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thesis entitled

Socioeconomic Status and Health:
An Association of Two Ambiguous
Variables

presented by

Lesley Swayze Dufner

has been accepted towards fulfillment
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SOCIOECONOMIC STATUS AND HEALTH: AN ASSOCIATION OF TWO
AMBIGUOUS VARIABLES

By

Lesley Swayze Dufner

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Department of Epidemiology
2001

ABSTRACT

SOCIOECONOMIC STATUS AND HEALTH: AN ASSOCIATION OF TWO
AMBIGUOUS VARIABLES

By

Lesley Swayze Dufner

It has been shown, through decades of research, that those of lower
socioeconomic status (SES) also experience lower levels of health. However, it
has not been revealed why this association persists, what the best way to
measure SES is, or what is meant by “health”. Through a review of the literature,
it was revealed that the most common measures of SES were education,
occupation and income. Health has been measured in terms of behaviors, health
conditions, status and mortality. Potential mediators of the association have
been identified as psychosocial factors, access to healthcare, physician attitudes
and healthcare coverage. This association was further investigated using data
from a community health survey. Education, occupation and income were
observed independently as indicators of SES in association with quality of life as
a measure of health. It was revealed that in addition to having a high BMI,
cholesterol and being diabetic, respondents of low education, occupation and
income also reported being dissatisfied with numerous aspects of their regular

source of healthcare.

Dedication

I dedicate this achievement to those who didn't give up on me, ever. More
specifically, I want to recognize all of my friends in the Cancer Control
Department at the American Cancer Society. They have supported me
emotionally and financially for six years. I am indebted to their belief in me even
when it wasn’t definite that I would ever be able to return to work. I also want to
thank the staff at PAR Rehab Services, especially Doctors Ginny Thielsen and
Bob Fabiano, who understood my brain and healed it. I cannot express how
grateful I am for their help in teaching me how to believe in myself, and
convincing me that I could finish this beast. My life has never be the same since
Kerry Cullen became part of it, she is truly the greatest friend I have ever had. I
thank her for always listening to me, agreeing with me and accepting me (even
though I'm the country version). You will finish this too, I know you will. I also
want to thank my parents for being so wonderful and always knowing what to do
and what to say. Most importantly, I want to thank my husband Greg who loves
me so much and didn’t leave when I couldn’t love him back. You are the best
thing about me, I am thankful every day that you are part of my life.

ACKNOWLEDGEMENTS

I want to give special thanks to my thesis advisors Dr Michael Collins, Dr Dorothy
Pathak and Dr G. Marie Swanson especially for being so encouraging and
helpful while still being constructively critical. I also want to thank Dr Bill Given

for his generous contribution to this thesis.

TABLE OF CONTENTS

LIST OF FIGURES

CHAPTER 1

CHAPTER 2
MEASURES OF HEALTH
OUTCOME...

Health BehaVIors '
Risk Factors for Disease...

Health Conditions...

Health Status/Expectancy . H ..

Mortality”
CHAPTER 3

MEASURES OF SOCIOECONOMIC STATUS
EducatIon
Occupation

Income...
SES Index .
Agreement between IndIcators

CHAPTER 4

MEDIATORS OF THE ASSOCIATION
Psychosocial Factors
Access to Healthcare
Physician AttItudes

Health LIteracy
...18

Combination of Etiologies......... 21

Healthcare Coverage........................................... ..

CHAPTER 5
NORTHERN LOWER MICHIGAN HEALTH SURVEY METHODS AND

CHAPTER 6

SURVEY RESULTS

CHAPTER 7

vii

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Northern Michigan Investigation ..................................................... 33

Socioeconomic Status .................................................................. 36
Measures of Health ..................................................................... 37
CHAPTER 8
FUTURE DIRECTIONS ......................................................................... 38
APPENDIX
NCC LOCAL HEALTH DEPARTMENT COMMUNITY SURVEY ..................... 43
BIBLIOGRAPHY .................................................................................. 80

vi

LIST OF TABLES

Table 1. Distribution of Demographic Characteristics within the Northern

Michigan Survey Population .................................................................. 24
Table 2. Components of Health-related Quality of Life Variable ..................... 26
Table 3. Variables Included in SES/QOL Analysis ...................................... 28

Table 4. Multivariate Linear Regression Coefficients for Variables Explaining
IogQOL .............................................................................................. 31

vii

LIST OF FIGURES

Figure 1. Conceptual decomposition of factors explaining health inequalities...21

viii

CHAPTER 1
INTRODUCTION

Socioeconomic status, by various measures, has long been inversely
associated with mortality and, to a lesser extent, other indicators of health. This
observation is not new to health research, nor has it gone unnoticed. Literally
centuries of observation and research have revealed that poorer people are less
healthy and die sooner than do their more affluent countrymen. Antonovsky
reported that in 1839 London the following observations were made:
“Gentlemen, professional men and their families, died, on average, at 45 years,
“tradesmen and their families” at age 26, and “mechanics, servants, labourers
and their families” at age 16.1 Similarly, current literature focuses primarily on
mortality as an outcome of socioeconomic status (SES). This thesis will suggest
a shift of focus away from mortality to earlier measures of health. Such a
redirection increases the possibility of revealing mechanisms that may be
modifiable during ones lifetime.

A review of the literature will uncover those factors that are associated
with SES that contribute to lower health status and Ultimately, higher rate of
mortality in low SES populations. One intention of this paper is to reveal that the
research to date has been more successful in documenting the existence of
health inequalities than explaining the persistence of them. Additionally, the
most appropriate measures of SES and outcome will be explored.

In exploration of a better understanding of the relationship between SES
and health-related quality of life, a survey of individuals in Northern Michigan will

be analyzed. This survey questioned 6,534 individuals in 21 counties in regards

to their demographic characteristics, health status, attitudes and behaviors.
Health-related quality of life will be used as an outcome to explore its association
with income, education and occupational status as indicators of socioeconomic
status

It is anticipated that the combination of a review of the literature, and an
analysis of a community health survey will provide a unique perspective on this

ongoing issue of socioeconomic status and health.

CHAPTER 2
MEASURES OF HEALTH OUTCOME

Socioeconomic status has been studied as a predictor of aspects of health
ranging from injury to, most commonly, mortality. Also, health outcome has been
assessed in terms of attitudes and behavior, such as screening and preventative
healthcare utilization. SES has been shown to affect all areas of health. While
mortality is the final measure of health, many attempts have been made to
measure outcomes that are potential predictors of early mortality.

Health Behaviors

An individual’s ability or willingness to participate in healthy behaviors is
not only a good marker of their concern for their general health, but also is a way
to measure their accessibility to such practices. It is anticipated that those who
are screened regularly will have better long-term health outcomes, based on their
access to healthcare and choice to use it.

Engaging in healthy activities such as participating in screening 22 and
exercising regularly 2 also has been shown to be inversely associated with SES.
Although physical activity and nutrition are very strongly related to health, their
relationship to socioeconomic status has been explored only recently.

A survey conducted in Pittsburgh, PA in 1986 investigated the physical
activity habits of high and low SES populations.2 Socioeconomic status was
determined by sampling an inner city and a suburban population. These
particular areas were chosen based on demographic characteristics identified in
the US Census data. These investigators divided physical activity into four

categories: leisure time, job-related, household and walking. They found that the

3

average time spent engaged in physical activity was highest for high SES women
(2,079 +I- 1,807 minutes/week), and lowest for low SES women (1,536 +/. 1,701
minutes/week). Men did not differ greatly by SES group in total amount of time
spent engaging in physical activity.

The significant finding from this investigation was the type of physical
activity engaged in by each group. Men were more likely to participate in leisure
and job related physical activity than women. Lower SES men spent more time
participating in walking and household activities than higher SES men. Women
of lower SES were significantly less likely to participate in physical activity of any
type than women in the other group. Women in both groups did, however, spend
a significantly greater amount of time engaging in nearly twice as much
household activity than men. Job related activity was higher for men of both high
and low 353.2

These are not unexpected results; it makes sense that more affluent
populations would have more time to spend on leisure activity. It is also not
surprising that women are more likely to spend time engaged in household
activity, 50.3% of the low SES women were either a homemaker or retired,
57.5% of high SES women were the same. A majority of men in both groups
were employed, so the amount of time spent on job related activity is not
unexpected.2
Risk Factors for Disease

A common way to study health in relation to SES is to observe risk factors
for a particular health outcome. In an attempt to determine the best measure of

SES to use to study cardiovascular risk factors, Winkleby observed these factors

4

using income, education and occupation as indicators of SES independently. For
this investigation, data were collected from the Stanford Five-City Project. Risk
factors included; cigarette smoking, systolic and diastolic blood pressure, and
total and high-density lipoprotein cholesterol levels.3 It has been documented
that lower SES populations have higher risk factor prevalence for many health
conditions. The intent is to gain insight into how best to identify and modify risk
factors in lower SES populations.
Health Conditions

A single or group of related conditions are often utilized in order to
examine the effects of SES on a particular health outcome. Because
cardiovascular disease has a number of SES influenced risk factors it is often
used as an outcome. Controlling for major cardiovascular risk factors such as
blood pressure, smoking and cholesterol levels does not completely remove the
effect of SES on risk of CHD.‘ Therefore, observing SES in relation to risk
factors only would not provide the entire picture of the relationship, which is why
health conditions themselves should be investigated as outcomes.
Health Status/Expectancy

An approach that identifies high-risk populations and focuses on a broad
range of health-related outcomes is “health expectancy". This concept is being
recognized, primarily in Europe, as a more effective way to monitor health than
reliance on mortality data.5

This method was investigated in New Zealand to determine whether
changes in health occurred during a time of social and economic disturbance.‘5

“Health expectancy” was estimated using standard population lifetables and

5

prevalence data on disability, handicap and other health problems. Disability and
health problem data were drawn from two national surveys, the Social Indicators
Survey (SIS) and the Household Health Survey (HHS). Indices were constructed
based on a number of questions from the surveys. The first index relied on two
questions regarding self-report of health problems and use of assistance with
normal daily activities. The next index was based on self-assessed general
health. The third was a measure of functional ability, participants were asked
regarding their capability to climb stairs. It was observed that all three indices of
“health expectancy” significantly declined across each decreasing level of SES.
The ultimate goal in tracking health expectancy is to shift the way of thinking from
mortality reduction to health improvement.:5
Mortality

The most common outcome used to measure SES differences in health is
mortality. Mortality is investigated either as all-cause mortality or death from a
specific cause, such as cancer or accidental death. The reason that death is
used as an outcome in the majority of the research is because it is very easy to
establish and collect. In the United States, each death that occurs is required to
be documented and reported to the National Death Index. The cause of death is
generally recorded, as are the underlying conditions related and unrelated to
death.

lnforrnation regarding mortality is readily available to researchers in the
United States. Lantz et al followed a population of men and women who had
participated in the Americans’ Changing Lives survey for seven and a half years.

These investigators examined the risk of death by SES, using the National Death

6

Index to track deaths among participants. These investigators found that when
cigarette smoking, alcohol consumption, sedentary lifestyle and relative body
weight were considered, low levels of income were significantly associated with
risk of dying.6 The National Longitudinal Mortality Study followed Americans
selected from the Current Population Surveys until their death or a maximum of
11 years. Higher mortality was observed in this study among unemployed
persons and persons of low income. Mortality in this study was also determined

from the National Death Index.7

CHAPTER 3
MEASURES OF SOCIOECONOMIC STATUS

In addition to the difficulty of defining the proper health outcome to relate
to SES, another complication that the literature reveals is that no standard exists
for measuring socioeconomic status. In an attempt to completely understand the
relationship socioeconomic status has with health, it is important to investigate
the individual components of SES. A more comprehensive review of the
elements that contribUte to SES may reveal unexplored associations.
Education

Education is often selected as an indicator for SES because of its close
relationship to occupation and income. Investigators assume that highly
educated populations are more likely to hold safer, better paying jobs than less
educated groups. It is also assumed, consistent with previous observations, that
this population is better informed about and has better access to healthcare. This
very often is the case, but there are numerous populations studied in which this
does not occur. This suggests that perhaps these are important modifiers of the
association.

