Rogers and Nicholaas: Understanding the Patterns and Processes of Primary Care Use

Anne Rogers and Gerry Nicolaas (1998) 'Understanding the Patterns and Processes of Primary Care Use: A Combined Quantitative and Qualitative Approach'
Sociological Research Online, vol. 3, no. 4, <http://www.socresonline.org.uk/3/4/5.html>

To cite articles published in Sociological Research Online, please reference the above information and include paragraph numbers if necessary

Received: 05/08/98 Accepted: 15/12/98 Published: 31/12/98

Abstract

This paper addresses the combined use of quantitative and qualitative methodology to understand the relationship between need, demand and use of primary care services.

The study conducted in three different areas in the North west of England was designed to, link health status to subsequent use of health care in a way which might be used for service planning and the allocation of resources, and to provide data to inform a long term programme examining the relationship between need and demand for primary care. The study was in two stages, a survey and diary study designed to ascertain frequency of health care utilisation and health status of households, followed by a linked qualitative study consisting of in-depth interviews on a subset of people experiencing a range of common complaints seen in primary care. The mixture of methodologies gave a broader understanding of the dynamics of health utilisation in the localities studied. The survey and diary data showed the way in which key variables can be used to map the patterns of primary care utilisation in a population and the extent of self care actions and lay management of illness undertaken within households. We found that ill people are far more likely to use self care than professional health care services, and when they do use formal services, this tends to be in addition to self care practices. The qualitative data illuminated more about the processes of health care utilisation, particularly the way in which the past experience of illness and service contact coalesced with peoples' more immediate decision making about using primary care services. The findings suggest that health care use is most appropriately viewed as an interplay between agency and structure rather than the outcome of 'expressed need', individual decision making or 'supply induced' demand.

Keywords:

Demand; Health Care Utilisation; Health Diaries; Health Survey; Need; Primary Care; Qualitative Interviews.

Introduction

1.1: The dynamics of the contemporary relationship between, need, demand and use of health services are not well understood. In part this has been related to the assumption that NHS care is universally and easily accessible to most of the population most of the time. The highlighting of a lack of access to health services for some populationgroups (Smaje and Le Grand 1997), the introduction of overt rationing and cost containment strategies within health services, together with a recognition of the impact of personal and financial resources on the problems experienced by certain population groups which may affect their use of services have radically undermined this assumption Additionally, in policy terms concerns about unmet need and increased demand for services that the NHS finds increasingly difficult to meet indicates an imperative to better understand the nature and scale of the need and demand for primary care services.
1.2: There are a number of traditional approaches which have been developed to understand health care utilisation. Clinical iceberg' studies from an epidemiological perspective have incorporated an analysis of the extent of service use by estimating rates and types of symptoms present in the community compared to those presented to primary care services (e.g.Wadsworth et al 1971). Studies based on the Health Belief' and 'rational choice' models have examined the way in which individual characteristics and attitudes influence the use of services (e.g Rosenstock 1966) and studies based on the socio -behavioural model have examined predisposing, enabling and need factors to explain patterns of health care use ( Anderson 1995). These 'traditional models' of health care use provide an understanding of utilisation with reference to a set of extensive contingencies ranging from the psychological - for example, patient preferences in the health belief model - to the external environment, including the policy context in the socio- behavioural model. However, they have been criticised for their neglect of process, the role of social networks and self care on the management of illness and for their inability to capture the complexity and dynamics underlying people's decisions to use health services ( Pescolido 1991; Rogers et al 1999)
1.3: A further drawback to studying health care utilisation in the UK is that there are no data sources which provide longitudinal data on health need linked to the use of health care ( Nicolaas et al 1997). The large scale quantitative studies which have been concerned with health care utilisation tend to focus on its relationship with demographic characteristics and socio-economic factors (McCormick et al 1995),( (Carr-Hill 1996), (Rice and Roland 1996), ) (Carr-Hill et al 1996) found high consultation rates among the permanently sick, the unemployed, those living in rented accommodation, individuals of low social class, women from the Indian sub-continent and those living in urban areas. However, even after taking account of these factors, there remains a large amount of variation between individuals in their use of health care services despite the presence of similar morbidity.
1.4: A contrasting qualitative methodological approach to understanding health utilisation has developed as one response to the lack of progress perceived to have been made by correlational and large scale quantitative surveys ( Mechanic 1979; Pescolido 1991). This type of research has traditionally been concerned with illuminating the processes of health care utilisation, lay referral and help-seeking. During the 1970's and 1980's, based on the illness career and illness behaviour approaches rooted in symbolic interactionism, a number of studies elaborated on patient action and interaction and the stages or pathways into care ( Robinson 1971; Zola 1973, Cowie 1976; Dingwall 1976; Alonzo 1980; Williams 1983; Bloor 1985; Cunningham Burley and Irvine 1987). Rather than viewing the motivation and determinants of decision making as fixed attributes of individuals these studies focused instead on the interaction of the patient with others and viewed the determinants of decision making as subject to the influence of a wide range of factors often beyond an individual's control. In particular studies of help-seeking identified the relevance of examining the timing between the onset of problems and consultation , the extent to which people are able to contain and cope with signs and symptoms within socially defined situations and contexts, the multiple possibilities in the decision making process (including the overturning of decisions as well as the reasons for seeking our formal help) the relationship between everyday events, activities, work and decisions to use care and the importance of social networks in decisions to seek care.

