Self-care in Israel: Physicians' views and perspectives

Sot. Sri. Med. Vol. 29. No. 2, pp. 233-244, 1989

0277~9536189 53.00 + 0.00 Pergamon Press plc

Printed in Great Britain

SELF-CARE

IN ISRAEL: PHYSICIANS’ AND PERSPECTIVES

VIEWS

JUDITH T. SHUVAL,* RACHEL JAVETZ and DIANA SHYE Hebrew University of Jerusalem and Brookdale Institute of Gerontology and Adult Human Development, Jerusalem, Israel

Abstract-This paper examines physicians’ perceptions about potential effects of lay self-care. The research was designed to explore these perceptions regarding three types of effects with particular reference to their general distribution and their inter-relationships. The findings showed that physicians distinguished clearly among the effects of self-care but that their opinions differ considerably regarding the effects on utilization, costs and hospitalization rates. The implications of these findings are discussed. Key

words-self-care,

Israel, professional medicine, attitudes

INTRODUCTION AND

THEORETICAL BACKGROUND

Self-care by lay persons refers to the set of preventive, diagnostic, curative and rehabilitative actions which lay people take with the aim of preserving or ameliorating their health. The view on which the present paper is based has been stated elsewhere: “Self care and self help are parts of a matrix in the health care system, whereby lay persons can actively function for themselves and/or others to prevent, detect or treat disease and promote health so as to supplement other resources” [I]. There is growing interest among professionals and lay persons in increasing lay autonomy which seeks to decrease dependence on the formal health services and promote independent health-oriented behaviour. Some have suggested that increased self-care by lay persons might result in more rational use of the primary health-care services, in terms of utilization rates and more effective performance by professional personnel. All of these could contribute to reduced costs of running the health-care system [2-6]. Self-care behaviour may occur with or without reference to the formal health-care system. Some self-care is supplementary to, in lieu of, or under the directives of health-care professionals whose views on such lay behaviour are therefore relevant to the lay person. But even when undertaken at lay initiative and with no direct contact with health-care professionals, there is an inherent thread connecting the formal health-care system and the lay person: the connection is through information concerning norms of appropriate health-care behaviour which generally flow from the system to the lay person. While these may be accepted or rejected, it is probably rare for such information and norms to be ignored except by individuals totally insulted in alternative ideologies providing their own health norms. A comprehensive view of self-care therefore it in the context of an overall health system,

places which

*Address correspondence to: Programme in Medical Sociology, Hebrew University of Jerusalem, Ein Karem, Jerusalem 91 010, Israel.

includes a variety of inter-related actors all of whom play specialized roles: the lay person (whose health is under consideration), the lay person’s lay reference groups (family, friends, informal informants), physicians (in primary, secondary or tertiary care settings), other health-care providers (a variety of allied health personnel) and alternative practitioners. Each of these is characterized by goals, norms and values concerning health, and by patterned interaction with others in the system. A lay individual’s decisions regarding health are a function of a process of direct and indirect interaction among the above actors at different times and in a variety of situational contexts. The salience and authority of the different actors vary in terms of their expertise, status, legitimation, availability and accessibility to each other. Physicians occupy a unique position of authority in this system. Indeed, in most Western societies and in many developing societies as well, this group of professionals is structurally dominant in terms of formal authority and control of the professional aspects of the system 171.This is undoubtedly the case in Israel, where doctors occupy a central and controlling role among the actors in the formal healthcare system. This paper is addreseed to an examination of Israeli physicians’ perceptions regarding the potential effects of lay self-care. We assume that changes in the amount, quality or context of lay self-care will effect processes of health-care delivery and the physicians’ role in a variety of ways. On the micro-level, relating to the doctor-patient relationship, self-care implies certain shifts in the balance of authority and power which could result in changes in the traditional asymmetry of that relationship and in the physicians’ feeling of control in caring for patients (8-111. On the macro-level, lay self-care could effect clinic utilization rates which in turn effect the cost of health-care delivery and might even change rates of hospitalization. All of these potential effects are relevant to the physician’s professional role and therefore to his general attitude toward lay self-care. The research is designed to explore physicians’ perceptions regarding three types of effects of lay

233

JUDITHT. SHUVAL

234

self-care. Two are micro-level effects and one, composed of three sub-effects, is on the macro-level. Micro -level effects:

A. Perceptions of the effects of specific self-care behaviours on the health of the individual. B. Perceptions of the effect of independence and initiatives by lay persons on the health-care process. Macro -level effects: C. Perceptions of the effects of lay self-care on the

health-care system in term of utilization, and hospitalization rates.

costs

These three perceived effects serve as the dependent variables of the research. The overall purpose of the research is to examine the three dependent variables in terms of their general distributions and in terms of their inter-relationships, in order to elucidate the structure of physicians’ perceptions in the area of self-care. In addition, the research seeks to study differences within the physician population by examining the correlates of these three variables. Physicians’ views regarding lay self-care are far from homogeneous and comprise only one element in their more general complex of attitudes and perceptions regarding health topics. There has been little in-depth scientific research regarding physicians’ specific views on self-care. One study carried out in the United States reports physicians to have generally negative attitudes, with many expressing concern about possible damaging effects of self-care [12]. A review of more general research which focuses on related topics indicates considerable variation among physicians in their attitudes and perceptions: these have been found to be a function of their professional training and practice experience, as well as of a variety of personal attributes. An examination of research findings which focus directly or indirectly on physicians’ attitudes and perceptions regarding patient self-treatment, lay initiatives in health-care and innovative changes in the organization of medical practice, which could affect physician autonomy, led to the choice of independent variables included in the present study. Most of the research reviewed was carried out in the United States or in Britain. Thus, the correlates found in these studies may or may not hold in other cultural settings. In seeking appropriate independent variables for the Israeli study we were concerned to include variables that showed a relationship to relevant attitudes in earlier research, but also meaningful variables that showed inconsistent or no relationships in previously studied settings. Among the personal attributes studied in earlier research, age has shown the most consistent relationship to physicians’ attitudes regarding self-care and to departures from traditional forms of medical practice. Younger practitioners generally express more positive views on these topics [12-141. Age is clearly associated with career stage: medical students and residents tend to be more accepting of newer approaches to health-care [ 15, 161. Most studies did not include a sufficient number of women physicians to analyse gender effects. One

et al

exception is the study by Heins er al. [17] which focused on attitudes toward innovative organization of medical practice. There is some indication that among older physicians, women were more accepting of such innovations. Several studies show Jews to be more accepting of self-care and of changes in the structure of medical practice than are Catholics and Protestants [12, 16, 18, 191. The effects of a variety of professional and practice characteristics have been examined in previous studies. Specialists have been found to be more accepting of innovation than general practitioners [ 14,201. There is evidence that surgeons may be a particularly conservative group [19,20]. But several other studies show no relationship by type or level of medical specialization. Physicians whose practice setting departs most from traditional, solo, fee-for-service practice settings are generally more accepting of self-care and of changes in the traditional forms of medical care [14, 15, 19-211. Physicians’ reports of a heavy patient load are associated with negative views on lay self-care [4, 13, 14, 191. In sum, the selection of independent variables examined in the present study included all of the above but also included additional variables which failed to show relationships in earlier research, but which were thought to be worth examining in the Israeli context. SETTING THE SCENE

