The d e s c rip tiv e q u a lita tiv e nature of th is research precluded the use of th e to ta l Area Health A u th o rity fo r the study. In any case n e ith e r the tim e nor the resources were a v a ila b le to do th is . A c o n tro lle d sampling procedure was required which would generate a reasonable number of care s e ttin g s to be. assessed, but which would not prem aturely omit under-users or be u n rep resen tative of the area in any system atic way. I t was also im portant to ensure th a t members of the sample should have the same p ro visio n a v a ila b le to them, so th a t c lie n t p referen ces in known s e ttin g s could be stu d ied .
CHAPTER 3: P ilo t work and re s u lta n t methodology 3 .2 * 1 . . Sources.of sampling ...
The sample was taken from c e rta in .H e a lth V is ito r s ' case, lo ad s although i t could have -been;derived, from a number of s ta r tin g -p o in ts , each of
which was considered and re je c te d :
a) .general p ra c titio n e r lis t s
b) h o s p ita l discharge, b ir th records
c) c lin ic cards h e ld a t each prem ises, or
d) circum scribed d is t r ic t s of the Area Health A u th o rity .
Each one posed d if f ic u lt ie s which would p re ju d ic e e ith e r the completeness .of. sampling possible or the co n tro l over accuracy th e researcher could m aintain.
a) The main reason fo r re je c tin g GP l i s t s as the source of sampling was. th e -p o s s ib ility th a t under-users may not be re g is te re d w ith a GP and so would be om itted a t the o u tset.
b) . I t would have been d e s ira b le in some ways to s ta r t sampling and m onitoring the study population a t the h o s p ita l, fo llo w in g the new mothers through the f i r s t year of th e ir baby's l i f e . This stra te g y would have, yield ed c lie n ts a ll over th e area , making assessments of provision fo r each one very d i f f i c u l t , als o we could not be sure th a t s u ffic ie n t numbers ..of., a sample so generated would have access to the same p ro v isio n . In any case such an am bitious scale was. not p o ssible given th e research resources. An ongoing study which co n cu rren tly monitored mothers could in te r fe r e in u n s p e c ifia b le ways w ith p a tte rn s of usage. A n o n -in te rfe rin g re tro s p e c tiv e a n alysis of usage was to be
CHAPTER.3: P ilo t work and re s u lta n t methodology.
• c ) C l i n i c -c a rd s .are.com pleted ( in it ia t e d ) when a. c lie n t .v is its th e . in fa n t w e lfa re sessions, thus p re ju d ic in g th e ... in c lu s io n of. . non-users .in the stu d y.
d) D iv id in g : th e area as a whole, in to d is t r ic t s o f .eq u al-size...fo r.
which p ro v is io n servin g each population was known was not p o ssib le, given the research resources (tim e, money*, s t a f f )
. .a v a ila b le .. There were.no n a tu ra l d iv id in g lin e s and i t became
evident th a t some populations would have no c lin ic in th e ir a re a , would be served by numerous changing h ealth v is ito r s and would prove unmanageable*
Each c h ild born in the area (e ith e r h o s p ita l or home) is a llo c a te d to a h e alth .v is ito r so we could be sure th a t no mother s a tis fy in g c r it e r ia fo r in c lu s io n in the study would be missed. (Any c h ild re n born, unsupervised by a h e alth worker or not n o tifie d to the b ir th r e g is tr a r remain outside of the study and an unknown group, and i t is not p o ssib le to s ta te w ith any accuracy whether th is was lik e ly to have o ccu rred .) I t is p o s s ib le .to document th e p ro visio n a v a ila b le to each of .th e .m others. on a h e alth v is it o r 's caseload and thereby e s ta b lis h the use made of i t by c lie n ts .
