massage therapy visits by the aged: testing a modified andersen model

242 Pages·2009·2.08 MB·English

MASSAGE THERAPY VISITS BY THE AGED:
TESTING A MODIFIED ANDERSEN MODEL

By

Kevin Donald Willison

A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Graduate Department of Public Health Sciences,
University of Toronto

© Copyright by Kevin D. Willison, 2009
Massage Therapy Visits By The Aged: Testing A Modified Andersen Model. Kevin Willison, PhD, ,
Dept. of Public Health Sciences, University of Toronto, 2009
Abstract
Growing evidence suggests that chronic health conditions and disability act as reliable
predictors of complementary/ alternative medicine (CAM) use. Such use may have the potential
for some to increase independence and quality of life. Moreover, research indicates that older
people are significant consumers of CAM services. Yet, understanding profiles of older
individuals of these services continues to remain under researched. Here, a widely used type of
CAM was considered – massage therapy (MT).
Towards better understanding MT user profiles, this study tested a modified version of
the Andersen Health Behavior Model to help ascertain if it is useful towards understanding
factors associated with massage therapy (MT) utilization. Respondents represented an elderly
sample (aged 60+) that resided within a large urban city in Ontario Canada (Toronto). Eligible
respondents at the time of the study were non-institutionalized and self-reported having one of
more current chronic illness conditions which they have had for six months or more, and had
been diagnosed by a medical doctor.
Using a quantitative method, retrospective data were gathered using a pre-tested English-
only mail questionnaire, developed specifically for this study. Data were gathered over a period
of 6 months, between late 2000 to mid 2001. Bivariate analysis suggests that inequity exists
whereby the ability to access massage therapy varies according to one’s socioeconomic status.
This is further supported using backwards step-wise regression analysis, whereby one’s total
annual household income was a strong predictor of MT use status. One’s CAM-related health
and social network as well as having back problems also emerged as strong predictors of MT
use. Overall findings suggest that a modified Andersen model as used in this study does have
utility in relation to helping to identify potential factors associated with the utilization of massage
therapy.
Based on regression analysis, findings here suggest, for example, that those with higher
incomes are 1.5 times more likely to use MT. This provides support that there are existing
inequities regarding access to rehabilitation-oriented health care services. With population aging
and rising numbers of people needing restorative and rehabilitation services, study findings will
increasingly have important public health as well as health care policy related implications.
ii
Acknowledgements

I am deeply indebted to my thesis Committee: Dr. Michael Escobar, Dr. Michael
Goodstadt and my supervisor, Dr. Ted Myers (senior professors of the University of Toronto) for
their time and helpful advice. Moreover, Dr. Robert Mann from the Centre for Addiction and
Mental Health (CAMH - Toronto) also kindly assisted. Naturally, any errors in this document are
entirely my own.
I am particularly indebted to my wife (Qing Zhu, M.Eng., BSc., BEd.) for her patience
and encouragement. She has been my anchor throughout this entire process.
Moreover, I am thankful to former staff of ICT™ Kikkawa College – a massage therapy
teaching school located in Toronto (Canada). Faculty at this school provided valuable insights
regarding the wording of the mail questionnaire developed and used for this study.
I wish to also acknowledge Mr. Bruce Foster. a practicing physiotherapist in Belleville
Ontario. Serving as his summer assistant, Bruce introduced me to the field of rehabilitation, and
strongly encouraged me to learn more. Thank you.
Last but not least, I thank Dr. John Roder PhD. He is a senior investigator affiliated with
the University of Toronto and the Samuel Lunenfeld Research Institute (SLRI). Working with
him for almost three years Dr. Roder encouraged me to run the good race and fight the good
fight. As a friend, I have appreciated his advice and encouragement over the years.
Collectively, the individuals noted above have directly or indirectly encouraged me to
pursue my dream of obtaining a PhD. I am obliged to admit, however, that the more I learn the
more I come to understand how little I actually know. My wife can vouch for this.

