The Journals of Gerontology Series B: Psychological Sciences and Social Sciences 62:P226-P229 (2007)
© 2007 The Gerontological Society of America
Does Greater Frequency of Contact With General Physicians Reduce Feelings of Mastery in Older Adults?
John Cairney,
Laurie M. Corna,
Terrance Wade and
David L. Streiner
1 Centre for Addiction and Mental Health, Department of Psychiatry
2 Department of Public Health Sciences, University of Toronto, Ontario, Canada.
3 Department of Community Health Sciences, Brock University, St. Catharines, Ontario, Canada.
4 Baycrest Centre for Geriatric Care, Toronto, Ontario.
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Abstract
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In this study, we test one aspect of Rodin's hypothesis concerning age-related decline in mastery: The effect of frequent contact with the health care sector on mastery. We conducted cross-sectional and longitudinal multiple regression analyses to examine the effect of general physician (GP) visits on mastery. In the cross-sectional analyses, a higher number of GP visits is associated with lower mastery, but this relationship is substantially weakened when physical health is entered into the analysis. These results are confirmed in the longitudinal analysis. The effect of GP visits on mastery thus appears to be significantly confounded by physical health problems. These findings direct attention away from the role of contact with the health care sector in influencing perceived mastery and toward the importance of physical health status as both a cause and potential consequence of changes in perceived control with age.
Personal control is a powerful predictor of health and well-being (Pearlin & Pioli, 2003
). However, cross-sectional studies have reported declines in personal control across age groups (Mirowsky 1995; Schieman & Turner, 1998; Wolinsky & Stump, 1996), and longitudinal studies have shown decreases in control with age (Ross & Mirowsky, 2002; Wolinsky, Wyrwich, Babu, Kroenke, & Tierney, 2003; but see Pitcher, Spykerman, & Gazi-Tabatabaie, 1987; Schulz, Heckhausen, & Locker, 1991). Increased occurrence of negative life events, increased health problems, and greater contact with the health care sector have been identified as key determinants of age-related decline in control (Rodin, 1986).
The last two explanations provided by Rodin (1986) are of interest because they raise questions regarding the influence of health status and health service use on perceptions of personal control in elderly individuals. Contact with the health care system is argued to be detrimental to control among older adults because of the power imbalance between provider and patient (Rodin, 1986).
This relationship may, however, be confounded by health status, which is strongly correlated with both service use (Andersen, 1995) and perceived control (e.g., Mirowsky, 1995). Alternatively, the relationship between contact with health care professionals, health status, and sense of control may be interactive rather than independent. For example, at higher levels of contact, individuals with poor physical health may feel less personal control because they require greater involvement of professionals in their daily lives. Such a multiplicative relationship between contact and physical health status on personal control was not discussed by Rodin (1986), and it has not been tested empirically. Finally, it is unclear whether the negative impact of contact on control varies with age. It may be, for example, that the effect is strongest among the older and oldest-old individuals, and less pronounced in middle-aged or among young-old individuals.
Rodin's explanations have been tested by Wolinsky and colleagues (2003), who found that, after adjustment for demographic variables and physical and mental health status, satisfaction with care was not associated with changes in sense of control. Satisfaction, however, was entered into the model after health status, making it impossible to determine whether the latter confounded the association between satisfaction and control. Moreover, the study did not examine an important component of Rodin's explanation, which is whether higher frequency of contact is associated with lower perceived control in older adults.
Here, we examine four questions: First, is greater contact with general physicians (GPs) associated with lower mastery in older adults? Second, is there an interactive effect between GP visits and physical health status on mastery? Third, does the impact of GP visits on mastery vary by age? Fourth, is the relationship between GP contact and mastery confounded by physical health status? We chose GP visits as our measure of contact rather than in-patient care contact, because those individuals who visit GPs in the community are apt to be healthier than those who utilize in-patient services. Consequently, it will be more difficult to find a confounding effect for health status in this population, thereby providing a more conservative test of the hypothesis.