In an analysis of the 1986 to 1990 National Health Interview Surveys data,
SES was defined by three categories of education for Americans in the last years
of life.8 The rationale the authors presented for using educational attainment as
the sole variable for SES was that a reduced income could result from poor
health. This idea, however, leads to an interesting opposing theory that is

presented by a number of authors known as drift hypothesis. Drift hypothesis

suggests that an SES-health association is a result of ill health on SES, not the
influence of SES on health.9
Occupation

Another measure of socioeconomic status frequently used is occupation.
Occupation is a very good indicator of income and social status in countries other
than the United States. European countries define occupation very narrowly, and
income and status are based primarily on occupational grade. This is not
necessarily the case in the United States.

Although occupation is a commonly used indicator of SES, this also has
the potential to be a problematic measure. Often, elderly people are retired, an
occupational category that is not reflective of a Iifetime’s worth of exposure.
Another potential dilemma is the tendency to change jobs numerous times
throughout a working career. Since this is an indicator employed to estimate
income and occupational exposure, how are individuals who do not work outside
the home, such as homemakers, but whose spouses do, categorized? In terms
of occupation and health, it is common for an individual to be unemployed for
reasons related to poor health.

In order to circumvent these potential problems with occupation as a
measure of SES, a number of techniques have been employed by investigators.
The United States Census employs a scaling system for occupation, which is
hierarchical in nature.10 Most countries have a similar categorization scheme for
occupation. Additionally, questions are asked similar to “ what were you doing

most of last week?”, and “what are your normal job responsibilities?” to gather as

much information about one’s occupation or daily activities.8 Some investigators
classify subjects as employed or unemployed.

Arguments have been presented against using occupation as the sole
source of socioeconomic status. Duncan developed an occupational index for
socioeconomic status". His explanation for doing so is in recognition of the fact
that occupation is only a fraction of SES. Duncan’s index was intended to
provide a standard way to report occupation in research in combination with
measures of income and education.

Other researchers who have observed moderate correlations between
education, income and occupation have substantiated Duncan’s approach.
Winkleby et al, in an investigation of cardiovascular risk factors and SES,
ascertained income/occupation correlation coefficients of +.41 and +.30 for men
and women respectively. The education/occupation correlations were slightly
higher +.67 and +.66 for men and women.3 These results suggest that
occupation, income and education are measuring different aspects of
socioeconomic status.

Income

Income is essentially a measure of one’s access to resources. It can
determine where a person lives, what they eat and to what level of medical care
they have access. Interestingly enough, income is not used as a sole indicator of
SES very often. Most commonly, income is used in combination with education
to determine SES.

Most commonly when income is used as an indicator of SES, respondents

are grouped into categories of either above or below a certain percentage of the

10

poverty level. A recent comparison of physician use and SES between Ontario
and the United States utilized three categories of family income based on 200%
of the US poverty level.12 The lowest group fell below the 200% of poverty level
(based on US dollars), the next group was between 200% and 400% of the
poverty level and the highest group was above the 400% of poverty mark.

SES Index

Despite the extensive use of such a composite variable, the arguments for
investigating the components independently are at least as convincing as those
supporting a combination of SES indicators. Proponents of combining education,
income and occupation into one indicator suggest that education prepares one
for an occupation, which leads to an appropriate income.12 This view accounts for
the inter-relatedness of these three variables. The other perspective insists that
a single index of SES is not appropriate for research purposes, or that it simply
does not exist.“

Although these characteristics of SES seem to be highly correlated, the
argument is that the relationship is superficial. In support of this, analysis of the
1950 census found that the variation between educational levels accounted for
only one third of the variation in occupational SES (correlation coefficient = .567,
variance = .5672 = .32). Furthermore, occupational status accounted for less
than one fifth of the variation in income (correlation coefficient = .419, variance =
.4192 = .18). Despite the fact that these data were collected 50 years ago,
Duncan suggests that SES indicators should be evaluated individually and

selected based on the focus of the study being conducted.12 There is sufficient

11

evidence to support the theory that other measures of socioeconomic status.
specifically income and education, are substantially independent of one another.
A detailed matched analysis of the 1960 census and death records,
revealed not only differential outcomes by SES measure overall, but also by race
and gender specific measures.“ Mortality ratios were obtained by years of
school completed and family income for white males and white females aged 25-
64 years. White females experienced age-standardized mortality ratios ranging
from 1.27 in the lowest educational category (0-7 years of school completed) to
0.84 for the highest level of education attained (college, 1 year or more). Similar
ratios for categories of family income ranged from 1.21 (under $2,000 a year) to
.86 ($10,000 or more a year). Education differentials were at least as high, if not
slightly higher, than income differentials. These differentials were slightly larger
when the rates were standardized for age and income or education, 1.21-0.89 for
education and 1.11-0.93 for income. White male mortality ratios ranged from 1.13
to 0.81 from lowest to highest in the age standardized education category and
1.05 to 0.87 in the age and income standardized category. Income related age
standardized mortality ratios spanned from 1.49 to 0.84, age-, education-
standardized ratios ranged from 1.40 to 0.90. These observations strongly
suggest that income and education should be viewed as independent of each
other. Unfortunately, these findings do not elucidate which measure of SES is
more important. It is clear that both indicators are significant and actually may

operate differently depending on the population under study.

12

Agreement between Indicators

It is interesting that the association between the various socioeconomic
variables and some measure of health or mortality do not always agree with each
other. A study of SES and functional status in elderly adults found that
occupation did not contribute significantly to this relationship. Educational
attainment was found to have a protective effect on functional status. Income
also showed a strong association with functional status; this association was
observed across all income and functional categories.15

In the Stanford Five-City Project, investigators examined the risk factors
for cardiovascular disease in relation to education, income and occupation
independently.‘ It was determined from this analysis that education was the
strongest, most conSistent predictor of risk factors (cigarette smoking, systolic
and diastolic blood pressure, total and HDL cholesterol) compared with income
or occupation. Higher prevalence of risk factors was exhibited within the lowest
level of educational attainment as compared with higher levels of education. This
same graded association was not observed within categories of income or
education. A univariate regression model approach revealed that correlations
were strong and significant across all risk factors for education. Correlations
were much lower and non-significant for income and occupation. Income and
occupation correlations also operated in the opposite direction of education for
total cholesterol. This examination concluded that education is the best predictor

of cardiovascular risk factors.‘

13

CHAPTER 4
MEDIATORS OF THE ASSOCIATION

While there is no question as to whether a relationship exists between
socioeconomic indicators and health, the specific SES-related causes of these
inequalities is yet to be fully explored. It will be shown that merely having a low
income is not a sufficient explanation for why a particular group is less healthy or
happy. Nor, as will be demonstrated, is not having healthcare coverage, or living
in a poorer section of town. Educational and occupational relationships to health
can be perhaps more adequately, yet not fully, understood.
Psychosocial Factors

Literally centuries of research have been done on the psychosocial
aspects of health and socioeconomic status. Although perhaps not scientific by
today’s research standards, valid theories have emerged from “primitive”
epidemiological research. In certain cases, these theories are still being
explored. In the late 1800’s, French sociologist Emile Durkheim studied suicide
from a population perspective.16 He investigated the characteristics of European
suicide populations. An interesting observation Durkheim made was that rates of
suicide increased in times of societal economic disturbance. Whether the
change resulted in more or less prosperity did not make a difference, rates of
suicide increased either way. Although Durkheim did not specify which income
groups were affected by suicide rates, it was clear that a change in the economic
climate resulted in a larger discrepancy between the richest and the poorest.
This indicates that economic uncertainty, or inequality, leads to a quality of life

that, for some, is no longer bearable.17

14

More recently, epidemiological studies have been conducted relating to
psychological stress and socioeconomic status. Psychological distress, including
depression and anxiety, was examined in association with income, education and
occupation.17 Data from eight national surveys were evaluated. These
investigators found that education, occupation and income significantly predict
distress in the negative direction. That is, the lower one’s income, educational
level or occupational status, the more “distressed” they are likely to be.
Accessto Healthcare

Preventive care includes an ongoing relationship with a physician, regular
medical checkups, diagnostic screening for breast, cervical, prostate cancer,
heart disease and awareness of new medical information. Reduced access to
these services can. potentially affect ones health. Additionally, one would
assume that in countries where guaranteed access to healthcare exists,
socioeconomic differences in healthcare utilization behaviors would be less
prominent. As will be shown, however, observations to date do not reflect this.
Physician Attitudes

Another interesting observation that has been made by some investigators
is that physicians handle patients of lower education, insurance and income
differently than those with more resources. A study of pregnant Hmong women
in Minnesota revealed that physicians did not provide women with information
that was not specifically requested by the patient. The majority of these women
had expected their physician to explain procedures.18

Physician beliefs have been closely observed to determine if patients are

treated differently based on their SES. It has been shown that physicians are

15

more likely to counsel patients about lifestyle changes if they feel they are willing
and able to do it.19 These findings suggest that if a patient does not seem to
understand the need to change their lifestyle, a doctor may not suggest that they
do.

Health Literacy

Many aspects of health are dependent on an individual's ability to
understand and adhere to healthy behaviors, take precautions and follow medical
advice or regimes. In situations where these abilities are necessary to ensure
good health, health literacy is of the utmost importance. In general, it is in one's
best interest to be aware of their health and how to maintain it. This is especially
true of populations at high risk for poorer health outcomes.

A study of HIV/AIDS infected persons was conducted in order to
determine whether their disease progression was associated with their health
literacy.20 Recently, a tool was developed to measure functional health literacy.
Functional health literacy measures illness-related knowledge, comprehension
and treatment perceptions for certain chronic illnesses. It has been
demonstrated within chronically ill populations that low health literacy is closely
associated with poor health, higher rates of hospitalization, negative treatment
outcomes, poor knowledge and understanding of their illness.20 This tool was
used to measure the health literacy of a population of 294 HIV infected patients.
It was observed that health literacy was significantly related to participant
education OR = 4.9 95% CI = 2.5 to 9.5. The health literacy test had to be read
toiparticipants who were unable to read. The lower literacy group completed a

mean of 11.6 years of education, while the higher literacy group had completed a

16

mean of 13.3 years. To test the independent effects of education and health
literacy, the authors formed four groups combining high (above 80%) and low
(below 80%) health literacy scorers with high (greater than 12 years) and low
(below 12 years) levels of education completed. Using non-parametric tests for
linear association, it was observed that the low health literacy/low education
group demonstrated the least amount of knowledge and understanding of their
disease and more treatment misconceptions as compared to the other three
groups.21

Low levels of health literacy had potentially dangerous effects on the
health of this population. Specifically, there was a marked difference in the
undetectable viral load between the high and low literacy groups. The low
literacy group was less likely to have an undetectable viral load, suggesting non-
adherence to their prescribed treatments. Additionally, those with low health
literacy held more misconceptions about HIV transmissibility during treatment for
HIV.21 The relationships found in this population suggests that less informed, less
educated populations are at a potentially greater risk of experiencing poor health
outcomes. In this study specifically, others are put in danger of infection because
of the transmission misconceptions of the infected.