The h e a lth , v is it o r caseloads chosen were the higher ones, .where under-usage is thought most lik e ly to occur. A comparison of these H ealth V is ito r caseloads w ith those of the re s t of the area was undertaken to ensure they were not otherw ise very unusual in any way
CHAPTER.3: P ilo t work and re s u lta n t methodology
..3*^, 2 * .Comparati ve caseload of heal th vi s i to r
I t was .im portant th a t th e h e a lth v is it o r caseload* i*.e * number..of c h ild re n under 1 year, should b e .... as nearly, .equal a s ... p o s s ib le , d iffe r in g caseloads could otherw ise be considered as one o f th e prim e
fa c to rs in the nonrusage of s e rv ic e s . I t was decided * to choose
s e ttin g s where th e h e a lth , v is ito r s tended to have.modal or. higher caseloads so th a t any d iffe re n c e s in uptake of the s e rv ic e would not p rim a rily be determ ined by th e higher numbers involved. .
Comparable . numbers in other aspects of the h ealth v is it o r 's caseload (eg c h ild re n under f iv e years, e ld e rly persons e tc ) were considered in order t h a t workloads across the s e ttin g s would be as uniform as p o s sib le .
A period of two years minimum length of service in a p a r tic u la r care settin g .w a s chosen as an ap p ro p riate length of tim e fo r a h ealth
v is it o r to become f a i r l y w ell estab lish ed in an area. I t was
im portant th a t the h e alth v is ito r s involved in the p a r tic u la r s e ttin g
were not id io s y n c ra tic in terms of experience in the area. There is
one re s e rv a tio n concerning the use of length of tim e in an area as a c r it e r io n in th a t more 'p ro b le m atic ' areas (eg those w ith high -unemployment, sub-standard housing, high incidence of non-accidental in ju r ie s to c h ild re n ) tend to have a high turnover of s t a f f . This means th a t such areas w ith in the area may not be represented. However, fo r th e purposes.of th is study, i t was p re fe ra b le not to use areas of high s t a f f turnover as th is again.could be a determ inant in
CHAPTER 3: P ilo t, work and re s u lta n t methodology
: .In .order. ...to s e le c t th e ..sample, th e to t a l o f. each :health v is it o r c as e lo a d .fo r th e year 1980 was examined and th o s e .h e a lth v is ito r s w ith th e ..modal /h ig h e r . caseloads s e le c te d . A fu rth e r s e le c tio n ..was made necessary as research., stu d ies were alread y under way in twd. o f th e ..possible s e ttin g s . Other p o ssib le s e ttin g s were excluded due to long term s ickn ess.o f s ta ff n e c e s s ita tin g emergency cover by another h e a lth v is it o r , or where th e p a r tic u la r s e ttin g was s ta ffe d by a fie ld w o rk teach er in v o lv e d in th e education of h e a lth v is it o r students and -th ere fo re having e x tra s ta ff in the f ie ld .
3 . 3 SELECTION OF MATERNAL SUB-SAMPLES
: A . cumber of fa c to rs had to be .considered when s e le c tin g th e m aternal sub-sample.
Socio-economic groups.: A com parative study across .a ll socio-economic, groups .could be undertaken or one could concentrate on socio-economic groups IV and V, where under-usage tends t o be more acute. In looking a t a l l groups, i t . may be possible to exp lain how and why some consumers make more ap p ro p riate, use o f the s ervice s, than o th ers. Comparison of ..users.and non-users w ith in a socio-economic group (ie those who share the same socio-demographic c h a ra c te ris tic s which may ..contribute to under-usage) is another im portant approach (McKinlay
1972b). A fu rth e r ap p ro ac h -is -to allo w c h a ra c te ris tic fe a tu re s and. a p a tte rn of usage to emerge through in v e s tig a tio n of a to ta l sample, and then to concentrate, on emergent groups a t a la t e r s ta g e .. This strategy.w as-used in the present study in order th a t (a) a more
CHAPTER 3 i P ilo t work and.re s u lta n t methodology
complete v ie w , of u t ilis a t io n . of th e services in th e a re a .c o u ld be determined,-....(h). a d e ta ile d - 'u t ilis a t io n , p r o file .' fo r . each set o f mothers .may be ^ p ro vid ed , and .(c) special emphasis.may be placed on
'w ith in group' d iffe re n c e s in u t ilis a t io n .