iii
Study Index
Page
Introduction CHAPTER 1

1.1 The Use of CAM Health Services …………..…………………………….… 1
1.2 Why a Focus on Massage Therapy? ………………………………………. 2
1.3 Why a Focus on the Elderly in this Study? .………………………………. 4
1.4 Use of the Andersen Model in this Study …………………………………. 4
1.5 Purpose of this Study ………………………………………………………. 5
1.6 Methodology ………………………………..……………………………… 6
1.7 Research Questions …………………………………………………….… 6
1.8 Format of this Thesis ……. ………………………………………..……….. 6

Theory CHAPTER 2
2.1 Introduction …………………………………………………….…………. 8
2.2 The Andersen Model: Key Concepts …………………….…..…….……. 8
2.3 Origins of the Andersen Model ………………………………….………… 9
2.4 Uses of Andersen’s Behavioral Model Over Time ……………………… 11
2.5 Use of the Andersen Model to Study Equity Issues Related to Health
Care Utilization ….………………….………………….…………………. 13
2.6 Applicability of the Andersen Model to Diverse Issues and Populations .. 15
2.7 The Present Study’s Use of a Modified Andersen Model…………………. 17
2.8 Summary…………..………………………………………………………… 19

Literature Review CHAPTER 3
3.1 Introduction ………………………………………………………………… 20
Part 1 - Contextual Characteristics:
3.2 Changing Demographics ………………………………………………… 21
3.3 The Focus on Cure as a Medical Community Value and Norm…………. 22
3.4 Increasing Use of Complementary and Alternative Medicine …..………. 24
3.5 Use of Health Care Providers ……………………………………………… 25
3.6 Population Morbidity Trends …………….……………………….……….. 26
Part 2 – Individual Characteristics:
3.7 Role of Beliefs and Values - Skepticism …………………….……………. 27
3.8 Satisfaction with Conventional Medicine and its Practitioners ………… 28
3.9 Belief in the Value and Potential of Massage Therapy ……………………. 29
3.10 Potential Role of Health and Social Networks Towards MT Use…….…. 32
3.11 Individual Illness and Morbidity Considerations…………………….…. 33
3.12 Use of CAM as a Self-Care Strategy …………………………………….. 33
3.13 Individual and Contextual Characteristics – Summary……………….. 36
3.14 Potential Limitations of Massage Therapy …………………………….. 36
3.15 Study Assumptions………………………………………………………. 37
Chapter 3 Endnotes …………………………………………………………… 39
iv
Study Index (continued)
Page
Methodology CHAPTER 4
4.1 Research Design……. …………………………………………………. 43
4.2 Using a Mail Questionnaire ……………………………………………… 43
4.3 Research Setting…………………………………………………………… 44
4.4 Outcome Measure ……………….……………………………………….. 44
4.5 Using Human Respondents – Ethics Board Approval…………………… 45
4.6 Criteria for Sample Selection ……………………………………………` 45
4.7 Instrumentation – Development of the Mail Questionnaire……………… 46
4.8 Assessing the Questionnaire with a Pilot Test………………………………. 48
4.9 Independent Variables Used …………………………………………….. 48
4.10 Respondent Predisposing Characteristics ……………………………… 49
4.11 Respondent Enabling Characteristics ……………………………… 55
4.12 Respondent Need Characteristics ……………………………………… 57
4.13 Data Input Coding Procedure ………………………………………… 59
4.14 Developing a Codebook……………………………………………………. 59
4.15 Data Collection Time Period …………………………………………… 60
4.16 Respondent Recruitment Strategies ……………………………………….. 61
4.17 Data Collection Procedure………………………………………………….. 66
4.18 Measures Taken to Increase Questionnaire Response Rates…………. 66
4.19 Data Analysis …………………………………………………………….. 67
4.20 Data Editing and Cleaning Procedures………………………………… 68
4.21 Item Non-response/Missing Data ………………………………………. 69
4.22 Maintenance of Confidentiality – Storage of Collected Data……….. 69

Descriptive and Bivariate Results CHAPTER 5
5.1 Introduction ……………………………………………………………… 70
5.2 Response Rate……….. …………………………………………………. 70
5.3 Reliability of Scales Used……………………………………………………. 72
5.4 Study Demographics …………………………………………………….. 72