Combining Qualitative And Quantitative Methods

2.1: The evident separation between qualitative studies such as these and health surveys using multi-variate analysis reflect a legacy of a dichotomised epistemological traditions evident in other areas of sociological research. The last two decades has witnessed attempts to overcome the methodological schisms operating between the two traditions. Evidence of the viability and benefits of combined research designs have been illustrated by commentators who have drawn attention to a range of studies which have successfully incorporated both methods ( Bryman 1988, Brannen 1992). Social researchers from both qualitative and quantitative traditions have stressed the need to incorporate aspects of both approaches in measuring overlapping and different facets of social phenomena(Silverman (1985); Laurie and Sullivan (1991) Scheff (1997). Arguments made for the complementarity of mixing qualitative and quantitative methods have pointed to the need to consider both epistemology and the technical aspects in carrying out and resolving tensions in combined work. That is attention needs to paid to both the technical aspects of carrying out such research (e.g. which method has priority over the other and how to achieve convergent or confirmatory findings) and the type of knowledge which is produced and the type of reality or object to which different methods are relevant
2.2: Arguments for using combined methodology within mainstream sociology are particularly relevant to the investigation of key areas of health and social policy. In relation to the continuity of care and use of mental health services medical sociologists in the US have pointed to the conceptual need to bring together the social process model (associated with a qualitative tradition) and social contingency model (associated with a quantitative model) in order to examine who accesses care in the context of when and how care is received and how choices and strategies relating to help seeking are socially organised ( Pescosolido 1991; Pescosolido and Kronenfeld 1995; Pescosolido and Boyer 1996). The relevance of this approach for exploring contemporary primary care use in Britain is that it holds out the possibility of providing a more comprehensive understanding of the patterns and processes of health care utilisation. Informed by the approach of Pescosolido and colleagues in the rest of this article we aim to demonstrate the benefits of using both quantitative and qualitative methods to better understand the dynamics of help-seeking and health care utilisation in primary care .
2.3: In this paper we focus on the methodological dimensions of combining survey based research with qualitative accounts of the rationale and actions shaping help seeking pathways and health care utilisation. We will show that linking retrospective and prospective survey data on health care actions with indicators of health need provides a better picture of the patterning and determinant of health care utilisation than existing routinely collected surveys and data sets ( Nicolaas et al 1997). Additionally we will argue that in-depth qualitative interviews with deviant cases' identified from the quantitative analysis (i.e. cases which are not predicted by the quantitative model) provide greater insights into the nature, processes and determinants of individual help seeking actions at a micro level.

Design And Methods

3.1

The data were collected in a feasibility study carried out in October-December 1996. The main purpose of the feasibility study was to test methods and procedures and it was therefore not necessary to select a nationally representative sample. Nevertheless, it was important to ensure adequate coverage of different types of areas and to include people with different demographic, social and economic characteristics.

Three areas in the North West Region of England

Area A:-a deprived, predominantly white, urban area

Area B: -a socially mixed urban area

Area C: -an affluent semi-rural area with a large elderly population

Different Sampling Designs Were Tested In The Feasibility Study.