Another hurdle that must be cleared by very uneducated patients, and was
an issue in this investigation, is the reliance on a medical provider to read and
interpret health-related material to them. There is the potential that a provider
will not take the time needed to do this, or that they are not aware that literacy is

a problem for this patient.21

17

Healthcare Coverage

A study conducted in Canada, a guaranteed healthcare country,
compared breast and cervical cancer screening rates in Ontario with those in the
United States, where coverage is not guaranteed.21 No difference in screening
rates was observed between the two countries for Papanicolaou tests and clinical
breast exams. When all women were included in the analysis, mammography
rates were higher in the United States than in Canada. However, the strength of
the association between income and mammography screening rates was greater
in the United States, Odds Ratio 2.7 (95%Cl 2.3-3.2) than in Ontario, Odds Ratio
1.8 (95%CI 1.3-2.6). When uninsured women in the United States (13.1%) were
examined separately, 3 linear decrease in screening rates with a decrease in
income was noted.’ Even in Ontario, utilization of preventive healthcare
increases with increased income. This suggests a strong link between income
and health.22

This study also investigated the link between educational level attained
and rates of screening utilization. Compared with women with less than a high
school diploma, college graduates were more likely to have a mammogram,
Odds Ratio 1.5 (95%CI 1.2-1.7). In this instance, the inverse relationship
between SES and screening holds true if either education or income is used as
the indicator variable.22

In Canada, the effectiveness of universal healthcare to lower SES
populations has been studied extensively. An investigation of invasive cardiac
procedures and mortality one year after myocardial infarction in Ontario, Canada

assessed the relationship of these events and their relationship to $58. The

18

cohort of interest consisted of all 51,591 patients that were admitted to a hospital
with a diagnosis of myocardial infarction in a three-year period. Median income
of neighborhood of residence was used as the indicator of SES. Though in
Ontario everyone has healthcare coverage, there was nevertheless a 5 percent
increase in one-year mortality and at least a 7 percent decrease in facilities
available at the hospital of treatment in the lowest income quintile compared to
the highest. This trend continued throughout the five income categories.
Ultimately, a highly significant association between income and mortality was
found. Each $10,000 increase in median neighborhood income resulted in a 10
percent reduction in risk of mortality within one year.”

A comparison of two universal healthcare countries reveals that health
inequalities persist in decreasing levels of social class, but vary greatly by
country. In. 1989, Vagero and Lundberg undertook an analysis of health
differences between social classes in the United Kingdom (specifically England
and Wales) and Sweden. For both countries, social class was categorized into
four groups according to the British Registrar General’s guidelines. The
investigators focused on mortality and long-term illness by social class.”

Death data were collected from the Office of Population Censuses and
Surveys in England and Wales, and the Deaths Registry in Sweden. Relative
risk of death increased with decreasing social class in both countries. In
England, RR of death in men aged 20-64 as compared to the total study
population, ranged from 0.79 in the highest social class to 1.17 in the lowest
classification. The ratio of the lowest two categories to the highest two categories

was 1.48. In Sweden, a similar, yet less strong association was observed. The

19

RR of death in Sweden ranged from 0.87 to 1.11. A ratio of 1.27 was observed
between the lowest and the highest-class categories. Although levels of
significance are not given, the ratio of lowest to highest class is 20% higher in
England, suggesting a greater social class gradient for health.”

The trends were similar, but the difference not significant, for the
prevalence of long-term illness by social class. Relative prevalence by social
class increased from 0.52 to 1.38 by class in England. In Sweden, a less
dramatic prevalence increase from 0.79 to 1.20 was observed.”

These findings suggest that healthcare coverage does not eradicate the
differences between socioeconomic groups. It does appear that in Sweden,
where strong attempts have been made to reduce class inequalities, the health
gradient is less steep between classes. This fosters the idea that the health/SE8
discrepancy is something more deeply rooted than access to care, and not yet
completely understood.

The well known Whitehall studies of British Civil Service employees is an
example of how occupation and insurance coverage can reveal conflicting
information. In England, Civil Servants fall into very distinct classifications:
administrators, professional, executive, clerical and unskilled laborers. A ten-
year follow up of 17,350 civil servants produced varied relative risks of mortality
by employment grade despite universal insurance coverage among this group.
Compared to the top administrators, the relative risk of mortality over this ten-
year period was 1.6 for the professional-executive grade, 2.2 for the clerical
grades and 2.7 in the lowest grades of unskilled workers. These findings point

toward an occupational or perhaps even an income based link to mortality and/or

20

health. In the case of British Civil Servants, insurance cannot be implicated as
the source of inequality.‘
Combination of Etiologies

This review has revealed that there is more than one factor that
contributes to the health/SE8 relationship. Many investigators have attempted to
classify the socioeconomic discrepancies that directly affect health. Feinstein
summarizes a structure that divides inequality explanations into four distinct
categories. Figure 1 illustrates this concept. The four categories included are:
materialist lifestyle effects, materialist health care effects, behavioral lifestyle
effects and behavioral health care effects.25

Materialist explanations of life span (lifestyle) related health outcomes are
defined as both personal financial resources required to acquire non-medical
goods and services that are used to produce good health, and public resources
that contribute to sanitary and safe living conditions. Examples include
automobiles and housing at the personal level, and public housing and
transportation, environmental and occupational conditions on the public level.
Behavioral explanations of life span health outcomes include those factors that
contribute to a healthy state, but that do not necessarily require financial
resources or cannot be purchased. Diet and exercise habits, smoking, alcohol

consumption and driving habits are all behavioral characteristics.”

21

SOURCE OF INEQUALITY
Access to and utilization

 

 

TYPE OF EXPLANATION

 

 

 

Life Span of health care system
3 o 13‘
g 3; 8 Housing, overcrowding, Ability to purchase health care,
.3 8 '5 sanitation, transit mode, ability to purchase
3 3 3 occupational hazards, pharmaceuticals, regular
g 3 9 environmental hazards physician
_ .Lé.’ Diet, smoking, exercise regime, Comprehensive medical
g 3 _ ,_.. leisure activities, risk taking, information, “playing the
“5 5 .g 2 alcohol and substance abuse system,” following instructions,
2 a. g g self diagnosis, awareness of
3 3 g, 3 recurrence

 

Figure 1. Conceptual decomposition of factors explaining health
Inequalities”

Access to and utilization of health care resources can also be evaluated at
the materialist and behavioral levels. The materialist perspective includes public
accessible forms of health care, sUch as; health insurance plans, health
management systems and government funded or universal health care. Since
this differs dramatically from place to place, health care coverage, whether
private or publicly funded, has been explored in this review. Behavioral
pathways to health care utilization are more variable and modifiable. Feinstein
classified behavioral utilization of care into four detailed stages; preventive care,
diagnosis and entry into the health care system, treatment efficacy, follow up and
readmission. As this paper will demonstrate, often low socioeconomic

populations lag behind at one of these steps.25

22

CHAPTER 5

NORTHERN LOWER MICHIGAN HEALTH SURVEY METHODS AND
POPULATION

To more fully understand what other researchers have faced in exploring
the socioeconomic issue, this chapter will provide a closer examination of
specific data. The intent of this analysis is twofold. First, it is the intent of this
investigator to observe the association between SES and health-related quality of
life that is represented in the literature. The variables that have been shown, at
least partially, to explain this relationship will be investigated. Although these
data are cross sectional and not comprehensive enough for thorough study, it is
hoped that what is uncovered may promote new ideas in socioeconomic
research. The second purpose of this investigation is to examine this
association utilizing three different measures of SES. Since SES. is not
represented uniformly across the literature, this investigation will look at the
different ways of approaching this important variable, and evaluate which might
be the best measure to use in future research.

The data used for the examination of SES and health-related quality of
life were collected by an independent research firm via telephone interview in
1995. The survey that was admistered is located in the Appendix. Six thousand,
five hundred and thirty four residents of twenty-one counties in Northern Lower
Michigan were surveyed. The health departments and hospitals in this area
commissioned and financed the survey. Respondents were required to be over
the age of 18 and were asked a number of demographic and health-related
questions. The distributions of participation by county, gender, age and race are

shown in Table 1.
23

Table 1. Distribution of Demographic Characteristics within the Northern
Mich Su lation

is

 

rand raverse
Leelanau

Indian,

24

For this investigation, three measures of socioeconomic status will be
compared; level of education attained, poverty status and occupational status.
Respondents were asked to provide the highest grade or year of schooling they
had completed. Answers ranged from 0 - never attended school, or kindergarten
only to 19 - doctorate. In order to conform to the majority of the literature,
respondents were divided into two categories of education (1) high school
diploma or less and (0) greater than a high school diploma.

The second measure of SES was poverty status. A 1995 Federal
threshold of poverty for the United States was used as a standard. The threshold
for one person in a household was $7470 each additional person added $2560 to
that threshold.26 To determine SES status the following formula was used. Each
response was assigned a value of 7470. The number of people in the household
over the age of 18 (including the respondent) was gathered. One was subtracted
from this number and each person over 18 was assigned a value of 2560. Three
questions were used to determine the number of children in the household under
the age of seventeen. The total number of children in the household was
multiplied by 2560 and added to the adult total. This represented the threshold
that each household’s income would need to be below to be considered “low
income” for this analysis.

The final measure of SES that was utilized was employment status.
Because this survey did not require specification of the type of job that was held,
the dividing feature became employment status, employed or unemployed.
Employed for wages, self employed, homemaker, student and retired were

considered employed (0). Out of work for more than one year and out of work for

25

less than a year were considered unemployed (1). Those who answered that
they were unable to work were deleted from the analysis. It was believed that
the inability to work would introduce a bias into this investigation considering that
those who are unable to work are presumably unable to do so for reasons related
to their physical or emotional health.

Answers to ten questions in the survey were combined to form the
response variable of interest which was a health-related quality of life measure.
Since this variable accounts for physical and emotional characteristics, it was
also considered to be a measure of health status. These ten questions were
chosen and scored based on the SF (short form)-36 test.27 This test was
developed from the Medical Outcomes Study and has been used extensively
since its development as a tool to measure health-related quality of life and
health status in ill and healthy populations. Each answer to a question in the SF-
36 was assigned a number score. The ten questions were combined into six
categories, shown in Table 2, to form composite scores. These composite
scores were transformed into percentages using the following formula; ((Actual
raw score-Lowest possible raw score)/Possible raw score range) X 100. For each
respondent, his or her six transformed composite scores were added together.
In order to create an outcome variable that was continuous and normal, the score
was subtracted from 100 and the log was taken of this new transformed score.

The variables included and scoring system applied are presented in Table 2.