IN ISRAEL

Before proceeding to the findings, it is important to make explicit certain cultural and structural characteristics of the Israel health scene, which could be relevant in understanding the findings. A survey of the literature suggests that this is the first study focusing on physicians’ views of self-care undertaken outside the United States and Britain. While Israel does not have a nationalized healthcare system, 94.5% of its population is covered by comprehensive health insurance which includes curative and ambulatory care, as well as hospitalization. Only 2% of the Jewish population are not insured. Health-care is organized by a number of sick funds of which the largest is the General Sick Fund (Kupat Holim Klalit) which in 1986 covered 83% of the insured Jewish population. Three smaller sick funds insure an additional 17% of that population. Regional hospitals are located within no more than 30 km of most communities; primary, curative and preventive services are easily accessible on a neighbourhood basis [22]. Israel is characterized by one of the highest physician to population ratios in the world: 36/10,000, i.e. l/279 [23]. This is a result of the high attractiveness of the profession to Israelis and the policy of admitting and licensing immigrant physicians who constitute a major portion of the primary care doctors [24]. The vast majority of physicians are salaried employees of one of the sick funds or of the Ministry of Health; very few are primarily self-employed in feefor-service practice, although some engage in parttime private practice in addition to their primary employment. The high utilization rates in the primary care clinics have resulted in no small amount of frustration

235

Self-care in Israel

among clinic physicians who feel over-burdened by frequent trivial or non-medically relevant complaints [25]. The easy accessibility of primary care physicians has contributed to some erosion of their status. Furthermore, the sharp dichotomy between community and hospital practice also contributes to this process in view of the concentration of high level specialists and sophisticated technology in the hospital system. Indeed, very few graduates of Israeli medical schools opt for community practice if they have a choice. The latter setting ranks lower in prestige than does hospital practice [26]. Health is a central value in the social-cultural context of Israeli society [27]. Jews in many countries have shown heightened awareness and concern for health, relative to other groups [16,27-301. In Israel, this orientation is expressed in patterns of health-care which are strongly medically-dependent and take the form of high confidence in physicians, frequent utilization of health services, and high drug consumption, both prescription and non-prescription [31,32]. The material rewards of salaried medical practice are limited by a strict grading system. The rewards of pratice therefore focus strongly on the intrinsic level: the satisfaction of high quality professional performance and professional fulfillment, which are derived from clinical work and from respect, compliance or deference from their patients. These intrinsic rewards assume special importance when the extrinisc material rewards are perceived as relatively low. While there is little systematic research on this topic in Israel, observation suggests that the traditional, asymmetrical physician-patient relationship is widespread. Physicians’ authority is generally accepted in health matters and there has been little evidence of consumerism among patient populations. Indeed, there appears to be widespread acceptance by lay persons of the appropriateness of the asymmetrical model, although adherence to medical instructions may not be as full as many physicians believe, few voices have yet been raised by patients or other lay persons to overtly question or criticize the style or quality of the doctor-patient relationship. The structural problems of the Israeli health-care system are such that increased self-care could, under appropriate conditions. make some contribution to their amelioration. A major problem of the primary health-care system is its high consulting rates which reach an average of 12 physicians’ visits per year [33]. Among those over 65. this figure is doubled [34]. As noted, it has been suggested that increased lay self-care could reduce clinic utilization rates [30,35-371. The Israeli health-care system, like most others in Western societies, is characterized by excessively high costs which it is finding increasingly difficult to meet. A more rational use of the health-care services, with appropriate self-care playing its part in the system, could contribute to some reduction in those costs. On a more general level. it is widely felt in Israel that the highly-developed social welfare services have encouraged patterns of dependency in many areas, among

*Details of the sampling procedure are reported in Ref. [41].

then in health-care. The general goal of lay self-care to strengthen individual independence and autonomy complements a more general goal that is thought by many in Israel to be important. Israel has been relatively slow to develop consumer consciousness or a formal consumer movement in the health area. These are in the early stages of development relative to many other Western countries. The same may be said of the feminist movement. These two social movements have played important roles in most Western societies in fostering lay self-care [38]. There are few clearly structured pressure-groups seeking to foster self-care as part of an ideological or political goal. Efforts by the major sick fund to promote health-care have taken the form of media messages and some health education programmes. It is unknown what effects these have had on self-care behaviour among lay persons. In sum, we may say that the Israel context regarding self-care is characterized by underdevelopment and several apparently paradoxical conditions: widespread exercise of physician authority which is most frequently accepted as normative by lay persons; major structural and economic problems of the health-care system which might be ameliorated by increased self-care; little ideologically-based consumer pressure advocating self-care. DESIGN OF THE RESEARCH

Defining self-care on an empirical level presents major theoretical and practical problems (391. We view self-care as a multi-dimensional concept, which probably cannot be studied exhaustively in any one research undertaking. As noted. we have chosen to focus on physicians’ perceptions of three potential effects of lay self-care. A pilot study based on 60 semi-structured interviews with Israeli physicians provided a rich array of qualitative findings which made it possible to formulate specific questions that would be meaningful in an interview context [40]. The study includes physicians engaged in primary health-care and in hospital practice. In Israel, primary health-care is provided in community clinics by the largest sick fund, General Sick Fund, and by the three small sick funds. The sampling framework therefore was structured in terms of three types of practice setting: the General Sick Fund clinics, the three small sick fund clinics, and the hospitals. In each setting, a systematic sample of physicians was chosen. In addition to general practitioners, doctors in the following specializations were sampled: internal medicine, family medicine, cardiology, gastroenterology and geriatrics. The practice settings included in the study were located in Jerusalem, Haifa, Beer Sheva and metropolitan Tel Aviv. The sample of 258 physicians who participated were distributed in the three practice settings as follows: General Sick Fund clinics-130, small sick fund clinics--53, hospitals-75. Interviewing took place between July 1985 and May 1986*. The research instrument was a questionnaire composed largely, but not exclusively, of closed questions. In addition to items geared to define the three types of effects of self-care, which served as the dependent