In area A households were selected from the Postcode Address File. In areas B and C patients were selected from the age/sex registers of a practice in each area. To ensure sufficient numbers of frequent users of primary care services for the analysis, those who had consulted their GP 5 times or more in the past six months were over sampled in areas A and B (3:1). In area A households with a frequent user were identified with a screening questionnaire. In area B frequent users were over sampled directly from the practice list. The elderly, people with chronic conditions and residents of communal establishments were targeted. In area C in order to assess the feasibility of using health diaries among these groups. The data have been weighted to take into account the unequal selection probabilities. The study consisted of a face-to-face structured interview and a four week structured health diary. Information was collected for all household members. The person who knew most about the health of all household members was selected as respondent; in most cases this was the eldest female in the household. A purposefully selected sub-sample was followed up with an in-depth interview.

3.2

The response to the structured interview was low. Overall the response rate was 57% (346 households covering 834 individuals) but this rate varied between the three areas. Areas B and C had acceptable response rates of 66% and 75% respectively. The response rate in area A was low (42%). Response rates tend to be lower in deprived areas. This was further intensified by the large number of tower blocks. Making contact in tower blocks is particularly difficult because of entry phones, large numbers of young people who are more likely to be out and a greater fear of opening the door to strangers. At the end of the 30 minute interview, 72% of household respondents accepted the health diary (248 households covering 638 individuals). Among those who accepted the health diary, 33 (13%) household respondents did not return a complete four week diary. The majority of these respondents (N=20) dropped out immediately whereas the remaining 13 returned an incomplete diary ranging from 1 to 3 weeks.

3.3

In-depth interviews were carried out among a subset of households which had kept diaries in order to explore in more detail the patterns and processes of utilisation identified by the survey and to provide a biographical, social and locality context for health care utilisation. We also wanted to illuminate and elaborate on the utilisation and management of illness in the 6 week period covered by the diary ( 4 weeks) and survey (2 week reference period) and to identify subsequent use of primary care services covering a longer period of time. The sample included users of primary care services experiencing a wide range of complaints commonly seen in primary care and representing the range of service use identified by the main survey. As with the survey we undertook interviews in all three localities. The fifty five interviews were carried out in a period ranging from between 3 weeks and 5 months after the completion of the diaries.

3.4

Aspects of the qualitative work have been reported elsewhere ( Rogers et al 1998), Rogers et al (1999). The purpose here is to illustrate with reference to a small number of qualitative case studies how combined methods illuminate the heterogeneity and complexity of health service utilisation for primary care. The intention was to elaborate on the enumerative induction of the survey which, established the patterns of use of informal and formal health care resources according to the health and social need characteristics of the research population. We selected to present an analysis of qualitative interviews fro a sample of those who did not fit the quantitative predictive model of utilisation (described below). Identifying and accounting for cases which fall outside a predictive model can serve to increase the inclusiveness of analytic schemes ( Silverman 1985) . The analysis of deviant cases can also illuminate processes that are evident to a greater or lesser extent in the data set as a whole.

Survey And Diary: Results And Discussion

4.1

Information about the experience of illness, self care and formal health care were recorded in a structured diary on a daily basis. It was therefore possible to identify episodes of illness and relate these to health care actions. An illness episode is defined as a block of one or more consecutive days on which the individual had experienced the same illness. We have taken illness episodes as well as individuals as units of analysis. Only adults aged 18 or over living in households with complete four week diaries were included in the analysis (N=423). First, the pathways of health care utilisation are described using basic statistical techniques. We then focus on frequent use of primary care services, defined as two or more contacts with a general practitioner or practice nurse during the four week diary period. Logistic regression is used to predict frequent use of primary care services. Variables thought to be associated with use of primary care services were included in the model: age, sex, employment status, proxies for social class (housing tenure and car availability), high education, limiting long-term illness, a proxy for severity of illness (number of illness days during the diary keeping period). Although ethnicity has been shown to be related to use of health care, it was not included in the model because the number of people in the sample belonging to ethnic minority groups was too small. We have allowed for between-area differences in the model. The area variable reflects supply, accessibility and environment. Given the exploratory nature of the analysis, the model was kept as simple as possible, i.e. only main effects and no interactions were fitted. The logistic regression model predicts for each individual whether they should have been a frequent user or not given their combination of characteristics. These predicted values were contrasted with the observed values for each individual to identify deviant' cases; i.e. those who should be frequent users according to the model but were not and those who should not be frequent users according to the model but were. These deviant' cases were investigated using qualitative methods.