Firm tTtim e m o th ers:. The /paternal sub-sample includes . prim iparous
mothers, o n ly , i . e . those .who have had no previous pregnancies and th e re fo re excludes women who may have had abortions or s t i l l b i r t h s and thus have had. previous contacts w ith the m aternal and. c h ild -h e a lth s e rv ic e s . Although under-usage of the c h ild h e alth ..services is considered to be more acute, amongst raultiparous women (CHS,. 1976; DH8S, 1979; CPAG, 1978), i t would he extrem ely d i f f i c u l t to get an accurate assessment of p o st-n atal, care fo r each pregnancy. These may have occurred in d iffe r e n t lo c a tio n s , s e ttin g s and w ith d iffe r e n t personnel a s s is tin g , thus adding to the wide v a r ia b ilit y of unknown fa c to rs . I t was considered th a t in choosing f ir s t - t im e mothers, a c le a re r idea of th e contact .and care received from the services would be obtained. The present study sought to examine the im pressions received o f, and a ttitu d e s developed towards, the a v a ila b le s e rv ic e s , and to consider the fu tu re in te n tio n s of f ir s t - t im e mothers in regard to use of th e serv ice s .
F ir s t-tim e mothers, then, were th e p re fe rre d ta rg e t sample fo r a number of reasons. T h eir contact w ith the services would be lim ite d to th is occasion and i t . would be p o ssib le to monitor e x a c tly which services they had made use of and conversely avoided. They were
CHAPTER 3 i P ilo t work and re s u lta n t methodology
lik e ly , to be younger. ..than o th e rs , thus forming a t le a s t .one o f .the
high r is k groups^causing, concern -to. h e a lth p ro fe s s io n a ls . They would:
be in . th e process of. forming th e ir, impressions of s e rv ic e s fo r fu tu re up take/non-uptake.and coul d be regarded as. those . most ' in : need' of. .h ealth s e rv ic e care as th e y . had no previous experience -of becoming
mothers*.
Age of c h ild a t tim e .of ; in te rv ie w : In order t h a t . a. meaningful .comparison.may be made, a lim it was placed on th e age of each c h ild at the tim e- of th e m aternal in te rv ie w . Each c h ild was to be between 12 ..and 15 months a t . th is tim e. In th e p ast, stu d ies have not used data
c o lle c te d a fte r the f i f t h p o s t-n a ta l month (Graham, 1979)f w h ils t the present -study sought to examine the period 0-15 p o s t-n a ta l months, to determ ine takeup and u t i l i t y of the services during th e c r it ic a l f i r s t y e a r, of l i f e . There is a tendency fo r system atic takeup a fte r the f i r s t few p o s t-n a ta l months to drop (Graham, 1979).. Reasons fo r th is may be.assessed more e ffe c tiv e ly when in v e s tig a tin g data fo r the f i r s t complete year of possible co n tact.
.C hildren who die. during th e f i r s t year: Mothers whose c h ild re n d ie d u rin g .th e ir f i r s t year would be a sp ecial group worthy o f separate study (Emery, 1976; Oakley, 1976). They are not included in the sub-samples o f the. present study, p a r tly because of th e in tensiveness o f th e care they may. re ce ive and also because of th e hum anitarian aspect.of. asking them to re c a ll occurrences which may be p a r tic u la r ly d is tre s s in g to them. There is also evidence to suggest th a t th is
CHAPTER 3* P ilo t work and re s u lta n t methodology
group of mothers has been subjected t o . f a i r l y in te n s iv e .s tu d y already (S teele*. 1966; D avis, 1976; Emery, 1979; H u ll, 1977; McWeeny*. 1977* O akley, 1976).
One^pareot. .families;. I t is possible to. co n tro l fo r th is ^ variab le by.
in c lu d lo g o n ly mothers, and c h ild re n from a tw o-parent background.