'0 '..u .. u- - n ' fi ”x \ 5o , - . s . o.)- DIFFERENTIAIS IN MORBIDITY AND IN THE USE AND COST OF hEALTH SERVICES IN WAKE COUNTY, NORTH CAROLINA by SHELDON GAYLON “LQWRY A DISSERTATION Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of DOCTOR OF PHI LOSOPHY Department of Sociology and Anthropology 1954 . ' 0' - >.‘,_...-o ‘ ' iCu‘...:: A3 ~ ~ ; ...- “fl." “ . s l . .9‘ 57"": "“‘ ‘ . .u-ao-O - o . ‘g'c"a.‘A. D‘q'.‘w 0...».-4uodd voqb~g . . . 0-1. a... .Aq 9". ‘zo. 7. oil “:14 g y.- 3‘ "Via. A. O " '-.: 3.6.9. 5. v p t!- " 0y - ’ “"“ é.“ D a”fig._~ 4 ‘ "an... R. A ‘- avl“:‘ac ._~ ‘. _ "- 5:: at _ d . S“‘3r$-f; .t’u‘ 93:; ‘L T-, ‘ 1-..‘1.fln 1":S I 3‘?» . “I? a? ‘ "A“ ‘.a N w. .U q 01-}- 'l vki \‘ b “-3‘ ‘L M.“ u. _‘ “ ‘2. i Q N s‘ ‘ .\ Sheldon G. Lowry Abstract - 1 There has been a pronounced increase in interest and activities in the field of health and health care in the last few years, both in North Carolina and the country as a whole. The present study was conceived as a result of a need for more information concerning the social and economic factors associ- ated with health and the health care activities of the peOple of the state. The investigation was based on a house-to-house canvass of a two percent sample of Wake County, North Carolina. The major objective was to collect and analyze data which could be used in planning more effective health programs for the county and to provide a basis whereby basic principles could be derived so that the health program of the county, the state, and the nation may proceed on a sound basis. The analysis was based on three dependent variables, morbidity, the use of health services and facilities, and the cost of health services and facilities. These variables were analyzed in terms of a set of selected social and economic factors or independent variables. Some of the more important conclusions are summa— rized below. In the reporting of illness the informant is not only influenced by the objective presence or absence of some morbid condition, but he is especially influenced by his definition of what constitutes illness. This definition of illness is based largely on standards of health and health care which have been derived from past experience or which have been handed down Sheldon G. Lowry Abstract - 2 from generation to generation. Since the standards of health and health care of medical science are based primarily on ob- jective information and those of the layman on a combination of objective information, customs, habits, attitudes, and superstitions, objective need for medical attention and the felt needs of the individual do not necessarily coincide. Furthermore, since subsequent behavior is based largely on the felt needs of the individual, these felt needs are of primary importance in any consideration of the use of health services and facilities. Of course, the use of health services and the felt needs themselves are also affected by conflicting goals, ability to pay, and attitudes toward the various means available for meeting the needs. 0n the whole, the higher social and economic groups appear to be more nearly recognizing and meeting their objective health needs than are the lower groups. This is due not only to differences in health stand- ards, but also to ability to pay for the needed services. Cost of health care, but particularly ability to pay, also influence the use of health services. However, ability to pay is a relative matter which depends not only upon family income or other economic resources, but also on other financial obligations, spending habits, conflicting goals and aspira- tions, and even the felt needs. Cost, in turn, is affected by the amount and type of service used. ‘ ‘ .. . o o I .5 re P. a. .0 .2 ~. 3.. .... .u T. a. .u u” .3 A .- sd‘ 0 . § "a‘.— ‘ A... ‘au . u. ii ACKNOWLEDGEMENTS The writer wishes to express appreciation to the North Carolina Agricultural Experiment Station under whose auSpices the data for this study were collected; to Dr. Charles R. Hoffer, who guided the writing of this dissertation and whose insight and encouragement proved to be an invaluable source of aid in the progress of this study; to Dr. Paul A. Miller, who read the manuscript and made many helpful suggestions; to Dr. C. Horace Hamilton, Head of the Department of Rural Sociology at North Carolina State College and director of the research project, for his constant stimulation and encourage- ment and especially for his guidance in the application of appropriate statistical techniques to the analysis of the data; to the Health Information Foundation for financial assistance in the preparation of the manuscript; to Ida Hodge and Dorothy Thompson who assisted in the tabulation and statistical analysis of the data; and to Mary Joe Singh for typing the original manuscript, for many suggestions on im- proving the grammatical construction, and for proofreading the final copy. Appreciation is also due Adele Covington for the excellent job of typing the final copy and for many suggestions of an editorial nature. Last, but certainly not least, my deepest appreciation to my wife, Gloria, who proved to be my major source of motivation and encouragement. hjar subject: mor subject: urgrapncal 1:87 5 iii Sheldon Gaylon Lowry candidate for the degree of Doctor of PhiloSOphy Final examination, Fall term, 1954. Dissertation: Differentials in Morbidity and in the Use and Cost of Health Services in Wake County, North Carolina. Outline of Studies Major subject: Sociology. Minor subject: Psychology. Biographical Items Born, August 25, 1924, Cardston, Alberta, Canada. Undergraduate Studies, Brigham Young University, 1942-1946. Graduate Studies, Brigham Young University, Summer, 1946, and Summer, EXperience: 1947; Michigan State College, 1947-1951. Instructor in music, Public School System, Pocatello, Idaho, 1946-1947. Graduate Assistant, Michigan State College, 1947-1950. Social Analyst and Field Representative for the National Child Labor Committee, New York City, on their study of Migrant Labor in Colorado, Summer, 1950. Graduate Assistant, Michigan State College, 1950-1951. Instructor (Research), Michigan State College, 1951-1952. Research Associate, Health Information Foundation, New York City, January-July, 1952. Assistant Professor, North Carolina State College, July, 1952 to present. Special Items: Publications: iv Graduate Assistantship and Tuition Scholarship four successive years at Michigan State College. Travel Fellowship from the Institute of International Education for research and study in Costa Rica. (Note: This was awarded but had to be declined due to illness in the family.) A personal grant from the Health Information Foundation to aid in health research connected with the doctoral dissertation. "Continuation Education in Colleges and Universities." Rural Social Systems and Adult Education. *East LanSing: Michigan State College Press, Chapter 10, 1953. (Co-authored with Dr. Olen E. Leonard.) "International Exchange of Persons." Rural Social Systems and Adult Education. Eastvlansing: Michigan State College Press, Chapter 11, 1953. (Co-authored with Dr. Olen E. Leonard.) Member of American Sociological Society, Rural Sociological Society, Society for Applied Anthropology, and Alpha Kappa Delta Sociological Fraternity. fin nu- ..- c: . :‘Jouvup - ‘- ‘--' .- .29 3:. - . - AQ:Q-..Q - n- ‘ J:.‘. ‘5‘- ~ H ..QQ¢ 9-- u C IU‘ '3. ~.u-4 V. 'lfivo’: ' , “. :n-..‘ ~‘- I” ‘4 83‘ .'.;e 3...; s ‘Ef‘l‘- 1-...9 ‘ C" n- J--. “ 'r PA'G :. I“; T ' .eud. _ n1 : D I A I_" Lace j. “.3 ‘91- ',_,,‘ “"a-t-J L I...F A f‘ --~ . ‘n\-. ., ~ L1. ““3” a. " i t: .. 5.6e 3. ‘ :_ 2‘ A a ' a- _ bray? ‘ z .‘ r4. . , fl" ‘0‘- U‘J.at‘-.‘_ C h 22:4" 3.: .~ ' | I II. III. IV. TABLE OF CONTENTS INTRODUCTION Significance of the Study Purpose and Scope of the Study The Sample Definition of Terms Other Studies in the Field ACUTE ILLNESS Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Crowding Index Education of Household Heads Summary and Conclusions CHRONIC ILLNESS Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Crowding Index Education of Household Heads Summary and Conclusions USE OF A DOCTOR Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Page m-qmswra H 27 34 40 46 49 59 62 66 70 73 78 81 82 86 89 92 93 96 98 100 102 104 106 110 114 117 119 122 123 127 ‘7! H 9.. ’l~ 0" by £29 1:5 5 I: :29 C: ?r 2.3-; ’Z" ‘ P.1:e of Y1 Q . 293-1: F': A“- Lax; :a 5.29 of ' 7. ‘ '- .- ‘ c psa"“ 0’ D A V . ..‘ “H Ha‘ta Ew‘ , V353“ ‘ LL, (‘3 1" (/1) W L!” ‘t .1. IV. VI. VII. USE OF A DOCTOR (Contd.) Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions USE OF HOSPITAL Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions DENTAL CARE Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions EYE CARE Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions vi Page 132 133 135 138 142 145 147 150 152 153 155 158 159 160 162 164 168 170 174 176 178 181 185 187 189 192 194 195 200 201 203 204 206 207 208 209 211 VIII. IX. XI, XII. PREVENTIVE CARE Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions DIAGNOSTIC SERVICES Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions COST OF HEALTH CARE Age and Sex Income Color Home Tenure Place of Residence Health Environment Index Communication-Participation Index Size of Household Education of Household Heads Summary and Conclusions SUMMARY AND CONCLUSIONS Summary Conclusions METHODOLOGICAL NOTE vii Page 213 217 219 222 227 227 230 232 234 235 238 241 242 243 244 245 246 247 248 249 251 253 255 258 261 263 264 265 267 268 269 271 274 275 275 287 295 3'3' ' ' yé‘-..‘ 3"”7' .a‘--- ..!.-"v-‘9 ,.4__. I C?‘ 30 no.3 . .u...- k a a. o---o R n, ‘ L. 2.1.”. viii Page BIBLIOGRAPHY 311 APPENDIX A. STATISTICAL METHODS USED IN THE STUDY 328 B. THE INTERVIEW GUIDE 333 C. BASE SAMPLE POPULATION TABLES 342 Table (.9 10. 11, 12. 13. 14. 15. LIST OF TABLES Rates of acute illness of 2125 individuals classified by age in Wake County, North Carolina, 1949. Rates of acute illness of 658 males and 725 females above the age of 17 years, classified by age, in Wake County, North Carolina, 1949. Rates of acute illness by income and age of 2125 individuals in Wake County, North Carolina, 1949. Rates of acute illness of 1498 white and 627 nonwhite residents, classified by age, in Wake County, North Carolina, 1949. Rates of acute illness of white population by sex and age. Rates of acute illness of nonwhite population by sex and age. Rates of acute illness by income and color. Median family income by home tenure, color, and place of residence. Rates of acute illness by income and home tenure. Rates of acute illness by home tenure and age. Rates of acute illness by place of residence and age. Rates of acute illness by income and place of residence. Rates of acute illness of whites by place of residence and age. Rates of acute illness of nonwhites by place of residence and age. Rates of acute illness of rural nonfarm residents by color and age. Page 27 33 42 43 4—3 45 47 48 48 53 54 55 ix .—O :50 A t... "1 I 0‘. IO Ox.) [\3 (J IO “45 [\J I!) H .-- e" r.3‘:‘: o ‘. f‘ 5'? C" ° - '3; P -5 s-- C"“' = '-'. a V. 3“ - .- A .5659: r g.-- 4- i...:.7 r. F. o .AO-~ ctd.:: : CA9. .... ¥-. 6 AL3~3Q A‘ " a. 1K ’8 to .r I w 1‘. O D . “an: n: ‘ VA “.3 r a”; 3“) ' kt Table 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. Rates of acute illness of rural farm residents by color and age. Rates of acute illness of urban residents by color and age. Rates of acute illness by health environment index and age. Rates of acute illness by income and health environment index. Rates of acute illness by communication- participation index and age. Rates of acute illness by income and communication-participation index. Rates of acute illness by size of household and age. Rates of acute illness by income and size of household. Rates of acute illness by crowding index and age. Rates of acute illness by males and females 18 to 44 years old by crowding index. Rates of acute illness by income and crowding index. Rates of acute illness by education of male and female household heads. Rates of acute illness by education of male household head and age. Rates of acute illness by education of female household head and age. Rates of acute illness by income and by education of male household head. Rates of acute illness by income and by education of female household head. Rates of chronic illness by age. Page 58 60 61 64 65 71 72 72 75 75 76 77 78 Table 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 45. 47. 48. 49. 50, 51. Rates Rates Rates Rates Rates of of of of of chronic chronic chronic chronic chronic chronic illness illness illness illness illness illness Rates of tenure. Rates of chronic illness and age. Rates of chronic illness of residence. Rates of chronic illness index and age. Rates of chronic illness environment index. Rates of chronic illness by sex and age. by income and age. by color and age. by income and color. by home tenure and age. by income and home by place of residence by income and place by health environment by income and health by communication- participation index and age. Rates of chronic illness by income and communication-participation index. Rates of chronic illness and age. Rates of chronic illness of household. Rates of chronic illness and age. Rates of chronic illness index. Rates of chronic illness household head and age. Rates of chronic illness household head and age. by size of household by income and size by crowding index by income and crowding by education of male by education of female Percent distribution of cases of use of medical attendants by type of attendant. Page 84 88 91 92 93 94 96 97 98 100 101 102 103 103 104 xi Table 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. Rates of use of a doctor by age. Rates of use of a doctor by income and age. Rates of use of a doctor by color and age. Rates of use of a doctor by income and color. Rates of use of a doctor by home tenure and age. Rates of use of a doctor by income and home tenure. Rates of use of a doctor by place of residence and age. Rates of use of a doctor by income and place of residence. Rates of use of a doctor by health environment index and age. Rates of use of a doctor by income and health environment index. Rates of use of a doctor by communication— participation index and age. Rates of use of a doctor by income and communication-participation index. Rates of use of a doctor by size of household and age. Rates of use of a doctor by income and size of household. Rates of use of a doctor by education of male head and age. Rates of use of a doctor by education of female head and age. Rates of use of a doctor by income and by education of male household head. Rates of use of a doctor by income and by education of female household head. xii Page 115 118 120 122 122 123 127 133 134 134 135 136 137. 137 Table 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. Rates of hospitalization and age. Rates of hospitalization Rates of hospitalization and income. Rates of hospitalization and color. Rates of hospitalization and home tenure. Rates of hospitalization and place of residence. by by by by by by type of sex and type type type type Rates of hospitalization by type and health environment index. Rates of hOSpitalization by income and health environment index. of of of of of illness age. illness illness illness illness illness Rates of hospitalization by type of illness and communication—participation index. Rates of hospitalization by type of illness and size of household. Rates of hospitalization by type of illness and education of male household head. Rates of hospitalization by type of illness and education of female household head. Rates of dental care by Rates of dental care by Rates of dental care by Rates of dental care by Rates of dental care by Rates of dental care by Rates of dental care by Rates of dental care by and age. color and type of care. age. income and age. color and age. income and color. age and home tenure. income and home tenure. place of residence xiii Page 146 147 149 152 153 157 159 160 161 161 166 169 172 175 176 177 178 179 xiv Table Page 90. Rates of dental care by income and place of residence. 180 91. Rates of dental care by health environment index and age. 182 92. Rates of dental care by income and health environment index. 184 93. Rates of dental care by communication- participation index and age. 186 94. Rates of dental care by income and communication- participation index. 187 95. Rates of dental care by size of household and age. 188 96. Rates of dental care by income and size of household. 189 97. Rates of dental care by education of male and female household heads. 190 98. Rates of dental care by income and by education of male household head. 191 99. Rates of dental care by income and by education of female household head. 191 100. Rates of eye care by color and type of care. 195 101. Rates of eye care by age. 197 102. Rates of eye care by income and age. 201 103. Rates of eye care by income and color. 203 104. Rates of eye care by income and home tenure. 204 105. Rates of eye care by place of residence. 205 106. Rates of eye care by income and residence. 206 107. Rates of eye care by income and health environ- ment index. 207 108. Rates of eye care by income and communication- participation index. 208 tn . . 0 {Li 0-. c O-'. ‘.fi a... 9‘. 1... “I 06.. “- ‘OU. Q‘- s 1.1,. 1‘. ‘ol. «.- ‘At. 3‘. e.’. 1'); My. “.5 \J :5; - O u :~ . ...l -: , q h1‘;‘ -’ ll“..= 4- iz'q; » ‘ -x a 1 Pat “‘35 Of '3 . 2’ ‘5» e 'lr3~.o—" ‘ E. Table 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. Rates of eye care by income and size of household. Rates of eye care by education of male and female household heads. Rates of preventive Rates of preventive Rates of preventive Rates of preventive cases cases cases cases of residence and age. Rates of preventive cases of residence and age. Rates of preventive Rates of preventive Rates of preventive residence. Rates of preventive index and age. Rates of preventive environment index. Rates of preventive participation index Rates of preventive and age. cases cases cases cases cases by by by of of by by by by by age. income and age. color and age. whites by place nonwhites by place income and color. residence and age. income and health environment income and health cases by communication- and age. cases by Rates of preventive cases by and female household heads. size of household education of male Rates of preventive cases by income and by education of male household head. Rates of preventive cases by income and by education of female household head. Rates of diagnostic Rates of diagnostic cases by age. cases by income and age. XV Page 209 210 218 221 223 225 225 226 229 231 232 232 234 236 237 237 242 243 Table 128. 129. 130. 131. 132. 133. 134. 137. 138. 139. 140. 141. 142. Rates of diagnostic cases by income and color. Rates of diagnostic cases by income and home tenure. cases by place of residence Rates of diagnostic and age. income and place Rates of diagnostic cases by of residence. Rates of diagnostic cases by income and health environment index. Rates of diagnostic cases by income and communication-participation index. Rates of diagnostic cases by income and size of household. Rates of diagnostic cases by income and by education of male household head. Rates of diagnostic cases by income and by education of female household head. Median costs and percent distribution of medical cases by total cost of health care and age. Median costs and percent distribution of medical cases by total cost of health care and income. Median costs and percent distribution of medical cases by total cost of health care and color. Median costs and percent distribution of medical cases by total cost of health care and home tenure. Median costs and percent distribution of medical cases by total cost of health care and place of residence. Median costs and percent distribution of medical cases by total cost of health care and health environment index. xvi Page 244 246 246 247 248 249 251 252 253 259 263 264 265 266 268 Table 143. 144. 145. 146. Median costs and percent distribution of medical cases by total cost of health care and communication-participation index. Median costs and percent distribution of medical cases by total cost of health care and size of household. Median costs and percent distribution of medical cases by total cost of health care and education of male head. Median costs and percent distribution of medical cases by total cost of health care and education of female head. xvii Page 269 270 272 273 IN. “I! ad ‘llfi t‘ut 3 \ CHAPTER INTRODUCTION Significance of the Study Due to the prominent place which health matters have had on the national, state, and local scene in recent years, this study is particularly timely. The last few decades have seen greater emphasis on health and health care programs in this country than at any other period of its history. This emphasis has been spearheaded by a strong drive for legislation to pro- vide a national program for the payment of medical costs. This drive has been equalled only by those who have favored complete private operation and control of health programs.1 Many 1. There is much literature relating to the background and history of the health controversy in this country. The reader is referred to the following sources as examples: Odin W. Anderson, "The Health Insurance Movement in the United States: A Case Study of the Role of Conflict in the De- ve10pment and Solution of a Social Problem," Published Doctoral Dissertation, Publication 959, Ann Arbor: University of Michigan, 1948. Helen Hershfield Avnet, Voluntareredical Insurance in the United States: Major Trends and Current Problems, New York: Medical Administrative Service, Inc., 1944. Oscar R. Ewing, "The Nation's Health--A Ten Year Program," Washington: United States Government Printing Office, September, 1948. Frederick L. Hoffman, More Facts and Fallacies of Compul- sory Health Insurance, New Jersey: Prudential Press, 1920. Sheldon G. Lowry, "Attitudes of Michigan Residents Toward Government-Sponsored Prepayment Plans for Health Care," Unpub- liShed Master's Thesis, East Lansing: Michigan State College, 1950, Chapter I. (3’: ‘4'54- M"‘i:' ‘V A..-- v . u I ..u u S. 9 . n» . 1 e . o o _ . . . s . . h . pk. . 4 .§. 0 . n S . «4 a . . . at is r. .u. v . . . ... .t. a. it .. . . . a .2 .L 3. A. 4; e o s .. . 1 Cu 2... «a a 0 i .Q . u u 0.; .4 a 1 l C. .P. . A Ti .5. «.4 n.-. .4 J .0 - Ad ‘I ’5 «H5 AU A!“ n.\ I .u. .3 . a .K. 0 2 ad 1 $k .7. «NV 9. u L. it.“ ‘9» in“ v . o . o . 0 . t .Pa 3. .u. ‘IA 0. n. .7.— I \C, 4.; P» S .L .d v... «( .fid n4 $1.. ‘4‘ c» .5. Q‘u \‘ .p. .F. t c nan a Any ‘1‘ I4 bib ‘4 a. a ‘5“ A: Q .I‘ v M PV p: FIN r «a. u . .\. .11 Q . ad. I. § I. A- N NJ. an». . A ‘4 nah 1‘ A. u it All Av an «30 ‘1‘ a... UN.) MH- ..|‘ allJ .94 .-v I a 1: .h. . . AIL .1. ‘Id n\ .1. O Mn {in at. “SN «VAN .Ju. 71.. .n Q .‘ c 5' «1.4 .4! tlk m1 VulN ”Hat 1|. «J and .v» .h- Q a be a .- sin .1 o nfik - M It 1. .1, .n o C. Ab. NI! h...- ANH. ”Mi \6 .u- :‘(l A: . ¢ DH u =— .1 0» hi. I «J n. 0» ct u' i ‘51. \K Y! u. u... uU.» a9 F): 34 h; Mil H0. in bra/.1 ”NH «.4 .nM . ‘ 0 O f‘ v I . f . . . A v I . v + i ; Q ' 'I\ I I I r n o v 0 l v w t 'u I r 9 I 4 fix . I l commissions have been appointed, and many studies have been made and are still being made, both local and nation-wide in scope.2 The state of North Carolina has had a tremendous upswing in in- terest and efforts in the field of health during the past few years. The establishment of the North Carolina Medical Care Com- mission, the hospital building program, the costly new and ex- panded medical school program at the University of North Carolina, increased efforts to make health insurance available to the peOple of the state, and the establishment of a medical educa- tion loan fund are all evidence of this interest.3 There is Harry Alvin Millis, Sickness and Insurance: A Study of the Sickness Problem and Health Insurance, Chicago: The Uni— versity of Chicago Press, 1937. A. M. Simons and Nathan Sinai, The Way of Health Insur- ance, Chicago: The University of Chicago Press, 1932. Pierce Williams, The Purchase of Medical Care Through Fixed Periodic Payment, New York: National Bureau of Economic Research, Inc., 1932. 2. The most recent federal commission to be appointed was The President's Commission on the Health Needs of the Nation which was created by an Executive Order on December 29, 1951. Dr. Paul B. Magnuson (M.D.) was selected as Chairman of the Com- mittee. The final report entitled, "Building America's Health," Washington: United States Government Printing Office, 1952, was in five volumes as follows: Volume 1, Findings and Recom- mendations; Volume II, America's Health Status, Needs and Resources; Volume III, America's Health Status, Needs and Re— sources--A Statistical Appendix; Volume IV, Financing a Health Program for America; VOlume V, The Peeple Speak—-Excerpts from Regional Public Hearings on Health. 3. 'In 1945 Mayo made a summary review of the existing medical facilities and services in rural areas in North Carolina, as well as the needs and efforts being made to fulfill those needs. See: Selz C. Mayo, "Post War Planning for North Carolina: Rural Health Services and Facilities," Raleigh: North Carolina State College, Department of Rural Sociology, Report No. 12 (Mimeographed), October, 1945. For a brief historical sketch of the development of health programs and activities in North Carolina see: "Hospital Resources and Needs,"'The Report of the North Carolina Hospital Study, 1951. «1'3" we” ' ‘ .,..' --».C ~3CIZ‘ fish-A 5“; 4' v.' 0‘ ‘uls Z} 326 S the filth c L. P,- v every indication that these measures constitute just a beginning in the development of programs whereby all of the people of this state can have ready access to the best care which modern medi— cine can provide. Although some studies have been made, there has been con- siderable need for a more detailed sociological analysis of the factors associated with health as reflected by living conditions, social contacts, race, education, income, and other social and economic factors. The present study is designed to provide some of this needed information for the various health agencies and groups, as well as for applied sociologists, social workers, and others who are concerned with the health of the peOple. Purpose and SCOpe of the Study This investigation is part of a larger state—wide study of health conditions and medical services and facilities which was directed by Dr. C. Horace Hamilton, Head of the Department of Rural Sociology at North Carolina State College, during the latter part of 1949. A scientific random sample was drawn from the entire county to yield a sample of 588 hhuseholds which in- cluded 2125 individuals. The study was based on a house-to- house canvass of the entire sample. For a review of the development of medicine in general and of the efforts 6f the pe0ple Of North Carolina in particular see Dr. Frank Graham's address in dedication of the University of North Carolina Medical School. Frank Porter Graham; "A Challenge to the Medical Schools and the Medical Profession," Reprinted from Pediatrics, V01. 13, No. 1, January, 1954, pp. 92-100. 5,. Js - a . O- - {rd 1C1. s“: i.