4.2

The four week health diaries were completed for 423 adults aged 18 and over. Almost half of these adults experienced one or more illness episodes, ranging from minor ailments such as a cold to more serious conditions such as heart problems. A large proportion of illnesses were minor: more than a third of all illnesses were reported as colds and flu.

4.3

In this sample, about one third of all adults had had some form of contact with formal health care professionals. Formal health care professionals included general practitioners, practice nurses, district nurses, doctors and nurses at accident and emergency departments, hospital staff, counsellors and physiotherapists. Contacts with pharmacists were also included if the pharmacists were asked for health advice. The majority of contacts tended to be with general practice. The type of contact ranged from telephone contacts for repeat prescriptions to face-to-face consultations with doctors.

4.4

In addition to formal health care services, information was also collected about self-care activities such as changes in daily activities because of an illness or injury (i.e. staying at home from work or school, staying in bed, changing diet/eating habits, using an aid/appliance) and taking non-prescribed medicines/remedies (i.e. home remedies, herbal products, homeopathic medicines and over the counter medicines). About two thirds of all adults reported one or more of these self-care activities.

4.5

Among the 199 adults who had experienced one or more illness episodes, a total of 448 illness episodes were recorded. Seventy eight of these illness episodes (17.4%) resulted in contact with formal health care services. This result compares to White's study where 20% of all symptoms and illnesses occurring within a month led to professional care ( White et al 1961). A health diary study carried out in Denmark also found that one in four to five illness episodes in a 27 week period led to some kind of professional care ( Bentzen et al 1989).

4.6

In addition to formal health care, we can also link self care activities to illness episodes. About 75% of all illness episodes involved some form of self care. We have classified illness episodes based on whether they involved self care and/or professional care:no health action was reported for 22% of illness episodes only self care activities were reported for 61% of illness episodes self care activities and professional health care were reported for 14% of illness episodes only professional care was reported for about 4% of illness episodes

4.7

The average length of an illness episode was about 7.4 days. However, the average length differed significantly between those who did not report any health action, those who reported self care activities but no professional care and those who reported professional care with or without self care: 2.3 days, 4.9 days and 8.6 days respectively. The length of an illness episode may be an indicator of the seriousness of the illness or an indicator of the increasing impact the illness may be having on the person's life.

4.8

The following analysis focuses on frequent users of primary care services. Among the 423 sampled adults for whom we had diary data, 10% had consulted their GP two times or more during the four week diary period.

4.9

The results of the logistic regression are presented in table 1. Perhaps not surprisingly, the fitted model shows that those with a limiting long-term illness were more than twice as likely to be a frequent user than those without, holding all other factors constant (OR=2.27). Consistent with results from other studies, women are more likely than men to be a frequent user (OR=1.35), although this result was only significant at the 10% confidence level.

Table 1 Odds Ratios Of Contacting GP Or Practice Nurse Two Times Or More In A Four Week Diary Period

Table 1: Odds ratios of contacting GP or practise nurse two time or more in a four week diary period

4.10

The predicted values were then contrasted with the observed values to identify deviant cases. Forty one individuals were not predicted by the model to be frequent users but were. This group included individuals who had visited the GP or nurse, but had not reported any illness days nor a long term illness. In some instances the use of the GP could be accounted for by visits to the GP for a repeat prescription for an ongoing condition for sickness notes or screening. Two cases from this group are presented below.

4.11

Another four individuals were predicted by the model to be frequent users but had not had contact with primary care services, despite having had to cut down on their normal activities for the whole diary keeping period. Of the 4 cases in this group were subsequently the focus of interviews and these cases are presented below

The Results And Analysis Of The Qualitative Interviews

5.1

The cases described below have been selected in order to illustrate the processes that might be operating, where high need was not indicated from the survey but where there was frequent utilisation. The interviews were to an extent driven by and constrained by the themes which formed the basis of the interview schedule and health diaries. However, these also provided the bases for respondents to provide an alternative or expanded narrative of events and of their patterns of health care utilisation. In the process of the interviews, interviewees greatly expanded on accounts to provide details of their experience of illness and the social domestic, personal and locality context of the use of services and other health care resources. Each of the interviews draws on a within-case analysis through a series of stages ( Ong and Jordan 1997). The description of events were matched with those provided in the diary and survey, together with additional account of events and processes that were identified by respondents as constituting their contemporary use of services . These were then linked to the deeper contextual narrative provided by respondents about their experience of illness their use and views of primary health care services.

