Rural health dialogue for the sustainability of help-seeking behaviors among older patients: Grounded theory approach

doi:10.21203/rs.3.rs-2822936/v1

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Research Article

Rural health dialogue for the sustainability of help-seeking behaviors among older patients: Grounded theory approach

https://doi.org/10.21203/rs.3.rs-2822936/v1

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Journal Publication

published 18 Oct, 2023

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Background

Help-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs.

Methods

All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20220002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants’ perceptions and behaviors regarding HSBs.

Results

Twenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs.

Conclusions

Mitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.

community participation

grounded theory approach

help-seeking behavior

healthcare sustainability

rural health dialogue

rural older patients

Help-seeking behaviors (HSBs) are essential for preventing diseases and promoting health conditions and are driven by social support and enhanced intentions toward HSBs [1–3]. HSBs are behaviors that address people’s symptoms and anxieties. When people approach symptoms and anxieties [4, 5], they are influenced by various social, demographic, and socioeconomic factors [6, 7]. Effective HSBs can mitigate difficulties in life and improve the overall quality of life (QOL) [8]. Social support, self-efficacy, and intention toward HSBs are essential [9] for overcoming such difficulties, leading to the effective use of healthcare resources [7, 10]. Dialogue between lay people and healthcare professionals is one of the social resources driving support and intention [11].

Dialogue with peers and medical professionals can improve HSBs’ quality and quantity and is particularly essential for older people. In communities, people engage in dialogue with others regarding their health conditions and may modify their HSBs based on others’ suggestions [12, 13]. In particular, older people change their HSBs based mainly on their relatives and family’s dialogues and suggestions due to limited access to communication resources and interactions with others [9, 14]. In addition, older people frequently use medical facilities, where dialogues with medical professionals can modify their HSBs for common critical symptoms [15–17]. Effective advice from physicians can motivate older adults to act based on their symptoms [18, 19]. The dialogue between older people and medical professionals should be further driven in medical institutions and communities to improve HSBs [18].

In the rural context, the lack of healthcare resources necessitates effective HSBs and dialogues between older people and medical professionals. Older people in rural communities have limited access to medical institutions, and hence, outreach projects regarding HSBs are essential [18–20]. A previous review suggested that rural contexts need additional outreach projects for older people’s HSBs and collaborations among physicians and citizens for better HSBs [18, 21]. For effective healthcare in rural contexts, physicians need to reach out to communities, have dialogues with older people regarding HSBs, and improve their intention for HSBs, leading to the effective usage of healthcare resources and a better QOL [18].

For effective dialogue with rural citizens, the involvement of family physicians is vital. Family physicians specialized in family medicine systematically treat patients from biopsychosocial aspects [20, 22]. Dialogues with rural citizens regarding HSBs may demand knowledge from multiple medical fields and social sciences, such as sociology and public health [5, 22]. To date, the effects of health dialogues between older rural citizens and their family physicians on the citizens’ HSBs have not been investigated. In this study, we aimed to investigate how health dialogues regarding HSBs among family physicians and rural older people could affect their attitudes toward their symptoms. In other words, we investigated the effect of health dialogues between medical professionals and rural citizens on their HSBs.

This qualitative study used a grounded theory approach regarding the health dialogues of participants in rural communities.

Setting

The study was conducted in Unnan City, Shimane Prefecture, Japan. Unnan City is in the eastern part of Shimane and borders Hiroshima Prefecture in the south. Its total land area is 553.1 km² and accounts for 8.3% of Shimane, most of which is covered by forests. A survey conducted in 2020 revealed the total population of Unnan City was 36,007 (17,316 men and 18,691 women), with 40.01% of the population being older than 65 years. Unnan City has 30 multifunctional autonomies, each with various functions for managing their respective social issues. In traditional protocols, different community groups have different functions (e.g., community organization, healthcare, and continual education). Thus, each autonomous community organization is comprised of directors, sub-directors, and clerks, who are active in three main categories, namely community organization, healthcare, and social/environmental development. Community organization refers to citizen empowerment, effective utilization of local resources, and solving community problems through the efforts of local leaders [23].