‘_ .III. _ :l‘J‘lc C); h' " 0‘ ~— RRQ I ,1 mm: 3.12-: JI’ .. r‘ 1...}, HA ~:.‘.“:‘ 32:..4. '~95 a_; fat ‘~ I I” a A ‘ h ‘ 5:: a: C; 'V 1“”!c. w 04M-.s' 1“; (A. 5" '12: 5‘ i'elliaa b ‘5‘ a-IA I ‘50 C o‘~ “°‘\ 15:. The objective of the study was to collect and analyze data which could be used to plan a more effective health pro- gram for the county and to provide a basis whereby basic prin- ciples could be derived in order that the health programs of the county, the state, and of the country as a whole, may pro- ceed on a firm foundation. The present analysis is based on three basic or dependent variables, namely, morbidity, the use of health services and facilities, and the cost of health ser- vices and facilities. These variables are analyzed in terms of a set of selected social and economic factors or independent variables. The study also sets forth in a methodological note some of the components of a theoretical scheme which can be used in similar studies in the future. By such an approach future studies will become more additive rather than a series of dis- creet inventories. The Sample The sample was drawn on the basis of approximately 2 per- cent of the entire pOpulation of Wake County, North Carolina, exclusive of the student and institutional pOpulation. This yielded a sample of 588 households and 2125 individuals. The sampling unit in the study was a household. The term, household, refers to the entire group of persons who occupy one dwelling unit. It may consist of one or more persons. It may also consist of one or more families depending on the house- keeping facilities and arrangements involved. - I': OJ- A v '- ‘ . v- I. ‘v 3e~n ”A A, .-Iua-‘ . . \ a. s-- O . 1‘1‘.';!. ‘— na-A \...--A\ J , ‘3 A IAO‘1 1 - .‘ " .3 a. .‘ ‘r t ‘. .. n2. O‘:_;~; . undo-4 .._..--'_ ‘ ‘ b. 1.3.... '3 ‘\ o 0 U"“::: :r ‘3‘“!- Ut‘byls ha"..-l '- ‘..- .I Sf‘-‘ ‘ m4: ‘6 ’a ‘1, .5“ -' 3 C‘in. _ ’ ~‘un_ a 3‘ The term, dwelling unit, is defined as the living quarters occupied by, or intended for occupancy by, one household. A dwelling unit may be a detached house; a tenement, flat, or apartment in a larger building or apartment house; an apartment hotel or section of a hotel devoted entirely to apartment rather than transient use; a room in a structure primarily devoted to business or other nonresidential purposes; a superintendent's living quarters in a public building, such as a courthouse or library; a watchman's living quarters in a factory, store, or warehouse; a chauffeur's living quarters in a garage; a tourist cabin, trailer, railroad car, boat, tent, etc., if occupied by persons having no other place of residence. Some large boarding and rooming houses, those with 5 or more roomers, such as resident hotels and other resident institutions, were sampled. However, this was not carried through system- atically and, as a result, 91 of these individuals were not included in the sampling procedure. The rural sample was selected by the route method.4 Each interviewer or pair of interviewers was assigned to an area. Using a map, they traveled over every road in the area and counted the houses with the aid of a tally counter. When the sample number was reached an interview was taken. Each house where an interview was taken was identified on the map by a map number shown on the schedule. 4. The 1940 United States Census definition of resi- dence was used throughout. 4‘95? a ‘1' 9 '1‘. J‘J.‘ . ..- I. uuA- - ‘ 7.. “.1":- "H .u -a- "‘ ‘ U‘ to ~ ‘ F .-. _.¢‘F\I 0.;s'n . 5" ' . b-v‘: 1“ that. ‘ J y ‘A, h ‘ I. D: . I . . . ,r’} ' ‘Aw ”1.111055— 1““ ‘ AA' p- P . . v ' . . . hasehclis we: . NEIZIISS, “.1. f ' ~'.~—3 contrv o :5 udc‘ n. . 8 ‘ r . 3y ab 1:] ‘ L kw “Elfin. . ““g in ‘:.J 31"“: “3': . -~ a r g ‘ Sample numbers were determined as follows. The first number was a random number between 1 and 50 which was selected from a table of random numbers. In order to get two houses which were not too far apart, the second sample number was de- termined by adding 8 to the first number. Thereafter, the sample number series continued in groups of two, 8 houses apart, for each 100 houses. For example, if the first number was 41 the others in the series would be 49, 141, 149, 241, 249, and so forth. If two households with separate living quarters were found to be living in the same house, records were taken from each household. However, multiple dwelling units with more than 2 households were treated as a series of single household dwellings. There were few units of this type found in the Open country or the small towns. Sampling in villages and small towns was handled in the same way as in the open country. Care was taken to count every dwelling in the town. In advance of the actual counting of the houses, a random route up and down the village street was pre- pared by means of a special street map. Houses under construc— tion and abandoned houses were not counted. Vacant houses were counted, and if they turned up as the sample dwelling the fact that they were vacant was recorded on the map. Trailers, tents, and other dwellings of a temporary character were included, but overnight trailer camps and similar dwellings were not counted. Every effort was made to locate houses which were hidden from view either in the woods or other isolated places. Every side road was explored. Information was obtained from either the female or male head of the household, depending upon the one available. No alternate system of selection was used. The interviewers were instructed to make as many return visits as were necessary to obtain the interview, until they were relatively certain it could not be obtained. Seventeen households were missed either due to outright refusal or the fact that the informants could not be contacted. Since no in- formation was obtained from these 17 households, they have not been taken into account either in the analysis or the tables of this study. Definition of Terms Place of Residence. Residence was divided into the three traditional categories of rural farm, rural nonfarm, and urban as defined by the 1940 Census of P0pu1ation. Essentially they are classified in the following manner:5 Urban includes incorporated places having a population of 2500 or more. ‘Ruggl includes all other areas. Rural farm applies to rural people who live on farms of three or more acres in size or pro- duce as much as $250 worth of agricultural products. £2331 nonfarm includes all other peOple, that is, people who are neither rural farm nor urban. 5. For a more detailed definition refer to the "1940 Census of Population." 92123. The race of the informant was designated as either white or nonwhite. There were only two races involved in the study, namely, Negroes and Caucasians. Tenure. Throughout the study tenure refers to home tenure, that is, whether the family owns their own home or whether they rent. Agg. The age of the individual was determined according to his last birthday and not by his nearest birthday as is sometimes done. ‘§g§. Sex was considered only beyond the age of 17 years since it was felt that it was of little consequence for this study below that age. Education. The education of the heads of households was determined by the last grade completed. Crowding_Index. The crowding index was calculated as the number of persons per room, that is, the number of persons in the household divided by the number of rooms in the dwelling unit, exclusive of bathrooms, storage rooms, etc. The term "crowding" in no way implies a subjective evaluation. It is simply a short, convenient term used, as in the Hagerstown 6 Morbidity Studies, to express the number of persons per room. Health Environment Index. The health environment index is an index of 20 items which were selected by the committee in 6. Edgar Sydenstricker, "Economic Status and the Inci- dence of Illness," Hagerstown Morbidity Studies No. X, Public Health Reports, Vol. 44, No. 30, July 26, 1929, p. 1822. . I g. - vao' r s..;-.': 0. 0 :1 1 :0‘1. .Iua 0-: ntgbiu bet-u b '. K. (D C). “K co 1‘: (A) (0 charge of the research on the basis of two primary assumptions: first, that the presence or absence of the items contained there— in provides some indication of the conduciveness to healthful living of the immediate surroundings in which the family lived; second, that these items provide some measure of the awareness of or attitudes toward healthful living. Some argument may possibly be raised about the inclusion or exclusion of certain individual items. However, it should be pointed out that the index is in an exploratory stage, and while further standardi- zation is necessary, it is felt that the group of items as a whole provides a useful index for the purposes of this study. The index is composed of the following items: 1) 2) 3) 4) 5) 6) 7) 8) The condition of the dwelling unit. Each dwell- ing was judged by the interviewer as excellent, good, fair, poor, or bad on the basis of certain selected criteria such as the condition of the foundation, floors, internal and external walls, ceilings, roof, doors, porch, etc. Detailed instructions were given to the interviewers to aid them in placing each dwelling unit into one of the above categories. The categories were then weighted from "0" for "bad" through "4" for "excellent." The remaining 19 items in the index were simply rated "1" for presence and "0" for absence. There- fore, the total possible score for the index was 23. Entrance not in the alley. Dual egress. Living room. One or more bedrooms per two pe0ple. Windows for all rooms. Insect-proof screens. Safe water supply (public system or privately drilled well, covered and prOperly located). 7. A well was considered to be properly located if it was on the "up-side" from the family privy and livestock yards, and as much as 50 or more feet away from these facilities. 10 9) Running water in house. 10) Carry water less than 50 feet. 11) Kitchen sink. 12) Sanitary sewage disposal (public system, septic tank, or approved pit pr§vy).8 13) Private bath and toilet. 14) Private kitchen.9 15) Running hot water. 16) Central heating system. 17) Electric lights. 18) Mechhnical refrigerator. 19) Ice box. 20) Rats and insects under control.10 Communication-Participation Index. As the name suggests, this index was composed of two major parts. The section on communication included the following items: 1) Automobile for family use. 2) Radio in Operating condition. 3) Telephone. 4) Daily newspaper. 5) Weekly or local newspaper. 8. An approved privy is one which has been constructed according to the approved plan of the public health department. It is of interest to note that, according to the 1950 U. S. Census, 5.9 percent of the households in Wake County had no toilet facilities at all. This rose to 8.4 for the nonwhite population. See: C. Horace Hamilton, "Statistics on Rural Population and Rural Family Living," Raleigh: The North Carolina Agricultural Extension Service, Compiled in the Department of Rural Sociology, North Carolina State College, November, 1953. 9. The word "private" refers to the fact that this item is not shared by any other family. 10. The informants were asked if they had any rats or insects at all. If the answer was'hd'or if they had taken ade- quate measures to rid themselves of such pests they were given a positive rating on this item. 0‘, ,. w r)” ‘ I L): v \4 \i/ ' hark c) a; -‘- ‘fi‘ " .L'J) ‘53 1‘) ('9' J. V- 139 5:.1 uceat or uzrk ( 1) C ;r 2) L‘;f 3) sz; 4) 9-5. 5) LaELr 5) C7332”: 7) Gener, 6 11) Soc 12) Boa r9 C) . , J ' 3‘1 5-4- (Li .1) 9‘ '1 ’ ' f 'I 11 6) Farm magazines. 7) Other magazines. 8) Encyc10pedia. ‘ 9) Home health guide.11 10) Government pamphlets on infant and child care. 11) Other government pamphlets on health. The section dealing with participation included attend- ance at or work in the following organizations: 1) Church. 2) Lodges and fraternal orders. 3) Civic and luncheon clubs. 4) Business and professional organizations. 5) Labor unions. 6) Cooperatives. 7) General farm organizations. 8) P.T.A. ‘ 9) Home Demonstration clubs. 10) Other educational organizations. 11) Social and recreational organizations. 12) Boards and committees of any organizations. Each of the communication items was simply rated "1" for presence of one or more of a particular item and "0" for absence, which made 11 possible points. The participation items were each rated "0" for "no" participation, "1" for "some" partici- pation, and "2" for "much" participation. This resulted in 24 possible points. The total possible score for the entire index, therefore, was 35.12 This index was based on the assumption that the possession or nonpossession of various means of communication and the partici- pation or lack of participation in various organizations will 11. "Home health guide" refers to a sort of home health encyclopedia such as that published under the editorship of Morris Fishbien, former Editor of the Journal of the American Medical Association. 12. The highest score received on the index was 25. . . . H"" F at. '-,.. . .55“: ‘ '1‘...e.‘:..5.-. I ‘ Q pOQA .. - :37...‘ 3 0-)? l: - .3; ' .,.,J ,_ , ,- ‘o. ‘4‘. 6 ‘V Vi: ’é‘Z“. z..- :?“' : "I (D Total r1 U r a.»4 0'7.) O) I l ‘. 41 thD 0‘; ~‘H _ ~11? ab]? to Country 1at103 1 apparent Varying availabl ounions 58 Table 17. Rates of acute illness of urban residents by color and age. Color Age Total White Nonwhite P Tbtal 30.0 37.1 14.3 .001 Under 6 60.3 80.8 23.3 .001 6-17 31.9 42.4 13.5 .01 18-44 27.0 31.5 16.1 .01 45-up 19.0 23.9 6.8 .01 P .001 .001 -- The rural nonfarm group of both races needs consider- ably more study. It is a relatively new phenomenon in the country's history. In North Carolina the rural nonfarm popu- lation increased by 53.6 percent from 1940 to 1950.54 It is apparently composed of peOple from many walks of life and from varying socio-economic levels. Sufficient information is not available at present to account for their acute illness rates. Ensminger and Longmore have stated that the traditional Opinions of farm peOple undoubtedly play a part in cutting down the number of the illnesses which people in rural areas report, that farm life is conditioned largely by nature which may at times drive the farmer into the fields despite a physical condition which would keep a city man inside.55 This is a 54. 1950 United States Census of Population, U. S. De- partment of Commerce, Bureau of the Census, Washington: United States Government Printing Office, 1952. 55. Carl C. Taylor, 22. cit., p. 161. rather commonly exploration. 1’ that traditiona in urban. Tue is conditioned do well to isoi in terms of in" as Ensminger a: large measure, health rather liVinE.56 59 rather commonly accepted assumption, and one which needs further exploration. It is not sufficient to proceed on the assumption that traditional Opinions are Operating in rural areas but not in urban. The health behavior Of both rural and urban people is conditioned by "traditional Opinions." Future studies would do well to isolate and describe them and show how they operate in terms Of influencing health behavior. In the final analysis, as Ensminger and Longmore pointed out, good health will, in large measure, be the result of the Observance of the laws Of health rather than any unconscious result of rural or urban living.56 Health Environment Index. TO the knowledge of the author, a health environment index such as this one has not been used in the analysis of health and health care before. The closest thing to it has been various level Of living indices. However, it would be inaccurate to assume that this is simply another level Of living index. The items of the index were deliberate- ly chosen to reflect, not level Of living, but rather some of the provisions that have been made around the home which tend to be conducive to good health. It can be assumed that this, in turn, gives some indication of the underlying values and attitudes which motivate people in the realms Of health care. Table 18 reveals that those whose physical surroundings are most advantageous in terms of promoting good health are actually those who report the highest rates of acute illness. 56. Ibid., p. 162. Table enviror Vironme were me there wg a°ute i: the latt in Table FeverSe 1 creasing 8V9), the it is .01 regardleSE 60 Table 18. Rates Of acute illness by health environment index and age. Health Environment Index Age Total 0-10 11-18 19-22 23 P Total 31.3 27.9 26.4 35.1 42.3 .001 Under 6 53.2 35.4 46.3 64.8 96.8 .001 6—17 33.8 30.3 25.6 46.8 46.7 .02 18-44 29.4 27.3 28.2 29.8 35.2 --- 45-up 19.4 14.5 14.4 23.3 26.5 .10 P .001 .10 .001 .001 .001 Among those with the highest health environment index, almost all Of the children under 6 years of age are reported to have had some kind of acute illness during the 6 months previous to the study. With increasing age the influence of health environment index on acute illness rates is lessened. Of interest at this point is to compare the health en- vironment index with income. If reporting of acute illness were merely a matter of income one would naturally expect that there would be a closer relationship between them than between acute illness rates and health environment index, even though the latter is associated with income. The results as shown in Table 19 reveal that, while the difference is not great, the reverse Of this is true. Acute illness rates increase with in- creasing index values as well as with increasing income. How- ever, the P value for the former is .001 and for the latter it is .01. High index groups tend to report the highest rates regardless Of income. However, the reverse Of this is not true. Tmfle h We; 1“ fa< StUdy that cultt attn his ( the 1 thes. in a Over Enci 61 Table 19. Rates Of acute illness by income and health environ- ment index. Income Health Environment Total Under $1,500- $4,000-up Unknown P Index $1,500 3,999 Total 31.3 28.4 29.2 39.1 31.9 .01 0-10 27.9 27.7 30.3 12.5 30.0 -- 11-18 26.4 . 25.8 23.9 39.5 38.2 -- 19-22 35.1 41.3 32.4 39.2 28.2 -- 23 42.3 100.0* 44.4 41.4 25.0* -- P .001 -- .02 —— *Rate is based on less than 10 individuals. In fact, the lowest rate in the table is found in the highest income group but within the lowest index group. This is an area which needs considerably more thought and study. The evidence here presented points to the conclusion that reporting of acute illness is highly related to social and cultural phenomenon. It is related to one's basic value- attitude system which influences one's health awareness and his definition of illness. Income is found to be related to the reporting Of acute illness because it too is related to these same factors, that is, there is a tendency for the peOple in a given income group to have similar value—attitude systems. However, this is far from a one to one relationship. TO single out any one factor as being the cause is to overlook the complexity of human behavior. One set of influ- encing factors involves the actual presence Of some morbid coziitioa. 323' health facilitie nature and invol afourth set in background of ti". View of the pres. be rezerbered tn: is related to one: syste: which is p 0:1 the various in T38 follow: 15311 int erviev o: 62 condition. Another set involves the presence or absence of health facilities and services. Another set is of an economic nature and involves the ability to purchase health care. Still a fourth set involves the value-attitude system and cultural background of the individual which influence what man does in view of the presence or absence Of the other three. It should be remembered that even the ability to purchase health service is related to one's value-attitude system, since it is this system which is primarily responsible for the priority placed on the various items in the family budget. The following instance is illustrative of the above point. In an interview on the Michigan state-wide health survey, one informant indicated that she had accompanied her neighbor to the grocery store on a recent occasion and that her neighbor had been complaining about the high cost of meat.57 She said she had not been able to buy any meat for her family at all for over a month. The interviewee Observed, however, that when they arrived at the store the neighbor purchased a dollar's worth Of candy for her children but still not any meat. It seems evident that some motivating factors other than economic were Operating in this case. Communication—Part1cipation Index. A detailed analysis of the individual items Of the index has not been made. However, there are certain characteristics which should be pointed out. 57. This case is one of many which the author experienced on the Michigan study. Like the he participati the higher most preval paper, auto The radio n dence group: fr0m 70.0 p1 96'1 Percem items in Orc on infant an and other £0 also Varied 63 Like the health environment index, the communication- participation index was positively associated with income, 1.9., the higher the income the higher the index score. The four most prevalent communication items were the radio, daily news— paper, automobile, and telephone, in decreasing importance. The radio held tOp place for both races and for all three resi- dence groups. However, even the prevalence of the radio varied from 70.0 percent among the nonwhite rural nonfarm group to 96.1 percent among the urban white. The four least prevalent items in order of decreasing importance were government pamphlets on infant and child care, weekly newspapers, home health guide, and other government pamphlets. The prevalence of these items also varied according to residence and color. Dr. Norris Smith, Chairman of the Medical Advisory Com- mittee to the Hospital Saving Association (Blue Cross), has indicated that one Of the major limitations in putting over the Blue Cross program in North Carolina is the inadequacy Of com- munication facilities and the inaccessibility of towns through- out the state.58 It would ordinarily be expected that those people who have a high index of community participation and access to modern means of communication would be more likely to have greater contact with the latest health information and, therefore, have less illness than those with a low index. On the other hand, on the basis of the above discussion on 58. Dr. 0. Norris Smith, "HOSpital Insurance Discussed," News and Observer, Raleigh, North Carolina, March 15, 1954. reportin: one woulc illness 1 the diffe large enc consiste: index an ,4 \1 Table 23. 64 reporting of acute illness and various socio-economic factors one would expect the higher index groups to report more acute illness than the lower groups. Table 20 reveals that, although the differences in the rates of the various index groups are large enough to produce a significant chi square, there is no consistent trend in relation to communication-participation index and reporting of acute illness. When income is considered, Table 20. Rates Of acute illness by communication-participation index and age. Communication-Participation Index Age Total 0-3 4-7 8-13 14-25 P Total 31.3 30.7 26.7 36.5 29.6 .01 Under 6 53.2 41.3 46.4 68.9 36.4 .05 6-17 33.8 36.5 25.5 36.2 44.8 -- 18-44 29.4 30.3 27.0 33.4 22.3 -- P .001 .05 .001 .001 .10 it was found there is also no significant difference between index groups within any incOme group. See Table 21. Table 22 Communic. Particip: Inde: _________ Total 0-3 4-7 8-13 14-25 P ‘Rate is b: It m “manicatic 65 Table 21. Rates of acute illness by income and communication- participation index. Income Communication- Participation Total Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Tbtal 31.3 28.4 29.2 39.1 31.9 .01 0-3 30.7 32.1 28.4 35.0 18.2 -- 4-7 26.7 24.1 24.9 37.2 35.1 -- 8-13 36.5 30.9 34.0 45.9 29.8 .05 14-25 29.6 35.7 25.0 31.0 44.4* -- P .01 -- -- -- *Rate is based on less than 10 individuals. It must be concluded, therefore, that either the report— ing Of acute illness shows no consistent relation tO indices of communication and participation or that the items making up this particular index need greater standardization. The latter conclusion is more likely to be the case. This is an area which needs considerably more study. Perhaps the index should be Split into two separate indexes, a communication index and a participation index. Thought should also be given to weighting certain items, depending upon their connection with health in— formation and health care. It has been found, for example, that in adult education certain organizations and agencies give con- siderably more time and effort to certain subject matter areas than do others.59 There is no reason to believe that the same 59. Charles P. Loomis, et alii, Rural Social Systems and Adult Education, East Lansing: The Michigan State COllege Press, 1953, Chapter 14 especially. would not be 20.0 percent phone, 73.7 t to 2.2 perce: hand, farm m; residents an: dication that but rather ha imPOI‘tahce Of “Ch as this tests of the environmen t . 6 these Conside Si & ant considera CIYde Hart 3 i} the Health In: With children 66 would not be true in the field Of health. Moreover, while only 20.0 percent of the rural farm peOple reported having a tele- phone, 78.7 urban residents reported having one. This drops to 2.2 percent for nonwhite rural farm residents. 0n the other hand, farm magazines rank fourth in importance among rural residents and last among urban. Therefore, there is every in- dication that the items in the index should not be equated, but rather have a system of weights devised depending upon the importance of the item. It is also probable that an index such as this has one of the same pitfalls as the intelligence tests of the past, namely, that they are geared to an urban environment.60 Any revision of the index would need to take these considerations into account. Size of Household. The size of household is an import- ant consideration in dealing with health and health care. Clyde Hart, in his recent national survey Of medical costs for the Health Information Foundation, found that those families with children under 18 years of age had the highest prOportiOn 60. For a discussion and analysis Of intelligence tests in this regard see: Sorokin, Zimmerman, and Galpin, $2..g£t., p. 266f. They analyzed 65 of the most important stud es up tO 1929 in which tests had been used to compare rural and urban intelligence. For a discussion of studies since that time see: C. A. McMahan, "Personality and the Urban Environment," in T. Lynn Smith and C. A. McMahan, The Sociology of Urban Life: A Textbook_with:Readings, New York: The Dryden Press, Inc., 1951, pp. 748-760. of fa: Statis crease come ii pect, c WOUld r reports: fI'Om 3 I Smaller, Table 22. .3" 67 of families reporting medical indebtedness Of any family type.61 Statistically speaking each additional member in a family in- creases the probability that some member of the family will be- come ill during any given period of time. Thus, one would ex- pect, on the basis of chance alone, that the larger families would report more illness. Table 22 shows that the highest acute illness rates are reported for children under 14 years of age in households with from 3 to 6 members. The rates for both the larger and the smaller households are significantly lower. This Observation Table 22. Rates of acute illness by size of household and age. Size of Household Age Total 1-2 3-6 7-up P Tbtal 31.3 24.8 35.3 23.5 .001 Under 53.2 0.0* 59.8 36.0 .02 6-13 42.9 25.0* 55.5 22.9 .001 14-17 16.0 20.0* 17.2 13.5 --- 18-44 29.4 28.0 30.8 24.1 --- 65-up 17.9 27.9 12.3 11.1* —-— p 0001 -" .001 .05 *Rate is based on less than 10 individuals. Odin W. Anderson, "Debt Among Families in the United States Due to Costs of Personal Health Services as of July, 1953," National Consumer Survey of Medical Costs and Voluntary Health Insurance, New York: Health Information’Foundation, SummaryReport NO. 4, 1954, Appendix A, Table 6. 