26

Table 2. Components of Health-related Quality of Life Variable

 

BUESTION (category)

SCORE

CATEGORY

 

Does your health now
limit you in this activity

 

Lifting or carrying
groceries

1.0-yes, limited a lot
2.0-yes, limited a little
3.0-No, not limited at all

 

Climbing several
flights of stairs

1.0-yes, limited a lot
2.0-yes, limited a little
3.0-No, not limited at all

 

Walking several
blocks

1.0-yes, limited a lot
2.0—yes, limited a little
3.0-No, not limited at all

Physical Functioning

 

How much bodily pain

6.0-None

 

 

normal social activities
with family, neighbors

1 .O-Extremely

have you had in the 5.4-Very mild

past four weeks? 4.2-Mild Bodily Pain
3.1-Moderate
2.2-Severe
1.0-Very Severe

Would you say that 5.0-Excellent

your general health is.. 4.4-Very good
3.4-Good General Health
2.0-Fair

_ 1.0-Poor

During the past

four weeks, to what

extent has your 5.0-Not at all

physical health or 4.0-Slightly Social Functioning

emotional problems 3.0-Moderately

interfered with your 2.0-Quite a bit

 

 

 

 

or ioups?
How much of the time
during the past four
_vy_eeks have you..
Felt calm and 6-All of the time
peaceful? 5-Most of the time
4-Good bit of the time

3-Some of the time
2-Little of the time
1-None of the time

 

Mental Health

 

27

 

 

rFelt downhearted and 1-All of the time
blue? 2-Most of the time
3-Good bit of the time
4-Some of the time
5-Little of the time
6-None of the time
Been a happy person? 6-All of the time
5-Most of the time
4—Good bit of the time
3-Some of the time
2-Little of the time
__ 1-None of the time

Felt full of pep? 6-All of the time

' 5-Most of the time

4-Good bit of the time
3-Some of the time Vitality
2-Little of the time
1-None of the time

 

 

 

 

 

 

 

Additionally, a number of variables, which were described in the previous
section, will be examined. In order to determine whether or not other factors are
associated with socioeconomic status in this population, previously unexplored
variables also will be examined.

A multiple linear regression analysis was employed to evaluate the
association between each measure of SES and health-related quality of life.
Socioeconomic related explanatory variables under investigation were classified
into five distinct categories; demographic characteristics, health behaviors,
health-related attitudes and beliefs and access to/satisfaction with current
healthcare. Each category includes variables that have been investigated in
previous research, or have been implicated as possible effect variables. The

specific variables included in these categories are listed in Table 3.

28

Table 3. Variables Included in SESIQOL Analysis

 

 

Demographics Health Beliefs Access to Healthcare
and Attitudes
- Gender What grade do you - Insurance coverage
- Age think children . When was your last checkup?
. Race should be taught - Did you seek medical care in the
- Marital Status about

 

Health Behaviors

 

. Smoking
I Alcohol
. Exercise

Health
Conditions

 

 

- Body Mass
Index greater
than 25

- High
Pressure

- High
Cholesterol

- Diabetes

Blood

 

- AIDS

I Family
Violence

- Drugs
Alcohol

I Pregnancy and
STDs

- Cigarettes and
Smokeless
Tobacco

I Would you
encourage a
sexually active
teen to use a
condom?

. Do you have a
fire escape
plan for your
household?

. Have you had
your house
checked for
radon?

- Do you wear a
seatbelt?

and

 

past year?

Do you have a usual source of
medical care?

How far is it to your usual source
of care?

Are you satisfied with your usual
source of care?

Why aren’t you satisfied?

Why don’t you have a usual
source of care?

Where would you go
needed care?

Is the location of your doctor’s
office convenient?

Are the hours convenient?

Access to specialists?

Access to hospitals?

Can you make appointments by
phone?

Do you have to wait a long time in
the office?

Do you have to wait too long
between when you make an appt
and the appt?

Do you have access to care when
you need it?

Can eruget prescriptions filled?

if you

 

29

 

CHAPTER 6
RESULTS OF ANALYSIS

A multiple regression analysis was utilized in order to investigate health-
related quality of life as a graded outcome. This was viewed as the most
accurate way to represent QOL since it is possible to be at any level of quality of
life. Four models were created each looking at a different measure of
socioeconomic status. Income, educational attainment and occupational status
were used individually and combined into a single model.

In preliminary univariate analyses, the regression analysis revealed that
low income, unemployment and less than a high school education were each,
independently and significantly associated with a reduced health-related quality
of life. Low income, unemployment and less than a high school education were
associated with 0.36, 0.36 and 0.21 increment increases in IogQOL respectively.
When each of the SES variables were controlled for each other in a single model,
the associations with QOL were smaller, but still significant; low income (0.31),
unemployment (0.30) and less than a high school education (0.19).

Two demographic variables age and gender, were found to be inversely
associated with health-related quality of life. Each year increase in age was
significantly associated (p < .01) with a decrease in quality of life in each of the
four models. Additionally, being female was associated with a decrease in
quality of life in each model. A number of health-related conditions were also
found to be inversely associated with the outcome variable. Diabetes, high
cholesterol and a body mass index greater than 25 were related to QOL in every

model.

30

Each indicator of SES was investigated independently in association with
health-related quality of life. The potential explanatory variables were added to
the model one at a time. If the variable was significantly associated with QOL (p
< .01) it was left in the model. The results are shown in Table 4.

When all three socioeconomic variables were included in the model; age,
gender, being diabetic, having high cholesterol and having a body mass index of
25 or greater were all significantly associated with a reduced health-related
quality of life. In addition, not being satisfied with the hours the doctor's office is
open and access to a specialist if needed were also significantly associated with
QOL.

Dissatisfaction with making arrangements for medical care by phone was
significantly associated with IogQOL (0.08) in the unemployed group only.
Additionally, dissatisfaction with the ability to. get medical information or advice by
phone was associated with low income and low educational attainment (0.13,
0.15). Dissatisfaction with length of time you wait between making an
appointment for routine care and the day of your visit was significantly associated
with quQOL in both Model 2 (0.11) and Model 3 (0.11). Both of these Models
revealed a significant association with not having had a routine check up in the

past year (0.13, 0.12).

31

Table 4. Multivariate Linear Regression Coefficients for Variables

Explaining IogQOL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variables Model 1 Model 2 Model 3 Model 4

Low Income 0.32 - - 0.29

Less than high school

education - 0.19 - 0.15

Unemployed - - 0.36 0.32

Age 0.004 0.005 0.0042 0.004

Gender 0.093 0.098 0.10 0.11
_Hi_gh Cholesterol 0.12 0.13 0.12 0.14

Diabetic 0.36 0.38 0.39 0.36

BMI >25 0.12 0.15 0.13 0.12

Did you seek medical care

in the past year? 0.19 0.32 0.28 NS

How satisfied are you

with the....

...arrangements for

making

appointments for medical

care by phone? NS NS 0.079 NS

...availability of medical

information or advice by

phone? 0.13 0.15 NS NS

...length of time you wait

between making an

appointment for routine

care and the day of your

visit? NS 0.11 0.11 NS

...your access to medical

care whenever you need

it? 0.15 0.17 0.21 NS

...hours when the doctor’s

office is open? NS NS NS 0.14

...access to the care of a

specialist when you need

it? NS NS NS 0.21

Has it been more than a

year since your last

routine check up? NS 0.13 0.12 NS

 

Model 1 includes low income as the only measure of socioeconomic status

Model 2 includes less than a high school education as the only measure of

socioeconomic status

Model 3 includes unemployment as the only measure of socioeconomic status

Model 4 includes low income, less than a high school education and

unemployment

 

CHAPTER 7
DISCUSSION

A comprehensive review of current literature on the topic of
socioeconomic status and health has revealed that this remains a complicated
relationship. The Northern Michigan data were an attempt to combine many of
the elements of current literature into the analysis of data from a single case
study. In most of the research a specific measure of health, such as a
cardiovascular event, or mortality are used as the outcome. The current case
study used a health outcome that was very broad and inclusive. It was intended
that this measure of health-related quality of life would be a better predictor of
health in general. The rationale for using this outcome was similar to that used
by Davis, Graham and Pearce in their investigation of health expectancy in New
Zealand 6, select a measure of health that can be modified. This raises the
concern raised by the drift hypothesis that a poor health event could lead to a
reduction in SES.
Northern Michigan Investigation

The Northern Michigan data revealed interesting results, some of which
have been corroborated in the literature, others of which have not. From these
data there are three categories that appear to impact health-related quality of life.
The first of these is demographics, the second of which is access to medical
care, and finally health conditions.

In terms of demographics, it was not unusual to observe that increased
age was associated with a reduced health-related quality of life. A number of

factors, including reduced activity, contribute to the aging process, which is

33

associated with a reduction in health. A more interesting, unexpected
observation is a reduction in health-related quality of life in the female population.
Given the fact that females contributed more than half of the survey population
and half of the population in general, this is a noteworthy effect. Thinking in
terms of the other factors that were found to be associated with health-related
quality of life, this begins to make more sense. Although not true in every case,
women, are more likely to arrange for their own or family’s medical care.
Therefore, their experience In regards to access to care may be greater and may
have a wider range of negative experiences from which to draw. A gender
specific investigation was not conducted in this analysis, but future research
could further explore this issue.

Another category that was not surprisingly related to a reduction in quality
of life was existent health conditions, specifically; high cholesterol, diabetes and
a body mass index greater than 25. It is interesting to note that low physical
activity was not found to be inversely related to health-related quality of life,
suggesting that perhaps diet and genetics plays a much larger role in quality of
life.

Additionally, a number of aspects of access to care were found to be
significantly related to a reduced quality of life. Specifically, relationships with
the physician and their office procedures seemed to be of concern. This is
reflective of some of the current literature. People of lower socioeconomic status
may be a lower priority to physicians, who may make their patients wait for
appointments before and when they get to their office. Interestingly enough,

insurance coverage was not found to be associated with a reduced quality of life,

34

so inaccessibility does not appear to be an issue of inability to pay.
Unfortunately, it appears as though physicians do not make themselves
accessible, either in person or by phone, to people who are in need of their
services.

The investigation by Green revealed that physician attitudes and activities
were influenced by their perception of the patient’s status or understanding.” If
this is indeed the case, it can be reasonably assumed that physician attitudes
and behaviors towards people with lower income, educational attainment and
employment status is in part responsible for the reduction in health that has been
consistently observed among this population. Not only does not having access
to medical care cause health to be poor directly, lower SES populations are
made to feel worse because they are not valued by physician's, which
contributes directly to their quality of life, and more indirectly to their health in
general. If further research determines that this is a major contributory factor in
the reduction in health-related quality of life, unfortunately there is little that can
be done by the low SES populations themselves. Emphasis must be put on
educating physicians about the influence their attitudes and behavior can have
on the health of so many peOple.

The socioeconomic indicator that led to the greatest changes in quality of
life was unemployment. Along the same lines as the access to care question,
this population may be unhappy due to their inability to find a job, or having lost
their job. This may contribute to their reduction in quality of life and perhaps
inability to utilize medical resources. Since these are cross sectional data, this

may reflect a temporary reduction in their quality of life only.

35

There are limitations to the conclusions that can be drawn from these data
based on the fact that they are cross sectional. Time order is the greatest
concern, it is not known between QOL and SES, which precedes the other.
Since cross sectional data are the fastest and most convenient to obtain, it is the
most efficient way for public health officials to collect information on their
communities.

Socioeconomic Status

An important issue that should be addressed is the definition of
socioeconomic status. Social class, government classification, educational level
attained, income, asset ownership, occupation and neighborhoods of residence
are all used as indicators of socioeconomic status. Although it is advantageous
that there are many ways to gather socioeconomic information, unfortunately
these measures individually do not always reflect each other. This investigation
observed the effects of three aspects of SES independently. This was the
approach taken because the majority of the literature indicated that income,
occupation and education operated quite differently in association with SES.

Sometimes, education is a much stronger predictor of health than income,
though in many cases, income is directly related to education. These are issues
that should be addressed separately for each investigation, but they make
comparing research much more difficult. If the goal is to impact the health of
these low SES populations, it is important to know whom, exactly, to target.
Measures of Health

A As has been shown in the literature, specific measures of health, such as:

mortality, cancer or cardiovascular events are commonly utilized. This is the

36

most convenient way to measure health, and perhaps the most accurate, but
once an individual is seriously ill, or dead, there is no longer anything that can be
done to improve their health. This is highly significant from a public health
perspective, preventing poor health is more practical, economical and efficient
than treating poor health, especially in lower SES populations.