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METHODS
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Participants
The National Population Health Survey is a biennial survey of a national probability sample of all Canadian residents. In 1994, using a multistage, stratified, random sampling procedure, Statistics Canada contacted 19,600 households. Of the 18,342 eligible individuals identified, interviews were conducted with 17,262 respondents, a response rate of 96.1%. The sampling frame excluded persons living on First Nations reserves, military bases, institutions, and some remote areas in Ontario and Quebec. We then selected only those adults aged 50 years and older, providing a sample of 6,202. Following listwise deletion of cases with missing values, our sample was reduced to 5,491 (respondents with missing data were more likely to be older, male, married, and report poorer physical health status). The 2000 National Population Health Survey, Wave 4, contained 3,033 respondents of the original 5,491 adults aged 50 and older after listwise deletion for the longitudinal analysis (over the 6-year period from Wave 1 to 4, 2.4% of the sample was institutionalized, 15.9% died, and 10.8% were lost to follow-up). We excluded Waves 2 and 3 from the analysis because mastery was only included in Waves 1 and 4.
Measurement
Mastery
A seven-item measure of mastery was available in the NPHS (Pearlin & Schooler, 1978), which is described in more detail in Cairney & Krause (2005). Scores range from 0 to 28, with higher ones indicating a greater sense of mastery. The internal consistency is 0.76 and the mean score in this sample was 19.1 (SD = 4.7).
GP visits
Respondents were asked how many times they had seen or talked with a family doctor or GP in the past 12 months, excluding any time that they might have spent as an overnight patient in the hospital (M = 4.48, SD = 5.45).
Health measures
Perceived health was assessed by asking respondents to rate their health on a scale from 1 (poor) to 5 (excellent). Because the majority of respondents reported their health as "good," "very good," or "excellent" (77%), we dichotomized this to "fair" or "poor" versus "good" or better health. The second measure of health status was based on self-report of 10 physician-diagnosed chronic conditions (e.g., arthritis, high blood pressure, urinary incontinence), which we combined into a count (0 to 10) of chronic health problems (M = 1.08, SD = 1.18). Finally, we included the number of reported limitations in activities of daily living as an index of impairment (M = 0.46, SD = 1.07).
Socioeconomic measures
We collapsed education into eight categories to form an ordinal measure ranging from no formal schooling to a completed graduate or professional degree. We used household income adequacy to measure economic status; low adequacy is defined as an income of <$15,000 for one or two residents; <$20,000 for three or four residents; or <$30,000 for five or more residents.
Controls
In the original data, age was coded into 5-year intervals from 50–54 to age 80 and older. We created an ordinal scale for age based on midpoints of each interval (1 = 52); we set the last interval to 90 (M = 65.85, SD = 11.19). We also included gender, marital status (common-law as the reference), and main activity (employed as the reference; also unemployed, caring for a family member, student, retired, and other).
Analysis
In both the cross-sectional and longitudinal analyses, we first regressed mastery on GP visits (Model 1) and then adjusted for sociodemographic variables (Model 2). We then added each indicator of health status separately (Models 3, 4, and 5) and together (Model 6). Rodin's frequency of contact explanation will be at least partially supported if a significant effect of GP visits persists in the final model. To assess whether GP Visits x Physical Health and GP Visits x Age interactions exist, we entered interaction variables for each combination into the full model.
The longitudinal analysis followed the same analytical strategy, but, using the residualizing technique (Kessler & Greenberg, 1981), we examined whether change in the dependent variable (mastery) over 6 years was associated with change in the predictor variables (physician contact and health conditions). Specifically, we regressed Wave 4 mastery on Wave 1 mastery as well as all Wave 1 and Wave 4 predictors. The effects of the Wave 1 predictors in these models can be interpreted as the baseline effect on change in mastery, whereas the Wave 4 coefficients assess the change in the predictor variable on change in mastery.