68 is in line with the above findings. Large families are no longer the norm in this country, but rather they are becoming more and more associated with poverty, disease, and low social status generally. This is confirmed, at least in part, by the fact that 42.4 percent of the individuals in households with 7 or more members were in families whose incomes were below $1,500 as contrasted with 22.4 percent for those with from 3 to 6 members. Therefore, on the basis Of the findings which have preceded, it is to be expected that the largest house- holds will report less acute illness than the next largest households, even though the probability of some member Of the family actually becoming ill is greater. In those households with only 1 or 2 members there are few children below 18 years of age and a large proportion Of Older peOple, especially those who are widowed, retired, and unable to work. This group also has a fairly high proportion, 34.0 percent, with incomes below $1,500. These factors account, at least in part, for the lower rate reported for this group. Beyond the age of 14 years the rates are quite similar for the different household sizes. One would suspect, from an Objective point of view, that women in the childbearing ages in the largest households would report much more acute illness than those in the smaller households. Actually there is no significant difference between these women and those in the the smaller households. Although the women in the largest households have higher rates than the men (the P value is .10), they are id er honsehol fact that 1 ing ages a: heads. Tabl report the group those 9’ rates th in both the nificant inc WEre the ma; the Same inf data d0 not that: in add the reportin cultural bac Table 23. R / 69 they are identical with the rates of the men in the next small- er households. However, the data are actually obscured by the fact that the analysis is based on all women in the childbear- ing ages and not just the mothers or even the female household heads. Table 23 reveals that middle-sized households tend to report the highest rates in each income group. In this same group those with the highest incomes report significantly high- er rates than those in the lower income groups. However, with- in both the larger and the smaller households there are no sig- nificant income differences. Here again, if economic status were the major determining factor, one would expect it to have the same influence regardless of the size of the family. The data do not support such a conclusion. It must be concluded that, in addition to the actual physical presence of illness, the reporting of acute illness is highly related to one's socio- cultural background, which is related to household size. Table 23. Rates of acute illness by income and size of household. Income Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 31.3 28.4 29.2 39.1 31.9 .01 1-2 24.8 25.9 19.9 30.3 30.0 -- 3-6 35.3 32.6 33.7 43.6 26.8 .05 P .001 -- .001 .05 70 Crowding Index. A measure similar to the size of house- hold is the crowding index. It is not only related to the num- ber of members in the household but also to the size Of the dwelling which, in turn, is related to income and other socio- economic factors. In general, excessive crowding is related tO low socio—economic status. Therefore, one would eXpect to find the behavior of the individuals in such households to approximate that of low status peOple generally. Table 24 reveals that the highest rate is reported in the index groups 1.50-1.99. The lowest rate is in the index group 2.00 and up. When age is considered, there are also certain tendencies which become manifest. Among the two lowest age groups, where acute illness rates are highest, there is a rather clear-cut distinction between the rates of those in households with 2 or more persons per room and those under 2, the latter having much higher rates. The age group under 6 years in homes with less than 1 person per room has a rate al- most three times as high as those in homes with 2 or more persons per room. In the next age group, 6 to 13 years, the rates are over four times as high for the less crowded group. This is in line with the statement above that the persons in more crowded conditions are more likely to be low status peOple and, consequently, to report lower rates. 71 Table 24. Rates Of acute illness by crowding index and age. Crowding Index Age Total Under 1.00- 1.50- 2.00-up P 1.00 1.49 1.99 Total 31.3 32.2 29.8 41.9 21.8 .001 Under 6 53.2 75.5 50.6 50.8 26.4 .001 6-13 42.9 60.5 33.7 64.0 14.3 .001 14-17 16.0 12.7 25.6 5.0 15.4 --- 18-44 29.4 29.2 27.7 35.7 29.3 --- 45-up 19.4 21.2 15.3 18.8 7.7 ~-- P 0001 0001 .001 .01 -- There is no consistent trend with regard to crowding index beyond the age of 13 years. However, there is a clear line of demarcation between the rates of those persons above and those below this age level. Those individuals 13 years of age or less have considerably higher rates than those above this age. This trend shows up for each crowding index except those with 2 or more persons per room, where the age differences are not significant. There are no statistically significant differences be— tween the sexes in any age group nor within any of the crowding index groups. In the age group 18 to 44 years the women in households with 1.50 or more persons per room report a slightly higher rate than do the men, but the reverse of this is true among those below 1.50 persons per room. However, in neither instance are the differences large enough to be significant, as can be seen in Table 25. 72 Table 25. Rates Of acute illness of males and females 18 to 44 years old by crowding index. Crowding Index 1.00 1.49 1.99 Total 29.4 29.2 27.7 35.7 29.3 --- Female 29.6 27.6 25.2 45.5 36.4 --- p __ -- -_ -- -- Of further interest is to compare the crowding index with income. These rates are shown in Table 26. It is only among those persons with a crowding index Of .50 to .99 that the income differences are significant. The trend is toward higher Table 26. Rates of acute illness by income and crowding.index. Income Crowding Tbtal Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Total 31.3 28.4 29.2 39.1 31.9 .01 Under.50 24.4 26.4 20.7 27.7 17.6 --- .50-.99 34.6 23.0 31.1 46.7 25.0 .001 1.00-1.49 29.8 35.0 27.0 27.5 38.7 --- 1.50-1.99 41.9 37.4 41.6 0.0* 84.6 --- 2.00-up 21.8 19.1 22.6 38.9 20.0 --- P .001 .05 .05 .02 I"Rate is based on less than 10 individuals. With: small acute rathe both a ref is a] with have highs relat heads hers in ad 0f th “Ornn K. since 0 Dr 73 rates with increasing income. The same trend exists for those with 2 or more persons per room but it is not statistically significant. Within income groups there does not seem to be any consistent relationship between crowding and reporting of acute illness. When the total rates for crowding groups are considered without reference to income, it can be seen that it is the smallest and the largest index groups which report the lowest acute illness rates.62 These two groups probably correspond rather closely with the smallest and the largest households, both of which have a comparatively low socio-economic standing. Education of Household Heads. Education is not simply a reflection of the amount of information one has gained, it is also related to social and economic status. However, those with the highest educational attainment do not necessarily have the highest incomes, nor do they necessarily have the highest social standing, but there is a high degree of cor- relation. This study proceeded on the assumption that household heads would be sufficiently aware of the illnesses of all mem- bers of the household that they could report for each member in addition to themselves. It was also assumed that, because of the role household heads play in the family structure, the norms and standards by which they direct their behavior would 62. This trend did not show up as well in Table 24 since the two smallest index groups had to be combined in order to provide sufficient cases for statistical computations. be reflected hold. It wc related to i only in the of the other tainly expec people, be a formation. socio-econo: t0 correSpon Table this study, 1 and female hc for hale heac both is betwe thOSe With 9 demarcation a then a, groups whose l 74 be reflected in the behavior Of the other members Of the house- hold. It would be expected, therefore, that if education is related to health and health care this will be reflected not only in the illness rates of the household heads but in those Of the other members of the household as well. One would cer- tainly expect that the more highly educated would, Of all people, be most likely to have access to the latest health in- formation. Also, since education is so closely related to socio-economic status one would expect the acute illness rates to correspond with those of other socio—economic indices. Table 27 shows that acute illness rates, as reported in this study, rise with increasing education Of both the male and female household heads. The relationship is more consistent for male heads than for female, but the major difference for both is between those with less than 9 years Of schooling and those with 9 years or more. There is a rather clear point Of demarcation at the high school level.63 When age is taken into account, it is the younger age groups whose household heads have the highest educations which report by far the highest rates. See Tables 28 and 29. It is also interesting to note that in those instances where the edu- cation of the household heads is under 4 years, the age 63. Using the symptoms approach, Hoffer found that the prOportion Of peOple with "all positive symptoms untreated" was significantly greater for those below the ninth grade than for those with nine or more years Of schooling. See: Hoffer, g2. cit., Bulletin 365, p. 20; and Hoffer, gp.‘gl£., Bulletin 3 2, pp. 18 and 20. difference primarily is found 2 Table 27 75 differences are not large enough to be significant. This is primarily a reflection of the lower rates among children than is found among the higher educated classes. Table 27. Rates of acute illness by education of male and female household heads. Education of Household Heads House- 4 hold Total Under 4-8 9-12 1-3 college- Others* P Head 4 college up Male 31.3 29.8 26.3 39.6 38.2 45.5 21.3 .001 Female 31.3 15.5 26.0 37.6 41.3 36.2 21.3 .001 *This category includes no answer, no male (or female) head, and male (or female) head not living. Table 28. Rates of acute illness by education of male household head and age. Education of Male Head 4 Age Tbtal Under 4-8 9-12 1-3 college- Others* P 4 college up Tbtal 31.3 29.8 26.3 39.6 38.2 45.5 21.3 .001 Under 6 53.2 31.3 47.4 68.1 80.8 85.0 15.0 .05 18-44 29.4 33.8 21.9 31.4 29.7 39.7 30.2 .10 45-64 19.8 10.3 18.0 26.8 27.3 23.8 15.5 --*** P .001 -- .001 .001 .01 .01 *This category includes no answer, no male head, and male head not living. **Rate is based on less than 10 individuals. ***Age group 45-64 and 65-up were combined for computations of chi square due to a small number Of individuals in certain of the cells. Ill I‘ll 76 Table 29. Rates of acute illness by education of female house- hold head and age. Education of Female Head 4 Age Total Under 4-8 9-12 1—3 college- Others* P 4 college up Tbtal 31.3 15.5 26.0 37.6 41.3 36.2 21.3 .001 Under 6 53.2 20.0 36.1 68.3 83.3 57.9 0.0** .001 6-13 42.9 12.5 30.3 57.0 66.7 83.3 15.4 .001 14-17 16.0 25.0**l6.0 10.0 10.0 50.0** 33.3** -- 18-44 29.4 14.6 29.3 28.3 41.9 25.4 32.8 .10 45-64 19.8 12.9 14.9 27.1 24.6 28.6 7.1 --*** 65—up 17.9 16.7 13.8 21.2 9.1 33.3** 20.0 --*** P .001 -- .01 .001 .001 .01 *This category includes no answer, no female head, and female head not living. **Rate is based on less than 10 individuals. ***Age groups 45-64 and 65-up were combined for computations of chi square due to a small number of individuals in certain of the cells. Tables 30 and 31 reveal quite clearly that it is the people whose household heads have the highest education, eSpecial- ly above the eighth grade, and who have the highest family in— comes that report the most acute illness. Even though education and income are quite highly correlated, education is shown to be more highly associated with reporting of acute illness than is income. ”'3'. T213] Educa .Eale Total Under . 4-3 9-12 1‘3 col 4 (301185 Othersea 77 Table 30. Rates of acute illness by income and by education of male household head. Income Education Of Total Under $1,500- $4,000- Unknown P Male Head $1,500 3,999 up Total 31.3 28.4 29.2 39.1 31.9 .01 Under 4 29.8 29.9 28.6 75.0* 22.7 -— 4-8 26.3 25.5 26.3 29.6 15.8 -- 9-12 39.6 36.2 35.7 44.7 46.9 -- 1-3 college 38.2 25.0* 43.9 33.8 20.0* -- 4 college-up 45.5 0.0* 41.2 48.8 12.5* —- 0thers** 21.3 28.0 17.2 10.3 23.1 P .001 -- .10 -- *Rate is based on less than 10 individuals. **This category includes no answer, no male head, and male head not living. ‘Table 31. Rates of acute illness by income and by education Of female household head. Income Education of Total Under $1,500- $4,000- Unknown P Female Head $1,500 3,999 up Total 31.3 28.4 29.2 39.1 31.9 .01 Under 4 15.5 18.8 4.8 28.6* 27.3 -- 4-8 26.0 27.2 22.3 29.2 38.6 -- 1-3 college 41.3 33.3 38.0 46.8 0.0* -- 4 college-up 36.2 42.9* 33.3 37.3 33.3* -- Others** 21.3 27.4 21.8 12.5* 5.6 P .001 -- .001 -- *Rate is based on less than 10 individuals. **This category includes no answer, no female head, and female head not living. divi 1111 star 9013‘ 62. as the re; ear l4 ra- en. te- tw in Wi no Ca hi “r Dc 78 Summary and Conclusions. It was found that the 2125 in- dividuals in the sample pOpulation reported 666 cases of acute illness of one kind or another for the six months prior to the study. This figure represents a rate Of 31.3 cases per hundred pOpulation. On an annual basis this would constitute a rate of 62.6 cases per hundred. The major trends revealed in the study can be summarized as follows. Age was found to be a highly influential factor in the reporting Of acute illness. By far the greatest amount was reported among the youngest ages, especially the preschool and early school years. The lowest rate was for those persons from 14 to 17 years of age, but it was not much smaller than the rates for those persons above 44 years. There were no differ- ences of any consequence between the sexes, nor between the tenure groups. There was also no consistent relationship be- tween acute illness rates and the communication-participation index. On the whole, family income was positively associated with the reporting of acute illness, but the association was not as great as that for the health environment index or edu- cation of household heads. White groups reported considerably higher rates than the nonwhite. However, this tendency showed up more in the urban areas than the rural farm or the rural nonfarm. 0n the whole, there was not much difference between the residence groups. The rural nonfarm group showed a tenden- cy to reporttigher rates than the others, but the differences were not extremely large. The households with from 3 to 6 79 members reported more illness than either the larger or the smaller households. This trend is undoubtedly due to the fact that they have a greater tendency to be higher on the socio- economic scale than do either of the other two household sizes. With regard to the crowding index groups, the least crowded and the most crowded groups reported the lowest rates. This tendency appears to be another reflection of the trends report- ed for the largest and smallest households. The evidence of this chapter suggests that the amount Of acute illness which the various socio-economic groups re- port is not determined solely by the Objective presence or ab- sence of such illness. The definitions of illness and the standards of health and health care vary considerably from one group to another. This tendency is reflected in the fact that, on the whole, the higher social and economic groups reported higher rates Of acute illness than did the lower groups. Ill- ness is not simply an objective phenomenon which involves the presence or absence of some morbid physical condition. It is also a subjective phenomenon which depends not only upon the actual presence of some affliction but also upon one's atti- tudes towards such conditions. The attitudes of the various individuals are a reflection of the norms or standards of health and health care of the groups to which they belong. These standards, in turn, are culturally conditioned. On the whole, the higher socio-economic groups tend to be more aware of and concerned over conditions which may affect fl .———- H-r- - ---q~ ra§- "- w. the health status of their family members. As a consequence, they report more acute illnesses, especially the minor cases. 0n the other hand, the lower groups tend to accept illness as part of the nature Of things, and, consequently, they have a tendency to overlook many of the relatively less serious ill- nesses and to report the more serious ailments. It is not simply that they cannot afford medical care, and, therefore, tend to accept their condition. Such groups do not have the same standards of sickness and health as do those in the higher socio-economic levels. 81 CHAPTER 111 CHRONIC‘ILLNESS "SO long as the pOpulation was youthful, and com- municable disease uncontrolled, it tended to monopolize medical interest and effort. The epidemics were spectacular and devastating; and not too many persons lived long enough to con- tract chronic ailments. But now as we see com- municable disease yielding to control, and half of the pOpulation ranging in age from more than 30 to 100 we are brought face to face with the tremendous volume of prolonged illness which renders so many peOple partially or totally disabled. And, as a society, we ari not yet prepared to OOpe with the problem." This statement by Lively is indicative of the trend of much of the literature on chronic illness. The Metro- politan Life Insurance Company indicates that "in 1950 the average lifetime of the American peOple reached a new high of 68.4 years."2 This is a gain of 21 years since 1900. These gains are attributed to advances in the medical and allied sciences, broadening of the number and scope of ac- tivities of the public health agencies both official and voluntary, and a rapid rise in the standard of living.3 The Committee on Aging and Geriatrics of the Federal Security Agency has stated that "the big increase in the relative 1. Charles E. Lively, "Some Problems Warrant Study for Continuing Health Improvement," The Journal of_Qsteopathy, November, 1953, p. 13. 2. "Record High Longevity at the Mid-Century," Sta- tistical Bulletin, New York: MetrOpolitan Life Insurance Company, Vol. 34, No. 7, July, 1953, p. l. 3. Ibid. 82 number of Older persons is the result largely Of gains in the control Of infectious diseases, other advances in the fields Of prevention and medical care and Of the general rise in the standard Of living. Fewer people die in childhood or their early adult years; more live to reach their 60's and 70's."4 Age and Sex. Despite some differences in definition of chronic illness, the findings Of various studies with regard to chronic illness and age are in essential agreement. The National Health Survey, for example, showed a marked trend of increasing chronic illness with increasing age.5 Kaufman and Morse not only show that chronic illness increases with in- creasing age, but also that most Of the illnesses of older persons are of a chronic nature, while those Of children and 6 McNamara found youth are Of a relatively short duration. essentially the same relationship to exist among the rural farm people of Missouri.7 The Baltimore health study also 4. Committee on Aging and Geriatrics, Fact Book on Aging, Washington: Federal Security Agency, NO date, p. 4. 5. National Health Survey: 1935-1936, "The Magnitude of the Chronic Illness Problem in the United States," Washington: U. S. Public Health Service, Bulletin NO. 6, 1938, p. 8. 6. Harold F. Kaufman and Warren W. Morse, "Illness in Rural Missouri," Columbia: University of Missouri, Agricul- tural Experiment Station, Research Bulletin 391, August, 1945, p. 16. 7. Robert L. McNamara, "Illness in the Farm Popu— lation of Two Homogeneous Areas of Missouri: Its Relation to Social and Economic Factors and Its Susceptibility to Small- Sample Study," Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 504, July, 1952, p. 25. reported a sharp increase in the rates of chronic illness with increasing age.8 The results of this study are in agreement with the studies reported above. Table 32 shows that there is a pro- nounced association between age and the reporting of chronic illness. The rates rise from 2.2 for children under 6 years of age to 59.0 for people 65 years Of age and over. As with acute illness, the individuals between 14 and 17 years Of age have a lower rate than the age groups immediately above and below them. Table 32. Rates of chronic illness by age. Age Total Under 6-13 14-17 18-44 45-64 65-up P 6 Total 15.8 2.2 8.2 5.6 11.2 32.4 59.0 .001 ____A__ ___ It should not be assumed, as was pointed out by the National Health Survey report, that chronic illness is limited to the Older peOple.9 While the chances of becoming chronically 8. Elizabeth H. Jackson, "Morbidity Among Males and females at Specific Ages-~Eastern Health District Of Baltimore," The Milbank Memorial Fund Quarterly, Vol. XXVIII, No. 4, October, ‘1950, pf‘445. 9. National Health Survey, Bulletin No. 6, op. cit., p. 13. 84 ill are greater as one grows Older, there is a certain amount of chronic illness at all ages. A considerable amount Of such illness is found below the age Of 50 years.10 Above 17 years of age the trend is for women to report a higher rate Of chronic illness than men, except in the high- est age group. See Table 33. It will be recalled that there was no significant difference between the sexes with regard to acute illness rates. Table 33. Rates of chronic illness by sex and age. Sex Age Total Males Females P Total 18-up 21.5 17.5 25.2 .01 18-44 11.2 8.3 13.9 .02 45-64 32.4 24.1 39.7 .01 65-up 59.0 61.4 56.7 —- P .001 .001 .001 McNamara states that relatively fewer men than women report chronic illness in the two rural farm areas which he studied in Missouri.11 Kaufman and Morse also report higher rates for females than for males, although the difference is not statistically significant.12 They state, however, that 10. This same viewpoint is expressed in McNamara, 11. Ibid. 12. Kaufman and Morse, gp. cit., p. 19. n” H ,_ _‘ it? ,4. 1..) .57 _. if deliveries and complications of pregnancy are excluded, females have slightly fewer illnesses. Although not necessarily speaking of chronic illness, the Committee on Costs Of Medical Care reports that there was a peak of severe bed cases of ill- ness in the age group 20 to 40 years, reflecting illnesses associated with childbearing.13 However, the data were not broken down by sex groups, so the conclusion is only presumptive. In the light of the data collected to date it seems quite conclusive that women tend to have higher rates of chronic illness than men, at least in the middle ages. The evidence points to several ways in which this difference can be explained. In the first place, women have a wide variety of illnesses incident to childbearing, many Of which show up not only during the childbearing ages but in later life as well. This tendency, in turn, may reflect inadequate medical care of acute illnesses, especially those related to the bearing of children. Furthermore, conditions connnected with the meno— pause seem to be more pronounced in women than in men and often last over a period Of months or even several years. However, it cannot be concluded that the difference is due entirely to genital and puerperal conditions. The Baltimore study reports that the rate for females was below that for males up to the 13. Selwyn D. Collins, "A General View of the Causes of Illness and Death at Specific Ages Based on Records for 9,000 Fami- lies in 18 States Visited Periodically for 12 Months, 1928—31," Public Health Re orts, Washington: Government Printing Office, Vol. 50, NO. 8, gefiruary 32, 1935, pp. 244 and 254. age Of 15 years, but it was above the male rate in the Older ages even when these conditions were excluded.14 A detailed analysis of the kinds of illness common to males and females is needed before definite conclusions can be reached. Income. Previous studies have shown that chronic ill- ness decreases with increasing inzome, and that the burden of such illness falls heavily on the lower socio-economic groups. Kaufman and Morse report the highest chronic illness rates among the lower income classes.15 However, there was not a uniform decrease with increasing income, but rather, after a moderate rise from the middle incomes, the rates leveled off.16 The major difference was that the low income groups had the greatest amount of chronic illness. Even this trend was not consistent in all five of the counties studied. In two counties the lowest income groups did not uniformly have the highest "rates," but rather the highest "rates" were in the highest income levels and the lowest "rates" were in the intermediate groups.17 The authors indicate that it is possible that per- sons in the higher economic levels had "a more liberal notion of sickness and were more conscious Of illness than those of 14. Jackson, 2p. git. 15. Kaufman and Morse, 22. 213., p. 22. 16. Ibid. 17. Ibid., pp. 23-24. 87 lower status."18 It should be pointed out, however, that the Negro part of the sample was entirely located in one Of these two counties, and Negroes are not generally noted for their liberal attitudes toward sickness. Furthermore, the data were not held constant by age, a fact which may account for many of the differences Observed. The authors do compare the mean days of illness by income class for the various age groups. They make the point that it is the Older persons in the lower income groups which have the greatest amount of chronic illness.19 The National Health Survey reports that the frequency of chronic disabling illness was greater among the relief and low income groups than among "the more comfortable groups."20 The results of the present study also show that there is a negative correlation between income and the reporting of chronic illness. Table 34 reveals that although the rates de- crease with increasing income, there is a leveling Off at $1,500. The major difference is between those with incomes of $1,500 and above and those below $1,500. While the trend to- ward decreasing rates with increasing income is visible in every age group except under 18 years of age, the differences are statistically significant only in the age group 18 to 44 years. It should also be pointed out that within every income group 18. Ibid., p. 24. 