The health-related quality of life outcome measure that was used in this
analysis covered a wide range of health-related issues. When the intention is to
prevent poor heath, it is unrealistic to target only those with very low quality of
life, supporting the rationale for using a linear regression analysis, expressing
QOL as a continuous variable. A gradient of SES in association with health has
been observed, a health gradient in association with SES can also be observed.
Various levels of quality of life could lead, potentially, to varying degrees of ill
health in the future. The current approach to studying health and SES focuses
on the very extreme and of health. A more broad approach to health, such as
this quality of life measure or health expectancy, could target high-risk people
before they get sick, or sicker. Focusing merely on populations who are very ill is
not useful to study in terms of prevention, which should be the goal of public
health. Health-related quality of life is a potential indicator of future poor health.
Further study of variables like this could uncover a great deal of useful prevention

interventions.

37

CHAPTER 8
FUTURE DIRECTIONS

Based on the information revealed in this investigation, there are many
directions that can be taken for future research. There are two that have the
potential to have the most impact on the lives of those of lower SES, measures of
socioeconomic status and measures of health.

The intent of the investigation into the Northern Michigan population was
to elucidate etiologic factors in the relationship between SES and health-related
quality of life. Many etiologies were considered, most of them suggested by the
literature. The type of outcome variable that was used is still very new to and
unexplored in socioeconomic research. Based on the research that has
previously explored the SES/health relationship, it is clear that there is still little
that is known about what causes lower SES populations to be less healthy.
Quality of life may have a cumulative effect on health. Investigations into
psychosocial status of lower socioeconomic populations while they are still
healthy may provide a better insight into why they are more likely to get sick.
Quality of life instruments should be altered and improved to measure quality of
life in the general population. In addition, this measure could potentially be
incorporated into routine physicals or yearly exams as a vital sign, similar to
blood pressure or respiration.

Additional questions that these data revealed are relative to specific
etiologies. A suggestion for future research is to investigate male/female
differences in quality of life. These data reveal that there may be more of a

health effect of low SES on males than there is on females. Another area that is

38

perhaps more difficult to research is genetic disposition and/or exposure to long
term poor health and low socioeconomic status. This could involve researching
trends in health and SES within extended and generations of families. It should
be determined if this is indeed a familial concern and if it is, whether it is a cycle
of behavior that needs to be broken, or a genetic predisposition that is more
difficult to escape. Clearly, further investigation must be undertaken into the
attitudes of physicians towards lower SES populations and the effect this has on
the patient. An observational study is likely the best way to research this issue,
because it is unlikely that a physician will admit in a survey that they treat people
differently based on their income or education. It is not merely an issue of pride,
but. more likely an unawareness of the biases they possess. Based on this
investigation, physician attitudes may be a most interesting direction of research.
The definition of socioeconomic status is more difficult issue with which to
deal. Each measure of SES reflects very different aspects of a person's life.
Additionally, socioeconomic research is conducted worldwide, where very
different indicators of SES may be appropriate. It is clear that for each study
question and each population, the indicator of interest will be different. In order
to maintain consistency for comparative purposes, an index of socioeconomic
status could be developed. It could be a composite measure, which could be
altered for the population being studied. For instance, in a less developed
country, a measure of assets that are available to trade or sell, such as livestock,
could be a measure of income that is equivalent to a measure of income in a
more developed country. This type of index would require a great deal of

expertise in the areas of health, economics and sociology, but could be highly

39

effective in elucidating similarities that exist among less advantaged populations
worldwide. To date, little research has been done comparing populations in
countries that are very different from each other. This is a weakness of
socioeconomic research, as it ignores a wealth of information that may hold the
key to unraveling these questions.

This investigation has been enlightening in revealing the discrepancies
that exist in socioeconomic research. It is unfortunate that the health issues of
such a large segment of the population worldwide are not being addressed
because not enough is known about them. It is clear that a majority of the
problem is that these less advantaged people cannot be identified because the
methods used to measure socioeconomic status is so varied and inconsistent.
Since the people who are most in need cannot be adequately identified, it is
difficult to study what the true reasons are for their special problems.

In recent years, researchers have attempted to develop new ways to study
the health of populations in association with social status, it is essential to
continue with this type of research. Years of traditional investigation has
revealed little about reduced health and increased mortality in low SES groups.
It is very clear that innovative methods must be employed in order to get to the

root of this longstanding problem.

40

 

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Illinois. 1897 reprinted 1971.

‘7 Kessler, Ronald C. A Disaggregation of the relationship between
Socioeconomic Status and Psychological Distress. American Sociological
Review. 1982;47: 752-764.

‘8 Ross, Marline A., Paul J. Etkin amd Nina L. Deinard. Sociocultural factors in
the use of Prenatal care by Hmong women, Minneapolis. American Journal of
Public Health 1995;85(7): 1015-1018.

‘9 Green, Lawrence W., Michael P. Eriksen and Edward Schor. Preventative
Practices by Physicians: Behavioral Determinants and Potential Interventions.
American Journal of Preventative Medicine 1988;Supplement: 101-107.

” Kalichman, Seth C. et al. Health Literacy and Health-Related Knowledge
Among Persons Living with HIV/AIDS. American Journal of Preventative
Medicine 2000;18(4): 325-331.

” Katz, Steven J and Timothy P. Hofer. Socioeconomic Disparities in Preventive
Care Persist Despite Universal Coverage Breast and Cervical Screening in
Ontario and the United States. JAMA 1994; 272: 530-534.

” Alter, David et al. Effects of Socioeconomic Status on Access to Invasive
Cardiac Procedures and on Mortality after Acute Myocardial Infarction. N Engl J
Med 1999; 341: 1359-1367.

2‘ Vagero, Denny and Oils Lundberg. Health Inequalities in Britain and Sweden.
The Lancet 1989;July 1: 35-36.

25 Feinstein, Jonathan S. The Relationship between Socioeconomic Status and
Health: A Review of the Literature. The Milbank Quarterly 1993;71: 279-322.

” US Department of Health and Human Services. Summary Historical Figures
and Federal Register References for the HHS Poverty Guidelines since 1982.

42

 

[Onlinel Available mmilaspehhsccvlmedylfigumtedreamm. October 10.

2000.

27 Ware JE, Snow KK, Kosinski M. SF-36 Health Survey: Manual and
Interpretation Guide, Lincoln RI: QualityMetric Incorporated, 1993,2000.

43

APPENDIX

(INTERVIEUER: MAKE SURE YOU ARE TALKING TO SOMEONE 18 OR OLDER)

Hello, this is calling on behalf of

District Health Department Number 3

which covers COUNTY NAME

county and the hospitals in your area. The health department and
hospitals are collaborating on an important survey to learn about
the health status and health practices of adults and children in
your area. This information is required so that useful services and
programs can be developed to better meet your community’s needs.

Your number has been chosen randomly to be included in the study.
Have I reached ( ### ) - ### . #### ?
1. CONTINUE
7. RETURN TO COVER SHEET (RNA, ANS MACH, REF, ETC.) --> ABORT
BUSINESS.CHECK
Is this a household or a business?

(PROBE FOR BEST ESTIMATE)

1. RESIDENCE (OR COMBINED RESIDENCE AND BUSINESS)
2. BUSINESS ---------------------------------------- > BUSINESS

3. NONRESIOENTIAL NUMBER 0R INELIGIBLE RESIDENCE ---> NONRES
, (00 Nor READ)

OK (OR APPT)

REF

4&5

NCC Local Health Department Conmuni

COUNTY.CHECK

Uhat county do you live in?

ty Survey July 1995

01. CHARLEVOIX 12. ALCONA
02. EHHET 13. OSCOOA
03. ANTRIN l4. OGEHAU
04. OTSEGO TS. IOSCO
05. GRAND TRAVERSE 16. CRAUFORD
06. LEELANAU 17. KALKASKA
07. BENZIE 18. NISSAUKEE
08. CHEBOYGAN l9. UEXFORD
09. PRESOUE ISLE 20. NANISTEE
10. ALPENA 21. ROSCONMON
11. MONTHORENCY 22. OTHER
.___________

(PROBE FOR 'COUNTY')

0K

REF

OZIP
Uhat is your zip code?
(PROBE FOR BEST ESTIMATE)
OK (OR APPT)
REF
PREFACE.2

I want to assure you that your
Your participati
quesrion lessens the accuracy of the

CONFIDENTIAL.

No information
household will
will be used to

which identifies
ever_be released
identify health needs in your city or county.

answers will be
on is

you or anyone else
or published.

kept STRICTLY
voluntary but each unanswered
final data.

in your
The information

46

Page 2

NCC Local Health Department Cormutity Survey July 1995 Page 3

ONIB
Our study requires that we begin by interviewing only one
adult, randomly selected to represent all the adults in your
household.
How many members of your household, including yourself, are
18 years of age or older?
(INTERVIEUER: HE ARE ASKING ABOUT PEOPLE UHO LIVE THERE AT THE TIME
OF CONTACT. PRESS “TAB“ TO SEE THE HELP SCREEN FOR THIS QUESTION)
__ 1 OF PEOPLE OVER 18 (ENTER 20 IF 20 OR MORE)
0! (OR APPT)
REF
0A1
How many members of your household are men?
(NUMBER)
OK OR APPT
0A2
How many members of your household are women?
(NUMBER)
OK OR APPT
0A3

who is the oldest man who presently lives in your household?

(IUER: IN CASE INFORHANT HESITANT, LET PERSON KNOU THAT NICXNAHES
ARE ACCEPTABLE, AS LONG AS HE HAVE A HAY OF IDENTIFYING
THE PERSON HE UANT TO TALK TO, INCLUDING PHRASES LIKE
FATHER, BROTHER, UNCLE, OR OLDEST HAN)

 

47

NCC Local Health Department Community Survey July 1995 Page 4

CAL
Uho is the next oldest man who presently lives in your household?
(IVER: IN CASE INFORMANT HESITANT, LET PERSON KNOU THAT NICKNANES
ARE ACCEPTABLE, AS LONG AS 95 HAVE A HAY OF IDENTIFYING

THE PERSON HE UANT TO TALK TO, INCLUDING PHRASES LIKE
FATHER, BROTHER, UNCLE, OR SECOND OLDEST HAN)

(REPEAT QUESTION FOR EACH OF REMAINING HEN.)

 

 

 

 

 

 

VO‘U‘S‘WN-fi

 

OAS
who is the oldest woman who presently lives in your household?

(wen: IN CASE INFORHANT HESITANT, LET PERSON (now THAT mcxnmes
ARE ACCEPTABLE, AS LONG AS we HAVE A may or IDENTIFYING
THE reason we UANT To TALK TO, mcwomc pauses LIKE
MOTHER, SISTER, AUNT, on OLDEST won“)

 

0A6
Uho is the next oldest woman who presently lives in your household?
(IUER: IN CASE INFORHANT HESITANT, LET PERSON KNCU THAT NICKNAHES
ARE ACCEPTABLE, AS LONG AS NE HAVE A HAY OF IDENTIFYING

THE PERSON HE UANT TO TALK TO, INCLUDING PHRASES LIKE
”OTHER, SISTER, AUNT, OR SECOND OLDEST UCHAN)

(REPEAT QUESTION FOR EACH OF REMAINING WOMEN.)