Participants

Between April 2022 and March 2023, 112 citizens from rural communities participated in health dialogues. Purposive sampling was performed to address the research purposes of ethnographic and semi-structured interviews. Two communities (Tane and Matsukasa) were chosen based on their substantial distance from the central part of Unnan City. Study participants from each community center were briefed about the study and provided informed consent to participate. All participants were screened for fever and other COVID-19 symptoms before the study. The participants wore facemasks and maintained a distance of more than two meters between them.

Rural Health Dialogue

A rural health dialogue among family physicians and older rural people was conducted to share experiences and knowledge regarding HSBs in rural communities. Health dialogues were held once a month in each community center. The number of participants in each session was between 10 to 12. Each session had one health theme, namely chronic diseases (hypertension, dyslipidemia, diabetes, and chronic obstructive pulmonary diseases), exercise, food, sleep, joint pain, constipation, polypharmacy, multimorbidity, and palliative care. The duration of each session was approximately 60 to 90 min.

In each health dialogue, family physicians initially explained one health topic regarding the prevalence of diseases in communities, related diseases, treatments, and concrete experiences regarding diseases. Next, participants voluntarily shared their experiences regarding health issues. Family physicians allowed the participants to share their experiences and answered prompted questions. Furthermore, based on the participants’ experiences, family physicians inquired about how they acted on their symptoms regarding HSBs. Various ideas and behaviors on how to control and approach the symptoms were shared; the family physicians respected each behavior and the reason underlying their HSBs. Finally, family physicians shared examples of effective behaviors to control symptoms and prevent exacerbations of symptoms and diseases.

Measurements

Ethnographic and focus group interviews

Ethnographic and focus group interviews were conducted with the participants. Only rural citizens were included in the ethnographic study. The specialties of the researcher included family medicine, medical education, rheumatology, and public health. Researchers worked in rural clinics, observed the interactions among community center participants, and took field notes during the study. One of the researchers, R.O., facilitated focus group interviews after each health dialogue in the community center room. The interview guide included the following four questions: What did you think of the health dialogue with medical doctors? How did you consider help-seeking behavior in your community? How did the health dialogue assist in changing your help-seeking behavior? How can you change your help-seeking behavior? Do you have any idea on how to improve the health dialogue? Each interview lasted approximately 60 min and was recorded and transcribed verbatim.

Analysis

The inductive grounded theory approach was used to investigate how participants in rural health dialogues changed their perceptions and behaviors regarding HSBs [24]. After reading the contents of the field notes and conducting in-depth semi-structured interviews, the first researcher coded the contents and developed codebooks based on repetitive readings of field notes, as the initial coding. The study used the process and concept coding method [24, 25]. Thus, the researcher induced, merged, deleted, and refined the concepts and themes by going back and forth between the research materials and initial coding for axial coding. Axial coding elaborates on the concepts and themes while refining the codes. For triangulation, the first and second researchers discussed the concepts and themes. The interview contents were analyzed iteratively during the research period for theoretical saturation. Finally, the theory was discussed by both researchers, who ultimately agreed on the final themes.

Ethical Consideration

Participant anonymity and confidentiality were ensured throughout the study. All participants provided written informed consent before participating in the conferences and answering the questionnaires. All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20220002).

Outcome of the grounded theory approach

Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue for the realization of HSBs, reflection on one’s own HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, thereby improving motivation for safe and secure HSBs (Table 1).

During the health dialogue, participants shared their experiences with HSBs and enjoyed talking to others. Sharing their HSBs revealed differences in their attitude toward health. Realization of these differences drove their reflections on HSBs. The latter was enhanced through dialogue with physicians and other participants regarding the improvement of their HSB methods. Through reflection, the participants realized their resources for HSBs and considered revising their HSBs based on the rural social resources. In addition, dialogues with physicians in communities enhanced the participants’ familiarity with physicians, which improved their motivation for safe and secure HSBs (Fig. 1).