236

JUDITH T. SHUVAL

variables, it included a set of independent three types:

variables of

Personal background characteristics of the physicians: gender, age, country of origin, number of years in Israel, education and occupation of parents and family status. Professional characteristics of the physicians: date and country of medical education, number of years of practice, specialization, post-graduate training. Practice characteristics (obtained from the respondent): organizational setting, patient load, hours of work per week, patient characteristics (e.g. perceived proportion of elderly and chronically ill patients). The full set of independent variables were examined for their relationships to each of the three dependent variables in univariate and multivariate analyses. PHYSICIANS’ PERCEPTIONS OF THREE EFFEfXS OF SELF-CARE: FINDINGS

Perceptions of the three effects of self-care will be discussed first in terms of the general distributions of physicians’ responses, and then in terms of the relationship of such responses to the personal background, professional and practice setting variables. Perceptions of the effects of specific self-care haviours on the health of the individual

be-

A useful taxonomy of self-care skills has been compiled by DeFriese et al. from a survey of standard self-care texts and training programmes, and was subjected to review regarding consensus by three panels of health professionals [42]. The self-examination, acute illness care, and chronic illness care items used in the present study, were based on this taxonomy. Self-medication items were derived from studies on this subject by Dunnell and Cartwright [13], as well as from material obtained from the pilot study [40]. Items relating to good preventive health-care, such as proper nutrition, appropriate physical exercise and non-smoking, are so widely accepted by physicians as to be ineffective in their discriminatory power and were therefore excluded, despite their obvious centrality in lay self-care. Table 1 presents the six health-care behaviours to which physicians were asked to respond. For each they were required to indicate the extent to which they believed it contributed positively, or was likely to damage, an individual’s health. The items in the

et a(.

table are ordered in terms of the frequency with which respondents stated that the specific behaviour generally makes a positive contribution to the individual’s health. As expected, there is considerable variation in physicians’ views regarding these behaviours. depending on the specific self-care behaviour considered. The figures in Table 1 vary from close to 90% to almost zero. There was widespread agreement among almost all the physicians that basic self-examination and diagnosis are likely to contribute to health. Over two thirds of the physicians expressed a positive view regarding the health effects of self-monitoring of blood-pressure by hypertensive patients. However, when referring more generally to self-care for medically diagnosed chronic and common acute illnesses, less than half of the population expressed a positive view. At the other end of the spectrum, most doubt was expressed regarding self-medication: only a fifth were prepared to state that use of non-prescription drugs contributes positively to the individual’s health, and virtually none accepted self-medication with prescription drugs, when this involves purchase of drugs with prescriptions previously filled, or use of previously prescribed drugs which are still stored in the individual’s home. In addition to observation of the individual items, a composite index was generated after factor analysis of the six items in Table 1 showed that they constitute a single factor which explains 86.2% of the variance. A summary score, ranging from 1 (negative) to 5 (positive), was computed (Cronbach’s alpha equals 0.59). The mean score was 3.12 (SD = 0.72). The Summary Score on the Perceived Effects of Self-Care Behaviour was first examined for relationships to the set of independent variables by means of a one-way analysis of variance. The following significant relationships emerged from that analysis. Physicians vary in their evaluation of the effects of lay self-care behaviours in terms of their practice settings, the level of their specialization, the number of years in practice and by the country in which they completed their medical education. While the differences are small, they are worth noting. Community clinic practitioners show less favourable attitudes to self-care behaviour than hospital physicians. Complementing this finding is the fact that most positive attitudes are expressed by residents and by younger physicians with least years of experience. The latter two groups are heavily concentrated in

Table I. Physicians’ perceptions of the effects of specific self-care behaviours on the health of the individual (N = 255)

Self-care behaviours* Self-examination and diagnosis, e.g. taking temperature. breast examination, urine tests, etc. Self-monitoring of blood pressure by persons with hypertension Self-care for medically diagnosed chronic illness Self-care for common acute illnesses Self-mediation with OTC drugs Self-medication with prescription drugs:

% Indicating a positive contribution to individual’s hcaltht 88 69 48 40 22 3

*The question presented to the physicians was the following: ‘To what extent does the following self-care behaviour generally contribute to or damage an individual’s health? Response categories ranged from 1 (is likely to damage health) to 5 (contributes postively to health). tThosc who responded that the given self-care behaviour contributed positively to the individual’s health ‘in most cases’ or ‘frequently’. $For example, by purchase of prescription drugs with out-dated prescriptions, USCof previously provided drugs which are kept at home, etc.

237

Self-care in Israel hospital practice. Physicians who completed their medical studies in Israel, in English speaking countries and in western Europe, are characterized by more favourable views on self-care behaviour than those educated in eastern Europe. The other independent variables showed no significant relationship in the one-way analysis of variance. Since the Summary Score on the Perceived Effects of Self-Care Behaviours is a metric variable, while the independent variables include both metric and nonmetric categorical variables, analysis of covariance was used for the multivariate analysis (SPSS ANOVA program). The categorical variables are labelled ‘factors’ while the metric ones are referred to as ‘covariates’. Factor and covariate effects were of equal interest, and no assumptions regarding causal priority between them were held. Therefore, a regression approach was chosen for the analysis, in which the effects of factors, covariates and interactions were assessed together, while controlling simultaneously for all of them. This approach resembles a standard multiple regression analysis involving both metric and dummy variables as predictors. A preliminary analysis of covariance was carried out using factors and covariates which showed significant, or nearly significant, zero-order correlations with the summary score, as well as other variables which were thought to have conceptual relevance to the dependent variable, e.g. gender. Two-way interactions were assessed at this stage.