 

 

 

 

 

 

~¢o~u1t~uana-¢

 

48

NCC Local Health Department Community Survey July 1995

THE FOLLOUING IS READ IF THERE IS ONLY ONE ADULT IN THE HOUSEHOLD
ONE.PERSON.NANE
May I have that person's first name please?
(IUER: IN CASE INFORMANT HESITANT, LET PERSON KNOU THAT NICKNAHES
ARE ACCEPTABLE, AS LONG AS HE HAVE A HAY OF IDENTIFYING

THE PERSON UE UANT TO TALK TO, INCLUDING PHRASES LIKE
FATHER, MOTHER, BROTHER, SISTER, UNCLE, AUNT OR NE)

 

OGET

"The person in your household that I need to speak with is..."
RESPONDENT NAME

RESPONDENT SELECTED IS ALREADY ON PHONE
RESPONDENT SELECTED COMES TO PHONE

RESPONDENT SELECTED IS UNAVAILABLE (MAKE AN APPT)
INFORHANT ON PHONE REFUSES TO COOPERATE FURTHER

S‘UN-J

49

Page 5

NCC Local Health Department Cahnunity Survey July 1995

INTROI IS READ FOR INFORMANTS UHO ARE RESPONDENTS

INTROT

(INTERVIUER: READ THIS ONLY IF IT IS A CALLBACK AND R IS
UNFANILIAR UITH STUDY: I want to assure you that your answers
will be kept STRICTLY CONFIDENTIAL. Your participation is
voluntary but each unanswered question lessens the accuracy
of the final data.

No information which identifies you or anyone else in your
household will ever be released of published. The information
will be used to identify health needs in your city or county.)

Great, you are the person I am supposed to interview.

INTROZ IS READ FOR RESPONDENTS UHO COME TO PHONE

INTROZ

Hello, this is calling on behalf of the

CQJNTY NAME

County Department of Health and the hospitals in your area.

The health department and hospitals are collaborating on an
important survey to learn about the health status and health
practices of adults and children in your area. This information
is required so that useful services and programs can be developed
to better meet your community’s needs.

Your number has been chosen randomly to be included in the study,
and you were randomly selected from all adults 18 or older living
in your residence.

I want to assure you that your answers will be kept STRICTLY
CONFIDENTIAL. Your participation is voluntary, but each unanswered
question lessens the accuracy of the final data. No information
which identifies you or anyone else in your household will ever be
released or published.

INTRO.DEMO

O.AGE

First, I would like to ask some general background questions
about you.

(PRESS SPACE BAR TO CONTINUE)

Uhat is your age?
__ YEARS (ENTER 97 IF 97 IF MORE)
DK
REF

50

Page 6

NCC Local Health Department Community Survey July 1995

O.GEN
(GENDER OF RESPONDENT: DO NOT ASK UNLESS UNSURE)

(IVER: IF NECESSARY, "Just to be sure, I need to ask whether
you are male or female.“

1. MALE
2. FEMALE
DK

REF

OOCC
Are you currently. . .
(READ LIST. ACCEPT ONE RESPONSE ONLY.)

01. Employed for wages,

02. Self-employed, '

03. Out of work for more than one year,
04. Out of work for less than one year,
OS. A Homemaker,

06. A Student,

07. Retired, or .

08. Are you unable to work?

OK
REF
01
Now I'd like to ask some general questions about your health.

First, would you say that in general your health is EXCELLENT,
VERY GOOD, GOOD, FAIR or POOR?

I. EXCELLENT
Z. VERY GOOD
3. GOOD
4. FAIR
5 POOR

02
Now thinking about your physical health, which includes
physical injury and illness, for how many days during the
past 30 days was your physical health NOT good?

DAYS

51

Page 7

NCC Local Health Department Community Survey July 1995

03

Now thinking about your mental health, which includes
stress, depression, and problems with emotions, for
how many days during the past 30 days was your mental
health NOT good?

DAYS

IF OZ AND 03 ARE BOTH ZERO DAYS, THEN GO TO OS.A

OL

OS.A

05.8

During the past 30 days, for about how many days did
POOR physical or mental health prevent you from doing
your usual activities, such as selfvcare, work, or
recreation?

__ DAYS

The following items are about activities you might do during a
typical day. Does your health now limit you in these activities
A LOT, A LITTLE, or NOT AT ALL?

How about...

Lifting or carrying groceries?

Does your health now limit you in this acrivity A LOT, A LITTLE,
or NOT AT ALL?

I. A LOT
2. A LITTLE
3. NOT AT ALL

DK
REF

(How about...)
Climbing several flights of stairs?

(Does your health now limit you in this activity A LOT, A LITTLE,
or NOT AT ALL?)

1. A LOT

2. A LITTLE
3. NOT AT ALL
DK

REF

52

Page 8

NCC Local Health Department Community Survey July 1995 Page 9

OS.C
(How about...)
walking several blocks?
(Does your health now limit you in this activity A LOT, A LITTLE,
or NOT AT ALL?)
1. A LOT
2. A LITTLE
3. NOT AT ALL
DK
REF
08
During the past four weeks, to what extent has your physical health
or emotional problems interfered with your normal social activities
with family, neighbors, or groups? Nould you say NOT AT ALL, SLIGHTLY,
MOOERATELY, ouxre A BIT, or EXTREMELY?
1. NOT AT ALL
2. SLIGHTLY
3. MODERATELY
A. QUITE A BIT
S. EXTREMELY
DK
REF
09

How much bodily pain have you had during the past 4 weeks?
Hould you say NONE, VERY MILD, MILD, MODERATE, SEVERE, or
VERY SEVERE?

1. NONE

2. VERY MILD
3. MILD‘

4. MODERATE
5. SEVERE

6. VERY SEVERE

53

NCC Local Health Department Cannxfity'Survey July 1995 Page 10

O10.A

010.8

These questions are about how you feel and how things have been
with you. How much of the time during the past four weeks
did you feel FULL OF PEP?

Uould you say ALL OF THE TIME, MOST OF THE TIME, A GOOD BIT OF THE
TIME, SOME OF THE TIME, or A LITTLE OF THE TIME?

1. ALL OF THE TIME

2. MOST OF THE TIME

3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME

5. A LITTLE OF THE TIME

6. NONE OF THE TIME/NEVER (DO NOT READ)

DK
REF

How much of the time during the past four weeks
Have you felt CALM AND PEACEFUL?

would you say ALL OF THE TIME, MOST OF THE TIME, A GOOD BIT OF THE
TIME, SOME OF THE TIME, or A LITTLE OF THE TIME?

1. ALL OF THE TIME

2. MOST OF THE TIME

3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME

5. A LITTLE OF THE TIME

6. NONE OF THE TIME/NEVER (DO NOT READ)

DK
REF

54

Department Community Survey July 1995 Page 11

: time during the past four weeks
DOUNHEARTED AND BLUE?

. say ALL OF THE TIME, MOST OF THE TIME, A GOOD BIT OF THE
JME OF THE TIME, or A LITTLE OF THE TIME?)

1. ALL OF THE TIME

2. MOST OF THE TIME

3. A GOOD BIT OF THE TIME
4. SOME OF THE TIME

5. A LITTLE OF THE TIME

6. NONE OF THE TIME/NEVER (DO NOT READ)

DK
REF

010.0

How much of the time during the past four weeks
have you been a HAPPY PERSON?

(Would you say ALL OF THE TIME, MOST OF THE TIME, A GOOD BIT OF THE
TIME, SOME OF THE TIME, or A LITTLE OF THE TIME?)

ALL OF THE TIME

MOST OF THE TIME

A GOOD BIT OF THE TIME
SOME OF THE TIME

A LITTLE OF THE TIME

U‘FWN-O

6. NONE OF THE TIME/NEVER (DO NOT READ)

DK
REF

011

Currently wheniyou receive medical care what insurance or type
of prepaid plans pay at least some of the costs of this care?

(SELECT ALL THAT APPLY) (NOTE: READ LIST ONLY IF NEEDED)

. MEDICARE,

. MEDICAID OR STATE WELFARE,

BLUE CROSS BLUE SHIELD, or

. OTHER PRIVATE INSURANCE,

an HMO, or HEALTH MAINTENANCE ORGANIZATION,
a PPO, or PREFERRED PROVIDER ORGANIZATION,
or some OTHER type of insurance? (SPECIFY)
. NONE

DK

REF

UVOMpHN-e

55

NCC Local Health Department Conmunity Survey

012

013

011.

About how long has it been since you had health care
coverage?

(PROBE FOR BEST ESTIMATE)
(ODY I NEVER)
(IF < 1 DY ROUND UP TO 1 DY)

it.'flififffifiiflittififitifi'ttiifiiitii'tfi

. CORRECT UNITS ARE As FOLLONS: '
...'."’C.""fi'1..'.'i'*'iiiififffifii
* DAYS --> or wEEks --> wk *
* MONTHS --> MO YEARS --> YR -
D.”. ....C beeneeeeenneemneeeeeep
DAYS, weexs, MONTHS, YEARS
ox
REF

was there a time during the last 12 months when you needed to see a
doctor, but could not because of the cost?

1. YES
2. NO

DK
REF

About how long has it been since you last visited a
doctor for a routine checkup?

(PROBE FOR BEST ESTIMATE)
(ODY 8 NEVER)
(IF < I DY ROUND UP TO 1 DY)

"m"""""fl.."'.‘.”"'*'."fi D I

' CORRECT UNITS ARE AS FOLLOVS: '
mtiifltivethfiflttintinti'ti'0'
' DAYS --> DY VEEKS --> UK '
' MONTHS --> MO YEARS .-, YR '
emeneneenne "Mitt”!ttfitt'o
DAYS, VEEKS, MONTHS, YEARS
DK
REF

56

July 1995

Page 12

NCC Local Health Department Camuanity Survey July 1995 Page 13

015
Did you seek medical care in the past year?
1. YES
2. NO
DK
REF
016
Do you have somewhere you usually go to if you need medical care?
1. YES
2. NO ~--> 020
or ------ > PRE021
REF
017
How many minutes or hours does it take you to travel to your
usual source of medical care?
(INTERVIEUER: ENTER xx HR xx MI )
(481 MI 3 MORE THAN 480 MINUTES OR 8 HOURS)
IC'"',QC"".‘I'"Q"C"C"fifiififlfiififlfiit
' CORRECT UNITS ARE AS FOLLOUS: '
"iiififiti'ii"...iiifiiifi'iiiiitfti'tflt9'
' MINUTES °-> MI HOURS --> HR '
'"i'fitiiitflfifiiifiifiiitflffiififiifi‘iiififiii
HOURS OR MINUTES
OK
018

Overall, how satisfied are you with the service you receive from your
usual source of medical care? would you say you are VERY SATISFIED,
SOMEUHAT SATISFIED, OR NOT SATISFIED?

1. VERY SATISFIED ------ > PRE021
2. SOMEUHAT SATISFIED
3. NOT SATISFIED

DK --------------------- > PREOZI
REF

57

NCC Local Health Department Canmxfity'Survey July 1995 Page 14

019

which of the following is the MAIN reason that you are not very
satisfied with the service you receive from your usual source of
medical care? would you say...

(READ LIST. SELECT ONE ONLY)

1. You wait too long,

2. Your doctor doesn't explain things,

3. You Often do not see the same physician,
4. It is too impersonal, or

5. some OTHER reason? (SPECIFY)

DK

REF

020

which of the following is the MOST IMPORTANT reason you don’t have a
a usual source of medical care? would you say...