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RESULTS
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Table 1 shows the cross-sectional regression analyses of mastery on GP visits. In Model 1, there was a consistent negative effect of GP visits on mastery: Each additional physician contact was associated with a decline of 0.15 in mastery. This effect decreased only slightly when we included sociodemographic variables (Model 2). In Models 3 and 4, chronic health conditions and limitations in daily activities accounted for 33% and 40% of the effect of GP visits on mastery compared with the adjusted effect in Model 2. Poor perceived health (Model 5) reduced the effect of GP visits by 40%. In the final model, with all three health indicators included (Model 6), the effect of physician contact on mastery was reduced by 75% from its adjusted effect in Model 2. Education and low or middle income were consistently and significantly associated with mastery across all models, whereas gender and marital status were not. Only unemployment and the category representing "other" were significantly related to mastery. Tests for interactions (not shown) between GP visits and physical health and GP visits and age were not significant.
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Table 1. OLS Regression of Mastery on Physician Contact, Sociodemographic Variabl<--CO?1-->es, and Measures of Physical Health Status.
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Table 2 shows the longitudinal results. In Model 1, mastery at Wave 1 was a significant predictor of mastery 6 years later. Partialling out the 6-year stability in mastery, we found that change in mastery over this period was significantly associated with change in GP visits. In Models 3 to 5, changes in chronic health, limitations in activities of daily living, or "good" perceived health reduced the effect of change in GP visits on change in mastery by between 33% and 50%. In the final model (Model 6), the inclusion of all three change measures of physical health status reduced the effect of change in GP visits by over 83%, rendering it nonsignificant. Change in activities of daily living and changes in perceived health remained significant predictors of changes in mastery.
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Table 2. OLS Longitudinal Regression Analysis of Change in Mastery on Change in Physician Contact and Physical Health Status.
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DISCUSSION
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To evaluate Rodin's (1986) hypothesis concerning the effect of contact with the health care sector on personal control among older adults, we assessed the independent effect of GP visits on mastery in a national sample of older Canadians.1 We also tested for possible GP Visits x Physical Health Status and GP Visits x Age interactions in predicting mastery. Consistent with Rodin's hypothesis, we did observe a negative effect of GP visits on mastery. However, this was no longer significant after we adjusted for physical health status; rather, the effect of physician contact on mastery is significantly confounded by health status. These results therefore call into question the role of the health care sector, at least with regard to frequency of contact with GPs, as an independent predictor of control in old age (Rodin, 1986). It appears to be more accurate to conceptualize frequency of contact simply as a proxy for health status. Our results do, however, highlight the negative influence of poor or declining physical health status on perceived control (Mirowsky, 1995; Wolinsky & Stump, 1996). These findings suggest that attention should be redirected from studying frequency of contact per se to that of physical health status as a cause and, potentially, a consequence of low perceived control in old age (Mirowsky & Ross, 2003). Furthermore, the potential role that the GP or other health care providers might play to offset or forestall loss of control caused by illness is an important area to consider that moves beyond frequency of contact.
There are limitations with these data that have to be acknowledged. First, reliance on mastery as the sole measure of personal control is problematic. Similar to that of previous work (e.g., Wolinksky et al., 2003), our measure of control is global rather than domain or role specific, precluding examination of perceived control across different domains or roles (Krause & Benjamin, 2003). The impact of health care contact, if it exists at all, is more likely to influence health-related control than other domains (e.g., personal relationships or finances). Related to this, a distinction has been made between different kinds of control, especially primary (externally focused) versus secondary (internally focused). It has been argued that secondary control may be substituted for primary control as a means of compensating for the loss of resources that accompanies aging (Schulz, Wrosch, & Heckhausen, 2003). In this context, greater contact with the health sector in old age may be associated with lower perceived primary control, but this may be offset by increases in compensatory, secondary control. In these data, we lack the detailed information that would be required to test whether the association between GP visits and mastery is different for specific conditions. Moreover, in the absence of more domain-specific measures of control, we cannot tell whether effective management of chronic conditions such as diabetes, which could include regular contact with GPs, leads to feelings of greater control. Clearly, work with multiple measures of perceived control is required to better understand age-related changes in control and the specific impact of contact with the health care sector on different kinds of personal control.
