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Coping with grief

Melinda Gill, Nai An Lai, Yu Ming Ong, Dzung Nguyen

Abstract

Unresolved grief leads to various physical and mental pathologies (Raphael, 1992). The 1992 report by the National Health and Medical Research Counsel indicated that both primary health care workers (including GPs) and bereavement support groups have important roles to play in helping the bereaved cope with grief. There is a need for GPs to act as the advocate. This study explores GPs' current management of bereaved patients. The focus is on the following areas: GPs' roles ;GPs' awareness of grief as a health issue ; and GPs' awareness of and the level of cooperation with bereavement support groups. To find out these information we interviewed 16 GPs in the Monash municipality and the data collected established our targets to increase GP's awareness and understanding of available bereavement support services and to produce a bereavement resource directory containing relevant information about such service with the goal of enhancing cooperation between GPs and bereavement support groups and ultimately contributes to the improvement of mental health care especially in the area of grief and bereavement. Data were collected and compiled . A directory was produced and distributed to the selected GPs for feedback interviews which we conducted over the phone. Our findings indicated that positive clearance of misconceptions among GPs and their lack of understanding of the functionings of support groups would significantly help to bridge the gap in communication between these two groups.

Key words:

GPs, support groups, cooperation, bereavement, grief, directory , counselling, bereaved patients, advocate

Purpose of the Report

This report aims to outline the procedures involved in producing a directory containing information about bereavement counselling services, support groups and training programs in the South Eastern suburbs of the Melbourne Metropolitan area, after establishing the need for such directory. The process of evaluating the value of the directory and the analysis of the results obtained will also be documented.

Health issue

Our principal health issue is the effects of grief due to bereavement on health, an issue that has yet to be adequately addressed in our society. The link between grief and various physical and mental pathologies has been established by numerous research while the value of clinical intervention and supportive therapy has been proven to be immense in reducing morbidity and mortality (Raphael, 1992). Currently there is a perceived lack of accessibility to various social and professional bereavement support services, one of the possible reasons being the inadequacy of cooperation between primary health care providers (including GPs) and the bereavement support groups. There is a need for GPs to act as the advocate for the bereaved who may have difficulty in seeking the support they required.

Priority populations

We started our project with the bereaved persons as our priority population but later realised the logistic impracticality and ethical controversy of such approach. Our final approach embraced two priority populations - GPs and bereavement support services.

GPs were randomly selected from those who practised in the city of Monash and who were affiliated to the Department of Community Medicine, Monash University. The reason for choosing the doctors in this area is ease of access to these practices to conduct interviews.

Efforts were put in to ensure that we had included all the important grief support groups in the City of Monash while groups in other areas within 20 km radius from Monash which provided services lacking in this municipality were also included.

Goals and targets

Figure 1: Goals and Targets

Strategies and methods

As we undertook our project we progressed through three phases.

PHASE 1: PRELIMINARY RESEARCH

Issues associated with death and grief are by nature quite complex. It was therefore necessary to devote a large portion of our time towards research. Information was acquired as a result of

1. background reading
2. information and advice from General Practitioner and
3. other professionals and lay people working in this area.

1.1 Background reading

During our first meeting with our supervisor it became very clear that we would need to rely very heavily on the wisdom and experience of others in order to obtain a better understanding of the issue ourselves. Several books and articles were recommended and each of us chose several in order to gain an understanding of the process of bereavement, the effect of grief on health and the possible roles for health and other community workers. Throughout the course of our project we gained insight not only from these books, but the experience of people whom we met along the way.

1.2 Interviewing General Practitioners

Before producing our resource book we thought it necessary to the interview GPs in order to gain an understanding of their experience in helping grieving patients, knowledge of the grieving process, and perception of their role and the role of other community groups in assisting bereaved people. Our supervisor arranged for Dr. Peter Schattner, a senior lecturer from the Department of Community Medicine, to oversee this part of our project. A questionnaire, which was to be conducted with up to twenty GPs in a fifteen minute interview, was produced and reviewed by Dr. Schattners, with whom we later rehearsed the interview and received his advice and feedback.

Dr. Schattner sent a letter to over thirty of his colleagues, explaining and requesting their participation in our project. It was intended that each of us conduct an interview with five from this list, though this eventually varied according to the ease at which each member of our group was able to make appointments. A total of sixteen interviews were conducted over the course of a week. Though often very busy, most GPs appeared pleased to share their experiences with us and many of the interviews progressed for much longer than the planned 15 minutes duration.