(READ LIST. SELECT ONE ONLY)

. You seldom get ill,

. You are new to the area,

. Your usual source of care is no longer available,
. You go to different places for care,

. You have no way to pay for services, or

. some OTHER reason (SPECIFY)

Dk

REF

QWS‘MN—O

021

which of the following would you go to if you needed medical care?
would you say....

(READ LIST. SELECT ONE ONLY)

1. A hospital emergency room,

2. An urgent care clinic,

3. A neighborhood clinic,

4. A local health department,

5. or some OTHER place (SPECIFY)
DK

REF

58

NCC Local Health Department Community Survey July 1995 Page 15

OZZ.A
The following set Of questions are about arranging for and getting
health care. Based upon your experience, please rate each item as
POOR, FAIR, GOOD, VERY GOOD,OR EXCELLENT.
(How about...)
The convenience of the location of your doctor’s Office?
would you say ....
(INTERVIEUER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
4. VERY GOOD
5. EXCELLENT
DK
REF
022.8

(How about...)
The hours when the doctor's Office is open?
(would you say...)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
POOR
FAIR
GOOD

. VERY GOOD
EXCELLENT

MbuNd
0 ea a

OK
REF

59

NCC Local Health Department Cannxfity'Survey July 1995 Page 16

022.C
(How about...)
Access to the care of a Specialist if you need it?
(would you say...)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
4. VERY GOOD
5. EXCELLENT
DK
REF
022.0
(How about...)
Access to hospital care if you need it?
(would you say....)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
4. VERY GOOD
5. EXCELLENT
DK
REF
022.E
(How about...)
Arrangements for making appointments for medical care by phone?
(would you say ....)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
A. VERY GOOD
5. EXCELLENT

OK
REF

60

NCC Local Health Department Community Survey July 1995 Page 17

022.F
(How about...)
The length of time spent waiting at an office to see the doctor?
(would you say ....)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
A. VERY GOOD
5. EXCELLENT

(How about...)

The length of time you wait between making an appointment for routine
care and the day of your visit?

(would you say ....)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
A. VERY GOOD
5. EXCELLENT
DK
REF

61

NCC Local Health Department Community Survey July 1995 Page 18

022.H
(How about...)
The availability Of medical information or advice by phone?
(would you say ...)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
4. VERY GOOD
5. EXCELLENT
DK
REF
022.I
(How about...)
Your access to medical care whenever you need it?
(would you say ...)
(INTERVIEwER: NOTE THE DIFFERENT SCALE)
1. POOR
2. FAIR
3. GOOD
4. VERY GOOD
5. EXCELLENT
OK
REF
022.J

(How about...)
Services being available for getting prescriptions filled?
(would you say ...)

(INTERVIEwER: NOTE THE DIFFERENT SCALE)
. POOR
. FAIR
GOOD

. VERY GOOD
EXCELLENT

UTFWNH
0

0K
REF

62

NCC Local Health Department Commwnity Survey

023

024

025

Blood cholesterol

About how long has it been since you last had your blood pressure
taken by a doctor, nurse or other health professional?

(PROBE FOR BEST ESTIMATE)
(OOY 8 NEVER)
(IF < 1 DY ROUND UP TO 1 DY)

'Wffiififi'iflfiiiiiitit ! filifflfif‘li‘lii it

' CORRECT UNITS ARE AS FOLLows: '
...fiffittfifi'f‘l‘lfiifii'ii iiiifiitifli'iifii
' DAYS --> DY wEEKS --> UK '
' MONTHS --> MO YEARS --> YR -
"."""""*"***‘l' 'iffi‘li‘l’ifitfitfif'
DAYS, wEEKS, MONTHS, YEARS
OK
REF

Have you ever been told by a doctor, nurse or other health
professional that you have high blood pressure?

1. YES
2. NO

OK
REF

1. YES

2. N0 --~> 028
OK ------ > 028
REF

63

July 1995

is a fatty substance found in the blood. Have you
ever had your blood cholesterol checked?

Page 19

NCC Local Health Department Community Survey July 1995 Page 20

026
About how long has it been since you last had your blood cholesterol
checked?
(PROBE FOR BEST ESTIMATE)
(OOY a NEVER)
(IF < 1 DY ROUND UP TO 1 DY)
tifiiiit'iiiitiiittiitfitttiififiifivtitii
? CORRECT UNITS ARE AS FOLLowS: '
90"".O!'O'Ottifittitfii'f'm'iititit,
' DAYS --> DY wEEKS --> UK '
* MONTHS --> MO YEARS --> YR ‘
......flt‘t'iiitiftivtfifiififlfififiiitfittii
DAYS, wEEKS, MONTHS, YEARS
OK
REF
027
Have you ever been told by a doctor, nurse or other health
professional that your blood cholesterol is too high?
1. YES
2. N0
DK
REF
028
Have you ever been told by a doctor, nurse or other health
professional that you have diabetes?
1. YES
2. ONLY wHEN PREGNANT
3. NO
DK
REF
0wGT

About how much do you weigh without shoes?
__ HEIGHT IN POUNDS ROUND FRACTIONS UP

OK
REF

64

NCC Local Health Department Community Survey

OTALL

OLOSE

OKEEP

OEAT

July 1995

About how tall are you without shoes?

(INTERVIEUER: ENTER XX FT XX IN )

(97 IN=

MORE THAN 96 INCHES 0R 8 FEET)

 

 

' INCHES °'> IN FEET '-> FT '
FEET, INCHES

OK

REF

Are you now trying to lose weight?

1. YES --> PREEAT
2. NO

OK
REF

Are you now trying to maintain your
to keep from gaining weight?

1. YES

2. NO '--> PREEX
DK ------- > PREEX
REF

Are you eating either FEwER CALORIE
lose weight/keep from gaining weig

current weight, that is

S or LESS FAT to
ht (depending on R's response) ?

(PROBE FOR wHICH ONE OR BOTH: would that be fewer calories or less

fat? OR which would that be,...)

YES FEVER CALORIES

. YES LESS FAT

YES FEUER CALORIES AND
. NO

c~uanJ—a
O I

OK
REF

65

LESS FAT

Page 21

NCC Local Health Department Commxfity'Survey July 1995 Page 22

OEXLOS

OM03 EX

039

040

061

Are you using physical activity or exercise to
lose weight/keep from gaining weight (depending on R's response) ?

1. YES
2. NO
OK
REF

In an average week, on how many days out Of seven do you get

30 MINUTES or more of AT LEAST MODERATE exercise, over the course
of the entire day? Brisk walking and moving somewhat heavy
materials are examples Of moderate exercise. This exercise can take
place over one 30 minute period or even over as many as four
periods of 7 or 8 minutes each.

__ NUMBER OF DAYS PER UEEK GET AT LEAST MODERATE EXERCISE

OK
REF

Have you smoked at least 100 cigarettes in your entire life?
(IF ASKED: 100 CIGARETTES = APPROXIMATELY 5 PACKS)

1. YES
2. NO ---> PREOCL
DK °°°°° > PREOLA

How old were you when you FIRST started smoking fairly regularly?
__ ENTER AGE

OK
REF

DO you smoke cigarettes now?

1. YES

2. N0 ---> 043
OK ------- > 043
REF

66

NCC Local Health Department Commxfity Survey .uny 1995 Page 23

042
On the average, how many cigarettes do you Now
smoke a day?
NUMBER OF CIGARETTES
OK
REF
043
How long has it been since you last smoked
cigarettes regularly, that is, daily?
(PROBE FOR BEST ESTIMATE)
(IF < 1 DY ROUND UP TO 1 DY)
"M'fifl'if'i"it'.i""'i"i"""'t
' CORRECT UNITS ARE AS FOLLOHS: '
iififiitififi"""iiiiiififiiififitiitii'fifiifl
' DAYS --> DY HEEKS --> HK '
' MONTHS --> MO YEARS --> YR '
"t'i'.iii'tfliitiifiiitttiiiiiitttfififi
DAYS, wEEKS, MONTHS, YEARS
OK
REF
OALC‘I
During the past month, have you had at least one drink of any
alcoholic beverage such as beer, wine, wine coolers, or liquor?
(IF NEEDED, PROBE “AS BEST AS YOU CAN RECALL")
1. YES
2. NO ---> 0ALC6
DK ------- > 0ALC6
0ALC2
During the past month, on about how many days per week or month
did you drink any alcoholic beverages?
__ ENTER DAYS HERE, AND UNIT OF TIME ON NEXT SCREEN
OK
0ALC.UNIT

(DO NOT READ UNLESS RESPONDENT DOES NOT MENTION UNIT OF TIME)
was that [] day(s) per week or per month?

(ENTER THE UNIT OF TIME THE RESPONDENT MENTIONED IN 0ALC2: HAS IT
DAYS PER HEEK OR PER MONTH?) °

1. PER wEEK
2. PER MONTH

OK
REF

67

NCC Local Health Department Community Survey July 1995 Page 24

OALC3
A drink is one can or bottle of beer, 1 glass of wine, 1 can
or bottle of wine cooler, 1 cocktail, or 1 shot of liquor.
On the day/s when you drank, about how many drinks did you
drink on the average?
NUMBER OF DRINKS (IF OVER 97, ENTER 97)
OK
REF
0ALC4
Considering all types of alcoholic beverages, how many times
during the past month did you have S‘or more drinks on an
occasion?
(IF NEEDED: By an occasion, we mean at the same time, or within
a couple of hours of each other.)
NUMBER OF TIMES (IF OVER 97, ENTER 97)
OK
REF
0ALC5
During the past month, how many times have you driven when
you’ve had perhaps too much to drink?
__ NUMBER OF TIMES
96. 96 OR MORE
97. DOES NOT DRIVE
DK
REF
0ALC6

During the past month, how many times have you ridden with a
driver who has had perhaps too much to drink?

___ NUMBER OF TIMES (IF OVER 97, ENTER 97)
DK
REF

68

NCC Local Health Department Community Survey July 1995 Page 25

MAM

MAMLONG

MAMUHY

CLINBR

A mammogram is an X-ray of each breast to look for
cancer. Have you ever had a mammogram?

1. YES

2. NO ---> CLINBR
DK °°°°° > CLINBR
REF

How long has it been since you had your last mammogram?
(PROBE FOR BEST ESTIMATE)

(IF < 1 DY ROUND UP TO 1 DY)
0 DY 8 NEVER HAD A MAMMOGRAM

.‘fi'.'.fiififiii..iiiflflitfifffifii""""'

' CORRECT UNITS ARE AS FOLLOwS: '
'0’!ttffifiiitiiitittiiititiiiittttttiti
' DAYS -'> DY wEEKS .., wK '
' MONTHS -~> Mo YEARS --> YR '
tfittttii'titflttiititt'i'i'iiiiitiittt'
DAYS, weexs, MONTHS, YEARS
DK
REF

was your last mammogram done as part of a routine checkup, because
of a breast problem other than cancer, or because you've already
had breasE cancer?

1. ROUTINE CHECKUP
2. BREAST PROBLEM OTHER THAN CANCER
3. HAD BREAST CANCER

A clinical breast exam is when a doctor, nurse, or Other
health professional feels the breast for lumps. Have you
ever had a clinical breast exam?