Predisposing Characteristics
5.5 Gender Differences between Groups………………………………………. 72
5.6 Marital Status………………………………….…………………………….. 73
5.7 Age Differences between Groups ………………………………………….. 73
5.8 Education of Respondents……..………………………………………. 74
5.9 Education of the Respondent’s Spouses……………………..………..……. 75
5.10 Occupational Background of Respondents ……………………………… 75
5.11 Skepticism …………………………………………………………………. 77
5.12 Satisfaction…………………………………………………………………. 79

v
Study Index (continued)
Page
5.13 Mastery …………………………………………………………………. 81
5.14 Self-Esteem…………………………………………………………………. 83

Enabling Characteristics:
5.15 Self-assessed Financial Situation………………………………………. 86
5.16 Money for Massage Therapy …………………………………………… 86
5.17 Payment Method for MassageTherapy …………………………………. 87
5.18 Respondent’s and their Spouses Employment Status…………………… 87
5.19 Respondent’s Employment Situation ……………………………………. 88
5.20 Spouse’s Employment Situation ………………………………………….. 88
5.21 Total Annual Household Income ………………………………………… 88
5.22 Added Health Insurance – Beyond OHIP ……………………………….. 89
5.23 Respondent’s Sources of Income…………………………………………… 89
5.24 Living Arrangement ……………………………………………………….. 90
5.25 Housing Arrangement ……………………………………………………… 91
5.26 Health Network Resources ………………………………………………… 91
5.27 Source of Referral to MT …………………………………………………. 93
5.28 Respondent’s Knowledge of Massage Therapy ………………………….. 94
5.29 CAM Knowledge Sources …………………………………………..… ….. 95
Need Characteristics:
5.30 Self-Perceived Health Status ……………………………………………….. 97
5.31 Morbidity …………………………………………………………………. 98
5.32 Chronic Condition Types ……………………………………………….. 99
5.33 ADL/IADL/Mobility ………………………………………………………. 100
5.34 Hospital Days ……………………………………………………………… 101
5.35 Correlation Findings ………………………………………………………. 103

Binary Logistic Regression Results CHAPTER 6
6.1 Introduction ……………………………………………………………… 108
6.2 Second Phase ……………………………………………………………… 111
6.3 Model Fit and Differences between Full Model & Parsimonious Model 114
6.4 Regarding Eliminated Variables …………………………………………… 116
6.5 Summary …………………………………………………………………….. 117

Discussion CHAPTER 7
7.1 Introduction ……………………………………………………………… 120
7.2 Utility of the Andersen Model in Understanding MT Utilization……….. 121
7.3 Sample Predisposing Characteristics ……....……………………………… 122
7.4 Sample Enabling Characteristics………………………………………….. 124
7.5 Sample Need Characteristics……………………………………………….. 126
7.6 Overview of Regression Analysis Results…………………………………. 127
7.7 Inequity of Access to Massage Therapy: Relevance to Health Care Policy
Development and to Health Care Practitioners…………………………….. 128

vi
Study Index (continued)
Page
7.8 Study Relevance to the Aged………………………………………………. 130
7.9 Relevance of Study to Public Health …………………………………….. 131
7.10 Contributions of this Study ……………………………………………….. 134
7.11 Study Limitations………………………………………………………….. 136
7.12 Study Participant Recruitment Issues …………………………………….. 138
7.13 Suggestions for Future Research………………………………………….. 139
7.14 Conclusion ………………………………………………………………… 141

References ………………………………………..…………………………….. 143

Appendixes

1 - Pre-tested (Final) Questionnaire
2 - Study Area (Metropolitan Toronto Map)
3 - Ethics Approval (U. of T.)
4 - Participant Information Sheets
5 - Participant Consent Form
6 - Codebook
vii
1