The above analysis showed significant interaction between practice setting and gender despite the fact that gender did not show a significant effect in the univariate analysis. A new variable expressing this was created accordingly. Multiple interaction classification analysis was then performed, permitting the assessment of the magnitude of the effects of the factors. Unstandardized partial regression coefficients were computed for the covariates, as well as the percentage of the total variance of the dependent variable which is explained by the factors and covariates included in the model. Table 2 presents the results of the multiple classification analysis and the percentage of the total variance explained by the variables included. The variables listed in Table 2 explain 27.0% of the variance (P c 0.001). All but two of the variables show significant independent effects on the Summary Score on the Perceived Effects of Self-Care Behaviour. Three of the four variables referred to in the one-way analysis of variance continue to show the same general effects with minor exceptions when controls are introduced. The role of practice setting noted in the univariate analysis remains in the multivariate analysis among male physicians: hospital practitioners are most positive, the General Sick Fund doctors are next, while the physicians practicing in the small sick funds are least favourable. The female physicians practicing in

Table 2. Summary score on the perceived effects of self-care behaviour by physicians’ personal, professional and setting traits: analysis of covariance (summary measure grand mean score = 3.12)

Covariatcs

Regression coefficient (adjusted for factors and other covariates)

F

P

-0.012 -0.005 0.003

7.294 5.506 2.581

0.007 0.020 0.110

Number of years in practice % Chronically ill patients in practice % Elderly among chronically ill patients

Catenorv

N

Mean score adjusted for factors and covariates

F

P

Beta*

Practice setting x gender

General Sick Fund, men Gender Sick Fund, women Small sick funds, men Small sick funds, women Hospitals, men Hospitals, women

51 72 37 IO 63 8

3.11 3.25 2.97 2.52 3.18 2.69

3.018

0.001

0.063

Level of specialization

General practitioners Residents Specialists

82 54 IO5

2.90 3.21 3.22

4.833

0.009

0.044

Perception of patient load

Optimal Acceptable Too heavy

29 98 II4

3.19 3.28 2.94

5.653

0.004

0.048

c 25% 2M% 45-59% > 60%

56 59 61 65

2.96 2.91 3.30 3.19

3.172

0.025

0.040

Israel English-speaking & South Africa Western Europe Eastern Europe U.S.S.R.

65 24 45 56 51

3.07 3.21 3.18 3.01 3.06

0.716

0.582

0.010

Factors

Percentage of elderly (60+)

in practice

Country of medical studies

Total N

241

Total explained variance = 27.0% (P = 0.001) *Beta and the regression coefficients do not add up to the total explained variance (27%) as they are not fully independent of each other or additive.

238

JUDITH T.SHIJVAL er al

the General Sick Fund are more positive in their views on self-care than almost any single sub-groups observed, including male physicians in the same setting. However, in the other two settings, females are less favourable than males, although there are too few cases in these female groups to permit generalization. The multivariate analysis shows that the least positive views are expressed by general practitioners, while residents and specialists-wherever they practice-are more positive in their views regarding selfcare. This analysis also confirms the findings concerning the weak negative effect of years of practice on the Summary Score. The effect of the country in which medical training took place is shown by the multivariate analysis to be an artifact which is eliminated when controls are introduced. A number of additional variables are seen in Table 2 to have some effect on physicians’ views regarding self-care behaviours when controls are introduced. Most interesting is the finding showing a significant effect of perceived patient load: those who report overload are less positive in their views regarding the effects of self-care. In addition, it may be seen that physicians who report a greater proportion of elderly persons in their practice tend to express more positive views regarding the effects of self-care behaviours: although the relationship is not fully monotonic, it is clear and significant. In sum, it appears, that Israeli physicians respond differently to various types of self-care behaviour by lay persons, and their perceptions vary from widespread approval to virtually unanimous disapproval, depending on the nature of the behaviour under discussion. However, their general views on self-care appear to be a function of their length of experience and certain situational characteristics of their practice setting; more positive effects of self-care seen among younger, hospital based, specialists or residents. Conversely, the data show that older general practitioners working in community clinics express less support for self-care behaviours. In addition, work pressures experienced in a heavy patient load, which occur most prominently in the community clinics of the General Sick Fund. are associated with more negative views. Physicians whose practice experience included large numbers of elderly patients express relatively positive views regarding the effects of self-care. Physicians’ perceptions of the effects of independence and initiatives by lay persons on the health -care process Self-care is often associated with attitudes and behaviour expressing independence and autonomy by lay persons in matters regarding their health. In that context, individuals may pose questions to the physician and lay judgement may be exercised in varying degrees. In some cases, such opinions may also be expressed by reservations regarding physician authority, thus contravening traditional assumptions concerning compliance and acceptance by patients of medical directives. In its most active form, self-care involves a different basic orientation by lay persons to health professionals, which may be perceived by some of the latter as inappropriate or threatening.

Traditionally, the normative model of the physician-patient relationship is an asymmetrical one, which fosters dependence and discourages initiatives. The physician is viewed as an expert, responsible in large measure for health-care, and is authorized to make decisions regarding the patient who is expected to comply. From this viewpoint lay initiatives and independence may be viewed by physicians as undesirable in that they challenge the traditional position of professional authority and introduce lay judgement in areas which are ostensibly the physicians’ domain. While this traditional model has undergone some modification in recent years. such changes vary between and within societies. and numerous elements of the traditional pattern of relationships persist [8-l I]. One of the objectives of the present research is to analyse physicians’ perceptions of the effect of expressions of independence and autonomy by lay persons on the health-care process and particularly on the physician-patient relationship [43]. The items selected to address this issue refer to a variety of autonomous behaviours reflecting lay initiatives in health, and may be seen in Table 3. They refer to the use of lay networks as a resource in decision-making in health-care, and to processes of bargaining with physicians as well as modification by lay people of recommended treatment. In addition, items were chosen which describe ‘behavioural challenge’ of physicians by patients and ‘consumerist self-care skills’ such as gaining access to medical records and obtaining a second opinion [8, 14,42,44,45]. Physicians were requested to indicate, for each item, whether they believe that the specific behaviour, when it occurs, generally contributes positively to his/her ability to provide good health care or is detrimental to that process. Categories ranged from 1 (negative effect) to 5 (positive effect). Table 3 presents mean scores on the individual items, as well as the percentage of physicians who indicated that the behaviour would generally contribute positively to the health-care process. On the whole, physicians show considerable reservation regarding patient initiatives of various sorts. No more than a third perceived positive effects of any of the behaviours in Table 3, while several of the items were rejected by almost all the respondents. This contrasts with the findings in Table 1 concerning the perceived effects of specific self-care behaviours on the health of the individual. It will be recalled that there was widespread approval by physicians of some of the types of self-care behaviour referred to. It thus appears that these professionals distinguish between certain specific self-care behauiours which are perceived to have positive effects under certain circumstances, and an attitudinal complex in which patients express independence and question physicians’ authority. There is widespread rejection of the latter. The mean scores and the percentages in Table 3 show a similar ordering of the items, reflecting physicians’ perceptions regarding patients’ expressions of autonomy. The items fall roughly into two groups distinguished by the extent to which physicians express acceptance of the consumer’s behaviour.

