1 2.34 1 2.35 3 6.86 1 2.3n 44Reason satisfied with inpatient care and treatment (n = 44)Nearby 24 54.5Staff courteous and friendly 24 54.5Short waiting period 15 34.1Doctor/health professional listened to the problem 27 61.3Doctor/health professional explained the condition 19 43.2Doctor/health professional explained the treatment possibilities 17 38.6Doctor/health professional provided good treatment or care 32 72.7Service easily available on a 24 – hour basis 5 11.4Pleasant environment 5 11.4Affordable 3 6.8Organised appointments 8 18.2Reason dissatisfied with inpatient care and treatment (n = 44)Too far 0 0.0Staff unfriendly 0 0.0Long waiting periods 4 9.1Doctor/health professional did not listen to the problem 4 9.1Doctor/health professional did not explain the condition 1 2.3Doctor/health professional did not explain the treatment possibilities 1 2.3Doctor/health professional provided inadequate or incorrect treatment 2 4.5Service difficult to access outside normal working hours 0 0.0Unpleasant environment 1 2.3Expensive 0 0.0No after care 0 0.093

APPENDIX 6Topic guidelinesJob TitleLength of time working in the areaTopic 1 (Health problems)In your experience what are the most common physical/mental health problems that you encounter?What problems occupy most of your time?Topic 2 (Services and resources)Do you have sufficient resources in your service to address the needs of the community?What are the main difficulties/barriers to effective delivery of services?Can you make suggestions how your service can be improved?In your opinion are there additional health services required in the area?Topic 3 (Co-ordination/teamwork)Is there co-ordination between services in the area?Are you satisfied with the level of co-ordination between services in the area?What facilities / services do you feel are required to facilitate the primary health care team to work better?The above questions are some guidelines as to the type of information we are looking for.94

APPENDIX 7Consent form for the service providers who participated in the studyCONSENT FORMIn-depth interviews of the health service providers in the Pearse Street area and in the Ringsend/Irishtown areas.All participants interviewed will be asked about their perception of the health needs of the people living in thearea, their service provision and the issue of co-ordination in a primary health care setting.Each interview will take 45 minutes. The details of the interview will be recorded on tape. Only the research teamwill use the tape. The tape will be erased once the tape has been typed. No individual will be identifiable oncethe interview is typed.Only the research team will have access to the information collected. Individual names will not be recorded.The information will be written up detailing common issues, differing opinions and some individual quotes toemphasise points made by the participants. No quotes will be attributed to any individual study participants.I have read the above explanation, and where required additional issues have been explained.On the basis of this information I agree to take part in the survey.SignedDate95

APPENDIX 8Silverman’s transcription symbolsNotes for the transcribers:The tape number indicates the interviewer number so all conversation attributed to the interviewee is denoted bythe tape number, for example, HSP2 for tape number 2 and HSP3 for tape number 3 and so on up to tapenumber 18 (indicated by HSP18)The interviewer was JD so all of the interviewer’s questions, clarifications or comments are attributed to JD.When each person speaks on the tape and you attribute the conversation to them,can you please format the text as follows:JD: Okay, em, have you ever treated leg ulcers?.HSP4: Yeah.JD: Now I'm going to ask you a little about your experiences treating leg ulcers,okay?,HSP4: Yeah.JD: Okay?. So just feel free to tell me anything you want to tell me.HSP4: I couldn't tell you why I started treating leg ulcers. When was about 12years ago I'd say, em,.Save document as ‘text’ only. Do not use automatic line spacing or paragraph spacing instead use the enter orreturn button.When transcribing the interviews will you please use the following notations.( ) ‘empty parentheses’ indicates talk too obscure to describe.hhh indicates hearable aspirations length proportional to number of hhhs] left sided bracket indicates over lapping conversation begins and [ right sided indicates over lappingconversation ends(( )) double parentheses indicates transcriber’s comments- indicates unfinished word such as "unfin -"Underlining of text indicates stress or emphasis96