Chapter 1

Introduction

1.1 The Use of CAM Health Services

Increasingly, Canadians, both healthy and ill, are turning to complementary and
alternative medicine (CAM) therapies, practices and products (Health Canada, 2001). This
reflects changing health care behavior (Fouladbakhsh and Stommel, 2007) and will likely
continue. Though the notion of CAM remains difficult to define in its entirety, this dissertation
posits CAM as an additional treatment resource (Slee et al., 1996) that is often used in
conjunction with conventional (biomedically-oriented) health care services. This study does not
define CAM as a replacement to conventional medicine, though some individuals do, in fact, use
such as a complete replacement (Egede et al., 2002; Hollenberg, 1998; Kelner and Wellman,
1997; Millar, 2001, Yeh et al., 2002; York, 1999; Sirois and Gick, 2002).
Of the 350 different types of CAM (Chez et al., 1999), this study has chosen to focus on
massage therapy (MT). One of the more frequently used provider-based forms of CAM is MT
(Foster et al., 2000; Lindquist et al, 2003; Williamson et al., 2003, Sohn et al., 2002).
According to Reed’s estimation (1998) approximately three percent of the general
population seeks out registered massage therapy services in Ontario. Statistics Canada supports
this estimate in a report indicating massage therapy use in Ontario to be 4 percent (Health
Reports, 1999). Nationally, Ramsey et al., (1999) have indicated that between 17-24 percent of
Canadians use massage. The Fraser Institute supports this data, noting that the percentage of
Canadians who used massage at the time of their review was 23 % (Health Canada, 2001).
Eisenberg (1998) found that massage use in the United States increased by 62% from
1990 to 1997. In Canada, an Environics Research Group study (n=2,526) indicated MT use in
2

1993 to be 4%. By 1999, its use rose to 10% (Berger, 1999). Together, this data supports Ernst’s
(2003) contention that massage therapy is currently experiencing a revival within health care
practice.

1.2 Why Focus on Massage Therapy?
Ontario Canada’s Massage Therapy Act (MTA – 1990, c.27, s.3) outlines massage
therapy’s scope of practice as follows:
“The practice of massage therapy is the assessment of the soft tissue and joints of
the body and the treatment and prevention of physical dysfunction and pain of the
soft tissues and joints, by manipulation to develop, maintain, rehabilitate or
augment physical function, or relieve pain.”

One definition posits massage as the hand motions practiced on the surface of the body
with a therapeutic goal (Boigy, 1950). Cook et al. (1997) define massage as the manipulation of
soft tissues of the body by a trained therapist as a component of a holistic therapeutic
intervention. This particular study considers 50-60 minute full body massage , (versus shorter
intervals, as often found in chair massage techniques). Swedish (“classic”) massage is the most
commonly practiced full body massage method in North America. The College of Massage
Therapists of Ontario (CMTO) sets all registration requirements as directed by the Massage
Therapy Act (1990), the Regulated Health Professions Act (1992) and Ontario’s Health
Professions Regulatory Advisory Council (HPRAC). A person cannot legally practice as a
massage therapist in Ontario unless he or she is registered under the CMTO. This study collected
data via assistance from Ontario registered (licensed) massage therapists only (chapter 4).
3

As a manual healing method (Chez et al., 1999), massage therapy overlaps with more
recognized biomedical professions such as physical therapy (Kaptchuck et al., 2001). Currently
the only three provinces in Canada with licensing requirements to practice massage are: Ontario,
British Columbia and, Newfoundland.
Many massage therapy programs consists of a minimum of 2200 hours of training. In
addition, practicing massage therapy in Ontario demands that individuals pass a series of written
and practical examinations in order to obtain a Certificate of Registration from the CMTO.
Hippocrates, the revered father of medicine, was an early advocate of massage and
recommended its use on a continual basis to ease pain and prevent stiffness (Sergen, 1998).
Indeed, the art and science of massage has been used in all cultures throughout history (Vickers,
1993). However, despite its long history, research pertaining to massage is still in its infancy
(Ernst, 2003).
In an Ontario study comparing the opinions, attitudes and knowledge of final year
medical students, including nurses, physiotherapists and pharmacy students, massage therapy
received a high knowledge rating (Baugniet et al., 2000). While physicians generally
demonstrate poor general knowledge of CAM, they appear to be most familiar with such
practices as acupuncture and massage (Suter et al., 2004).
Nurses and other health care professionals have used massage therapy for centuries. As
the predominance of conventional medical practices in North America became established in the
early twentieth century, doctors reassigned time-intensive Semergent physiotherapists shifted
their interest from massage therapy to therapies that make use of high-tech equipment (Snyder
and Wieland, 2003).