We were also limited to one single measure of contact: GP visits. Although this work is the first to include frequency of contact, a major component of Rodin's (1986) explanation, future research should include expanded measures of quantity and quality of services. Contact with providers other than GPs, as well as more direct measures of the nature of the interactions between patient and provider, should be examined. Such measures should take into account more than just perceived satisfaction with care, which does not appear to influence perceived control in older adults (Wolinsky et al., 2003). Future research might also benefit from the inclusion of a measure of cognitive impairment or dementia. Lastly, as expected with longitudinal surveys, missing data caused by attrition is a problem that must be considered when one interprets the findings reported here.
Notwithstanding these limitations, to our knowledge this is the first study to explore the association between frequency of contact with GPs, physical health status, and mastery in this population. Future research will have to disentangle the effects by using multiple measures of control in the same individuals across multiple time points. Only then can domain-specific relationships between control and contact, as well as reciprocal pathways connecting control to physical health status, be ascertained.
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Footnotes
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1 In addition, we also tested to see whether number of hospital visits, an obviously more serious form of contact with the health care sector, had a similar negative effect on mastery. The results were comparable with those observed with GP visits. When included in the same model, both hospital and GP visits were independently associated with mastery. However, similar to the association observed with GP visits, the coefficient representing hospital visits was reduced substantially and was no longer significant once we made an adjustment for chronic health problems. 
Decision Editor: Thomas M. Hess, PhD
Received for publication July 4, 2006.
Accepted for publication February 8, 2007.
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References
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- Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36,1-10.[Medline]
- Avison, W., Cairney, J. (2002). Social structure, stress and personal control. In S. H. Zarit, L. I. Pearlin, & K. W. Schaie (Eds.), Personal control in social and life course contexts (pp. 127–164). New York: Springer.
- Cairney, J., Krause, N. (2005). The social distribution of psychological distress in older adults. Journal of Aging and Health, 17,807-835.[Abstract/Free Full Text]
- Kessler, R. C., Greenberg, D. F. (1981). Linear panel analysis: Models of qualitative change. New York: Academic Press.
- Krause, N., Benjamin, A. (2003). Role specific control, personal meaning, and health in late life. Research on Aging, 25,559-586.[Abstract]
- Mirowsky, J. (1995). Age and the sense of control. Social Psychology Quarterly, 58,31-43.
- Pearlin, L. I., Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19,2-21.[Medline]
- Pearlin, L. I., Pioli, M. (2003). Personal control: Some conceptual turf and future directions. In S. Zarit, L. I. Pearlin, & K. Schaie (Eds.) Societal impacts on personal control in the elderly (pp. 1–19). New York: Springer.
- Pitcher, B. L., Spykerman, B. R., Gazi-Tabatabaie, M. (1987). Stability of perceived control for older black and white men. Research on Aging, 9,200-225.[Abstract]
- Rodin, J. (1986). Aging and health: Effects of the sense of control. Science, 233,1271-1276.[Abstract/Free Full Text]
- Ross, C. E., Mirowsky, J. (2002). Age and the gender gap in the sense of personal control. Social Psychology Quarterly, 65,125-145.
- Schieman, S., Turner, H. A. (1998). Disability, and the sense of mastery. Journal of Health and Social Behavior, 39,169-186.[Medline]
- Schulz, R., Heckhausen, J., Locker, J. L. (1991). Adult development, control and adaptive functioning. The Journal of Social Issues, 47,177-196.
- Schulz, R., Wrosch, C., Heckhausen, J. (2003). The life-span theory of control: Issues and evidence. In S. Zarit, L. I. Pearlin, & K. W. Schaie (Eds.), Personal control in social and life course contexts: Societal impact on aging (pp. 233–262). New York: Springer.
- Wolinsky, F. D., Stump, T. E. (1996). Age and the sense of control among older adults. Journal of Gerontology: Social Sciences, 51B,S217-S220.[Abstract]
- Wolinsky, F. D., Wyrwich, K. W., Babu, A. N., Kroenke, K., Tierney, W. M. (2003). Age, aging, and the sense of control among older adults: A longitudinal reconsideration. Journals of Gerontology: Social Sciences, 58B,S212-S220.
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Abstract
Methods