Table 1

Results of the grounded theory approach
Theme	Concept
Joy-driven dialogue toward the realization of HSBs	Joy of dialogue
Joy-driven dialogue toward the realization of HSBs	Realization of HSBs in communities
Reflection on personal HSBs through learning from others	Changing attitudes and learning from others
Reflection on personal HSBs through learning from others	Deepening the understanding of HSB
Revising HSBs based on rural social resources	Importance of the connections in communities
	Improvement in collaboration through dialogues
	Revision of HSBs
Familiarity with physicians, thereby improving motivation for safe and secure HSBs	Change in the relationships with physicians
	Familiarity with physicians
	Mental accessibility to rural medicine

Joy-driven Dialogue For The Realization Of Hsbs

The health dialogue allowed participants to share their health experiences openly in the community. As they aged, they lost the opportunity to talk to each other; therefore, they felt joy during the dialogue. Participant 2 stated, “I enjoyed talking with other in different communities. I wanted to talk about health, but there were no opportunities. This opportunity for dialogue is essential for our health.” Previously, they felt that talking openly about health might invade their privacy. Through the joy of dialogue, they realized that sharing their healthcare difficulties was beneficial for their HSBs in communities. Participant 5 stated, “Joy can be important in this dialogue. The participants could share their difficulties in health. Initially, I considered that privacy was challenging in this dialogue. However, dialogue with joy about health allowed me to openly discuss my difficulty.”

Furthermore, the dialogue allowed the participants to understand others’ ideas and behaviors regarding their health problems, some of which were different or new among the participants. They could get the time required for realizing their specific behaviors regarding their health problems. Participant 13 stated, “I was surprised to listen to others’ behaviors regarding their health. They completely behaved differently from me. I considered that they should take rest, but they are healthy now. So, I realized that my health behaviors could be wrong or modified.”

Reflection On Own Hsbs By Learning From Others

Through health dialogues, participants began to reflect on their own HSBs. The ones that had a dialogue regarding HSBs in communities before participating in this dialogue could understand other citizens’ behaviors using multiple resources. Participant 4 stated, “Some of the participants did know new ways of dealing with their health problems, such as calling physical and internet-based clinics. Also, they have connections with retired medical professionals and ask for help before using rural healthcare resources.” The participants openly talked about their difficulties in health issues and began to know and use new social and healthcare resources to manage their health problems. Participant 8 stated, “I was amazed because different participants have different resources to use for their health. I could acquire new ways of dealing with my symptoms.”

The process of acquiring new knowledge and skills regarding HSBs was based on continual reflection. Some participants continuously participated in health dialogues and reconsidered their HSBs several times. The process of reflection enhanced their learning about HSBs. Participant 1 stated, “Initially, I did not think I could reflect on my usual behaviors regarding HSBs. However, by participating in the health dialogue several times, I could consider my behaviors from various perspectives and was motivated to change my behaviors.” The new knowledge of HSBs included multiple social resources in rural communities. The participants were motivated to achieve effective health control in rural contexts. Participant 17 stated, “In reality, rural areas have various resources. I am satisfied and secure. I am motivated to use more health resources in rural communities for better health.”

Revising Hsbs Based On Rural Social Resources

Health dialogues have emphasized the importance of connections in communities. The participants considered that rural contexts lack healthcare resources compared to urban areas. Mutual understanding and assistance among rural citizens are essential for effective HSBs. Participant 3 stated, “There are few hospitals, clinics, and pharmacies in rural areas. Public transportation systems are lacking. The sharing of knowledge of HSBs among rural citizens is fruitful. The connections among us should be driven for an effective control of health.” The connection among rural citizens was found to be a critical and valuable social resource.

Collaboration among rural residents must be improved to ensure effective connections. Improvement in collaboration through dialogue was considered adequate. Participant 11 stated, “Through this dialogue, I could know new ways of health control, but above all, the foundation is the relationship between us. I should frequently improve the collaboration with neighbors to share and effectively use healthcare resources in rural contexts.” For effective collaboration, social interactions need to increase. Owing to the COVID-19 pandemic, older people in rural contexts were reluctant to go out and meet others. The participants considered that their perception should be changed for better healthcare. Participant 8 said, “COVID-19 is dangerous, but I feel that going out and regaining social relationships with others in the community is better for improving health conditions.”

HSBs can be revised based on mutual understanding and effective collaboration among rural citizens. Social resources are lacking in rural areas. However, the participants realized that, based on their collaboration, the practical use of their knowledge and skills could improve their HSBs. Participant 21 stated, “The lack of social resources may be a drawback in rural areas, but I have social relationships among citizens. The effective usage of relationships and collaborations help me act effectively to improve my health conditions.”