239

Self-care in Israel Table 3. Physicians’ perceptions of the effects of mdependmce and initiatives by lay persons on the health-care process: response to individual items (means and percentages; N = 258)

Mean

SD

% Indicating a positive contribution to the treatment processt

Patient requests a second opinion before accepting your recommended treatment

3.00

1.16

34

Patient states that your recommended treatment is complicated or difficult and requests simpler treatment

2.88

1.32

32

Patient consults family and friends on whether to consult a physician for a health problem

2.81

I.10

21

Patient asks to see his medical record

2.17

I.17

10

Patient states that your recommended treatment is not essential in his case

I .80

1.03

8

Patient consults with family and friends, to obtain their views regarding the treatment you have recommended

1.66

0.94

4

Patient does not carry out your instructions fully, and changes some or all of your recommended treatmmt

I .30

0.72

2

Patient behaviours*

*The question presented to the physicians was the following: ‘How does the following patient behaviour, when it appears, a&t your ability to provide good care for that patient? Responsecategories ranged from I (generally negative effect) to 5 (generally positive effect). tThose who indicated the two most positive categories.

The most acceptable items of behaviour, which are viewed positively by 20-30% of the respondents, focus on seeking a second opinion, requesting less complicated treatment, and obtaining lay advice about consulting a physician. The remaining four items elicited more negative responses. The behaviours refer to patient requests to see medical records, questioning of the recommended treatment, use of lay referral systems for advice on treatment, and non-compliance with a prescribed regimen. All of these are perceived negatively by 90% or more of the physians; the final item concerning non-compliance and self-initiated modification of treatment, is rejected by virtually all. In addition to observation of the individual items, a summary score was constructed for physicians’ perception of the Effects of Independence and Initiatives by Lay Persons on the Health-Care Process. Factor analysis indicated that the seven items together explain 84.2% of the total variance. Reliability was estimated by Cronbach’s alpha = 0.64. Scores range from 1 (negative effects) to 5 (positive effects). The summary score for each respondent was the mean of his scores on all items. It is of interest that this summary measure was only weakly related to the Summary Score on the Perceived Effects of Self-Care Behaviours discussed above (r = 0.18). This indicates general independence of physicians’ perceptions regarding these two aspects of self-care: those who tend to perceive positive effects of self-care behaviour by lay persons do not necessar-

ily perceive positive effects from expressions of independence and autonomy among such persons in the course of treatment, and vice versa. The Summary Measure was examined in relation to physicians’ personal background, professional and practice setting variables. One-way analysis of variance showed significant, although small, differences on a number of variables. There is a difference between male and female physicians regarding perceived effects of independent initiatives. Male physicians are more favourable than females. Physicians’ views on lay autonomy are related to their practice setting and specialty status. Least positive effects are perceived by physicians in community clinics of the General Sick Fund and among general practitioners with no specialty status. Physicians who report the most overload regarding patient consulting rates, are also relatively negative. Conversely, those perceiving the most positive effects of patient independence are the hospital practitioners, with specialty status, who report least overload. Analysis of covariance was used to estimate the joint effect of the independent variables on the summary measure. on Independence and Initiatives in Health-Care. Table 4, which presents the findings, includes variables which have a significant zero-order relationship as well as a number of others which seemed conceptually relevant. The model explains only 12.5% of the variance, and only two of the variables contribute a significant

240

JUDITH T. SHIJVAL et al.

Table 4. Summary measure of physicians’ perceptions of the effects of independence and initiatives by lay persons on the self-care process by physicians’ personal, professional and practice setting traits: analysis of covariance (summary measure grand mean score = 2.24)

Covariatcs Number

F

P

-0.008

4.565

0.034

of years rn oractice

F

P

Beta*

2.21 2.1 I 2.23 1.94 2.43 2.17

I.973

0.083

0.05

General pracutioners Residents Specialists

85 54 I08

2.18 2.05 2.36

4. I86

0016

0.04

Optimal Acceptable Too heavy

29 101 117

2.28 2.30 2.15

I.501

0 225

0.01

Iv

Category setting x gender

General Sick Fund. men General Sick Fund, women Small sick funds, men Small sick funds, women Hospitals. men Hospilals. women

Level of specializauon

Perception

of patient

load

247

N

Total explained

Mean score adjusted for factors and covariatcs

54 73 37 II 64 8

Factors Practice

Total

Regression coefficient (adjusted for factors and other covariates)

variance = 12.5% (P = 0.001)

*Beta and the regression other nor addttive.

coefficient

do not add up to the total explained

effect. This finding suggests considerable randomness and little structuring of this attitudinal complex in the physician population. The multivariate analysis generally confirms the picture regarding each of the variables seen in the one-way analysis of variance. Although the effect of the new composite variable (gender and practice setting) is not significant, it may be seen that male physicians consistently tend to express more positive views than females regarding initiatives and autonomy of lay persons; the hospital setting is the most conducive to positive attitudes while both types of community practice settings are less positive.* The findings regarding level of specialization are partly confirmed when controls are introduced: physicians with specialty status are most positive in their views regarding lay independence and autonomy, but the genera1 practitioners, who are less positive than the latter, are nevertheless somewhat more positive than the residents. All of these differences are small. The multivariate analysis confirms the effect noted above regarding perceived patient load, but the difference is small and not significant. In addition to the above, length of professional experience has a small significant effect: ‘physicians with more years of experience are somewhat more negative in their perceptions of the effects of lay independence and initiatives on health-care. Taken together, these findings suggest that a general factor conditioning physicians’ perceptions regarding the effects of lay independence in self-care is a situational factor relative to the extent to which he or she feels over-worked or harassed by excessive consulting and trivial complaints. The feeling that *The number of female physicians in the small sick funds and in the hospital reliable.

is negligible and therefore

not

variance

(12.5%) since they are neither fully independent

of each

many patient visits to the clinic are medically unjustifiable, and the associated sense of overload, may result in lowered willingness by physicians to accept patients’ expressions of independence. Affirmation of professional authority may serve as a mechanism to facilitate the handling of excessive numbers of patients. Physicians’ perceptions of the effects of increased lay self-care on the health-care system

On the macro-level, a more collectively oriented issue focuses on the possible effects of self-care on the overall health-care system. Physicians were asked whether they believed that increased practice of selfcare for acute and chronic illness would have an effect on three aspects of the health-care system: utilization rates of primary care services, costs of running the health-care system, and need for hospitalization. Table 5 presents the distribution of physicians’ responses. Table 5. Physicians’ Perceived

perceptions of the effects of lay self-care on the health-care system (N = 258)

effect*

% of physicians

Regarding consulting mtes Reduce No cflcct Increase Total

61 I6 23 loo

Regarding costs Decrease No effect Increase Total

46 31 23 lo0

Regarding hospitalization Decrease No effect Total

rates 35 65 100

‘The question put to the physicians was as follows: ‘How would the health-care system be affected if increased numbers of lay persons learned to engage in self-chagnosis and self-care for acute or chronic illness?