1. YES

2. NO ---> BCHIST
DK ------ > BCHIST
REF

69

NCC Local Health Department Community Survey July 1995 Page 26

CLINLONG

CLINHHY

BCHIST

How long has it been Since you had your last clinical breast exam?
(PROBE FOR BEST ESTIMATE)

(IF < 1 DY ROUND UP TO 1 DY)
D DY 8 NEVER HAD A CLINICAL BREAST EXAM

mnit'fwfliiiIiifltfiiniifiiiini

* CORRECT UNITS ARE AS FOLLOHS: '
f"'m"..""f*‘i"t'"i'""I..."
' DAYS .., DY weexs --> HK *
- MONTHS --> No YEARS --> YR '

MCifiifi"i'i‘ififfifi'tttfifliififiitiff.
DAYS, wEEKS, MONTHS, YEARS

DK
REF

was your last breast exam done as part of a routine checkup, because
Of a breast problem other than cancer, or because you've already
had breast cancer?

1. ROUTINE CHECKUP
Z. BREAST PROBLEM OTHER THAN CANCER
3. HAD BREAST CANCER

DK
REF

Including living and deceased, were any of your BLOOD relatives
including mother, sister, and grandmothers, ever told by a health
professional that they had breast cancer?

1. YES
2. NO

DK
REF

7()

NCC Local Health Department Conmmwnty'Survey July 1995 Page 27

PAP
A Pap smear is a test for cancer of the cervix. Have you
ever had a Pap smear?

1. YES
2. NO ---> PREPREG
OK ------ > PREPREG
REF
PAPLONG
How long has it been since you had your last Pap smear?
(PROBE FOR BEST ESTIMATE)
(IF < 1 DY ROUND UP TO 1 DY)
O DY = NEVER HAD A PAP SMEAR
.ii'fiififififiiittfi'flfli'fiitittfliifl'.fiti
' CORRECT UNITS ARE AS FOLLOwS: '
it"‘tittfiifitfii'fifittvifititttitfiffiiittf
' DAYS -~> DY wEEKS --> wK '
' MONTHS --> MO YEARS --> YR '
"Q!""""'i""i"t'.......‘D'QCQC'
DAYS, wEEKS, MONTHS, YEARS
DK
REF
PAPHHY
was your last pap smear done as part of a routine checkup, or to
Check a current or previous problem?
1. ROUTINE CHECKUP
2. CHECK A CURRENT PROBLEM
3. CHECK A PREVIOUS PROBLEM (PROBE IF NECESSARY)
OK
REF
PRES

To your knowledge, are you now pregnant?
1. YES

2. N0
OK OR NOT SURE

71

NCC Local Health Department Commxfity'Survey' July 1995 Page 28

OCHL.A
How many children live in your household who are

less than 5 years old?
__ NUMBER OF CHILDREN LESS THAN 5 YEARS OLD

DK
REF.

THE FOLLOHING QUESTION IS FOR RESPONDENTS HHO ANSHERED > 0 TO

THE PREVIOUS QUESTION
0CHL.6MO
Now many children live in your household who are
between 6 months and 5 years Old?

NUMBER OF CHILDREN 6 MONTHS TO 5 YEARS OLD

OK
REF

0CHL.B
How many children live in your household who are
5 through 12 years old?
__ NUMBER OF CHILDREN 5 THROUGH 12 YEARS OLD

OK
REF

0CHL.C
How many children~live in your household who are
13 through 17 years old?
NUMBER OF CHILDREN 13 THROUGH 17 YEARS OLD

DK
REF

72

NCC Local Health Department Community Survey July 1995 Page 29

OBELT
How often do you use seat belts when you drive or ride in a car?
would you say ALHAYS, NEARLY ALHAYS, SOMETIMES, SELDOM, or NEVER?
1. ALHAYS
2. NEARLY ALHAYS
3. SOMETIMES
4. SELDOM
S. NEVER

6. NEVER DRIVE OR RIDE IN A CAR (DON'T READ)

0FIRE

Has your family practiced or discussed an escape plan in case
of a fire at home?

1. YES
2. NO
3. RESPONDENT LIVES ALONE
OK
REF
ORADON

Have you heard of radon, which is a radioactive gas that
occurs in nature?

1. YES
2. NO "'> PREAID

OK -—-:---> PREAID
REF
ORADT

Has your household air been tested for the presence of radon gas?

1. YES
2. NO
OK
REF

7T3

NCC Local Health Department Community Survey July 1995 Page 30

OAIOI

If you had a child in school, at what grade do you think
he or she should begin AIDS education in school?

__ GRADE IN HHICH CHILD SHOULD BEGIN AIDS EDUCATION
00 = CHILD SHOULD NEVER BEGIN AIDS EDUCATION
01 FOR KINDERGARTEN AS HELL AS FIRST GRADE
DK
REF
OAIDZ

At what grade do you think he or she should begin education
for the prevention of pregnancy and sexually transmitted diseases?

__ GRADE IN wHICH CHILD SHOULD BEGIN PREGNANCY EDUCATION
00 = CHILD SHOULD NEVER BEGIN PREGNANCY EDUCATION
01 FOR KINDERGARTEN AS HELL AS FIRST GRADE
OK
REF
OAID3
(At what grade do you think he or she should begin education...)
what about...
education regarding the use of alcohol or drugs?
__ GRADE IN wHICH CHILD SHOULD BEGIN ALCOHOL EDUCATION
00 2 CHILD SHOULD NEVER BEGIN ALCOHOL EDUCATION

01 FOR KINDERGARTEN AS HELL AS FIRST GRADE

DK
REF

74

NCC Local Health Department Community Survey July 1995 Page 31

0AI04
(At what grade do you think he or she Should begin education...)
what about...
the use of cigarettes or smokeless tobacco?
__ GRADE IN wHICH CHILD SHOULD BEGIN TOBACCO EDUCATION
00 a CHILD SHOULD NEVER BEGIN TOBACCO EDUCATION
01 FOR KINDERGARTEN AS HELL AS FIRST GRADE
OK
REF
OAIOS
(At what grade do you think he or she should begin education...)
what about...
issues of family violence?
__ GRADE IN HHICH CHILD SHOULD BEGIN FAMILY VIOLENCE
EDUCATION
00 = CHILD SHOULD NEVER BEGIN FAMILY VIOLENCE EDUCATION
01 FOR KINDERGARTEN AS HELL AS FIRST GRADE
OK
REF
0A1D6

If you had a teenager who was sexually active, would you encourage
him or her to use a condom?

1. YES
NO

3. HOULD GIVE OTHER ADVICE

OK
REF

75

NCC Local Health Department Community Survey July 1995 Page 32

OENV

ORACE

OHISP

OMARR

which of the following eight environmental problems do you think
poses the GREATEST risk to human health in Michigan? would you say...

what is

Are you

Are you:

(READ LIST. SELECT ONE ONLY)

01. Great Lakes pollution,

02. Contaminated dUTp sites,

03. Home air pollution,

O4. Contaminated fish,

05. Pesticides in food,

06. Radioactive waste,

07. waste incinerators, or

08. Comnercial and residential land development?

OK
REF

your race? would you say:

. HHITE

BLACK or AFRICAN AMERICAN

. ASIAN, PACIFIC ISLANDER

. AMERICAN INDIAN, ALASKA NATIVE, or

are you a MEMBER or SOME OTHER RACIAL GROUP (SPECIFY)

mfiuN-P
e a

REF

of Hispanic or Spanish origin?

1. YES
2. NO
OK
REF

1. MARRIED
2. DIVORCED
3. HIDOHED
4. SEPARATED
5. have you NEVER BEEN MARRIED, or are you
6. a MEMBER OF AN UNMARRIED COUPLE?

DK
REF

76

NCC Local Health Department Community Survey July 1995 Page 33

OEDUC

what is the highest grade or year of school that you
have completed?)

(PROBE FOR YEAR OR GRADE 'COMPLETED')
(READ LIST ONLY IF NECESSARY)

DO. NEVER ATTENDED SCHOOL, OR KINDERGARTEN ONLY
01-11. ENTER GRADES 1 THROUGH 11

12. HIGH SCHOOL GRADUATE OR GED

13-15. ENTER SOME COLLEGE

16. COLLEGE GRADUATE

17. SOME GRADUATE SCHOOL

18. MASTERS

19. DWTORATE

OK
REF
OINC

what was your ANNUAL HOUSEHOLD income from all sources
before taxes in 1994?

ANNUAL HOUSEHOLD INCOME IN 1994
999,997=999,997 OR MORE

DK
REF

OPH.1

Do you have more than one telephone number in your household?

1. YES

2. NO ~-°> END.STATEMENT
DK ------ > END.STATEMENT
REF

0PH.Z
How many residential telephone nuibers do you have?
(IF MORE THAN 1 THEN PROBE wITH: “Then you have (x)
different RESIDENTIAL nuibers, not extension phones
or business numbers".)
_ # OF RESIDENTIAL NUMBERS (IF OVER 7, ENTER 7)

DK
REF

77

NCC Local Health Department Community Survey July 1995

END.STATEMENT

That's my last question. I would like to remind you that
all information will be kept completely confidential. Thank
you very much for your time and cooperation.

(PRESS ANY KEY TO GO TO COVERSHEET)

78

Page 34

NCC Local Health Department Community Survey July 1995 Page 35

THE FOLLOHING ARE READ DEPENOING ON THE CIRCUMSTANCES

BUSINESS
we can only interview people whom we reach at households.
Unfortunately, you do not qualify.

I do want to thank you very much for your time, however.

BAD.COMM

As I mentioned earlier, we can only interview people who fall
into certain groups. Unfortunately you do not qualify because
you live outside of the required geographic area.

I do want to thank you very much for your time, however.
NONRES

we can only interview people whom we reach at households.
Unfortunately, you do not qualify.

I do want to thank you for your time, however.

AGE.TERMINATE

As I mentioned earlier, we can only interview people who fall
into certain groups. Unfortunately your household does not

qualify because no one in your household is 18 years of age or
over.

I do want to thank you very much for your time, however.

DK.HHEL

(THANK AND MAKE APPT.)

(IF NECESSARY, ASK HHEN SOMEONE HOULD BE HOME
HHO HOULO KNOH THE INFO ABOUT THE HH)

(IF I DOESN'T KNOH HH INFO. AND IS ONLY PERSON IN HH

ASK I TO FIND OUT'NECESSARY INFO. AND SCHEDULE
APPT. FOR TOMORROH)

79

NCC Local Health Department Community Survey July 1995 Page 36

DK.N18

(THANK AND MAKE APPT.)

(IF NECESSARY, ASK HHEN SOMEONE HOULD BE HOME
HHO HOULD KNOH THE NUMBER OF ADULTS OVER 18)

MAKE.APPOINTMENT

RESTART.

RESTART.

RESTART.

(THANK AND MAKE APPT.)
DIAL

Hello, this is calling on behalf of

District Health Department B

which covers COUNTY county and the hospitals in

your area. The health department and hOSpitals are

collaborating on an important survey to learn about the health
status and health practices of adults and children in your area.

we called earlier to interview someone in this household,
and would like to complete the interview now.

(Have I reached ( NNN ) [FIRSTS] - [LASTS] ?)
May I please speak with
INSERT NAME ?

1. CONTINUE (R ALREADY ON PHONE)
2. R COMES TO PHONE
3. RETURN TO COVERSHEET (RNA, AM, ETC.)
(IF POSSIBLE, ARRANGE TIME FOR CALLBACK)

INTRO IS READ IF THE RESPONDENT 0R PROXY COMES TO THE PHONE ON CALLBACK
INTRO

Hello, this is calling on behalf of the

CCXJNTY NAME

Department of Health and the hospitals in your area.

The health department and hospitals are collaborating on an
important survey to learn about the health status and health
practices of adults and children in your area.

we called earlier to interview someone in this household,
and would like to complete the interview now.

Is this a convenient time to complete the interview?

1. CONTINUE
2. RETURN TO COVERSHEET

8O

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