High Need No Utilisation

6.1

These two cases illustrate adapting to illness and dealing with high need in a way which reduces levels of demand on formal health care services.

Case 1 Mr A

Mr A is a man of 46 living with his wife in a deprived inner city area. He is unable to work because of long term musculoskeletal problems and claims disability benefit and income support. In the past Mr A had undergone (failed surgery) for ' crushed discs' and his wife reported extensive levels of need. During the 6 week period covered by the diaries 27 illness days for his back were reported. Health action taken included cutting down on normal domestic/ leisure activities and the taking of prescribed medication. Formal contact from primary care was not sought. There appeared to be a number of reasons for non- consultation. The most important of these seemed to be related to decreasing expectations about the likely effectiveness of services and other forms of illness management. Within this there seemed to be a process of rational appraisal that contact with services could do little to alleviate the man's condition. The account provided of his illness career trajectory identified previous contact with alternative, conventional medicine and self care most of which was experienced as ineffective . A failed operation had been followed by physio- therapy which,'made it worse'. Similarly, subsequent exercise on prescription from the GP just didn't work'. Having tried a variety of lay and formal care options over a long period of time there seemed to be an established minimalist illness management strategy in place as described by his wife:

Transcript Mr A:

I: "Does he try to treat himself, or get any home remedies or do anything to make himself feel better, apart from what he gets from the doctor?"

R:"erm no not really, just on the prescription from the doctor. It's permanent all the time"

I:"What does he have?"

R:" just pain killers and anti-inflammatories"

6.2

Overall contact with health services and strategies to manage long term disability and illness appeared to be low. The qualitative interviews illuminated further on the nature and extent of a pattern of health care utilisation which had become established over time. Between the end of the diary period and the follow up qualitative interview (two months) three consultations with primary care were reported both for his long term health problem and for an acute illness unrelated to the more long term problem. For the long term illness, service contact was a result of service' rather than patient induced demand in so far as attendance was in response to bureaucratic procedures required for the continued entitlement to benefits. Utilisation had, for the most part, been reduced to routine and official use rather than active and intensive therapy for dealing with his ongoing problem. The typicality of use of health service in this way is described by his wife:

Transcript Mrs A:

I: "And how often does he go to the doctors your husband?"

R: "... Only when he needs to for prescriptions I just get a repeat, I just take it in"

I: "Oh so doesn't he have to see his doctor regularly?"

R: "No"

I: "And what..?"

R: "Well actually he has got to go because he's got a form off the doctor, so in the next couple of weeks he'll be going."

I: "Is that just like normal."

R:"Just to see how he is- about once a year"

I:"But apart from that he does he go ?"

R: "No unless like I say he's just got laryngitis so he's just been twice."

Thus service use was in response to short term need with only residual attention being given to this mans' main and long term health problems.

Case 2 Mrs B

Mrs B is a 74 year old widowed woman with multiple health problems including a history of back pain, breathing difficulties, heart disease and high blood pressure. Data from the diary and survey revealed 28 illness days for angina and breathing difficulties but no primary care consultations. Illness action recorded in the diaries included the consumption of prescribed and over the counter medication'.The qualitative account revealed that the illness episode reported in the diaries did lead to consultation immediately after the end of the diary period. According to the woman's account, the extent of her use of primary care for long term health problems was subject to flux, but overall had decreased over time. This quote describes the use of the 'on - off' nature of formal service contact and the not insubstantial part played by the GP in generating demand

"Well when I started with the breathing problem, then they wanted to see me pretty regular. ..... At first I was going once a week and then tailing off to two monthly visits based on doctors recommendation and returns at two monthly intervals."

6.3

A number of things deterred the use of services during the 4 week period covered by the diary and more generally. As in the previous case described above, the point this woman had reached in her illness career meant that a number of options had been tried, experienced and discarded. A fatalistic acceptance of living with distressing symptoms was evident from this woman's biographical account of her two main illnesses. Her reluctance to use services seemed to form part of a process of appraisal of available feasible options from health services to ameliorate incapacitating symptoms.