Familiarity With Physicians Improved Motivation For Safe And Secure Hsbs

Physicians’ participation in health dialogues changed rural citizens’ perceptions of their relationships with physicians. Physicians facilitated citizens’ discussions about their health conditions and listened to their symptoms at citizens’ pace. The situation was very different from that in medical institutions. Participant 17 stated, “In medical institutions, physicians are always busy and may not have time to listen to patients well. In this dialogue, they kindly listened to my symptoms and behaviors. I could say a lot about things during the dialogue.” Participant 2 stated, “Taking up with physicians here is beneficial for me. I knew the personality of each physician and changed their perception.” Through health dialogues with physicians, the participants could flexibly change their perception of physicians to a familiar existence.

The effective usage of relationships and collaborations help me act effectively to improve my health conditions. Rural areas have few medical professionals; therefore, rural citizens feel that physicians are far away from their lives and are inaccessible. Through dialogue, the participants realized that the physicians were familiar with them and that they could share their thoughts openly. Participant 22 stated, “I could say a lot of things to the physicians, and they replied to me kindly. I thought that physicians did not respond to me in-depth, and I just got a prescription in the medical institution.” Participant 9 stated, “Through this dialogue, I could change my image of physicians and say everything related to health. The image of physicians changed completely after communicating with them continuously.” The continual dialogue between citizens and physicians positively changed the physicians’ image and made them open-minded about medical issues.

Familiarization with physicians changed the image of rural medical institutions. Participants previously felt that rural medical institutions were busy and inaccessible to older people. Through dialogue with the physicians, they felt that rural medical institutions could be used effectively. Participant 12 stated, “For me, medical institutions were far from my life. These were inaccessible because of their estranged images. This dialogue was effective in changing the image of rural medical institutions.” The participants understood physicians’ working conditions and the differences in their attitudes between medical institutions and communities. They believed that they should adjust their perceptions and behaviors regarding their symptoms. Participant 6 stated, “Physicians are fundamentally busy in their working settings. However, they desired to listen to patients’ stories and approach their symptoms. I understand this point, so now I do not have difficulty accessing medical institutions.”

This study clarified that rural health dialogues can help citizens share their experiences of HSBs and promote positive conversations by talking to others. Sharing their HSBs through health dialogues could facilitate rural citizens’ reflections on their own HSBs, realize their resources for HSBs, and consider revising their HSBs accordingly. In addition, dialogues with physicians in communities increased participants’ familiarity with physicians, which further improved their motivation for safe and secure HSBs.

Health dialogues are essential for driving health promotion in communities, increasing the opportunity to feel joy, and recognizing HSBs among older patients. COVID-19 restricted older patients’ mobility and interactions within communities, owing to their vulnerability and mortality from the infection [26–28]; they suffered from a lack of social interaction with relatives and friends in their communities [29]. The effects might be vital in rural contexts, where older patients live independently [29, 30]. Previous studies have shown that the COVID-19 pandemic has caused physical and psychological instability and increased frailty and depression in older patients [31, 32]. The lack of community dialogue also induced social isolation among older adults, further deteriorating their HSBs [33, 34]. As shown in this study, health dialogues facilitated by physicians can allow older people to see other community members and motivate them to consider improving their HSBs. As reported in previous articles, in the post-COVID-19 period, the sustainability of rural communities demands effective collaboration among citizens [35, 36]. The use of a joy-driven health dialogue, as suggested in this study, can be one of the solutions to increase social interactions and joy related to health in rural communities.

Reflection on one’s own HSBs could change the perception of others’ behaviors, from interest to intention, leading to better health. Regarding HSBs, the change in perception from interest to intention may be related to the QOL [9]. The current study showed that health dialogues can drive participants to reflect on and improve their intentions for HSBs in better ways. Thus, health dialogues can improve a participants’ QOL. The opportunities for dialogue regarding health conditions in communities may have decreased owing not only to COVID-19 but also to privacy issues [37, 38]. The latter in rural contexts may impinge on dialogues among older patients, thereby inhibiting collaborations among rural people [39]. In rural areas that lack social resources, collaborations among older adults are essential for the sustainability of healthcare [16]. An increase in opportunities for health dialogues can improve people’s health and should be driven by rural communities.