19. Ibid., p. 26. 20. National Health Survey, Bulletin NO. 6, op. cit. there is a pronounced increase in rates as age increases, with by far the highest rates being in the age group 65 and over. Table 34. Rates of chronic illness by income and age. Income Age Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 Under 18 5.1 5.4 5.4 5.2 2.0 -- 18-44 11.2 15.8 12.6 5.8 6.6 .02 45-64 32.4 37.8 31.1 28.4 37.9 -— 65-up 59.0 68.5 52.3 53.3 25.0* —- P .001 .001 .001 .001 *Rate is based on7less_thah 10 individuals. It appears that the greater emphasis of high income groups on illness, especially in the beginning stages, may have the effect of lessening the amount of chronic afflictions which they will have. In effect, the greater concern over ill— ness becomes a preventive measure as far as chronic illness is concerned. Also, greater ability to finance medical care un- doubtedly is influential in lessening the susceptibility to long-term illness. Furthermore, it is likely that in report- ing illnesses which persist over a period of two or more months one is governed less by cultural compulsives and more by the Objective presence or absence Of a morbid condition. The result, therefore, would be less underreporting by the lower economic groups as well as less reporting Of minor ailments by the higher groups. Color. Few studies have treated chronic illness among the colored people. Kaufman and Morse report that the chronic illness rates (mean days of illness) of Negroes are slightly higher than those of white, but that difference between them is not significant even though the majority of Negroes have incomes under $500.21 However, the authors do not make it clear whether they are comparing white rates with Negro rates or simply the rates of the one county, which included all Of the Negro portion of the sample, with the other counties.22 The Negroes interviewed constituted one—sixth of the individuals surveyed in that particular county. Table 35 reveals that there is no Significant difference between the chronic illness rates of the two color groups as a whole nor in any age group. There is also no significant difference between white and colored males or females. However, both white and nonwhite females report higher rates than the respective males. This trend shows up particularly in the age groups 18 to 44 and 45 to 64 years for the white group and in the age group 45 to 64 for the nonwhite. As was mentioned above, one factor which may tend to account for this rather unexpected lack of difference between color groups is that in reporting illnesses which persist over a period Of time it is less likely that there will be underreporting among nonwhite 21. Kaufman and Morse, gp. cit., p. 37. 22. Ibid. ....— ,-.-4_ 7a- 90 persons. Likewise, the tendency to report minor afflictions on the part Of the white people is probably reduced to a minimum since such afflictions are not so likely to persist over a long period of time. Table 35. Rates Of chronic illness by color and age. Color Age Total White Nonwhite P Total 15.8 16.2 15.0 -—- Under 18 5.1 4.9 5.5 —-— 18-44 11.2 10.9 12.1 -—- 45-64 32.4 32.1 33.3 --- 65-up 59.0 57.1 65.4 --- P .001 .001 .001 Due to the small number of nonwhite persons in the in- come bracket $4,000 and up, it was difficult to get an accurate picture Of color differences among the higher income groups. Nevertheless, Table 36 reveals a trend toward decreasing rates as income of both the white and nonwhite groups increases. When the two upper income groups are combined there is no dif- ference between the color groups, but among the low income families the white individuals report significantly higher rates than the nonwhite. As with acute illness, this latter trend may reflect cultural differences in definition and recog— nition of illness, although this tendency is probably not as pronounced for chronic illness, as was mentioned above. It may also indicate, as Hamilton has pointed out, a tendency to report an illness only if some medical service is obtained?3 Since Negroes generally receive less medical service than whites, they would report lower rates. Another factor which should be considered is that the life expectancy for nonwhite persons is appreciably below that for white persons.24 The nonwhite chronic illness rate is probably not quite as great as it would be if the nonwhite peOple had an older pOpulation. Table 36. Rates Of chronic illness by income and color. Income Color Total Under $1,500— $4,000- Unknown P $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 White 16.2 26.9 16.0 13.1 11.8 .001 Nonwhite 15.0 17.0 12.9 5.0 --* ** P —- .02 -- ** *There were no individuals in this cell. **Chi square was omitted due to the small expected frequency in the nonwhite, high income cell. 23. C. Horace Hamilton, "Many Family Incomes in Wake County Too Low For Good Health Care," News and Observer, Raleigh, North Carolina, February 15, 1950. See also C. Horace Hamilton, "Rural Health and Medical Service in North Carolina: Papers and Preliminary Reports of Surveys, 1944-1949," Raleigh: North Carolina State College, Agricultural Experiment Station, Progress Report RS-9, August, 1950, pp. 20-21. 24. The MetrOpolitan Life Insurance Company indicates that "Among nonwhites the expectation of life at birth in 1950 was 59.2 years for males and 63.2 years for females." 0n the other hand, the life expectancy for white females was 72.4 years and for white males it was 66.6 years. See: "Record High Longevity at the Mid-Century," pp, 213., pp. 1 and 3. 92 Home Tenure. Table 37 reveals that, when tenure is considered as a whole, there is no significant difference be— tween the chronic illness rates of owners and renters. How- ever, within the age groups 18 tO 44 and 65 and up the renters report significantly higher rates. The P values are .05 and .10 respectively, indicating that the differences are not high- ly significant. The data are not sufficient to explain these differences. Table 37. Rates of chronic illness by home tenure and age. Tenure Age TOtal Owners Renters P Total 15.8 16.7 15.0 -— Under 18 5.1 5.5 4.9 -- 18-44 11.2 8.3 13.4 .05 45-64 32.4 30.7 35.3 -- 65-up 59.0 50.6 79.4 .10 P .001 .001 .001 Females have higher rates than males among both the owners and renters, except for those 65 years of age and over where there is no significant difference between the sexes. Table 38 shows that, while there is a significant de- crease in the reporting of chronic illness with increasing in— come among owners, there are practically no income differences among renters. Reuters in the two lowest income groups report lower rates than owners, but there is no difference between 93 them in the highest income group. Table 38. Rates of chronic illness by income and home tenure. Income Tenure Total Under $1,500- $4,000— Unknown P $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 Owners 16.7 28.0 17.5 11.7 11.4 .001 Renters 15.0 17.6 13.2 15.3 12.3 -- P —- .02 .10 —- Sufficient information is not available concerning the social-psychological and cultural backgrounds of owners and renters to account for the differences observed here. Per- haps neither group is sufficiently homogeneous within itself to be treated as separate and distinct from the other. On the other hand, as has been pointed out previously,tenure would probably be more meaningful if it were broken down by resi- dence and color. Place Of Residence. Rural areas generally have a dis- proportionate share of both the young and Old. Therefore, one would expect such areas to have higher chronic illness rates, although the rates may not necessarily be different within given age groups. The National Health Survey reports that the towns (2500 to 5000 pOpulation) and urban areas report I fewer cases per 1000 population of chronic illness disabling 94 for 7 days or more than the villages under 2000 population and the Open country.25 Table 39 reveals no significant difference between resi- dence groups in the rates of chronic illness at any age. There are also no significant residence differences among either the white or nonwhite pOpulations, with the sole exception Of non- white persons 18 to 44 years of age. The rural farm rate in this category is somewhat higher than either of the other places Of residence, but the difference is not highly signifi— cant. Table 39. Rates of chronic illness by place of residence and age. Residence Age Total Rural Rural Urban P Farm Nonfarm Total 15.8 15.2 15.7 16.4 -- Under 18 5.1 3.3 6.2 6.4 -- 18-44 11.2 13.7 8.8 11.2 —- 45—64 32.4 29.6 37.1 32.0 -- 65-up 59.0 67.4 66.7 46.8 v-- P .001 .001 .001 .001 In contrast to acute illness rates, there is no differ- ence in chronic illness rates between the color groups in any of the places of residence. The only exception to this trend is the urban nonwhite group from 45 to 64 years of age, which 25. Reported in Carl C. Taylor, et alii, Rural Life in the United States, New York: Alfred A. KnOpf, 1949, p. 162} has a higher rate than the white. However, even this difference is on the borderline of significance and could possibly be due to sampling variations. There is a tendency for the females of the age group 18 to 44 years to report more chronic illness than the males in the rural farm and rural nonfarm areas, but this tendency is not found in the urban areas. In the age group 45 to 64 years females report higher rates than the males in all three resi- dence groups, but the differences are significant only in the rural nonfarm and the urban areas. The P value is only .10 in both instances. There are no sex differences in the age group 65 and up in any place of residence. These trends point up the advisability of giving greater emphasis to the sex factor in chronic illness. It appears to be an influencing factor for both races among both rural and urban residents. Perhaps further study will isolate more definitely the factors involved, whether they be of an Objective nature actually involving more chronic illness, or of a subjective nature involving social and cultural motives. Table 40 reveals that chronic illness rates decrease with increasing income in each residence group. The differences are not statistically significant in the rural farm group. There are no significant differences between residence groups within any income group. On the basis of the preceding discussion, it appears that residence, as such, has little if any influence on the rates 96 Table 40. Rates Of chronic illness by income and place of residence. Income Residence Total Under $1,500- $4,000— Unknown P $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 Rural Farm 15.2 18.4 14.1 13.5 2.2 -- Rural Nonfarm 15.7 23.8 14.5 10.7 12.3 .05 Urban 16.4 22.5 16.2 13.3 22.0 .10 p __ -- __ _- of chronic illness reported in this study. As was mentioned above, one would expect rural areas generally to have more chronic illness per hundred population because they tend to have more Old people. However, this tendency is not revealed in this study. The factor of underreporting should not be over- looked, but additional research would be needed to confirm such an explanation. Health Environment Index. Table 41 shows that, although there is no significant association between chronic illness rates and the total health environment index, there are certain dif- ferences within age groups which should receive attention. Under 18 years of age the general trend is for the rates to in- crease as health environment index increases. For those 18 years Of age and above, the trend is reversed. This trend is probably more significant than it appears on the surface, since er 00 de gr in 97 it is the Older age groups which, on the whole, tend to have the highest rates of chronic illness. It would appear that those in the higher index groups are giving more attention to the care of chronic as well as acute illness in the younger ages and by this means are cutting down the tendency toward chronic illness in the older age groups. The trend may also reflect a greater indulgence On the part of higher index groups toward their children. However, due to the low level Of significance these trends are only suggestive. Table 41. Rates of chronic illness by health environment index and age. Health Environment Index Age Total 0-10 11-18 19-22 23 P Total 15.8 16.3 16.4 16.1 12.0 -- Under 18 5.1 4.6 3.0 7.5 8.2 .10 18-44 11.2 17.4 11.3 9.0 7.6 .05 45-64 32.4 31.3 38.4 32.5 18.3 -— 65-up 59.0 95.2 62.2 43.1 50.0* .10 P .001 .001 .001 .001 .02 *Rate is based on less than 10 individuals. Table 42 reveals that there are no significant differ- ences between health environment index groups within any in- come level. On the other hand, chronic illness rates tend to decrease with increasing income in all but the highest index group, although the differences are not large. In certain index groups the differences are not significant. Income appears 98 to be more influential in the chronic illness rates than is the health environment index. Table 42. Rates Of chronic illness by income and health en— vironment index. Income Health Environment Total Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Tbtal 15.8 20.5 15.2 12.7 11.8 .01 0-10 16.3 18.8 10.9 12.5 10.0 .10 11-18 16.4 21.5 14.9 14.0 10.9 -— 19—22 16.1 28.3 18.2 12.7 11.3 .05 23 12.0 0.0* 9.7 12.5 25.0* -- p _- __ __ __ *Rate is based on less than 10 individuals. Communication-Participation Index. There is a small, though significant, trend toward decreasing chronic illness as the communication-participation index rises. As can be seen in Table 43, this trend is evident only in the total and in age groups 18 to 44 and 65 years and up. As was the case with the health environment index, those individuals 65 years Of age and over in the lower index groups report by far the highest rates Of chronic illness. Those in the lowest index category report a rate Of 82.6 cases per hundred pOpulation as contrasted with 25.0 for those in the upper index group. However, the trend is only on the borderline of statistical significance and needs more study. 99 Table 43. Rates of chronic illness by communication- participation index and age. Communication-Participation Index Age Total 0-3 4—7 8-13 14-25 P Total 15.8 17.9 19.4 13.0 11.9 .01 Under 18 5.1 4.8 5.4 3.9 8.8 -- 18-44 11.2 15.6 15.4 7.9 3.2 .01 45-64 32.4 28.6 40.8 31.6 22.5 —- 65—up 59.0 82.6 67.4 48.6 25.0 .10 P .001 .001 .001 .001 .001 It cannot be concluded that a low communication- participation index is the "cause" of greater chronic illness rates, nor that a high index prevents such illness. It is possible, however, that prolonged illness has prevented par— ticipation in various community activities. Further study is needed to prove or disprove this assumption. When income is considered, it is found that there are no consistent differences between index groups within the in- come groups. There is a significant increase in chronic ill- ness with increasing income in the index groups 0-3 and 8—13, but income differences are not significant in the other index groups. 100 Table 44. Rates of chronic illness by income and communication- participation index. Income Communication- Participation Total Under $1,500— $4,000- Unknown P Index $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 0-3 17.9 23.0 10.5 10.0 9.1 .02 4-7 19.4 18.5 21.3 19.2 12.3 -- 8-13 13.0 22.7 12.1 9.6 13.4 .01 14-25 11.9 7.1 9.8 14.2 0.0* -— P .01 —- .01 -- *Rate is based on less than 10 individuals. Size of Household. Table 45 reveals that the rates of chronic illness decrease as size Of household increases. This tendency is to be expected since the prOportion of Older people is greater in the smaller households. Within any given age group, individuals in one size of household are as likely to report chronic illness as those in another size. The one single exception to this is that individuals under 18 years of age in households with from 3 to 6 members have higher rates than the other household groups. However, the difference is only on the borderline of significance. As in the case Of acute ill- ness, this relationship may represent a greater concern over illness for children in these households which have a little higher economic standing. It may also indicate an overindul- gence of the parent toward the child, with the result that his ailments may be extended as a means of gaining attention. However, the trend is not marked and needs further exploration. Table 45. Rates of chronic illness by size Of household and age. Size of Household Age Total 1-2 3-6 7-up P Total 15.8 27.1 14.6 10.1 .001 Under 18 5.1 0.0 6.3 2.9 .10* 18-44 11.2 13.4 10.2 13.9 ——- 45—64 32.4 30.5 34.2 29.5 --- 65-up 59.0 72.1 49.2 66.7** --- P .001 .001 .001 .001 *Due to the low expected frequency, the cell for the small- est household size was omitted from this computation of chi square. **Rate is based on less than 10 individuals. Table 46 shows that chronic illness decreases with in- creasing income for each size of household. However, the trend is not statistically significant for the largest households and is Of doubtful significance for those individuals in households with 3 to 6 members. Nevertheless, there is a rather consistent decrease in chronic illness rates with increasing size of house- hold within each income group. The individuals who report the highest rates are those in the smallest households with the low- est family incomes. These households have the highest prOpor- tion of older people and, consequently, higher rates of chronic illness. They are also in the poorest economic circumstances, a condition which makes it difficult to receive adequate medical care. Of course, the illnesses of these individuals no doubt contributes to their inability to earn larger incomes. The Size House Total 1-2 3-6 7~uD rates Simila largel less c ed by Signif; 102 peOple with the lowest rates, on the other hand, are in the largest households with the highest incomes. These households have prOportiOnately fewer Old peOple and, being in better financial circumstances, have been better able to give more adequate attention to their ills. Table 46. Rates of chronic illness by income and size Of household. Income Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 1-2 27.1 34.5 27.2 20.2 0.0 .001 3-6 14.6 18.8 14.2 11.6 15.2 .10 7-up 10.1 13.6 9.2 6.4 0.0 -- P .001 .001 .001 .10 Crowding Index. Table 47 reveals that chronic illness rates decrease as the crowding index increases. The trend is similar to that for size Of households noted above, and is largely due to a greater concentration Of older peOple in the less crowded households. This Observation is further support- ed by the fact that within any given age group there is no significant difference between crowding index groups. Within the various income groups, chronic illness rates Table 47. Rates of chronic Crowding Index Age Total Under .50— 1.00- 1.50- 2.00- P .50 .99 1.49 1.99 up Total 15.8 30.2 .9 14.4 11.4 11.4 .001 Under 18 5.1 17.6 5.4 4.5 6.2 3.2 —-- 18-44 11.2 7.4 9.8 12.1 17.9 12.2 --- 45-64 32.4 38.5 8.4 29.6 8.3 54.5 ——- 65-up 59.0 57.9 0.0 74.1 50.0* 75.0* --- P .001 .001 .001 .001 .01 .001 *Rate is based on less than increase as crowding decreases. due, in large measure, 10 individualS. See Table 48. 103 illness by crowding index and age. This trend is to the larger proportion of older peOple in the low index groups and a large prOportion of children in Table 48. Rates Of chronic illness by income and crowding index. Income Crowding Total Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Total 15.8 20.5 15.2 12.7 11.8 .01 Under .50 30.2 45.3 33.3 22.8 11.8 .10 .50-.99 14.9 20.4 15.0 12.1 16.2 -- 1.00-1.49 14.4 21.7 14.5 2.5 9.7 .01 1.50-1.99 11.4 16.5 6.9 ——* 0.0 .05 2.00-up 11.4 13.2 9.7 11.1 6.7 -- P .001 .001 .001 .001 *There were no individuals in this cell. 104 the high index groups. The highest rates are among low income persons in households under .50 persons per room. The lowest rates tend to be among individuals in the high index categories, especially those where the family income is also high. Education of Household Heads. Without reference to age, education of the male household head does not show any consis- tent relationship to the reporting of chronic illness. See Table 49. When age is considered, however, it is found that among individuals under 18 years Of age chronic illness rates rise very slightly with increasing education. This trend corresponds to a similar increase in this age group for health environment index groups.26 It is also only of borderline Table 49. Rates Of chronic illness by education Of male house- hold head and age. Education Of Male Head Age Total Under 4-8 9-12 1-3 4 Others* P 4 college college- “D Total 15.8 18.7 14.2 12.5 21.8 12.0 19.9 .05 Under 18 5.1 4.3 3.4 5.1 9.1 10.0 5.9 .10 18-44 11.2 12.2 14.5 9.0 14.1 2.7 12.3 .10 45-64 32.4 30.8 27.0 31.0 36.4 26.2 40.8 -— 65-up 59.0 85.0 63.0 68.8 53.8 100.0** 38.5 —- P .001 .001 .001 .001 .001 .001 *This category includes no answer, no male head, and male head not living. **Rate is based on less than 10 individuals. 26. It is interesting that there was not a similar in- crease among income groups. 105 significance. However, beyond age 17 there are no consistent differences between education groups. The major influencing factor is age rather than education. In every education group, without exception, chronic illness rates increase with increas- ing age. Table 50 shows that, on the whole, there is a very slight decrease in reporting of chronic illness as education of the female head increases. However, within the various age groups there are no consistent trends. Rates of chronic illness by education of female household head and age. Table 50. Education of Female Head 4 Age Total Under 4-8 9-12 1-3 college- Others* PI 4 college up Total 15.8 21.7 17.7 12.1 14.1 14.9 23.2 .05 Under 18 5.1 5.1 4.8 5.1 5.5 9.1 3.4 -- 18-44 11.2 7.3 15.1 10.9 8.1 7.5 7.8 -- 45-64 32.4 25.8 41.8 22.4 27.9 28.6 42.9 .10 65-up 59.0 83.3 69.0 48.5 27.3 50.0** 60.0 -- P .001 .001 .001 .001 .001 .01 *This category includes no answer, no female head, and female head not living. **Rate is based on less than 10 individuals. come, within income groups. When education of male head is considered along with in— it is found that there are no consistent education trends Within education groups there is a slight 106 tendency for the persons with higher incomes tO report less chronic illness. However, this trend is not entirely consis- tent. Furthermore, when the rates are compared by education of female head and income, it is readily seen that there are no significant differences between education groups within the various income groups nor between income groups within education groups. The reporting of chronic illness seems to be a little more highly associated with family income than with education of either household head. However, the difference is not large. Age is more influential than either income or education. Summary and Conclusions. The rate Of chronic illness re- ported for the entire sample of this study was 15.8 cases per hundred pOpulation for the six months prior to the study. Age was found to be the most influential factor in the rates of chronic illness of all factors studied. There was a pronounced increase from a rate of 2.2 for those individuals under 6 years Of age to a rate of 59.0 for those persons 65 years old and above. While it is true there was considerable chronic illness in those ages below 45, most of the illness in the ages 45 years and above was of a long—term nature. On the other hand, most of the illnesses in the younger ages were acute, as has been shown in Chapter II. In view Of the aging population in the nation, coupled with the declining productivity and earn- ing power as people grow Older, the implications of these trends are obvious. 107 Sex was also influential in the rates of chronic illness. As would be expected, the rates were higher for females than for males. This tendency was manifest primarily in the age groups 18 to 44 and 45 to 64. Family income was another factor which was found to have a rather consistent relationship to chronic illness rates. The tendency was for the rates to decrease with increasing in- come. The major difference was between those individuals with family incomes under $1,500 and $1,500 and up. This trend reflects a greater concern Of the higher income peOple over illness, especially in the beginning stages; this wiention tends to lessen the diSpositiOn toward long—term illness. The greater financial ability of such groups to finance adequate medical care is also influential in lessening such illnesses. Another factor is that among the lower income groups there would be less underreporting of ailments which persist over a long period of time. However, age was somewhat more influential in the rates of chronic illness than was income. There were no significant differences between the color groups as a whole nor within any age group. However, among the lower income groups the highest rate was reported for the white individuals. The tenure differences were not consistent. There was no significant difference between owners and renters without reference to age or income. However, there was a slight ten- dency for individuals in renter households to report higher 108 rates than individuals in owner households in the age groups 18 to 44 years and 65 and up. However, owners reported the high- est rates in the lower income groups. There were no signifi- cant residence differences within any age Or income group. There was some tendency for chronic illness rates to increase with increasing health environment index among those individuals under 18 years of age, but to decrease with in- creasing index beyond this age. These trends were only sug- gestive and need more study. With income constant there were no significant trends for the health environment index. There was a slight tendency for chronic illness rates to decrease with increasing communication-participation index. However, this trend showed up only for the total and for the age groups 18 to 44 and 65 and up. The trend for the latter age group was only on the borderline of significance. Within income groups there were no significant index trends. There was a general decline in the rates as size of household increased. This trend was Obviously due to the in— verse prOportion of older peOple as size of household increases, because with age held constant there were no significant dif- ferences. Individuals under 18 years of age in households with 3 to 6 members reported higher rates than individuals in the other household sizes. However, the trend was only of border- line significance. The trend for the crowding index was very similar to that for size of household. There was a general decrease in chronic __a_ _ ..... illn grou ship and ness grou cati .10, 1? w with cone illne the j IeVe] 109 illness rates as the crowding increased. However, within age groups there were no significant differences. This relation- ship reflects the Older average age for the lower index groups and the younger average age for the higher groups. There was no consistent relationship between chronic ill- ness rates and education of male household heads. In the age group under 18 years the rates increased with increasing edu- cation; however, the P value for the chi square test was only .10. On the other hand, chronic illness rates decreased slight- ly with increasing education of female household heads, but with age constant there were no consistent trends. Family in- come seemed to be a little more closely associated with chronic illness rates than was education of household heads, but even the income trends were not consistent throughout all education levels. In the reporting of chronic illness, variations due to differences in definitions of illness and in the awareness Of and concern over such illness are reduced to a minimum. There is less tendency for the lower social and economic groups to ignore illnesses which persist over a long period of time. Furthermore, since minor afflictions usually do not persist, the difference between the various groups in the reporting Of such cases would be negligible. These factors tend to account, at least in part, for the rather inconsequential differences found between the socio—economic groups in the reporting of chronic illness. Age stood out as the primary influencing factor in the chronic illness rates, with sex also being important in the age groups 18 to 44 years. 