6.4

For example, she had anticipated her lack of suitability for an operation (although this has not been confirmed by a GP) vis:

"Well its usually my hip that bothers me more than anything, but they won't do it if you are overweight."

6.5

Additionally, her experience of cortisone injections were that they worked for a short time but then they became ineffective. Similarly, the side effects of anti-inflammatory drugs were considered severe but were currently tolerated in the context of a lack of perceived alternatives that were available.

6.6

Additionally, staying at home is one means of managing illness which may bring about dissonance in seeking help. This is evident in this description of an angina attack

"I had a bad angina attack and then of course I was confined to the house it takes 3/4 days to get over a bad one, you've just got to rest you can't do anything else really ."

6.7

The immediate availability of an alternative form of support was also important in preventing recourse to formal primary care services. During the 6 weeks covered by the survey and diary the availability of lay care provided by the woman's daughter was a factor in delaying the use of care. Not only was her relative a source of health care and support but she acted as a mediator when contact is eventually made with services:

"So I woke up one morning and pain in my back and my leg and I couldn't believe it, its a terrible pain it really is.... I knew my daughter was coming everyday you see which she does most times anyway and she came and she said 'what on earths to do' I said I can't get out of bed....I said the pain is driving me crackers anyway she said, 'oh get the doctor', you see so it was from that she sent for the doctor and he came."

6.8

A further influence militating against the ready resort to the use of services is related to ease of access. Unlike the previous case the locality of the surgery for Mrs B acted as a deterrent to use made more difficult by progressively worsening angina and breathing problems. Access to services was effectively limited to when her daughter could provide transport.

"where I go it's the other end of town. Well if you are fit enough there is no problem but you have to get 2 buses. ..You go into town and then you get one from town onto the road where the medical centre is and then you've to walk across to it. But its the you know getting there (laughs). I mean tomorrow if I had to go to the doctor I'm alright because my daughter comes for me and we go to Quiksave in B."

6.9

The possibility of changing to a nearer surgery was rejected on quality grounds. Mrs B considered the newer surgery to offer a poorer service in terms of facilities, professional care and the provision of information.

Unpredicted Utilisation Of Services - Low Need And High Use?

7.1

The two case studies drawn from the group who had reported two or more contacts with the GP or practice nurse during the diary period but were not predicted correctly' by the quantitative model were classified as being frequent users in the absence of a limiting long term illness (LLTI). LLTI was considered to be a major indicator of health need predicting utilisation used in the quantitative stage of data collection. These case studies suggest that the circumstances of utilisation and relationship with objective indicators of health need are both complex and diverse.

Case 3 Mrs C

This case illustrates that the level and nature of the service utilisation is linked to a number of complex processes operating at the level of interaction with professionals, prior personal experience of illness, the immediate social context and social networks. During the six week period covered by the survey and diary Mrs C a 40 year old woman in full time paid employment living with husband aged 43 sons of 14 and 4 years of age respectively with no apparent long term limiting illness reported consulting the GP 15 times. Ms C had experienced Colitis once before 6yrs previously. She was also aware of the nature and remedies available for this condition from her sister who also suffered chronically from this complaint. After 4 days of experiencing symptoms she consults the doctor for the first time:

Transcript Mrs C:

I:"What finally made you decide to go to the doctors?"

R: " realised it wasn't just diarrhoea, but was something different than the runs."

7.2

This decision was based on the failure of self care remedies to work (Dirolyte and Arrowroot) and the failure to cope with and contain her symptoms at work (she worked as a bar attendant at a local pub).

"Working behind a bar, I couldn't work with the symptoms, serving and I'd thought, oh my God it's coming, it was that bad, once it did come and I though Oh, it's so embarrassing and I nearly died a death..."

7.3

Armed with information from her past episode of illness and from her sister a specific demand for the patients' treatment of choice is made but not responded to in the expected way by the health service.

"It was like Dr B I asked her for these tablets my sister told me to get and she (the GP) said they will help you but I can't give you them,' ...You see I asked the doctor for these tablets and she said yes they probably will clear it up but you must go to the hospital first to see what it is..."