The use of social and healthcare resources should be considered to effectively revise HSBs in rural contexts. As shown in this study, the participants realized new social and healthcare resources through health dialogues. The realization of new social resources motivated the participants to revise their HSBs using the new resources. In rural contexts, healthcare resources are limited; therefore, older patients’ HSBs may also be limited [40]. Previous reports had shown that the limited resources impinge on older patients’ HSBs and their QOL [41, 42]. To improve HSBs, social and healthcare resources should be clarified in rural contexts and informed to older patients [3, 37]. As demonstrated in this study, rural contexts provide mutual help to communities, supporting people’s lives socially. In current medical care, there is an insufficient provision of information and clarification of social resources in rural contexts [11]. Local governments and communities should clarify these issues for effective HSBs and support for older patients [16].

Increasing familiarity with physicians in rural contexts can improve older patients’ motivation to secure HSBs. In rural contexts, older patients feel psychologically distanced from their physicians owing to their previous experiences [43, 44]. Due to the lack of medical resources and an imbalance between need and demand in rural contexts, physicians can perform their duties with hope and respect for patients’ opinions, without paternalism [45, 46]. Patients’ experiences of paternalism impinge on the image of medical professionals, making them appear arrogant and selfish [47]. Changing the image of medical professionals, especially physicians, is essential to improve healthcare in rural contexts. As shown in this study, continual health dialogues between physicians and citizens in rural contexts can positively modify the image of physicians. Changes in image can increase the familiarity of physicians and medicines in rural contexts [48, 49]. Mental accessibility to healthcare and HSBs influences the health conditions of older patients [9, 50]. This study demonstrated the possibility of improving rural health dialogues and effectively driving collaborations between citizens and physicians. Future studies should investigate changes in subjective and objective health outcomes through continual collaborations among communities.

The current study has several limitations. The first concern was the motivation of participants to learn about HSBs. The participants could have the motivation to learn HSBs. In this study, the researchers clarified the changing processes regarding the motivation of multiple participants through iterative data collection. Another limitation was transferability since this study was conducted only in rural Japanese communities. To improve the reliability of data, we used iterative data analysis and prolonged data collection. Future studies should investigate effective educational methods in other regions and international contexts, including this research theory. Additionally, the first author coded the interview data, which may have affected the study’s credibility. To improve research quality, the second researcher reviewed the processes of coding, concepts, and themes through theoretical triangulation.

Rural health dialogues can help rural citizens share their experiences of HSBs and promote joyful conversations by talking to others. Sharing their HSBs through health dialogues could facilitate rural citizens’ reflection on their own HSBs, realize their resources for HSBs, and consider revising their HSBs based on rural social resources. In addition, dialogues with physicians in communities increased participants’ familiarity with physicians, which improved their motivation for safe and secure HSBs. The possibility of improving rural health dialogues and effectively driving collaborations between citizens and physicians should be investigated in the future.

HSBs

help-seeking behaviors

QOL

quality of life

Ethics approval and consent to participate

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no external funding.

Authors’ contributions

RO: Conceptualization, Methodology, Investigation, Data curation, Visualization, and Project administration; CS: Supervision; RO and CS: Validation, Formal analysis, Writing—original draft preparation, Writing—review and editing. All authors read and approved the final manuscript.

Acknowledgments

We thank all the patients who participated in this research.

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No competing interests reported.

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published 18 Oct, 2023

Read the published version in BMC Geriatrics →

Editorial decision: Major revision
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Reviewers invited by journal
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Rural health dialogue for the sustainability of help-seeking behaviors among older patients: Grounded theory approach

Status:

Journal Publication

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Abstract

Figures

Background

Materials And Methods

Setting

Participants

Rural Health Dialogue

Measurements

Ethnographic and focus group interviews

Analysis

Ethical Consideration

Results

Outcome of the grounded theory approach

Joy-driven Dialogue For The Realization Of Hsbs

Reflection On Own Hsbs By Learning From Others

Revising Hsbs Based On Rural Social Resources

Familiarity With Physicians Improved Motivation For Safe And Secure Hsbs

Discussion

Conclusions

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1