110 CHAPTER IV USE OF A DOCTOR The development of scientific medicine is relatively recent. Maes has pointed out that only "60 years ago prac- tically all Operations were of an emergency nature, undertaken with little hope Of success and only because death was in- evitable under any circumstances."1 Bernard J. Stern,‘in his book, Society and Medical Progress, has written a very interesting summary of medical progress from the magico- religious practices Of the primitive societies to the "scien- tific foundations" of Twentieth Century medicine.2 Full appreciation of many of the present-day superstitions, customs, attitudes, and values concerning health and health care cannot be had without understanding the long road over which medical science has traveled. The scientific approach is relatively young in the history of medicine. It would be folly to assume that it has completely erased the vestiges of the past even among the medical profession, not to mention the medically uneducated masses. 1. Urban Mass, "Aseptic Surgical Techniques," Hagers- town, Maryland: Practice Of Surgery, (Edited by Dean D. Lewis, et alii), Vol. 1, 1937, Chapter 7, quoted in Selwyn D. Collins, "Frequency of Surgical Procedures Among 9,000 Families, Based on Nation—Wide Periodic Canvasses, 1928-31," Public Health Reports, Vol. 53, NO. 16, April 22, 1938, pp. 587-588. 2. Bernard J. Stern, Society and Medical Progress, Princeton: Princeton University Press, 1941, especially Chapters I and II. 111 Although great advances have been made, home remedies, magic, and ritual have been embedded in the beliefs and customs Of the people and passed on from generation to generation.3 A vivid example of such reliance on tradition and at times actual distrust for medical science is found in the recent ex- periences Of Dr. George F. Bond when he first began to establish his medical practice in a small rural community in western North Carolina.4 Dr. Bond not only met with indifference and suspicion, but on occasion even with Open resistance, before he was able to establish his practice on a sound basis. Hoffer has pointed out the lack of agreement among the people as to when one should seek medical attention.5 He has indicated that for some the criterion is the amount of pain which they have or whether they are unable to work. In some instances it is a matter of time or reluctance to spend money for the services. On the other hand, there are those people who feel they can "get the best" of their ailments if they have enough determination. In a similar vein, Lively has stated that, among certain groups if a doctor is difficult to Obtain, 3. For an interesting discussion of home care of the sick see: Iola Meier and C. E. Lively, "Family Health Practices in Dallas County, Missouri," Columbia: Universityvof Missouri, Agricultural Experiment Station, Bulletin 369, June, 1943, pp. l7ff. For a detailed list Of home remedies used see the Appendices of that study. 4. Joseph Phillips, "The Revolution Of Hickory Nut Gorge," Readers Diggst, November, 1952, pp. 117-121. 5. Charles R. Hoffer, "Health and Health Services for Michigan Farm Families," East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 352, September, 1948, p. 27. 112 the peOple simply resolve to "try harder not to get sick."6 It is not known how wideSpread such attitudes and practices are. To the extent that they prevail, the use of health ser- vices will be affected by them. The use Of a doctor has received considerable attention from various research workers over the past few years. Such studies have been approached from many points of View. Some researchers have investigated the total number of office calls or home calls per family, per individual, or per sickness. Some have studied the percentage Of individuals reporting a given number of doctor's calls. Still others have been con- cerned with the percentage of illnesses for which a doctor's care was received. Combinations and modifications of the above approaches have also been used. The present study is concerned primarily with the rate of use of a doctor for all purposes. Although any given condition may have required a series of doctor's calls, the rates which are reported here include a maximum of one call per condition. For this reason, the rates which are analyzed here are not entirely comparable to the per- centage of individuals reporting one or more doctor's calls, since any given individual may report a series of conditions, each of which requires the services Of a doctor. Nor are the rates comparable to the percentage of illnesses for which a doctor's services were used. In many instances a doctor is 6. Charles E. Lively, "Some Problems Warrant Study for Continuing Health Improvement," Reprinted from The Journal of Osteopathy, November, 1953, p. 19. 113 used for reasons other than the treatment of sickness as such. The present method has the advantage of including each separate condition for which a doctor was used, but it avoids having one or two severe cases of illness weight a given socio-economic group with an excessive number of doctor's calls. The merit of these various methods is not in question. Each type has its value for the particular purpose at hand. The trends sug- gested by the various methods will be used for comparative purposes in order to further elucidate the findings of the present study. Of the various medical attendants available to the peOple, those which were used most frequently by the peOple of this study were M.D.'s, M.D. specialists, and dentists. The distribution is shown in Table 51. The M.D.'s received about twice as many calls as either of the other two. There were only 24 cases for which a non-M.D.7 was used and only one case for which a midwife was used.8 7. In the Michigan state-wide study it was found that one or more members of almost half of the families had used "a doctor who was not an M.D." See Charles R. Hoffer, et alii, "Health Needs and Health Care in Michigan," East Lansing: Michigan State College, Agricultural EXperiment Station, Special Bulletin 365, June, 1950, p. 49. 8. Contrary to what would be expected, the person using a midwife was a white person. Grisette has shown that in 1952, of the 1277 registered nonwhite births in Wake County 298 were attended by a midwife. This ratio is in contrast to 8 out of 2340 white births. See: Felix A. Grisette (Editor), "North Carolina Facts," Raleigh: North Carolina Research Institute, Vol. II, No. 14, April 3, 1954, p. 3. 114 Table 51. Percent distribution of cases of use of medical attendants by type of attendant. L fiv Type of Medical Number Percent Attendant Total 1503 100.0 M.D. 685 45.5 M.D. Specialist 311 20.7 Dentist 342 22.8 Nurse 137 9.1 Non-M.D. 24 1.6 Midwife 1 .1 All others 3 .2 The present chapter will be limited to a discussion of the use of M.D.'s and M.D. specialists. These two cate— gories will be combined and referred to under the common designation of "doctor" or "physician." The use of dentists is treated in another chapter. Since the nurses reported in the study were almost exclusively public health nurses, they will not be treated separately, but will be included in the chapter on preventive care. All other medical attendants were used so infrequently that meaningful comparisons cannot be made. For this reason, these attendants are excluded from the analysis. Age and Sex. The rate of use of a doctor for the 2125 individuals during the six months prior to the present study was 46.9 per hundred. Table 52 shows that the rates are high- est for the youngest and the oldest age groups. The lowest rate is for the age group 14 to 17 years. Further examination 115 of the data reveals that both acute illness and the use of a doctor for such illness were greatest among the younger age groups. On the other hand, chronic illness and the use of a doctor for such illness were greatest among the older age groups. The trend is also influenced by slightly higher diag- nostic rates in the lower ages and the higher rates of eye care in the older ages. Table 52. Rates of use of a doctor by age. Age Total Under 6 6-13 14-17 18-44 45-64 65-up P _‘ Total 46.9 62.3 41.5 22.9 43.9 50.5 56.4 .001 _Kaufman reports that, although children under five years of age had about the same prOportion of illnesses treated as older peOple, the total number of doctor's calls increased with increasing age.9 He attributes this trend to the relatively short duration of children's illnesses as contrasted with the long duration of the chronic illnesses of the older people which, he says, require more doctor's calls. In the age groups 18 to 44 and 45 to 64 years, females re- ported significantly higher rates of use of a doctor than did males. However, the findings of other studies are not in agree- ment as to the relative influence of sex on the use of a doctor. 9. Harold F. Kaufman, "Extent of Illness and Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Progress Report No. 5, April, 1945, p. 8. 116 For example, the Committee on the Costs of Medical Care stated that the rates for adult women were above those for adult men even when female genital and puerperal diagnoses were exclud- ed.10 The Committee states that this excess is due to more illness rather than to more calls per case.11 Kaufman, on the other hand, reports just the Opposite of this finding. He states that the use of a practitioner by females was greater "even though the illness rates for men and women were very similar."12 The same general conclusion was reached by Galloway, except for his Negro study in which more women were reported to have used a doctor and to have had more calls as well.13 10. Selwyn D. Collins, "Frequency and Volume of Doctors' Calls Among Males and Females in 9,000 Families, Based on Nation- lide Periodic Canvasses, 1928—31," Public Health Repgrts, Vol. 55, No. 44, November 1, 1940, pp. 1990-1991. 11. Ibid., p. 2011. 12. Harold F. Kaufman, "Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 400, Rural Health Series NO. 2, April, 1946, pp. 32—33. 13. Robert E. Galloway and Harold F. Kaufman, "Health Practices of Rural People in Lee County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, NO. 1, December, 1950, p. 3; Robert E. Galloway and Harold F. Kaufman, "Health Practices in Choctaw County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, NO. 2, December, 1950, p. 3; Robert E. Galloway and Marion T. Loftin, "Health Practices Of Rural Negroes in Bolivar County," State College: Mississippi State College, Agricultural Experi- ment Station, Sociology and Rural Life Series, NO. 3, April, 1951, p. 4; Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural People in Forrest County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, NO. 4, July, 1951, p. 3. 117 Income. With very few exceptions, the reports of the various studies indicate a rather marked decrease in the use of a doctor as income increases, regardless Of the method of measuring the volume of use. Hoffer has also shown that the prOportion of individuals with unmet medical need declines with increasing income.14 Three studies reported no consistent relationship between income and doctor's calls per attended 15 A fourth study found that the major difference illness. was not whether the illness was treated but rather the number of office calls made for the treatment.16 The latter increased as income increased. Table 53 shows that the rate of use of a doctor in the present study increases with increasing income. The association is highly significant. This trend is especially prevalent in the younger age groups. In the highest income group a rate of 113.2 doctor's calls per hundred population was reported for children under 6 years of age. It will be remembered that 14. Hoffer, et alii, pp. cit., p. 19. 15. Marie Mason, "Rural Family Health in a Selected County in Kentucky," Lexington: University of Kentucky, Agri- cultural Experiment Station, Bulletin 538, June, 1949, p. 22; Ruth M. Connor and William G. Mather, "The Use of Health Services in Two Northern Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural Experi- ment Station, Bulletin 517, July, 1949, p. 17; W. G. Mather, "The Use of Health Services in Two Southern Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural EXperiment Station, Bulletin 504, July, 1948, p. 13. 16. Kaufman, Research Bulletin 400, op. cit., pp. 20, 22, and 28. 118 these calls were each for a separate condition, and that any given condition may have involved more than one doctor's call. The second highest rate was reported for children be— tween the ages of 6 and 13 years in households with the high- est family income. The rate in this instance is 100.0, com- pared with a rate of 18.3 in the lowest income group. It should be pointed out, however, that as age increases income becomes less important in the use of a doctor. In the age group 14 to 17 years the income differences are only of border- line statistical significance. Beyond the age of 17 years there are no significant differences between the income groups. Table 53. Rates of use of a doctor by income and age. Income Age Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 Under 62.3 22.7 69.0 113.2 50.0 .001 6-13 41.5 18.3 32.8 100.0 55.0 .001 14-17 22.9 14.0 20.0 38.7 30.0 .10 18-44 43.4 40.8 43.5 47.6 44.3 -—— 45-64 50.5 48.0 45.5 60.3 48.3 --- 65-up 56.4 68.5 45.5 33.3 100.0* --- P .001 .001 .001 .001 *Rate is based on less than 10 individuals. Kaufman states that "less demand among the low—income groups is to be explained by the lack of feeling of need for 119 certain services as well as by an absence of purchasing power."17 He further states that this lack of feeling of need implies that a health education program should go hand in hand with plans for financing adequate medical and health care. These trends point up the relatively greater concern of the high income peOple over the health status of their children. Such children have a large number of relatively less serious conditions for which a doctor is used, but the number of doctor's calls per case is comparatively low. On the other hand, among the older age groups where the relatively more serious and chronic conditions prevail, the difference between the income groups no longer exists. 92123. The North Carolina Sickness Survey conducted in 1916 showed that the percentage of cases of illness which were attended by a physician was higher for the white group than for the colored.18 The respective percentages were 63.3 and 57.4. In 1945 Mayo found that in Greene County, North Carolina, "white persons made about two and a half times as many visits to a doctor as Negro persons."19 The Mississippi reports also 17. Ibid., p. 29. 18. Lee K. Frankel and Louis 1. Dublin, "A Sickness Survey of North Carolina," Reprinted from Public Health Reports, Vol. 31, No. 41, October 13, 1916, p. 23. 19. Selz C. Mayo and Kie Sebastian Fullerton, "Medical Care in Greene County," Raleigh: North Carolina State College, Agricultural Experiment Station, Bulletin 363, November, 1948, p. 21. 120 tend to show a slightly higher percentage of white people using a doctor than Negroes.20 However, one of the reports shows a higher average number of doctor's calls for Negroes than for white people.21 No explanation was given for this difference. Table 54 reveals that the rate of use of a doctor among the white people in the present survey was more than double that of the nonwhite group. The tendency for the white peOple to make greater use of a doctor than nonwhite people is es- pecially evident in the younger age groups. As age increases Table 54. Rates of use of a doctor by color and age. Color Age Total White Nonwhite P Total 46.9 55.5 26.2 .001 Under 62.3 83.6 22.0 .001 6—13 41.5 59.7 11.3 .001 14-17 22.9 28.8 14.0 .10 18-44 43.9 47.5 33.9 .01 45-64 50.5 58.7 26.7 .001 65-up 56.4 54.9 61.5 --— P .001 .001 .001 the difference between the color groups diminishes. At age 65 and up there is no significant difference between them. This 20. Compare Galloway, Sociology and Rural Life Series, 23. cit., No. 3, p. 2 with No. l, p. 2; No. 2, p. 2; and No. 4, p. 15. 21. Galloway, Sociology and Rural Life Series, No. l, ibid., pp. 2 and 11. 121 table reveals that the tendency to show considerable concern over the illnesses of the younger children is concentrated primarily in the white group. The highest rates of use of a doctor among the nonwhite people were reported in the oldest age group. The white rate is considerably higher than the nonwhite rate in both the rural farm and the urban areas, but there is no significant difference between them in the rural nonfarm area. The nonwhite people in this area report a much higher rate of use of a doctor than do the nonwhite people in either of the other two places of residence. Among white people the rates increase with increasing urbanity. However, as pointed out above, among the nonwhite peOple the rural nonfarm residents report the highest rate, while the other two residence groups have practically identical rates. When income is considered it is seen that the rate of use of a doctor among white peOple is about double the rate among the nonwhite peOple in every income group. See Table 55. In fact, in the two highest income groups the white rates are more than double the nonwhite rates. Furthermore, while the white rates increase slightly with increasing income, there is no significant difference between the income groups of the nonwhite peOple. The only conclusion that can be drawn is that the use of a doctor is not determined by need alone nor by income alone. Social and cultural factors are also highly in- fluential. 122 Table 55. Rates of use of a doctor by income and color. Income Color Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 White 55.5 51.2 52.7 64.3 47.9 .02 Nonwhite 26.2 27.6 24.2 25.0 0.0* --- P .001 .001 .001 .05 *There were no individuals in this cell. Home Tenure. Table 56 shows that owner households re- port a slightly higher use of doctors among their members than Table 56. Rates of use of a doctor by home tenure and age. Tenure Age Total Owners Renters P Total 46.9 50.3 43.8 .05 Under 6 62.3 65.3 60.6 --_ 6-13 41.5 61.9 29.4 .001 14-17 22.9 28.6 17.6 --- 65—up 56.4 53.0 64.7 --- P .001 .01 .001 do renter households. However, the only age group where the difference is significant is between 6 and 13 years of age. Among both owner and renter households the highest rates were reported for the youngest and the oldest age groups. 123 Table 57 reveals that high income renters report a significantly higher rate of use of a doctor than do high in— come owners. However, the rates in the other income groups are practically the same. It should also be pointed out that it is only among the renters that the rates increase signifi- cantly with increasing income. Table 57. Rates of use of a doctor by income and home tenure. Income Tenure Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 Owners 50.3 40.8 49.4 54.8 55.7 --— Renters 43.8 34.2 41.7 81.8 38.5 .001 P .05 -- .10 .001 Place of Residence. The various studies are not in agreement as to the differences in the use of doctors by rural and urban peOple. Whether the lack of consistency is due to differences in the section of the country surveyed, differences in the type of sample, or differences in method is not known. In reporting the number of calls per case, Wilson states that "town people employed a doctor more often than country people, and country people more often than village."22 The author 22. Isabella C. Wilson, "Sickness and Medical Care Among a Rural Bituminous Coal-Mining P0pu1ation of Arkansas," Fayette- ville, Arkansas: University of Arkansas, Agricultural Experi- ment Station, Bulletin No. 394, June, 1940, p. 31. 124 states that "financial ability was a strong controlling factor in this situation."23 However, the differences to which she is referring amount to only two-tenths of one percent.24 Hoffer reports only minor residence variations in the average number of home and office calls.25 Mather, on the other hand, reports more borough disabilities treated by a doctor than rural disabilities.26 The Committee on the Costs of Medical Care also reports more doctor's calls per thousand population in the cities than in the Small towns and rural areas.27 The general finding of the Mississippi studies was that the nonfarm peOple used doctors to a greater extent than did the farm peOple.28 The only exception to this was in Choctaw County where no difference was found.29 23. Ibid. 24. Compare ibid., p. 31 with Table 20, p. 32. 25. Hoffer, et alii, op. cit., pp. 25-26. 26. Mather, op. cit., p. 3. 27. Selwyn D. Collins, "Frequency and Volume of Doctoré' Calls Among Males and Females in 9,000 Families, Based on Nation- Wide Periodic Canvasses, 1928-31," op. cit., p. 2011. 28. Galloway, Sociology and Rural Life Series, op. cit., No. 1, p. 3; No. 3, p. 3; No. 4, p. 3. 29. Galloway, Sociology and Rural Life Series, op. cit., No. 2, p. 2. 125 It is readily seen in Table 58 that the rural farm people report the lowest rate of use of a doctor in the present study. The other two residence groups have almost identical rates. This tendency is manifest only in the younger age groups. Beyond the age of 17 years there are no residence dif— ferences that are significant. By far the highest rates were reported for urban children under the age of six years. Table 58. Rates of use of a doctor by place of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban P Total 46.9 38.0 53.0 50.1 .001 Under 62.3 40.0 65.6 79.3 .001 6-13 41.5 29.1 44.6 55.6 .01 14-17 22.9 13.0 40.0 26.7 .05 18—44 43.9 42.1 47.9 42.6 -- 45-64 50.5 43.5 59.6 50.5 -— 65-up 56.4 62.8 66.7 44.7 -- P '.001 .001 -- .001 When income is considered, as shown in Table 59, it is seen that the differencesbetween the residence groups in the highest income level are not significant. However, in the lower income groups the distribution is significant with the rural nonfarm residents reporting the highest rates of use of a doctor. There is little difference between the rates of the rural farm and the urban residence in those income categories. Furthermore, 126 it is only in the rural nonfarm group that the rates do not increase with increasing income. The rates for the various income groups among rural nonfarm residents are practically identical. Table 59. Rates of use of a doctor by income and place of residence. Income Residence Total Under $1,500- $4,000- Unknown P $1,500 3,999 up . Total 46.9 36.1 45.3 62.6 47.9 .001 Rural Farm 38.0 32.4 39.5 56.8 37.0 .01 Rural Nonfarm 53.0 52.5 56.9 54.4 35.1 -—- Urban 50.1 29.5 42.1 67.0 78.0 .001 P .001 .01 .01 -- In discussing some of the attitudes of the people with regard to the use of a doctor, Hoffer has pointed out the de- sirability of educational programs which will cause the rural people to ". . . realize the advisability of taking care of their health according to approved standards of medical science."30 The present study is in agreement with this 30. Hoffer, Special Bulletin 352, op. cit., p. 27. 127 statement by Hoffer, not only as it applies to rural peOple but also to all groups whose standards are at variance with those of modern medical science. Health Environment Index. Table 60 shows that the re- lationship between the use of a doctor and the health environ- ment index is positive and highly significant. The highest rates were reported for children in the highest index groups. In this category children under 6 years of age have a rate of 161.3 compared with 21.2 in the lowest index group. However, as age increases the health environment index becomes less im- portant. In fact, in the oldest age group the trend begins to be reversed, although it is not significant. Table 60. Rates of use of a doctor by health environment index and age. Health Environment Index Age Total 0-10 11-18 19—22 23 P Total 46.9 28.1 39.9 56.9 74.8 .001 Under 6 62.3 21.2 53.7 82.4 161.3 .001 6—13 41.5 16.5 30.1 64.9 114.3 .001 14-17 22.9 7.1 26.7 25.0 33.3* —-- 18-44 43.9 38.5 36.8 48.2 60.0 .01 45-64 50.5 22.9 46.4 60.9 56.7 .01 65-up 56.4 71.4 54.1 58.8 12.5* —-— P .001 .001 .02 .001 .001 *Rate is based on less than 10 individuals. Table 61 shows that there is a consistent and signifi- cant increase in the use of a doctor as both income and health environment index increase. However, income differences are 128 not significant within any health environment index group. On the other hand, within every income group there is a signifi— cant increase in the use of a doctor as health environment in- dex increases. This same trend also shows up for the use of a doctor for acute illness alone, but for chronic illness neither the income nor the health environment index differences were significant. These trends point up the tendency for the high socio-economic groups to be more concerned over the less serious illnesses, especially among their children, than are the lower groups. The concern among the lower groups tends to be centered on the more serious and chronic conditions. This tends to account, at least in part, for the lack of difference between these groups in the use of doctors for chronic illness, most of which is found in the older ages. Table 61. Rates of use of a doctor by income and health environment index. Income Health Environment Total Under $1,500- $4,000— Unknown P Index $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 0-10 28.1 30.0 25.2 25.0 10.0 --- 11-18 39.9 40.2 37.7 55.8 43.6 --- 19-22 56.9 54.3 54.9 60.4 54.9 --- 23 74.8 100.0* 80.6 72.4 62.5* --- P .001 .01 .001 .10 *Rate is based on less than 10 individuals. 