7.4

The respondent then went on to describe a sequence of visits in which both primary and secondary care services were considered to have failed to provide an appropriate response to her illness episode. Repeated visits to the doctor were part of a strategy to gain such a response, as illustrated by this account:

"And it was still happening, so I was going to the doctors, every time they shouted out it's not her again', I was a mess- a complete mess even at home I was crying and I cried and I cried ......and then they gave me a hospital appointment after three weeks she (the GP) put me on the scales and I'd lost over half a stone and she said 'I'm sorry but I think this is more serious than just the diarrhoea I think we'll have to do something about it', so she got me an appointment but I had to wait seven weeks for that... I said is there no chance you can get me in any earlier' and they said no chance at all' so in the meantime I said have I just got to put up with it?' and they said Yes I'm sorry'. Anyway after seven weeks of having it I went to the hospital and by that time I'd lost one and a half stone..."

7.5

At the point of secondary care contact she was told to wait a further two weeks for tests at which point she resorted to taking her sister's tablets.

"So I saw my sister and she gave me these tablets I was so bad it was Christmas week I was working and I felt so down and I'd lost so much weight, so I thought what harm can it do? I've never done it before take other peoples tablets...I've been smashing since."

7.6

The barriers to an effective response and the nature of use has to be seen in the context of the severe distress and disruption the illness caused and the contact that was being made with lay and familial support. The lack of responsiveness of the NHS as a services was also related to the view of private versus publicly provided health care:

"My sister told me about these tablets they gave her when she went to hospital, she had to go private in the end because she was that bad (our emphasis)."

7.7

Thus, in this case informal management turned out to be the most effective in resolving the problem despite very high service contact over a short period of time and the lack of legitimacy that this would be considered to have from formal health care providers:

"I daren't tell my doctor, I've not been to the doctor since because I've not had nothing wrong. They (the GP's)were very nice its just that I don't think I seemed to get anywhere with it."

Case D: Ms D

The final case Ms D is a lone parent of 26 years working part time as a cleaner who has a four year old child suffering from asthma. She too suffers from intermittent asthma. The frequent use recorded in the diaries related directly to the material resources available to deal with an illness episode rather than solely to levels of health need. Visits to the doctor are made for exempt' prescriptions (for which no payment is required) to obtain medication which the respondent knows it is possible to obtain over the counter from the chemist. This includes prescriptions for decongestants for herself and Calamine lotion and Calpol for her child:

Transcript Ms D:

I:"Are there times when you go to your chemists rather than your doctors?"

R: "No You have to pay at the chemists. ...Well your over the counter stuff it can be expensive can't it you know why pay when you can get it free?"

7.8

At another point in the interview it is clear that this woman pre-formulates what she requires from the service and then follows this through assertively:

"I don't go to the doctors unless I need something so I always do come away with a prescription....you can generally work out what's wrong with yourself anyway can't you?"

7.9

Perceptions about the role and authority of primary care are clearly a relevant factor influencing the point at and way in which services are accessed. This respondent had tested out fully the extent to which she might get a response from the service. She had formulated what was wrong and what she wanted from the service prior to her contact. Similarly, as with the last respondent, prescribed medication for dealing with illness is obtained from a lay source. She uses antibiotics given to her by her friend. However, unlike the previous case this medication is used as an initial attempt to deal with the illness herself. Just as the lack of a car prevented the ready use of the same GP practice for Mrs B in the case of Ms D utilisation of services was made possible by having a car.