Self-care in Israel

241

show approximately the same distribution as seen in Table 5. A multivariate analysis of the findings presented in Table 5 was done by means of logistic regression [46,47]. The system variables were dichotomized for this purpose using the ‘positive’ category in each case (reduce consulting rates, decrease costs, decrease hospitalizations) against the others. The logistic regression analysis, using the set of relevant background and practice setting variables, indicates that the correlates described above on the basis of the univariate analysis held when controls were introduced, although the total proportional reduction in log likelihood due to the variables in the model is small (13% for effects on utilization rates, 7% for effects on costs and 6% for effects on hospitalization). The correlations among physicians’ perceptions of the three ‘system effects’ variables are positive and significant. The strongest correlation is between perceived effects on utilization rates and on costs (r = 0.64). These two variables are more weakly related to the perceived effects on hospitalization rates (r = 0.29 and r = 0.26 respectively).

Close to two-thirds feel that increased self-care would reduce the number of consultations. Nearly half feel that it would reduce the costs of health-care and about a third feel that it would reduce hospitalizations. At the same time there is a more pessimistic group of about a quarter of the physicians who believe that increased self-care would have the opposite effects: it would result in increased utilization of primary care services (because people might be sicker as a result of inappropriate and delayed treatment) and would augment costs of the health-care system. Furthermore, two-thirds believe that it would not decrease hospitalization. The view that increased self-care would reduce utilization rates is most frequent among General Sick Fund clinic physicians who are most exposed to high utilization and frequently for what they view as trivial complaints. Fully 72% of these practitioners state that increased self-care will reduce utilization of primary care services, as compared to 55% of the hospital physicians, and 43% of the small sick fund physicians (P = 0.000). No other independent variable showed a significant relationship. Only one variable among the personal, professional and practice characteristics showed a significant relationship to physicians’ attitudes concerning the effects of self-care on the costs of the health-care system: length of professional experience. The less experienced (less than 10 years of practice) are most optimistic in this regard: 56% believe that this would reduce such costs while among those with l&25 years of experience the percentage is 47% and the veterans (more than 25 years of practice) are least optimistic in this regard with only 36% expressing such hopes. It will be recalled that a similar relationship was found regarding the perceived Effects of Self-Care Behaviour. None of the independent variables are related to the perceived effects of self-care on hospitalization rates. This indicates that all sub-groups examined

Relationships

among the three dependent variables

There is a clear and significant relationship between physicians’ perceptions concerning the Effects of Specific Self-Care Behaviours on the Health of the Individual (Summary Measure) and their perceptions concerning the effects of self-care on primary care utilization rates (Table 6). Seventy-nine percent who perceive positive effects of self-care behaviour thought that it would reduce unnecessary clinic visits, while only 47% of those who viewed self-care behaviour negatively thought so. Of those who scored most negatively on this measure, 35% thought selfcare would increase clinic utilization, while only 9% of those who scored positively thought so. The health effects variable is more weakly related to physicians’ views concerning the effects of self-care on costs and on hospitalization rates.

Table 6. Relationship of physicians’ perceptions concerning health effects of self-care behaviours (summary measure) and systemic effects of self-care (%) Perceived effects of specific self-care behaviours on health

.. Positive Perceived effects of self-care on Consulting

effCCt

No effect

Detrimental effect

61

47

Sianificance

rates

Decrease consulting rates

79

No effect on consulting rates

I2 9 100%

Increasing consulting rates Total

I7

I8

22 100%

35 100%

x2 = 18.9 df = 4 P < 0.001

Costs Decrease costs

57

44

38

No effect on costs Increase costs Total

2s I8

37

100%

19 100%

31 31 100%

45

27

35

55 100%

73 100%

65 100%

7s

94

84

1’ = 8.5 d/=4 (P = 0.076)

Hospitali:ation

Decrease hospitalization

rates

x2 = 6.2 df=2 P -< 0.05

No effect on hospitalization Total N

SSM 2904

rates

JUDITH T. SHWAL

242

There is no association between physicians’ perceptions of the Effect of Independence and Initiatives by Lay Persons on the Health-Care Process and their perceptions of the three systemic effects of self-care. As already noted, the former variable tends to reflect a separate dimension of self-care, which is not related to the other two dimensions considered here. SUMMARY

AND DISCUSSION

The paper views self-care in systemic terms as part of the overall health-care structure. The study focuses on one group of actors in that system: physicians in Israel. Physicians’ perceptions regarding the effects of self-care have been examined in three substantive areas, two relating to the micro-level of clinical practice, and one focusing on the macro-level which concerns the health-care system. More specifically, we have examined perceptions of: (A) the effects of specific self-care behaviours on the health of the individual; (B) the effects of independence and initiatives by lay persons on the health-care process; (C) the effects of lay self-care on the health-care system in terms of utilization, costs and hospitalization rates. General distributions, inter-correlations and correlates of physicians’ perceptions of these three variables were examined. Interviews provided data from a sample of 258 physicians employed in two types of primary care settings and in hospitals. The findings are considered against the background of the Israeli health context which is characterized by the high value placed on health in the culture, widespread exercising of physician authority in the doctor-patient relationship, common acceptance of the latter as normative by most lay persons, the little ideologically-based consumer pressure advocating self-care. In addition, the Israeli health-care system, like many in the world, is troubled by major structural and economic problems. A central overall finding which sets the scene for the more detailed conclusions stems from the relationships among physicians’ perceptions regarding the three types of effects of self-care. Two of thesethe first and the third (A and Ct_are positively related while the second (B) is related to neither. Subtantively this means that physicians who see positive health effects of self-care behaviours also perceive positive effects of the latter on the healthcare system, and vice versa. The association is strongest with regard to the utilization category of C, i.e. self-care by individuals is viewed by physicians as related to the problem of high utilization rates in the primary care system: most believe that self-care behaviour could contribute to the reduction of this disturbing phenomonon which has long plagued the Israeli health-care system. The same general finding is seen with regard to costs of running the system and to hospitalization rates, although the relationship is less pronounced. We may therefore state that substantial groups of physicians perceive a relationship between the micro- and macro-level effects of selfcare behaviour and view it in a practical, utilitarian light, as a process that could alleviate some of the real problems characterizing the health-care system. The attitudinal complex termed ‘independence and initiatives by lay persons in health-care’ (B) is, as