1.3 Compilation of information about community organisations

In order to make the task of contacting each group more manageable we initially divided the organisations into four categories, those that were church, hospital, community, and funeral services based. Our first list of contacts were obtained from the Yellow Pages and later community services data obtained through the computer network at local libraries proved useful . This created a snow ball effect as certain groups were able to provide the names of others working in the area, and because these were most often "community based" groups we reallocated many of these to other members of our group. Although we were often confronted with answering machines and other obstacles that made it difficult to contact the various groups, the enthusiasm that we eventually received made our efforts worth while. We received their approval of our project and agreed with us that there was a need for more community awareness about the services available to bereaved people.

During this phase of our project we were also able to attend a brain storming session about the Bereavement and Loss Awareness week to be held in mid-October. We had some imput during this meeting and were subsequently followed up for requests for further participation.

PHASE 2: PRODUCTION OF THE RESOURCE DIRECTORY

2.1 Evaluation of the GPs responses

In our construction of the questionnaire we included indirect questions that would help us make conclusions about their attitudes and practices concerning the management of bereaved patients, together with questions concerning the proposed content and format our directory. The responses of the GPs were then summarised and analysed (See Results) and the nature of the resource directory fashioned accordingly.

2.2 Compilation of data

After the format of the directory was decided, the data obtained from the various organisations was sorted and compiled into an appropriate form. Information to be covered included lists of support and self help groups, funeral and counselling services, state and national organisations, and training courses. Organisations and groups were organised into type of bereavement for easy access. Information about each group include: name of organisation, people catered for, service/s, contact, address and phone number.

2.3 Assembly and printing of the resource directory

The assembly of the directoryís contents and formatting was done on Word 6.0. Because of financial constraints, the directory was produced using manual arrangement on the photocopying machine which our Convenor generously let us use. Twenty copies were printed.

2.4 Distribution

Each of the GPs interviewed were posted a copy of the directory, together a letter of explanation. Many of the organisations we contacted requested a copy of the resource directory and were also sent copies.

PHASE 3. EVALUATION PLAN

We allow about one week for the GPs to peruse the directory. After that, we made a phone call to each GP and conducted a brief phone interview to evaluate the presentation, content and potential usefulness of the directory . The phone interviews also evaluate whether we achieved our targets and goal.

The effectiveness of the project can be measured by addressing four key aspects of evaluation:

• Needs evaluation - this established the targets of the project and involved evaluating the needs to
• promote awareness of grief due to bereavement as a health issue among GPs. The information which formed the basis of this target came from background reading, published research material and via our supervisorís knowledge suggested a neglected need.
• promote awareness and understanding of available bereavement support services and produce a bereavement resource directory containing bereavement support services for GPs. The information which formed the basis of this need arisen through the difficulties we encountered in locating a central source of information where such groups would be listed; no such directory for the metropolitan Melbourne area existed; support groups and funeral directors strongly encouraged production of such a directory; and the survey interviews with GPs found that there were general lack of awareness of such groups ín existence and details. Because of the busy practices GPs would want readily accessible information.

Process evaluation- this looks at how our goal is achieved. Due to the GPs' busy practices we had difficulties in arranging for interviews with the proposed 20 GPS at mutually suitable times. We managed to have 17 confirmed appointments but only 16 were conducted because 1 GP had an emergency on the day of the interview and postponed it to a later date which was too late according to our schedule. There was mixed enthusiasm among the Gps about our project. Although busy, many GPs still granted us an interview. We felt this may be related to our approach to Dr Peter Schattners, head of the group of GPs in the Monash area to advise the GPs of our intended interviews and his support of our project in a letter he sent to the Gps. Only 11 feedback interviews were conducted. The reasons why the other 5 couldnít be contacted were:

1. 2 GPs have taken leave from their practice
2. 3 other GPs have very busy practice and havenít had time to look through the directory. Their evaluative feedback wonít be available until the date of submission of this report and thus will not be included.

Impact evaluation - this evaluate whether we achieved our targets. We achieved our targets to a great extent. The production of the directory and the results of our interviews ( both verbal ( survey) and phone(feedback)) with the GPs forms the basis of this evaluation ( see apendix C2 & C3 respectively)

Outcome evaluation - this evaluated whether we achieved our goal of increasing cooperation between our two priority populations. The results from the feedback phone interviews with GPs compared with the earlier survey interviews indicated only partial success.