Understanding The Patterns And Process Of Primary Care Utilisation

8.1: The combined qualitative and quantitative data that we have presented above suggests a complex relationship between health need and demand for primary care. The predictive' quantitative model demonstrates the way in which key variables can be used to chart the patterns of primary care utilisation in a population. Structured diary data mapped the self-care actions of individuals within households and the part played by significant lay others as a health care resource alongside and instead of contact with services. The data suggested that there was a strong tendency to first try self-care before contacting professional health services. The qualitative data illustrated more about these processes and the complexity and diversity of utilisation left implicit in the survey data alone. In particular it illuminated the way in which the past experience of health illness and service contact coalesced with influences in people's more immediate social and domestic contexts in shaping the ways in which acted. This was illustrated in the first two cases where the low use of services at times of high need were linked to a learning process over-time about what could be expected from services operating specific rules together with the actual health status and progression of illness . The third case, showed that over a much shorter time, the failure of the services to respond to the presentation of acute or new illness episodes can lead to the eliciting of alternative help from within the lay network. These findings also raise questions about the commonly held assumption that people with a chronic illnesses place increasing demands on the NHS as their illness progresses. Whilst we can not generalise from the cases presented here, our qualitative data suggests that there may be a more variegated relationship between need and demand for those with long term health needs in which service use can decline significantly over time. The accommodation of symptoms in preference to formal service use has been identified in other qualitative studies ( Bendelow 1996). There have been cautions about the validity of and over reliance of the long term illness variable as a predictor of health care utilisation in health surveys such as the General Household Survey ( Parkin et al 1998). Similarly, the cases where there was an apparent lack of a long term health need but high use of services, illustrated the way in which material circumstances can exacerbate the need to use services (as in case 4), the substantial need that can arise over a short period of time and how high levels of interaction with services can leave health needs unmet (as in case 3).
8.2: At the level of theorising about health care utilisation the findings from this combined methodological study suggests that health care use is most appropriately viewed as an interplay of structure and agency rather than as a uni-linear outcome of expressed need' or individual decision making on the part of individuals or supply induced' demand on the other. The finding about the coalescence of lay with formal care confirms the utility of the Net Work Episode model described by Pescolido and Boyer for analysing primary care use. The NEM conceptualises services use as the range of patterns and pathways of practices and people both within and out with the formal health care sector who are consulted during an illness episode ( Pescolido and Boyer 1996).

Implications For Combining Methods In Applied Sociological Research

9.1: The experience of carrying out this study raised issues which resonated with debates about theory and the use of qualitative and quantative methods in other applied sociological research contexts. With regard to theorising, the analysis of the demand for primary care would benefit further from being re-conceptualised with reference to structuration theories, and analytical dualism evident within mainstreanm sociology (e.g. Archer, 1996; Willmott, 1997; Williams, 1995; and Schilling, 1997). These theoretical orientations bring to the fore the relative interplay between structure and agency and their expression and embodiment in peoples' everyday practices. They transcend the dualism of objectivism and subjectivism evident in the ways in which many aspects of contemporary social organisation and practices are conceptualised from outside the discipline of sociology.
9.2: The process of carrying out the study confirmed the utility of using methodological pluralism as a means of identifying and exploring aspects of agency and structure and of generating micro-macro theories. An initial mapping of the patterns of a social phenomena (i.e. health utilisation) represented the first step in a more in-depth emic approach to understanding individual action and processes associated with a more biographical tradition within mainstream sociology ( Stanley 1993). This aspect of the study illustrated the way in which social structure is represented not only by the variables used in the quantitative survey and structured diary, representing the traditional macro influences on peoples lives (e.g. social class, material circumstances location ) but also how social structure is implicated and translated at the individual level. Similarly, the use of a structured diary format permitted the capturing and enumeration of events close to when they happened and the tracing of events over a designated period, whilst the narratives derived from in-depth interviews provided a view of how specific people internalise and make sense of social expectations from past and present experiences of contact with health organisations and significant others. The narratives also challenged the meaning and conceptual bases of key variables used in the structured phase of the study (e.g. the long term illness variable and restrictive activity as an indicator of self care).
9.3: However, there were also limits to the complementarity of the mixed methods. The need to organise the qualitative data around the events and timing of the two structured methods meant that the determination of meaning and action was in part already framed for respondents by the researchers. The room for respondents to break out of the discourse set by the researchers was therefore limited. In particular the timing of interviews to 'capture' a more in-depth view of utilisation survey did not always match the temporal accounts of events from the respondents' perspective. Instead, people's contextualised accounts of a health utilisation timescale followed significant events and points in their illness career which took place over a number of years.

Conclusion

10.1: Pescolidos' (1992) point that past conceptual and methodological approaches to understanding the patterns and processes of the demand for and use of services is limited has been borne out by this study. The use of a multi-method approach illustrates more about the combined patterns and processes of patient actions in dealing with illness and primary care use than previous qualitative or quantitative studies undertaken alone. In the future it is likely that combined methodology will be most useful in designs which seek to make specific changes to services and where establishing the extent of change will need to be accompanied by examining the mechanisms and processes underlying them. The diversity and complexity of factors and determinants of health care utilisation suggests that qualitative interviewing at different time points might usefully be applied to health services research aimed at assessing the impact of interventions on peoples' help seeking and utilisation.

Acknowledgements

: This study was funded by the Department of Health as part of the Core programme of the National Primary Care Research and Development Centre which is based at the University of Manchester.

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