et al

noted, unrelated to either of the above dimensions. It may be viewed as an independent dimension in this area, on which few physicians expressed favourable views. Perceptions concerning independence and initiatives (B) are ‘isolated’ from other attitudes concerning self-care (A and C). The challenge to the traditional physician-patient relationship. which is reflected in the independence and initiatives variable, is largely rejected in terms of effects on the health care process, and the implied behaviours are perceived as separate from the other two more ‘practical’ aspects of self-care. This lack of structure probably reflects the ‘under-development’ of self-care in Israel. Physicians who see the relationship of specific self-care behaviours to certain problematic system-linked issues, do not necessarily perceive ‘independence and initiatives’ as part of a more general concept of self-care. Additional evidence for the absence of a general concept of self-care among Israeli physicians is seen in the absence of strong correlates of the views expressed. All the dependent variables regarding the effects of self-care were examined for relationships with personal background, professional and practice setting characteristics. The findings show that physicians’ views are distributed somewhat randomly in the population: only weak relationships were found with background and practice setting variables. We view this set of findings as a further indication of the lack of structure in the complex of attitudes examined. A considerable range of views was expressed by physicians regarding the effects of self-care behaviours on individual health. In general, behaviours perceived as less risky and potentially effective for promoting health were viewed in a favourable light, while those involving potential risk, especially with regard to self-medication, were least favoured. The criteria that physicians seemed to use to evaluate the effects of specific self-care behaviours are pragmatic and focus on the potential contribution and risk to health that these behaviours entail. The relationship noted above to the systemic effects suggests that the physicians may be considering the fact that such behaviours could ameliorate some of the high utilization and cost problems as well. The physicians who are most likely to perceive positive effects of specific self-care behaviours are the younger, hospital-based specialists and residents who contrast with the general practitioners working in community clinics, who express less positive views. The greater confidence and professional status of the former, as well as their greater exposure to newer views of health-care expressed in the literature and in growing professional or lay circles, are associated with more positive views on self-care [48]. On the other hand, the lower status community clinic practitioners, especially those without a status-giving specialty license, are less willing to relinquish elements of control in health-care to lay persons. Indeed, a heavy patient load, which occurs most prominently in the General Sick Fund community clinics, is associated with more negative views regarding self-care behaviours. The second aspect of self-care examined physicians’ perceptions of the effects of independence and

Self-care in Israel

243

explored. Research has already been undertaken on by lay persons on the health-care process. a population of allied health professionals [49]; conOn the whole, considerable reservation was expressed sumers’ views and perspectives will complete the with regard to the items used to assess views in this systemic picture. Information from these additional area and on some there was almost universal disapgroups will help explain the absence of structure in proval. This complex of lay behaviours expresses the views expressed by the physicians. We have noted some challenge or scepticism regarding the traditional that the Israeli health scene is characterized by the doctor-patient relationship, and suggests greater concentrality of health in the value system, and by trol of that relationship by the patients. Although relative underdevelopment of consumer awareness or responses varied in terms of the specific items posed, positive responses were never given by more than a advocacy regarding self-care. It may be suggested in conclusion that the general lack of structure which third of the physician population and several items were almost unanimously rejected. In the absence of characterizes physicians’ views on this subject complements the stance of consumers who have been slow comparative data, we are unable to judge whether or reluctant to take a position regarding self-care. this population differs from comparable groups in While some forms of self-care are, and always have other countries. Limited data from the United States been, widely practiced, there has as yet been little also shows that physicians express serious doubts regarding self-care initiatives by lay persons [12, 141. ‘consciousness raising’ on the subject in the society. There are few significant correlates of this variable Acknowledgements-The authors appreciate the support of and those found are not strong. the Israel National Council for Research and Development Despite the weak relationships, it is worth pointing and of ESHEL-the Association for the Planning and to some differentials on this variable in the popuDevelopment of Services for the Aged in Israel. lation of physicians. When controls are introduced, the data show somewhat more positive views regardREFERENCES ing the effects of independence and initiative by lay persons among the following sub-groups of phys1. U.S. DHEW Publication No. (HRA) 7-3181. Consumer icians: males, those practicing in hospital settings, self-care in health. National Technical Information with specialty status, relatively few years of practice, Service, Springfield, Va, 1977. and reporting relatively less patient load. These sub2. Dean K. Self-care response to illness: a selected review. groups are characterized by relatively higher status Sot. Sci. Med. lSA, 673687, 1981. 3. Dean K. Lay care in illness. Sot. Sci. Med. 22, 275-284, than their counterparts (i.e. females in community 1986. clinic practice, with no specialty status and greater 4. Levin L. S. and Idler E. L. The Hidden Health Care patient load). It may be suggested that physicians System: Mediating Structures and Medicine. Ballinger, whose professional status is less secure are more likely Cambridge, Mass., 1981. to be concerned with retention of authority, control 5. Levin L. S., Katz A. H. and Holst E. Ser/ Care: Lrry and the accompanying power these imply. Such Initiatives in Health. Prodist, New York, 1979. concerns may be expressed in attitudes of scepticism, 6. Mechanic D. From Advocacy ro Allocation. Free Press, caution, reservation and in some cases outright objecNew York, 1986. tion to lay independence or initiatives in health-care, 7. Freidson E. Professional Dominance: The Social Slructure of Medical Care. Atherton Press. New York, 1970. especially when these are perceived as a potential 8. Hayes-Bautista D. E. Modifying the treatment: patient threat to physician authority on the micro-level. The compliance, patient control and medical care. Sot. Sci. more harassed community clinic physician may seek Med. 10, 233-238, 1976. certain rewards of practice in exercise of control and 9. Pratt L. V. Reshaping the consumer’s posture in health authority. These also serve as a mechanism to facilicare. In The Doctor-Patienr Relationship in rhe Changtate the handling of large numbers of patients, many ing Health Care Scene (Edited by Gallagher E. B.), of whom bring what physicians consider to be trivial pp. 121-123, U.S. DHEW, Publication No. (NIH) complaints. 78-183, 1978. The findings show that physicians distinguish 10. Lazare A., Eisenthal S., Frank A. and Stoeckle J. D. Studies on a negotiated approach to patienthood. In clearly among effects of self-care on various problemThe Doctor-Patient Relationship in the Changing Health atic aspects of the health-care system. Thus views Scene (Edited by Gallagher E. B.), pp. 119-139. U.S. differ considerably regarding effects on utilization, DHEW, Publication No. (NIH) 78-183, 1978. cost and hospitalization rates. The most positive 11. Katon A. and Kleinman A. Doctor-patient negotiation effects of self-care are perceived with regard to clinic and other social science strategies in patient care. In The utilization rates, which over half of the physicians Relevance of Social Science for Medicine (Edited by believe will be reduced if self-care is increased. A Eisenberg L. and Kleinmen A.), pp. 253-279. Reidel, decrease in the costs of running the health-care Amsterdam, 1981. system is another widely perceived effect of increased 12. Linn L. S. and Lewis L. E. Attitudes toward self-care among practicing physicians. Med. Care 17, 183-190, self-care, but less than half the physicians view this 1979. effect as likely. Even fewer believe that increased 13. Dunnell K. and Cartwright A. Medicine Takers, Preself-care will have the effect of reducing hospitalizscribers and Hoarders. Routledge 8c Kegan Paul, Lonation rates. What is more, there are non-negligible don, 1972. sub-groups who hold negative views regarding the 14. Haug M. and Lavin B. Consumerism in Medicine: effects of self-care on these system variables. Challenging Physician Authority. Sage, Beverly Hills, In conclusion, it should be recalled that the overall Calif., 1983. approach of the research is a systemic one and 15. Goldman L. Factors related to physicians’ medical and the physicians are only the first set of actors whose political attitudes: a documentation of intraprofessional variations. J. Hlth sot. Behav. 15, 177-187, 1974. views and perceptions regarding self-care have been initiatives