Results

1. The directory

A copy of the bereavement directory is included in appendix E (not available on-line)

2. The interviews with GPs

We interviewed 16 general practitioners. The findings showed polarisation among the GPs into 2 groups of roughly the same number as shown below:

Table I: Polarisation of results among GPS from our survey interviews

A summary of what GPs perceived their roles in helping bereaved patients is in figure 1, page 11. Many GPs found that their own management as adequate.

75% of the GPs gained their skills from experience and only < 40% of them received formal training in grief management. A small percentage of GPs admitted they had no skills in grief counselling or support and so ìCounselling Servicesî section was needed in the directory. About 50% of GPs would like to improve their skills. These information prompted us into adding a ì Trainingî section to our directory which included bereavement courses, seminars and workshops that GPs could attend to fuirther improve their skills.

3. Contacts with bereavement support services

The support services we contacted showed great support in our project. They expressed genuine enthusiasm, interest in cooperating with GPs but the enthusiasm was not reciprocal. Several organisations attempts to reach out to GPs in the past have been met with resistance and lack of interests.

[Picture not online]

Figure 1: Perceived roles of GPs in helping bereaved patients

4. Feedbacks from GPs concerning the directory

Of the sixteen GPs we interviewed we could obtain evaluation of our directory from only eleven of them. Generally, we were pleased with the feedbacks. The average rating (out of 10) for the directory ís presentation was 7.9; content was 7.8; and potential usefulness was 7.1.

Suggestions for improvements of the directory included the following:

• inclusion of an index of support groups and phone number at the back of the directory for easy referencing
• inclusion of community outreach groups that offer a ssocial atmosphere which is not neccessarily with other bereaved people
• inclusion more professional services
• make the directory more comprehensive
• provide a mean for the information to be updated

The feedbacks showed that our targets were achieved. Over 90% of GPs said that the directory have increased their awareness moderately to enormously. The fact that we did this interview helped achieved our target of promoting greater awareness of grief as a health issue among GPs. The production of a bereavement directory achieved our third target.

Our goal of increasing cooperation between GPs and support groups have only been partially met. 45% ( 5 out of 11) said that the referrals they make to such groups in the future would not increase or only increase by only a little and the remainder said moderately.

Discussion

One important implication from this study is the need to address an important issue: the reasons why there is a lack of motivation among many GPs to cooperate with the bereavement support groups. Many possible reasons found were:

• the belief that there is a lack of effective professional leadership in bereavement support groups hence referrals to such groups would be like having the blind leads the blind with no beneficial outcome.
• the belief that reciprocal sharing of experience among a group of bereaved people is not beneficial (ie everyone sink together)
• some GPs felt disempowered that they would be surrendering another aspect of medical management.
• the rare occurrence of high risk bereavement and difficulties encountered hence most GPs felt their own counselling and support was adequate. Also, many bereaved patients ( largely griefing over death of an elderly spouse) coped well with the loss because of low level of unexpectedness.

We initially thought that the lack of awareness of bereavement support groups led to the perceived lack of interest in cooperating and hence the important need to produce a bereavement resource directory. These findings implicated the need to address the misconceptions and some lack of understanding of the functioning of bereavement support groups which a resource directory couldn't replace.

Because of time constraints, only a small number of GPs could be interviewed. Further investigations should include more GPs to determine how widespread the misconceptions are. We believed subtle involvement of bereavement support groups and willing GPs to clear up these misconceptions would be highly beneficial to increase future cooperation.

During our study we came in contact with another study, the Peninsula Bereavement Support Project, a community health study of the Peninsula Hospice Service, a project which promotes understanding of the grief process and grief support services. The project is funded by The Victorian Health Promotion Foundation. The existence of this project and the great enthusiasm and support we received from various health agencies, funeral directors and bereavement support groups concerning our project highlights the significance of grief as a health issue and the real need for future health promotion initiatives in this area in the future.

Acknowledgments

1. We would like to express our sincere thanks to the following people, without whose support and co-operation much of this project would not have been possible.
2. The General Practitioners who sacrificed their time to share with us something of their experiences concerning bereavement.
3. The many organisations, devoted to the welfare of the bereaved, whom we contacted throughout the course of our project.
4. Dr. Bridget Hsu-Hage, unit convenor, for her support and guidance.
5. Our project supervisor, Prof. Michael Ashby, to whom we are indebted for the advice, encouragement, direction, time and patience he offered us.
6. Dr. Peter Schattner for his willing involvement in our project and invaluable assistance.
7. Karen Spehr for her encouragement and advice.

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