129 It has been shown in an earlier chapter that the higher income groups reported the highest rates of acute illness. Hamilton's explanation of such reporting was that ". . . upper income groups are more likely to be able to recognize illness, and that there is a tendency to report illness only when some medical service is obtained. The upper income parent, having the money to pay and not having so many children, will take a child to the doctor at the slightest indication of illness; whereas, a low income parent will not pay much attention to minor illnesses, particularly since they are unable to seek medical service."31 The results of this study are in agreement with the statement that the upper income groups are more likely to be able to recognize illness, and they seem to have a greater concern for and awareness of illness, especially the minor ills. However, the data do not entirely support the explanation that illness is reported only when some medical service is obtained. There were 22.5 percent of the cases of acute and chronic ill- ness for which no medical attendant of any kind was used. While only 13.9 percent of the cases in the highest income group were reported to have had no medical attendant, 32.1 percent of the cases in the lowest income group were unattended. The per- centages for the highest and the lowest health environment index 31. C. Horace Hamilton, "Rural Health and Medical Service in North Carolina: Papers and Preliminary Reports of Surveys, 1944-1949," Raleigh: North Carolina State College, Agricultural Experiment Station, Progress Report RS-9, August, 1950, pp. 20-21. 130 groups were 14.2 and 38.4, respectively. A similar trend was found for the communication-participation index and the edu- cation of household heads. While there was no significant difference between residence groups, the white group reported 18.8 percent of the cases unattended, as contrasted with 35.1 percent for the nonwhite group. Therefore, if there is a tend— ency to report only those illnesses for which medical care was received, it seems to be limited primarily to the higher socio- economic levels rather than the lower groups. It seems more likely that the higher groups recognize more illness and, consequently, report more, as Hamilton pointed out. However, along with their greater recognition of illness is also a greater recognition of the values of prompt medical attention, and a greater financial ability to pay for such service. The lower groups tend to report less illness, but what they do report is of a relatively more serious nature. This tendency is further evidenced by the fact that of the illnesses which they report there tends to be a higher proportion which are fully disabling than are those of the higher groups. The reasons for not seek- ing medical attention are partly financial and partly social— psychological. Larson and Hay have pointed out that it would be a mistake to infer that to increase the income of the low income group or to provide health services without cost or at a reduced cost would bring the utilization level and pattern of this group up to that of the higher income groups.32 Loomis 32. Olaf F. Larson and Donald G. Hay, "Hypotheses for Sociological Research in the Field of Rural Health," Rural Sociology, Vol. 16, No. 3, September, 1951, p. 234. 131 has aptly stated that "the standards of 1iving--i.e., those goods and services which people desire--and the levels of living--i.e., those goods and services which people have and use—-are not determined entirely by money income."33 He states further that "health conditions are a part of the entire cul- tural setting and hence, are affected by it. Money income is important but not determinant."34 In the report of the Michigan State-Wide Health Study, Hoffer stated that 43.3 percent of the persons with one or more untreated symptoms reported that they felt they should have seen a doctor, but they had not done 50.35 While the single reason most frequently given for not seeing a doctor was "too expensive," this constituted only 26.2 percent of the reasons given. There were 73.8 percent who gave some reason other than the expense involved. Such reasons as "lack of time," "neglect," "symptoms not thought serious," "believe doctor unable to help" indicate something of the lack of con- cern over symptoms which from a medical point of view needed attention, and which they themselves admitted should have been treated. Hoffer states that the findings "might indicate a rather widespread need for the dissemination of health and hygiene education."36 33. Charles P. Loomis, Foreword in Charles R. Hoffer and Clarence Jane, "Health Needs and Health Care in Two Selected Communities," East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 377, June, 1952, p. 2. 34. Ibid. 35. Hoffer, et alii, op. cit., p. 28. 36. Ibid., p. 29. 132 Communication-Participation Index. The use of a doctor showed a general increase with increasing communication- participation index up to the two top index groups where the rates were practically the same. See Table 62. This trend exists primarily in the lower ages. Table 62. Rates of use of a doctor by communication—participation index and age. Communication-Participation Index Age Total 0-3 4-7 8-13 <__14-25 P Total 46.9 31.6 42.2 55.1 53.0 .001 Under 6 62.3 20.6 55.4 91.6 59.1 .001 6-13 41.5 18.4 20.2 53.4 94.4 .001 14-17 22.9 35.7 19.6 19.3 31.8 —-- 18-44 43.9 39.3 44.7 46.8 37.2 --- 45—64 50.5 16.7 45.4 59.5 58.8 .01 65-up 56.4 73.9 55.8 51.4 43.8 --- P .001 .001 .001 .001 .01 Within income groups the index trends are not consistent. See Table 63. Those persons in the low index group have the lowest rate, but there is not a consistent increase with in- creasing index within income groups. On the other hand, the rates do increase with increasing income within index groups. The communication-participation index appears to have some influence in the use of a doctor, but family income is obviously more influential. Table 63. Rates of use of a doctor by income and communication— participation index. Income Communication- Participation Total Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 0-3 31.6 32.6 28.4 45.0 18.2 -—- 4-7 42.2 35.3 42.0 65.4 42.1 .01 8-13 55.1 42.7 52.2 67.0 53.7 .02 14-25 53.0 42.9 44.6 57.4 77.8* --- P .001 -- .02 -- *Rate is based on less than 10 individuals. Size of Household. As shown in Table 64 there is an inverse relationship between the use of a doctor and size of household. The major difference is between those with 7 or more members and those with less than 7 members. The latter reported less than half the amount of use of either of the other two. As would be expected, individuals in households with 1 to 2 members reported a greater amount of use of a doctor for chronic illness than the other two. This tendency is ac- counted for by the greater prOportion of older peOple in these households. On the other hand, individuals in households with 3 to 6 members reported a higher rate of use of a doctor for acute illness than did either of the others. This trend is a reflection of the higher socio-economic status of this group. 134 Table 64. Rates of use of a doctor by size of household and age. Size of Household Age Total 1-2 3-6 7—up P Total 46.9 56.1 50.9 25.0 .001 Under 6 62.3 0.0* 75.5 27.9 .OOl** 6-13 41.5 50.0* 59.0 12.4 .001** 14-17 22.9 40.0* 27.6 13.5 .10** 18-44 43.9 54.8 42.6 35.2 .05 45—64 50.5 54.6 50.7 36.4 --— 65-up 56.4 69.8 50.8 33.3* —-- p f ' .001 -- .001 .01 *Rate is based on less than 10 individuals. **Households with l to 2 members and those with 3 to 6 members were combined for this computation of chi square. Table 65 reveals that members of the largest house- holds report the lowest use of a doctor in every income group. Individuals in households with 3 to 6 members are the only ones whose use of a doctor increases with increasing family income. There is no significant difference in the income groups of the other household sizes. Table 65. Rates of use of a doctor by income and size of household. Income Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 1-2 56.1 49.1 55.9 68.5 30.0 -—- 3—6 50.9 37.6 49.5 65.7 49.1 .001 7-up 25.0 24.1 21.4 29.8 50.0 --- P .001 .01 .001 .02 135 Education of Household Heads. Two Pennsylvania studies considered the influence of the education of the family head upon the percentage of illness attended by a doctor.37 Tables 66 and 67 reveal a pronounced increase in the use of a doctor by household members as education of both the male and the female head increases. The rates are distributed into three rather distinct levels, namely, the college, high school, and public school level. It is obvious that the edu- cation of household heads has an influence on the use which the various members of the family make of a doctor, at least Table 66. Rates of use of a doctor by education of male head and age. Education of Male Head Age Total Under 4-8 9-12 1 college- Cthers* P 4 up Total 46.9 37.8 35.4 55.2 76.5 35.3 .001 Under 6 62.3 31.0 37.1 84.6 134.8 22.5 .001 6-13 41.5 21.2 24.5 57.6 128.5 8.9 .001 14-17 22.9 23.5 14.5 34.6 30.8 24.2 —-- 18-44 43.9 44.6 37.7 45.1 55.5 40.7 --— 45-64 50.5 30.8 45.9 57.7 65.1 45.6 .10 65-up 56.4 80.0 51.9 62.5 73.3 38.5 --- P .001 .02 .01 .001 .001 *This category includes not living. no answer, no male head, and male head Connor and Mather, op. cit., p. 16; Mather, op. cit., pp. 12 and 32. 136 Table 67. Rates of use of a doctor by education of female head and age. Education of Female Head Age Total Under 4-8 9-12 1 college— Others* P 4 up Total 46.9 27.1 35.8 52.1 68.6 40.6 .001 Under 62.3 13.3 32.8 79.4 114.3 0.0** .001 6-13 41.5 12.5 16.8 58.9 107.4 23.1 .001 14-17 22.9 25.0** 24.0 20.0 25.0 22.2** —-- 18-44 43.9 22.0 40.5 43.4 58.2 40.6 .01 45-64 50.5 22.6 50.0 49.5 62.5 47.6 .10 65-up 56.4 72.2 48.3 63.6 35.3 60.0 --- P .001 .01 .001 .001 .001 *This category includes no answer, no female head, and female head not living. **Rate is based on less than 10 individuals. in the sample under study here. This tendency is especially pronounced in the younger age groups. Among children whose household heads have one or more years of college the rates are well over 100. However, as age increases the influence of education decreases. One would assume this difference is due to a generally higher economic level of the more highly educated peOple which would lessen the economic barrier. However, when income is held constant, as shown in Tables 68 and 69, the rates increase significantly as education of household head in- creases in every income group except the lowest. However, when education is held constant, income differences are of little consequence. Table 68. of male household head. 137 Rates of use of a doctor by income and by education Income Education of Total Under $1,500- $4,000- Unknown P Male Head $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 Under 4 37.8 38.9 35.7 75.0* 27.3 —-- 4-8 35.4 33.5 34.7 44.9 15.8 —-- 9—12 55.2 46.8 55.3 58.9 53.1 --- l college-up 76.5 50.0* 75.9 78.4 61.5 --- Others** 35.3 32.9 33.5 31.0 69.2 P .001 -- .001 .01 *Rate is based on less than 10 individuals. **This category includes no answer, no male head, and male head not living. Table 69. of female household head. Rates of use of a doctor by income and by education Income Education of Total Under $1,500— $4,000- Unknown P Female head $1,500 3,999 up Total 46.9 36.1 45.3 62.6 47.9 .001 Under 4 27.1 36.2 16.7 28.6* 9.1 .10 4-8 35.8 31.7 34.2 44.4 61.4 -- 9-12 52.1 38.7 52.7 58.4 52.4 .10 l college-up 68.6 60.0 60.6 75.8 50.0* -- Others** 40.6 45.1 42.3 37.5 22.2 P .001 -- .001 .01 *Rate I; based on less than 10 individuals. **This category includes no answer, no female head, and female head not living. 138 Kaufman has pointed out that "the advances of medical science have far outdistanced the utilization of this know- ledge in the improvement of the health and well-being of the average person."38 It appears quite evident, as would be ex- pected, that this lack of utilization of knowledge is concen— trated among persons whose household heads have the lowest education, as well as those situated in the lowest social and economic levels generally. In addition to the fact that these peOple are less likely to have access to such informa- tion, this tendency is due to the lack of internalization of the standards of health and health care which have accompanied the advance in medical knowledge. Summary ang Conclusiopo. It has been pointed out in this chapter that the development of scientific medicine is relatively recent. Furthermore, while considerable advances have been made, the standards of health and health care which have accompanied the rise of modern medicine have not been accepted without reservation by all of the people. The findings of this study have shown that the medical doctor (both the specialist and the general practitioner) and to a lesser extent the dentist were the medical attendants most often used by the sample population. This chapter has been devoted to the use of the doctor. The number of calls per ill- ness was not of primary concern in the analysis. The relation- ship of the use of a doctor to the various socio-economic indices used in the study is summarized below. 38. Kaufman, Research Bulletin 400, op. cit., p. 5. 139 The rate of use of a doctor was 46.9 cases per hundred population during the six months prior to the survey. On the whole, the young and the old had the highest rates of use of a doctor, because there is a tendency to use a doctor for acute illness in the younger ages and for chronic illness in the older ages. Of course, these trends were also influenced by the use of a doctor for purposes other than acute or chronic illness, such as eye care and diagnostic care. An examination of the data from the standpoint of color showed that the rates of the white peOple were considerably higher than those of the nonwhite people in every income category. However, the difference diminished with increasing age. Individuals in owner households reported slightly more use of a doctor than did members of renter households, but this tendency was significant only in the age group 6 to 13 years. On the other hand, renters with thehdghest family in- comes reported significantly more use than did owners in the same income category. Within the other income groups, the rates were about the same. For all places of residence the rural farm people reported the lowest rate of use. However, this tendency was manifest only in the younger ages. Beyond the age of 17 years, there were no significant residence dif— ferences. There was an inverse relationship between the use of a doctor and size of household. The primary difference was between those persons with 7 or more members per household and those with less than 7 members per household. 140 There were definite increases in the rate of use of a doctor with increasing income, health environment index, communication—participation index, and education of household heads. However, this tendency, like those noted above, was found only in the younger ages. In every instance, it became less pronounced as age increased. This trend seems to be a reflection of the greater concern of the higher socio-economic groups over the illnesses of their children than is found among the lower groups. It also appears to be a reflection of the tendency for the lower groups to overlook many of the less serious illnesses and to be more concerned over the more serious and chronic conditions. Since such conditions are more likely to be found among adults, the rates of use of a doctor by the lower groups tend to more nearly approach those of the higher groups. The data of this study tend to illustrate the statement by Sargent that ". . . one does not respond to a situation per se, but to the situation as he perceives, defines, experiences, and interprets it. One behaves in a way that seems to him appropriate according to how he 'sizes up' the situation."39 Whether a person seeks the services of a physician is not determined solely by the presence or absence of illness from a medical point of view. The individual's decision and his consequent action are determined on the basis of how he perceives 39. S. Stansfeld Sargent, Social Psychology: An Inte- gpative Intgppretation, New York: The Rénald Press CBmpany, 1950, p. 279. 141 the situation. From his point of view, he may not even be sick. Furthermore, even if he does define the situation as one in which he is ill, for him, a doctor may not be a possible means to the end of relieving or curing that illness. In addition to economic factors involving the relative cost of the service and the priority of other goods and services in his mind, there are other factors which are also influential in his decision. These factors are based on the social-psychological and cul- tural backgrounds of the individual concerned. These factors not only include the attitudes, fears, and customs which prohibit the use of a doctor in a given situation, but also the lack of knowledge and understanding as to when and for what a doctor should be used. The indication is that many people, especially those in the lower socio-economic levels, do not have access to such information. At least, it appears that they have not internalized the health standards which such information implies. 142 CHAPTER V USE OF A HOSPITAL For many years hospitals were dreary places which offer- ed little more than custodial care and routine treatment to the poor.1 They were used almost exclusively for surgical cases or severe accidents. Due to a comparatively high rate of mortality of such cases, many considered the hospital as a place to go to die. Hospitalization was sought only as a last resort. With the advancement of scientific medical knowledge, many improvements have been made in the field of hospital care. The hospital, which was once little more than an auxiliary to medical practice, is becoming the center of medical service.2 It not only has been gaining more and more reSpect as a place for relief of pain and the cure of illness, but also as a medium for diagnosis of illness and for education and training. However, the full potential of the hospital remains to be real- ized, especially in the area of preventive medicine.3 1. Committee on Medicine and the Changing Order of The New York Academy of Medicine, Medicine in the Changing Order, New York: The Commonwealth Fund, 1947, p. 163: 2. Ibid., p. 164. 3. Ibid. 143 The use of a hospital has been variously reported in terms of the average number of days in a hOSpital per person hospitalized, per hundred pOpulation, or per illness; the per— centage of families with one or more persons hospitalized; the prOportion of individuals using a hospital one or more times; the rate of hospital admissions per hundred pOpulation; and the percentage of illnesses hOSpitalized during a given time. The present analysis deals primarily with the rate of hospital admissions per hundred population. However, with the exception of two cases, this rate corresponds with the percentage of cases of acute and chronic illnesses which were hospitalized. The results of studies of the percentage of people using a hospital during the course of a year have ranged from 3 per- cent in rural Missouri to 6.6 percent (3.3 percent for 6 months) in Michigan.4 Other reports show the percentage of cases of 4. Charles R. Hoffer, et alii, "Health Needs and Health Care in Michiganfl East Lansing: Michigan State College, Agri— cultural Experiment Station, Special Bulletin 365, June, 1950, p. 30; Harold F. Kaufman, "Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Ex- periment Station, Research Bulletin 400, Rural Health Series No. 2, April, 1946, p. 13; C. Rufus Rorem, "The Economic Aspects of Medical Services," A reprint of two chapters of Publication 27 of the Committee on the Costs of Medical Care, Chicago: The University of Chicago Press, 1935, p. 9; Robert E. Galloway and Harold F. Kaufman, "Use of Hospitals by Rural People in Four Mississippi Counties," State College: Mississippi State College, Agricultural Experiment Station, Circular 174, July, 1952, p. 5; Selz C. Mayo and Kie Sebastian Fullerton, "Medical Care in Greene County," Raleigh: North Carolina State College, Agri— cultural Experiment Station, Bulletin 363, November, 1948, p. 12. 144 illness which were hospitalized to be slightly higher, ranging from 7.5 percent in one study to 14 percent in another study.5 Some of the differences in the results of these studies may be due to how recently the studies were made, as well as to differ- ences in location. The national study of the Committee on the Costs of Medical Care from 1928 to 1931 reported a rate of 61.6 hospital cases per 1000 pOpulation (6.2 per hundred) per year.6 The nation—wide survey conducted by the National Opinion Research Center for the Health Information Foundation in 1953 showed an admission rate of 12 cases per hundred persons.7 If these surveys can be assumed to be representative of the national picture for those years, as apparently they are, the rate of hOSpitalization has doubled in the last 22 years. 5. Selwyn D. Collins, "Frequency and Volume of Hospital Care for Specific Diseases in Relation to All Illnesses Among 9,000 Families, Based On Nation-Wide Periodic Canvasses, 1928- 31," Reprint No. 2405 from the Public Health Reports, Vol. 57, No. 38 and No. 39, September, 1942: p. 48; Marie Mason, "Rural Health in a Selected County in Kentucky," Lexington: University of Kentucky, Agricultural Experiment Station, Bulletin 538, June, 1949, p. 22; Ruth M. Connor and William G. Mather, "The Use of Health Services in Two Northern Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 517, July, 1949, p. 6. 6. Collins, Reprint No. 2405, ibid. 7. Odin W. Anderson, "Voluntary Health Insurance and Utilization of Personal Health Services in the United States, July 1952 through June 1953," National Consumer Survey of Medi— cal Costs and VoluntaryHealth—Insurance, New York: Health—In- formation Foundation, Summary Report No. 3, 1954, p. 5. 145 The results of the present study show a hospital ad- mission rate of 5.5 during the six-month period. The yearly rate would be 11 cases per hundred population, which is almost identical with the rate reported in the N.O.R.C. study. Most of the hospitalization was for acute illness. The rate for acute illness was 4.1, contrasted with 1.2 for chronic illness. Age and Sex. The studies are not in agreement concern— ing the relative influence of age upon hospitalization rates. This discrepancy seems to be due in part to the differences in the methods of determining use, and in part to differences in the locality of the study. There seems to be general agreement that the average number of days in a hospital increases with age.8 In terms of the percentage of persons using a hospital, Kaufman reports that 2 percent of the persons under 15 years of age used a hospital during the year, contrasted with 3 to 4 percent of the individuals above 15 years.9 However, no tests of significance were reported. It is doubtful that the differences are significant. Mayo reported that the highest _porcentage of people using a hospital was between 30 and 44 years of age.10 The Committee on the Costs of Medical Care found rela- tively little age variation in the hospital admission rates.11 8. Kaufman, op. cit., p. 29; Collins, Reprint No. 2405, op. cit., p. 8; Galloway and Kaufman, op. cit., p. 8. 9. Kaufman, ibid., p. 30. 10. Mayo, op. cit., p. 13. 11. Collins, Reprint No. 2405, op. cit. 1‘10 The results of the Wake County study are shown in Table 70. Although some variations in the rates of hospitalization appear, the differences as a whole are not significant. The distribution of hospitalization rates for acute illness is only on the borderline of significance. The highest rates are reported for children under 6 years of age and for adults 18 to 64 years of age. There is no significant difference between the hospitalization rates for chronic illness. Table 70. Rates of hOSpitalization by type of illness and age. Type of Illness Age Total Acute Chronic Total* Under 6 6—13 14-17 18-44 45—64 65—up mmmpwm m mmmmmq m memmm a QQwHHA H H O I- * p _- *There were two cases of hospitalization which were classed neither as cute nor chronic illness. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Females report a significantly higher rate of hospital— ization than do males. As shown in Table 71, this tendency is found only in the age group 18 to 44 years. There is no difference between the sexes at other ages. Further obser- vation of the data reveals that this higher rate shows up only 147 Table 71. Rates of hospitalization by sex and age. Sex Age Total Male Female P Total 18—up 6.1 4.6 7.6 .05 18—44 6.2 3.4 8.7 .01 45—64 6.8 7.3 6.4 —- 65-up ' 3.4 3.5 3.3 -- P -- .10 -- for acute illness. The hospitalization rates for chronic ill- ness are practically identical. Although the Specific causes of hospitalization were not analyzed, this higher rate for women for acute illness is undoubtedly due to illness associated with childbearing. The studies which have treated the sex factor seem to agree that females in the childbearing ages make greater use of a hospital than do males.12 Both the Committee on the Costs of Medical Care and the Eastern Baltimore study showed that there is relatively little difference between male and female hospital admission rates when the comparison excludes female genital and puerperal diagnoses.13 Income. Studies which have been made on the relation- ship of income to the use of hospitals have shown conflicting 12. Ibid.; Galloway and Kaufman, op. cit.; Mayo, op. cit. 13. Collins, ibid., p. 14; Jean Downes, "Causes of Illness Among Males and Females," The Milbank Memorial Fund Quarterly, Vol. XXVIII, No. 4, October, 1950, pp. 412 and 415. 148 results. For example, Meier and Lively report that the in- fluence of income on the proportion of families with one or more members using a hospital was not obvious.14 Marie Mason also reports no consistent income differences in the use of a hospital.15 The nation—wide study conducted by N.O.R.C. reports an admission rate of 12 cases per hundred persons in every income group, except one in which the rate was 11.16 However, those studies which have found income differences re- port from two to three times as much use by the high income groups as by the low income groups.17 Galloway and Kaufman found a decided increase in the use of a hospital as level of living increased.18 They attribute this difference to a recog- nition of the value of such care as well as to financial ability to pay. Table 72 shows that, for the present study, the major difference in rates of hospitalization where income is concern- ed is between those under $1,500 and those with $1,500 or more. l4. Iola Meier and C. E. Lively, "Family Health Practices in Dallas County, Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Bulletin 369, June, 1943, p. 14. 15. Mason, op. cit., p. 27. 16. Anderson, op. cit., Table 1. l7. Harold F. Kaufman, "Extent of Illness and Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Progress Report No. 5, April, 1945, p. 9; Kaufman, Research Bulletin 400, op. cit., p. 24; Rorem, op. cit., pp. 8-9. 18. Galloway and Kaufman, op. cit., p. 7. 