244

JUDITH T. SHUVAL

16. Mechanic D. Religion, religiosity and illness behavior: the special case of the Jews. Hum. Org. 22, 202-208, 1962. 17. Heins M., Hendricks J., Martindale L., Smock S., Stein M. and Jacobs L. Attitudes of women and men physicians Am J. publ. Hlrh 69, 1132-1139, 1979. 18 Colombotos J. Social origins and ideology of physicians: a study of the effect of early socialization. J. Hlth sot. Behav. 10, 1629, 1969. 19 Mechanic D. (Ed.) Factors affecting receptivity to innovations in health-care delivery among primary-care physicians. In Politics, Medicine and Social Science. Wiley, New York, 1974. J., Kirchner C. and Millman M. Physicians 20. Colombotos view national health insurance: a national study. Med. Care 13, 369-396. 1975. 21. Mechanic D. General medical practice: some comparisons between the work of primary care physicians in the United States and England and Wales. Med. Care 10, 402420, 1972. Bureau of Statistics. Starisrical Abstracf of 22. Central Israel, No. 35, 1984. 23. World Health Starisrics Annual, 1986, WHO, Geneva, 1986. 24. Shuval J. T. Social functions of medical licensing: a case study of Soviet immigrant physicians in Israel. Sot. Sci. Med. 20, 901-909, 1985. 25. Ellencweig A. Y. and Grafstein 0. Inequality in health: a case study. Hebrew University-Hadassah Medical School, Jerusalem. 1986. 26. Shuval J. T. Entering Medicine: The Dynamics of Transition. A Seven Year Study of Medical Education in Israel. Pergamon Press, Oxford, 1980. 27. Antonovsky A. A model to explain visits to the doctor: with special reference to the case of Israel. J. Hlth sot. Behav. 13, 446454. 1972. 28. Zborowski M. and Herzog E. Life is Wirh People. International Universities Press, New York, 1952. 29. Suchman E. A. Sociomedical variations among ethnic grops. Am. J. Sot. 70, 319-331, 1964. 30. Twaddle A. C. Health decisions and sick role variations: an exploration. J. Hlrh sot. Behuv. 10, 105-114, 1969. 31. Shuval J. T. Primary care and social control. Med. Cure 17, 631-638, 1979. 32. Shuval J. Medical manpower in Israel: political processes and constraints. Paper presented for the Inrernational Conference on the Political Dynamics of Physician Manpower Policy, London, 24-27 May, 1988. Unpublished. 33. Bare11 V. and Zadka P. Health care systems in Israel. In Proceedings of rhe Inrernational Collaborative Effort on Perinatal and Infunr Morfaliry, Vol. 1. U.S. Department of Health and Human Services, U.S. Public Health

34. 35

36

37

38

39

40

41.

42.

43.

44. 45. 46. 47.

48.

49.

er ul.

Service, National Center for Health Statistics, 1984. Central Bureau of Statistics. Smtistical Absrracr of , Israel, No. 37, 1986. Estabrook B. Consumer impact of a cold self-care center in a pre-paid ambulatory care setting. Med. Cure 17. 1139-l 145. 1979. Zapka J. and Averill B. W. Self-care for colds: a cost effective alternative to upper respiratory infection management. Am. J. publ. Hith 69, 814-816, 1979. Berg A. 0. and Logerfo J. P. Potential effect of self-care algorithms on the number of physician visits. New’ Engl. J. Med. 300, 535-537, 1979. Ruzek S. B. The Women’s Health Movement: Feminist Alternatives IO Medical Conirol. Praeger, New York, 1978. Fleming G. V.. Sellers C. and Anderson R. Self-care: what are the relevant dimensions for study? Unpublished manuscript, Center for Health Administration Studies, University of Chicago, Ill.. 1982. Shuval J. T. and Shye D. Self-care in Israel: a providers’ view. Unpublished report, Brookdale Institute of Gerontology and Adult Human Development and The Hebrew University of Jerusalem, 1984. Shuval J. T., Javetz R. and Shye D. Self-care in Israel: physicians’ views and attitudes. Brookdale Institute of Gerontology and Adult Human Development, 1987. DeFriese G. H., Steckler A. B.. Schiller P. L., Beery W. L.. Graham R., Woomert A. and Barry P. Z. An empirical toxonomy of self-care skills. Health Services Research Center, University of North Carolina at Chapel Hill. Paper presented to the Annual Meefing of rhe American Public Health Associarion, Montreal, Quebec, 1982. Williams T. F. The physicians’ viewpoint. In Elderly Patients and Their Docrors (Edited by Haug M. R.), pp. 42-46. Springer, New York, 1981. Freidson E. Client control and medical practice. Am. J. Social. 65, 374-382, 1960. Stimson G. V. Obeying doctor’s orders: a view from the other side. Sot. Sci. Med. 8, 97-104, 1974. Kahn H. A. An Inrroduction IO Epidemiologic Methods. Oxford University Press, New York, 1983. Schlesselman J. J. Case Control Studies: Design, Conduct, Analysis. Oxford University Press, Oxford, 1982. Javetz R. Conflict and crisis in the health system: the doctors’ strike from the profession’s point of view. Unpublished, Ford Foundation, 1987. Javetz R.. Shuval J. and Shve D. Self-care in Israel: views and perspectives of allied health professionals. Brookdale Institute of Gerontology and Adult Human Development, 1987.