149 Table 72. Rates of hospitalization by type of illness and income. Type of Illness Income Total Acute Chronic Total* 5.5 4.1 1.2 Under $1,500 4.1 2.7 1.2 $1,500-3,999 6.0 4.8 1.1 $4,000-up 6.2 4.5 1.7 Unknown 4.9 4.2 0.7 p --** --*** -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. **When the two upper income groups are combined the P value ***W:en12he two upper income groups are combined the P value is .05. This same trend shows up for acute illness, but there is no significant difference in the rates of hospitalization for chronic illness. This relatively low association between income and rates of hospitalization can be explained, at least in part, in the following way. An affliction serious enough (from a medical point of view) to require hOSpitalization is not as readily overlooked as a minor illness. Therefore, the individu- al is more likely to consult a physician for such cases. On the other hand, the decision to go to a hospital is influenced largely by the attending physician. This view has been clearly expressed by Galloway and Kaufman in the following statement: "The attitude and practices of physicians have long been regarded as a key factor in hospital use. This is true as a person 150 seldom goes to a hospital direct but rather enters on the advice and introduction of his physician."19 Furthermore, Hoffer pointed out in the Michigan study that only a small prOportion of those who were advised by their doctor to go to the hospital did not go.20 On the other hand, the propor- tion who themselves felt that they should see a doctor but did not do so was considerably larger.21 Of course, the doctor's decision to recommend hospitalization is influenced to some extent by the economic circumstances of the patient and his family, in addition to other factors which may cause undue hardship or inconvenience. SElEE‘ Galloway and Kaufman report that in Mississippi the percentage of Negroes entering a hOSpital during the year was smaller than the percentage of white people; however, the averageibngth of stay for Negroes was longer.22 The authors state that the longer stay of the Negroes indicates that this group enters the hospital only for the more serious kinds of illness. The feeling was also expressed that more frequent hospitalization might raise the level of health without neces- sarily increasing the amount of hospitalization.23 19. Galloway and Kaufman, op. cit., p. 10. 20. Hoffer indicated that 17.5 percent of the sample pOpu- lation with positive symptoms were advised by a doctor to go to the hospital and that 14.6 actually went. Hoffer, op. cit., p. 29. 21. Ibid., p. 28. 22. Galloway and Kaufman, op. cit. 23. Ibid. 151 Mayo also found a higher use of hospitals by the white peOple than by the Negroes.24 He indicates that, even though the Negroes had larger families, the percentage of white fami— lies with one or more members hospitalized during the year was over twice as high as the percentage of Negro families.25 However, the author reports that, while a greater prOportion of females was hospitalized than males, the percentage of females hospitalized was the same for the white and Negro groups.26 Table 73 shows that the white people report a slightly higher rate of hospitalization than the nonwhite. The differ- ence is only on the borderline of significance. This tendency is evident for acute but not for chronic illness. When resi- dence was considered, it was found that the only area in which the white group has higher rates than the nonwhite is in the rural farm area. Even there the P value is only .10. However, the median length of stay in the rural farm areas is 8.1 days for the white group compared with 14.5 for the nonwhite group. The ratio in the urban area is 6.9 to 11.0, and in the rural nonfarm it is 6.7 to 12.2, respectively. The median length of confinement in a hospital is 7.0 days for the total white group and 12.1 days for the nonwhite group. 24. Mayo, op. cit., p. 11. 25. Ibid. 26. Ibid., p. 13. 152 Table 73. Rates of hospitalization by type of illness and color. Type of Illness Color Total Acute Chronic Total* 5.5 4.1 1.2 White 6.1 4.7 1.3 Nonwhite 4.0 2.7 1.1 P .10 .05 --- *There were two cases of hospitalization which were classed neither as cute nor chronic illness. It has been stated earlier that the nonwhite people tend to report only the more serious ailments and to ignore the minor ills. Even when an illness is recognized, the non- white peOple tend to put off seeking medical attention to a greater degree than the white people. No medical attendant was sought in 35.1 percent of the acute and chronic cases of illness among the nonwhite group compared with 18.8 percent of the cases among the white group. The doctor, in turn, tends to avoid hospitalization if possible, when it would work a financial hardship on the patient. These delays tend to in- crease the length of time necessary for complete cure. Home Tenure. Table 74 reveals no difference in the rates of hospitalization for the individuals in owner households and renter households. The rates for both chronic and acute illness are practically identical. There is also no significant differ- ence between the tenure groups in any place of residence. 153 Table 74. Rates of hospitalization by type of illness and home tenure. Type of Illness Tenure Total Acute Chronic Total* 5.5 4.1 1.2 Owners 5.7 4.1 1.6 Renters 5.3 4.2 0.9 p -_ __ -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. Place of Residence. In the Michigan study, Hoffer found that the proportion of families with one or more members hOSpitalized within "the last year or two" was greater in the rural than the urban areas.27 On the other hand, studies in Pennsylvania report that the percentage of cases of illness which were hospitalized was higher in the boroughs than in the rural areas.28 The Mississippi report shows that a smaller percentage of farm people were hospitalized than nonfarm, but that the average number of days hospitalized was greater for the farm people.29 The authors explainthis smaller use by farm people in terms of their lower levels of education and 27. Hoffer, op. cit., p. 52. 28. Connor and Mather, op. cit.; W. G. Mather, "The Use of Health Services in Two SafithEFH Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 504, July, 1948, p. 4. 29. Galloway and Kaufman, op. cit., p. 8. 154 socio-economic status, and the relative value which they place on hospital and home treatment.30 Table 75 shows that the rates of hospitalization of the rural nonfarm and urban residents are more than double those of the rural farm people. This higher usage shows up for the total hOSpitalization rates and hospitalization for acute, but not for chronic illness. However, the median number of days in the hospital was slightly higher for the rural farm resi- dents than for the rural nonfarm or urban peOple. The respec- tive medians were 9.7 for the rural farm, 7.5 for the rural nonfarm, and 7.7 for the urban people. Table 75. Rates of hospitalization by type of illness and place of residence. Type of Illness Residence - Total Acute Chronic Tbtal* 5.5 4.1 1.2 Rural Farm 3.0 2.0 1.0 Rural Nonfarm 7.2 5.5 1.3 Urban 6.3 5.0 1.3 P .01 .01 -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. Several factors help to explain this difference. In the first place, the rural farm residents have lower incomes 30. Ibid. 155 than either of the other two groups. They are also less likely to carry any kind of health insurance. The economic barrier, therefore, is a factor which tends to delay their going to a hospital. Rural persons tend to be more highly regulated by the seasons of the year than the urban or rural nonfarm. Hence, they will often put off going to the hOSpital during especially busy seasons. Furthermore, going to a hospital does not seem to be as much a part of the traditions of rural people as it is of urban peOple. Another factor, and one which has been suggested by Hoffer, is that "there may be more resistance among rural people to the use of a hospital until the ailment becomes serious."31 These explanations and others need to be studied specifically and in detail to determine the relative influence and importance of each. Health Environment Index. It is shown in Table 76 that hospitalization rates increase with increasing health environ- ment index. The rates increase from 2.0 in the lowest index group to 9.4 in the highest. The two middle groups have about equal rates. This same trend was found for acute illness, but there is no significant difference in the rates for chronic illness. 31. Hoffer, op. cit., p. 30. 156 Table 76. Rates of hospitalization by type of illness and health environment index. Type of Illness Health Environment Total Acute Chronic Index Total* 5.5 4.1 1.2 0-10 2.0 1.3 0.7 11-18 6.3 4.6 1.6 19-22 5.4 4.4 1.0 23 9.4 7.3 1.7 P .001 .01 -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. The influence of cultural factors is brought out in Table 77 even more clearly. When health environment index was held constant, there was no significant difference between the income groups. However, the rates tend to increase with increasing health environment index within the income groups, especially the highest income group. Thus, it would seem, at least for the group under study here, that both cultural and economic factors have an influence in the rates of hospitali- zation. 157 Table 77. Rates of hospitalization by income and health environment index. Income Health Environment Total Under $1,500- $4,000— Unknown P Index $1,500 3,999 up Total 5.5 4.1 6.0 6.2 4.9 --- 0-10 2.0 2.3 1.7 0.0 0.0 ** 11-18 6.3 6.7 5.0 4.7 9.1 _-_ 19-22 5.4 4.3 6.8 4.6 2.8 --- 23 9.4 0.0* 9.7 9.9 0.0* ** P .001 *** .10 .05 *Rate is based on less than 10 individuals. **The expected frequency was not large enough in the lowest income cell to warrant computing chi square. ***The expected frequencies were not large enough in certain cells to warrant computing chi square. However, when all index groups above 10 are combined the resulting rate is significantly higher than the rate for the lowest index group. The P value is .05. Various studies have illustrated the influence of cultur- al tradition in the use of hospitals. For example, many of the Hopi Indians of Arizona have refused to be hospitalized for childbirth because the hospital staff does not observe the cus- tomary taboos of the people.32 But such beliefs and practices are not limited to the so-called primitive peoples. In compar- ing the use of medical services (including hOSpitals) in Missouri with the Lee and Jones professional standards of medical care, Kaufman concluded that to bring the rates of the Missouri 32. Sheldon G. Lowry, "The Major Rites of Passage of the Hopi Indians," An unpublished paper based on secondary sources, 1948, p. 1. 158 population up to these standards "would require a revolutionary change in current habits and practices with respect to medical 33 He stated further that the people must not only service." have the purchasing power, but they must also realize the need for such services.34 Meier and Lively have indicated that some people express marked fear of hospitals and indicate that they "would rather die at home than go to one."35 It should be indicated that the trends spoken of here were found for all illnesses combined and for acute illness, but not for chronic illness. Some chronic illnesses are of such a serious nature that they demand hOSpitalization even in the face of financial handicap or other hardships. In such cases, some families must rely on public welfare or other forms of charity in order to overcome the economic barrier. Communication-Participation Index. Table 78 reveals that, although the rates appear to be slightly higher in the higher index groups, there is no significant relationship be— tween rates of hospitalization and communication-participation index. There is no significant difference in the rates for either acute or chronic illness. 33. Kaufman, op. cit., p. 46. 34. Ibid., p. 47. 35. For a discussion of the basis for such fears see: Meier and Lively, 923 cit., p. 14. 159 Table 78. Rates of hospitalization by type of illness and communication-participation index. Type of Illness Communication- Participation Total Acute Chronic Index Total* 5.5 4.1 1.2 0-3 3.5 2.2 1.3 4-7 4.7 3.6 0.9 8-13 6.7 5.1 1.5 14-25 5.9 4.8 1.1 p .. .. .— *There were two cases of hospitalization which were classed neither as acute nor chronic illness. Size of Household. It is seen in Table 79 that the households with less than 7 members report more hospitalization than those with 7 or more members. However, the trend is not highly significant. This trend is visible for hOSpitalization for all causes as well as for acute illness. The slight dif- ference shown for chronic illness is not significant. 160 Table 79. Rates of hospitalization by type of illness and size of household. Type of Illness Size of Household Total Acute Chronic Total* 5.5 4.1 1.2 1-2 6.8 4.8 1.7 3-6 5.8 4.5 1.2 7-up 3.2 2.5 0.7 p .1o** --*** __ *There were two cases of hospitalization which were classed neither as acute nor chronic illness. **When the two smaller household groups, which have nearly the same rates, are combined the P value is .05. ***When the two smaller household groups, which have almost identical rates, are combined the P value is .10. Education of Household Heads. Mason reports no signifi- cant education differences in terms of the percentage of persons hospitalized.36 However, the Mississippi study found a high positive association between the use of a hospital for childbirth and the education of the mother.37 Tables 80 and 81 reveal a tendency for hOSpitalization rates to increase with increasing education of the household heads, especially for acute illness. The relationship is not expecially pronounced. The major difference is between those with less than a high school education and those with high school or more. 36. Mason, op. cit., p. 26. 37. Galloway and Kaufman, op. cit. 161 Table 80. Rates of hospitalization by type of illness and education of male household head. Type of Illness Education of Male Head Total Acute Chronic Total* 5 5 4.1 1.2 Under 4 4.4 2.7 1.3 4-8 3.5 2.7 0.8 9-12 7.5 6.4 1.2 1—3 college 6.7 5.5 1.2 4 college-up 6.6 4.2 1.8 Others** 5.4 3.8 1.7 P .05 .05 -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. **This category includes no answer, no male head, and male head not living. Table 81. Rates of hospitalization by type of illness and education of female household head. Type of Illness Education of Female Head Total __ Acute _Ehronic Total* 5.5 4.1 1.2 Under 4 3.9 2.3 1.6 4-8 4.2 2.6 1.5 9-12 6.6 5.7 0.9 1-3 college 4.7 4.2 0.5 4 college-up 7.8 6.4 0.7 Others** 5.8 3.2 2.6 P -- .05 -- *There were two cases of hospitalization which were classed neither as acute nor chronic illness. **This category includes no answer, no female head, and female head not living. 162 Summary and Conclusions. This chapter has shown that the rate of hospitalization for the sample population of Wake County during the six-month period was 5.5 cases per hundred population. Although age differences were not significant, females reported a significantly higher rate of hospitalization than did males. This tendency, however, was found only in the age group 18 to 44 years. White people reported slightly higher rates than did nonwhite people. On the other hand, the nonwhite group reported a higher median days of confine- ment to a hospital. The rural farm residents reported a rate of hospitalization which was less than half the rates of the rural nonfarm and urban people. However, the median length of stay for the rural nonfarm people was considerably above that for the other two residence groups. The largest house- holds reported the lowest rates of hospitalization. On the other hand, there was no difference between the rates of owners and renters. It should also be pointed out that there were no significant differences in the rates of hospitalization for chronic illness for any of the socio-economic groups tested. There was some evidence of income differences in the rates of hospitalization, but this showed up primarily for acute illness cases. The major break was at the $1,500 level. There was a positive relationship between hospitalization rates and health environment index. The association was highly significant. There was also a tendency for the rates to be higher in those households whose heads had the highest education. 163 However, the communication-participation index showed no sig- nificant relationship to rates of hospital admission. The results of this study, along with the findings of other studies, indicate that several factors influence the use of hospitals. Among those factors are: medical need, the proportion of cases attended by a physician, ability to pay for such service, and a group of socio-cultural factors such as fears, superstitions, attitudes, and traditions. The data suggest the probability that greater emphasis upon health edu- cation and public relations may induce more effective use of hospitals. The findings of the study, especially those on color and residence, indicate that a more accurate picture of the use of hospitals may be had by the combined approach of rates of ad- mission and the average length of confinement. 164 CHAPTER VI DENTAL CARE E. C. Kirk has stated that "modern dentistry is a recent development. Extraction was practically the only cure for toothache until the latter part of the eighteenth century. The entire development of modern dentistry occurred in the nineteenth century, and mainly in the latter half of that period."1 During this time the standards of good dental care changed considerably. The new norms include professional care of the teeth twice each year, and involve daily home habits such as cleaning the teeth after each meal and massaging the gums daily. The norms are also directed toward certain dietary measures to insure sound development of the teeth.2 Along with a well—balanced diet, an adequate intake of calcium and the avoidance of excessive amounts of sweets are two items particu- larly stressed. The former is especially aimed at prospective mothers whose calcium supply must be shared with the develOping fetus. l. E. C. Kirk, "Dentistry," Encyclopaedia Britannica, 13th Edition, Vol. 8, pp. 50—54 in Selwyn D. Collins, "Frequen- cy of Dental Services Among 9,000 Families, Based on Nation- Wide Periodic Canvasses, 1928-31," Poblic Health Reports, Vol. 54, No. 16, April 21, 1939, p. 629. 2. The relationship of diet to dental health is briefly discussed in the following article: "Basic Rules Apply to Dental Health for All Ages," Skilled Techniques in_Boilding Group Action, New York: The Education Service of J. Walter Thompson Co., Vol. 4, No. 1, May, 1953, p. 2. 165 Studies in recent years have shown that extractions still hold a high place among the various kinds of dental care used by the peOple. For example, Almack has demonstrated in a study in Missouri that "more persons visited a dentist for the purpose of having teeth extracted than for any other type of service."3 Meier and Lively, in another Missouri study, have pointed out that most of the dental care received con- sisted of extractions.4 Hoffer has indicated that in Michigan some individuals went to a dentist regularly every year, but that there were others who would not go to a dentist except to have a tooth extracted.5 The National Health Survey report on dental care in Detroit, Michigan, indicates that the dental care received was largely for extractions and fillings.6 It also indicates that there was a slightly higher percentage of extractions in the lower socio—economic groups, but that the reverse was true for all other dental treatments. 3. Ronald B. Almack, "The Rural Health Facilities of Lewis County, Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943, p. 30. 4. Iola Meier and C. E. Lively, "Family Health Practices in Dallas County, Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Bulletin 369, June, 1943, p. 13. 5. Charles R. Hoffer, "Health and Health Services for Michigan Farm Families," East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 352, September, 1948, p. 35. 6. Rollo H. Britten, "A Study of Dental Care in Detroit," National Health Survey, Public Health Reports, Vol. 53, No. 12, March 25, 1938, p. 455. 166 Table 82 reveals that extractions also hold a high place among the residents of Wake County, North Carolina, in relation to other kinds of dental care. In fact, other kinds of dental care received by the nonwhite people were almost nonexistent. Even the rate of extractions was less than half that of the white group. Among white persons, fillings ranked first in importance, and extractions and "teeth cleaned" were tied for second. None of the nonwhite pOpulation reported having had their teeth Cleaned during the six months prior to the survey, and only three-tenths of one percent reported having received fillings. Table 82. Rates of dental care by color and type of care. Color Type of Care Total White Nonwhite 3. N H H 0') mmeommqw U‘I COCOACDNOJOOC) N Total Teeth filled Extractions Teeth Cleaned Dentures Orthodontic Diseased teeth Check-up Other dental N OOCOOOUIOHOJ U! HOODOGI Hwhpm l I J The Committee on the Costs of Medical Care states that the annual rate for dental services among the 9000 families 167 which it studied was 269 per 1000 population (26.9 per hundred).7 The nation-wide survey conducted by the National Opinion Research Center in 1953 for the Health Information Foundation indicated that 34 percent of the peOple saw a dentist during the preced- ing year. The corresponding percentages for two Pennsylvania studies were 29 percent and 28 percent.8 The Michigan study k reported that 22.6 percent saw a dentist during a six-month 9 period, a figure which would amount to 45.2 percent for a year. The prOportion recorded in the Michigan study is by far the highest of any reported. Even during the depression years the National Health Survey found that 33 percent of the peOple of Detroit had seen a dentist for purposes other than cleaning during the past year.10 In the present study the rate of dental services receiv- ed during the six-month period prior to the survey was 16.2, or a yearly rate of 32.4. It should be remembered that rates 7. Collins, op. cit., p. 655. 8. W. G. Mather, "The Use of Health Services in Two Southern Pennsylvania Communities," State College: The Penn- sylvania State College, Agricultural Experiment Station, Bulletin 504, July, 1948, p. 22; Ruth M. Connor and William G. Mather, "The Use of Health Services in Two Northern Pennsylvania Com— munities," State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 517, July, 1949, p. 8.. 9. "Charles R. Hoffer, et alii, "Health Needs and Health Care in Michigan," East Lansing: Michigan State Coflege, Agricultural Experiment Station, Special Bulletin 365, June, 1950, p. 26. 10. Britten, op. cit. a“. 168 will generally run somewhat higher than the percentage of people receiving service, because certain individuals receive care more than once during a given period of time. Although the populations studied are not entirely equi- valent, the various studies show a rather close agreement in the amount of dental care received in different areas of the country. Even so, there is some evidence of sectional differ- ences which national surveys would do well to consider. Age and §ox. The National Health Survey indicates rather marked age differences in dental care. Excluding visits for extractions only, it found that the persons receiving dental care varied from 7 percent in the age group 3—5 years to 31 percent in the age group 15—19 and back down to 6 percent in the age group 65-up.11 These percentages would be higher, especially in the middle age groups, if extractions were in- cluded. The rates for the present study show the same general trend for age as did those in the Detroit survey; that is, the lowest rates are found among the youngest and the oldest age groups. See Table 83. The association between dental care and age is highly significant. Examination of the table, and further tests of association reveal that those individuals below 6 years of age have significantly lower rates than those 65 years and above. Each of these rates is significantly lower than the rates of 11. Ibid. 169 Table 83. Rates of dental care by age. Age Total Under 6-13 14-17 18-44 45-64 65—up P 6 Total 16.2 2.8 19.1 16.0 19.4 20.2 7.7 .001 all the other age groups, that is, those from age 6 to 64 years. There is no significant difference between the age groups from 6 to 64 years. Clearly, the bulk of dental care is provided to those between these ages. This trend is due largely to the fact that beyond 64 years of age the individual is more likely to have his own teeth replaced with bridgework, or per- haps removed and not replaced at all. Below 6 years of age the child is too young to have had much dental trouble develop. The Committee on the Costs of Medical Care reports a greater frequency of dental services of all kinds for females than for males.12 This finding was true especially for those from 20 to 55 years of age. Below 20 years of age and above 55 the rates were about the same. Studies in Mississippi also indicate a greater rate of dental care for women than for men among both white and colored peOple.13 12. Collins, op. cit., p. 655. 13. Robert E. Galloway and Harold F. Kaufman, "Health Practices of Rural People in Lee County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 1, December, 1950, p. 5; 170 In the present study women also tend to report more dental care than men. The rates are 21.2 and 15.8, respectively. The P value is .02.14 Two factors, among others, must be taken into account in explaining the higher dental rates for women. In the first place, childbearing has considerable influence in the decaying of the expectant mother's teeth. In the second place, women are traditionally more concerned with regard to the appearance of their teeth than are men. Income. Many studies have shown a positive relationship between rates of dental care and family income. The income in- tervals used and the resulting rates have varied rather widely, depending on the time the survey was made and the population under study. Nevertheless, there is general agreement that dental rates increase with increasing income. A report of the Health Information Foundation nation—wide survey states that Robert E. Galloway and Harold F. Kaufman, "Health Practices in Choctaw County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 2, December, 1950, p. 5; Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural Negroes in Bolivar County," State College: MissisSippi State College, Agricultural Experi— ment Station, Sociology and Rural Life Series, No. 3, April, 1951, p. 6; Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural People in Forrest County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series,No. 4, July, 1951, p. 5. 14. It will be remembered that sex was not compared be- low 18 years of age. However, it has been shown that, among elementary school children, girls have a hgher caries experience than boys of the same age. This tendency is due to the fact that girls' teeth erupt earlier and are exposed longer to the risk of attack, although girls show no greater susceptibility to caries than boys. See Henry Klein and Carroll E. Palmer, "Studies on Dental Caries VII. Sex Differences in Dental Caries 171 "no personal health service appears to be so closely correlated with income as dental service."15 It indicates that the per- centage of persons seeing a dentist in one year varies from 17 percent for those with incomes below $2,000 to 56 percent for those with incomes of $7,500 and over. The Committee on the Costs of Medical Care reports that dental rates during the year ranged from 10 percent for individuals with family incomes under $1,200 to 60 percent for those with incomes of $10,000 18 19 or more.16 Studies in Arkansas,17 Missouri, and Mississippi Experience of Elementary School Children," Public Health Reports, Vol. 53, No. 38, September 23, 1938, p. 1689. This study cover- ed virtually the entire elementary school pOpulation of Hagerstown, Maryland. 15. "Health Information Foundation Survey of Medical Costs and Voluntary Health Insurance," (Highlights from a National Survey), New York: Health Information Foundation, January 24, 1954. 16. C. Rufus Rorem (Editor), "The Economic Aspects of Medical Services," A reprint of two chapters of Publication 27 of the Committee on the Costs of Medical Care, Chicago: The University of Chicago Press, 1935, p. 9. l7. Isabella C. Wilson, "Sickness and Medical Care Among a Rural Bituminous Coal-Mining Population of Arkansas," Fayette— ville, Arkansas: University of Arkansas, Agricultural Experi- ment Station, Bulletin 394, June, 1940, p. 26. 18. Harold F. Kaufman, "Extent of Illness and Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Progress Report No. 5, April, 1945, pp. 7 and 11; Harold F. Kaufman, "Use of Medi- cal Services in Rural Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 400, Rural Health Series No. 2, April, 1946, pp. 25 and 50. 19. The Mississippi studies used "level of living" rather than income, but the resulting trend is undoubtedly much the same. See Galloway, Sociology and Rural Life Series, Numbers 1, 2, 3, and 4, gp,git. 172 also indicate a positive association between dental rates and family income. Furthermore, some studies have shown unmet dental needs to be inversely correlated with income.20 The findings of the present study are in accord with the results of the studies presented above. Table 84 reveals a significant increase in dental rates as income increases. Those in the highest income group report rates which are over five times as great as the lowest income group. The rates in- crease with increasing income in every age group except the age group 65 and above. Table 84. Rates of dental care by income and age. Income Age Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 Under 6 2.8 0.0 2.6 7.5 5.0 * 6—13 19.1 5.4 20.2 42.0 20.0 .001 14-17 16.0 9.3 16.7 29.0 0.0 —--** 18-44 19.4 6.5 15.6 34.5 32.8 .001 45-64 20.2 9.2 17.4 35.3 13.8 .001 65-up 7.7 7.4 6.8 6.7 25.0* * P .001 .10 .001 .02 *The expected frequencies were not large enough in certain cells to warrant computing chi square. **The P value lacked .5 of reaching the .10 level. Despite such a close association between dental rates and income, it would be erroneous to assume that the only 20. Kaufman, Research Bulletin 400, op. cit., p. 25; Meier and Lively, op. cit. 173 barrier to adequate dental care is an economic one. It can probably be demonstrated that brushing and general care of the teeth in the home are also positively correlated with economic status. However, it would certainly not be concluded that the cost of a tooth brush deterred people from brushing their teeth. The Mississippi studies reported that the reasons most frequently given for not seeing a dentist for needed dental care were "neglect," "couldn‘tafford it," and "fear of dental treatment," in order of importance.21 In their study, Meier and Lively indicated that the explanation usually given was that "there was not enough money to cover all needs and dental service was one of the things that the family could do without."22 This explanation does not necessarily imply that the people could not "afford" dental care, but rather that their norms were such as to place other goods and services in higher priority. Such items range all of the way from cigar- ettes to television sets and other articles. Other reasons given in this same study for not seeing a dentist were such things as "afraid to go to the dentist," "just neglected to go," and "it was difficult to get to a dentist when the tooth hurt; when it did not ache there was no need to go."23 These examples are clear indications of some of the norms and values which influence the behavior of people with regard to dental care. 21. Galloway, Sociology and Rural Life Series, No. l, op. cit., p. 6, and No. 2, op. cit., pp. 5-6. 22. Meier and Lively, op. cit. 23. Ibid. 174 Kaufman has indicated that the percentage of peOple in rural Missouri using services other than extractions increases decidedly with income.24 He goes on to say that "a more ex- tensive use of remedial dental care in the higher income groups probably indicates not only that these persons are better able to purchase such service but also that they regard its value more highly."25 Regardless of income, the rates of dental care found in the present study, as well as those in the studies which were reviewed, fall considerably short of the norm of a dental examina- tion every six months, or even one every year. Color. As is the case with other types of medical care, few dental studies have dealt with the color factor. A study of the white and colored males at the Ohio State Reformatory, a rather unique pOpulation, revealed more previous dental treat- 26 However, there was ment of the white males than the nonwhite. also evidence of a greater frequency of dental caries among the white group, but the difference was probably not sufficient- ly great to account for the higher rate of treatment. In the present study white peOple report a dental rate which is almost 7 times as high as that reported among non- white people. See Table 85. The difference between white and nonwhite persons is especially evident in the age groups from 6 to 64 years. 24. Kaufman, Research Bulletin 400, op. cit. 25. Ibid. 25. W. M. Gafafer, "Results of a Dental Examination of 1,908 White and Colored Males at the Ohio State Reformatory," t" in, -Q. Table 85. Rates of dental care by color and age. Color Age Total White Nonwhite P Total 16.2 21.5 3.5 .001 Under 6 2.8 4.3 0.0 * 6-13 19.1 28.4 3.8 .001 14-17 16.0 26.4 0.0 .001 18-44 19.4 24.8 4.0 .001 45—64 20.2 24.6 7.6 .001 65-up 7.7 8.8 3.8 * P .001 .001 .10 *The expected frequencies were not large enough in certain cells to warrant computing chi square. Three of the four counties studied in Mississippi in- 175 cluded both white and nonwhite persons, and the fourth includ— ed only colored people.27 By comparing these county reports, some measure of comparison between color groups can be achieved. Such a comparison reveals that the percentage of colored people receiving dental care was considerably lower than the percent- age of white people. When the results of the study which in- cluded only colored people are compared with the results of the other three, are among the higher level of living groups. of living classes, Furthermore, it is found that the greatest color differences the color differences were negligible. In the lower level the level of living differences in the Negro study Public Health Reports, Col. 51, No. 13, March 27, 1936, p. 332. 27. cit., pp. 5 and 11; No. 2, op. cit., pp. 6; and No. 4, op, cit., pp. 5_an av.- p. 3'13. Galloway, Sociology and Rural Life Series, No. l 5 and 10; No. 3, i 176 were very small compared with the variations found in the other studies which included both white and Negro people. The distribution of dental rates by income and color for the Wake County study is shown in Table 86. The white group reports significantly higher rates than the nonwhite in every income group. Although the rate for the highest income group of nonwhite peOple is a little higher than the lowest in- come group, the difference is not large enough to be signifi- cant. The differences found between the white and nonwhite groups and the lack of difference between income groups among nonwhite peOple indicate that income is only one of the factors involved. Further explanation must be sought in the norms of the different groups. Table 86. Rates of dental care by income and color. Income Color Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 White 21.5 10.4 17.8 32.4 20.8 .001 Nonwhite 3.5 3.6 3.2 5.0 0.0* --- P .001 .01 .001 .05 *There were no individuals in this cell. Home Tenure. Table 87 shows that renters reported some- what lower rates than owners, a tendency which holds true for 177 Table 87. Rates of dental care by age and home tenure. Tenure Age Total Owners Renters P Total 16.2 20.4 12.4 .001 Under 6 2.8 3.4 2.5 * 6-13 19.1 28.6 13.6 .01 14-17 16.0 25.7 6.8 .01 18-44 19.4 23.1 16.5 .05 45-64 20.2 22.6 16.3 --** 65-up 7.7 10.8 0.0 * P .001 .001 .001 *The expected frequencies were not large enough in certain cells to warrant computing chi square. **The rates in this age group are almost identical with those in the age group 18 to 44 years. The difference in P value is due to the fact that the latter group contained about twice as many individuals. every age group. However, as Table 88 reveals, the difference between the tenure groups shows up only in the lowest income group. As income increases the difference narrows, and in the upper income group the renters begin to show a slight edge over the owners. However, the difference is not significant. The tenure difference in the lower income group may be a reflec- tion of the concentration of nonwhite renters in this group. The number of dental cases was so small in the low income renter group that a more detailed cross-tabulation did not seem to be justified. It should be mentioned that among both owners and renters dental rates increased with increasing income. The increase is much greater for renters than for owners, a trend which is 178 probably an indication of the difference in the composition of these two segments of the pOpulation. Table 88. Rates of dental care by income and home tenure. Income Tenure Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 Owners 20.4 14.0 15.6 29.3 21.5 .001 Renters 12.4 3.0 12.6 35.8 20.0 .001 P .001 .001 -- -- Residence. The various studies are in general agreement that the urban peOple have higher dental rates than the rural peOple. Hoffer reports that a significantly lower percentage of residents in the Open country saw a dentist in the six- month period before the survey than did residents in the metro- politan or urban areas.28 The respective percentages were 18.6, 23.4, and 26.1. The Committee on the Costs of Medical Care reports a greater frequency of dental services in the cities than in the rural areas for all kinds of dental care except extractions.29 The Committee also states that the resi- dence differences were smaller than income differences. The Mississippi studies report that the greatest use of a dentist 28. Hoffer, Special Bulletin 365, op. cit., pp. 26-27. 29. Collins, op. cit., pp. 647ff. 179 was made by the "non—farm" residents.3O Connor and Mather, who conducted a study in Pennsylvania, also report a higher percentage of the "borough" population using a dentist than of the rural pOpulation.31 Table 89 reveals that there is a general increase in dental rates with increasing urbanity. This trend is found in the age groups 6 to 13, 18 to 44, and 45 to 64. However, Table 89. Rates of dental care by place of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban P Total 16.2 9.5 16.2 21.3 .001 Under 6 2.8 1.0 5.6 2.5 * 6—13 19.1 12.6 19.6 27.3 .05 14-17 16.0 13.0 20.0 17.8 --- 18—44 19.4 11.6 19.7 23.9 .01 45-64 20.2 8.7 15.7 28.6 .001 65-up 7.7 7.0 11.1 6.4 * P .001 .05 .10 .001 *The expected frequencies were not large enough in certain cells to warrant computing chi square. Table 90 shows that it does not hold true in the two lowest in— come groups. differences significant. Only in the highest income group are residence One would suspect that the low in- come groups living in urban areas would tend to report higher 30. Galloway, Sociology and Rural Life Series, No. 1, 0p. cit., p. 5; No. 2, op. cit., p. 5; and No. 4, op. cit., pT's. 31. Connor and Mather, op. 180 Table 90. Rates of dental care by income and place of residence. Income Residence Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 Rural Farm 9.5 5.2 11.8 16.2 15.2 .01 Rural Nonfarm 16.2 9.8 16.1 22.3 19.3 .10 Urban 21.3 4.7 14.1 38.1 29.3 .001 P .001 -- -- .01 dental rates than the rural since dental services are more readily available in urban areas. On the other hand, one would expect that, among the high income groups where the economic barrier is not so great, the rural and urban rates would be more nearly alike. As has been indicated earlier, place of residence is not a single factor but a compound factor. Dis- tance cannot be accepted as the explanation either. If it were the major factor involved, the residence differences would tend to show up more in the lower income groups rather than the high groups, since high income classes have better access to trans- portation and communication facilities. Also, other studies have shown that individuals often travel long distances beyond the nearest dentist to one with whom they have established some Special relationship; however, this practice does not necessarily hold true for other services.32 Furthermore, in 32. Hoffer, Bulletin 352, op. cit., p. 33; Meier and Lively, op, cit., p. 12. 181 those studies which have investigated the reasons for not see— ing a dentist when there was need, distance has not been men- tioned as one of the deterrents.33 Further study is needed in order to account for the residence differences observed here. Health Environment Index. There is a positive associa— tion between health environment index and dental rates. The association is highly significant. Table 91 shows that those persons in the highest index groups have a dental rate 11 times that of the individuals in the lowest index group. With some minor exceptions, this trend is manifest in each age group. It is most apparent among those individuals from 45 to 64 years of age. In this age category the highest index group reports over 22 times as much dental care as the lowest index group. The two highest index groups reported 75.8 percent of all dental care which was reported, although these two groups constitute only 44.0 percent of the sample. It is evident that the people in these index categories are receiving the bulk of the dental care. Since the dental profession and health educators general— ly recognize that everyone should have a dental examination at least twice each year, some allowance should be made for those who report the amount of dental care they think they should have received, rather than what they actually received. This tendency would be more likely in the high index categories than 33. Meier and Lively, op. cit, p. 13; Galloway, Sociology and Rural Life Series, No. l, op. cit., p. 6, and No. 2, op. cit., pp. 5’13. in the low, but it is probably not sufficiently prevalent to affect the distribution to any appreciable degree. Neverthe- less, even the highest index groups fall considerably short of the norms of good dental care. Table 91. Rates of dental care by health environment index and age. Health Environment Index Age Total 0-10 11-18 19-22 23 P Total 16.2 3.6 9.0 24.0 39.7 .001 Under 2.8 0.0 1.1 5.5 9.7 ** 6-13 19.1 6.6 11.8 31.2 61.9 .001 14-17 16.0 3.6 9.3 31.3 55.6* .001 18—44 19.4 4.3 10.2 28.4 41.9 .001 45-64 20.2 2.1 11.3 24.5 46.7 .001 65-up 7.7 4.8 2.7 13.7 0.0* ** P .001 ** .10 .01 -- *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. It is not surprising to see that peOple with a high health environment index report a higher rate of dental care than low index peOple. If the care which peOple give their teeth at home were studied, the same type of relationship would probably be found. That is, the frequency and consistency with which the teeth are cared for in the home would undoubtedly be correlated positively with health environment index and with general socio—ecnnomic status. However, as has been mentioned previously, there is no reason to believe that income, per se, ‘ 183 has much influence on habits of dental care in the home. The difference in home care is one of difference in the internali- zation of the norms of proper care and treatment of the teeth. It cannot be denied that many people with low incomes may not be able to afford adequate professional care of the teeth, es- pecially such things as dentures or special bridgework which are often extraordinarily expensive for low income budgets. Even so, there is every indication that much educational work is needed before even daily routine care of the teeth at home will meet minimum dental requirements. This observation is further evidenced by the fact that when dental rates are broken down by both health environment index and income, as shown in Table 92, dental rates do not consistently and significantly increase with increasing income within health environment index groups. However, without ex- ception, the rates do increase with increasing index value with- in each income group. This trend indicates the close connection between dental care and the normative order. It is the normative system which tends to govern the priority placed on all kinds of health care, hence, the purchase of such care. Hoffer has indicated that "people have been advised to see a dentist twice a year, although it is a well—known fact that many individuals will not go to a dentist unless they have a toothache. The idea of receiving dental care at regular intervals is not ac- cepted, or at least is not practiced, by many persons."34 34. Hoffer, Special Bulletin 365, op. cit., p. 26. 184 Table 92. Rates of dental care by income and health environ- ment index. Income Health Environment Total Under $1,500- $4,000— Unknown P Index $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 0—10 3.6 3.3 5.0 0.0 0.0 -—- ll—18 9.0 7.7 9.0 7.0 16.4 —-- 19-22 24.0 15.2 21.3 28.1 26.8 --- 23 39.7 50.0* 26.4 46.7 25.0: ** P .001 .01 .001 .001 *Rate is based on less than 10 individuals. **The expected frequency in the lowest income group was not large enough to warrant computing chi square. Further evidence of the general lack of internalization of the norms of good dental care as set up by the health pro- fession is illustrated in the following statement by Meier and Lively: "Twenty-five families stated that they used no dentist. Among these families it was not un- common to find persons who had never been in a dental chair. Some told of trips to a neighbor's house for the purpose of having an aching tooth pulled. Such neighborhood dentistry was usually accomplish- ed by means of a pair of pliers or forceps. Many adults pulled their own teeth . . . . Some men attributed their good teeth to the fact that they chewed tobacco. ”Most people sought the services of a dentist only when a tooth began to ache. Many persons gauged the need for dental work by the pain ex- perience; so long as teeth did not hurt no dental service was needed. Many adults had no teeth, or at best only a few snags. These they resolved to keep as long as possible. Some felt that they were too old to be wasting money for dental care. 185 It was rare for persons to obtain a dental exami— nation once a year. Most dental work consisted of extractions. The view was common that teeth were not worth filling and that it was cheaper to have them pulled. Fillings were as expensive as extractions, and 'the tooth would have to be pulled later anyway.‘"35 Another example of the gap which often exists between the values of the individual and those of the dental profession is shown in the following incident which recently took place in a small North Carolina community. A young man about 17 years of age entered the office of a local dentist with his father. They showed the dentist one of the young man's in- cisors which was slightly out of line and requested him to pull it. The dentist carefully examined the tooth and told them that there was no need to pull it, that it was in good condition and could be straightened without much difficulty. They in- sisted that he pull it, but he refused on the basis that the tooth was in excellent condition. The dentist indicated that peOple frequently came in with similar requests. He said, "They will go from dentist to dentist until they find someone who will pull that tooth even though it is in good condition." Communication-Participation Index. Table 93 reveals a positive association between dental rates and communication- participation index. The general tendency is for dental rates to increase with increasing index within each age group. With the exception of the lowest index group, within each index group the old and the young have the lowest rates, the former 35. Meier and Lively, op. cit., PP. 12-13. 186 being slightly higher than the latter. Within the lowest index group the age differences are negligible. Table 93. Rates of dental care by communication—participation index and age. Communication-Participation Index Age Total 0-3 4—7 8-13 14-25 P Total 16.2 3.5 11.5 V 19.4 34.4 .001 Under 6 2.8 0.0 2.7 4.2 4.5 * 6-13 19.1 4.1 11.7 23.3 47.2 .001 14-17 16.0 7.1 11.8 10.5 45.5 * 18-44 19.4 4.1 15.8 23.4 37.2 .001 45—64 20.2 4.8 10.8 24.7 35.0 .001 65—up 7.7 4.3 4.7 11.4 12.5 t p .001 * .02 .001 .10 *The expected frequencies were not large enough in certain cells to warrant computing chi square. The rates increase with increasing income within each index group. See Table 94. They also increase with increas— ing index within each income group. The rates are highest in the high index-high income group and lowest in the low index-low income group. The data reveal that those persons who have a high in— dex of communication and participation also have the highest rates of dental care. How much of this association is due to higher family income is not indicated. Undoubtedly there is some relationship. However, the influence of the various means of communication and of community participation should not be 187 underestimated. Such channels provide greater access to the most recent information, and supply greater influence of group pressure. Both of these factors stimulate an awareness of dental problems and concern for prOper care of the teeth. There is also more Opportunity to check the validity of such information. .. Table 94. Rates of dental care by income and communication- participation index. Income Communication- Participation Total Under $1,500— $4,000- Unknown P Index $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 0-3 3.5 2.1 6.3 5.0 0.0 .10 4-7 11.5 7.6 10.9 23.1 15.8 .01 8-13 19.4 5.5 16.5 29.4 26.9 .001 14-25 34.4 35.7 22.8 41.3 33.3* .10 P .001 .05 .01 .01 *Rate is based on less than 10 individuals. Size of Household. Table 95 shows inverse relationship between size of household and rates of dental care reported. Since those households with 3 to 6 members have higher average incomes, they would be expected to report the highest rates. However, the individuals in the smallest households reported significantly larger rates than either of the other household groups. Part of this difference can be traced to the fact that there are very few young children in the smallest house— holds. Households with a large prOportion of adult members 188 would tend to have higher rates than those heavily concentrated with children. However, age is not the full explanation. In the age groups 18—44 and 45-64 the households with l to 2 members reported a significantly higher rate than those in households with 3 to 6 members.36 Table 95. Rates of dental care by size of household and age. Size of Household Age Total 1-2 3—6 7—up P Total 16.2 24.2 16.9 6.7 .001 Under 6 2.8 0.0* 3.5 1.2 ** 6-13 19.1 0.0* 24.3 11.4 ** 14—17 16.0 0.0* 20.7 9.6 ** 18—44 19.4 26.8 20.0 5.6 .001 45-64 20.2 29.1 17.3 6.8 .01 65-up 7.7 4.7 10.8 0.0* ** P .001 ** .001 ** *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Probably the most important trend in the table is the tendency for persons in the largest households, those with 7 or more members, to report much smaller rates than those in the other household sizes. Table 96 shows this trend to be especially evident in the highest income group where the next largest households reported a rate almost 8 times as high. 36. Among those from 18 to 44 years of age the differ- ence is on the borderline of significance. The P value lacks .035 of reaching the .10 level. 189 The smallest households had rates over 9 times as high as the largest households. The largest households are also the only ones whose dental rates do not increase with increasing in- come. Of course, it should be remembered that the larger families have more members to share the family income, a factor which undoubtedly has a considerable influence on the rates of dental care. However, income alone would not account for the differences observed here. Table 96. Rates of dental care by income and size of house- hold. Income Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 1-2 24.2 10.3 26.5 39.3 20.0 .001 3-6 16.9 6.0 12.3 32.8 23.2 .001 7-up 6.7 3.1 10.4 4.3 9.1 .05 P .001 .10 .001 .01 Education of Household Heads. Table 97 reveals, as would be expected, that dental rates of the members of the householdsincrease with increasing education of both the male and the female household heads. The major difference is be- tween those with less than 9 years of schooling and those with 9 years or more. There is also considerable difference between those with a high school education and those with a college education. These trends are found consistently throughout the various age groups. Table 97. Rates of dental care by education of male and fe— male household heads. Education of Household Heads House- - 4 hold Total Under 4—8 9-12 1—3 college— Others* P Head 4 college up Male 16.2 4.4 9.1 19.5 27.9 45.5 12.8 .001 Female 16.2 3.1 8.4 17.7 36.6 35.5 11.0 .001 *This category includes no answer, no male (or female) head, and male (or female) head not living. The question naturally arises as to the relative influ- ence of education and income. Tables 98 and 99 reveal that both income and education are highly influential factors in dental care. Dental rates are considerably higher for those individuals with the highest family incomes and whose household heads have the highest educational attainment, especially those with at least some college. Further study of these two factors is necessary before definite conclusions can be drawn as to the relative influence of each. For example, the higher educated persons not only have readier access to information on dental hygiene, but they are also in a better position to evaluate such information. These groups also tend to have higher in- comes, which put professional services more readily at their disposal. 191 Table 98. Rates of dental care by income and by education of male household head. Income Education A of Total Under $1,500- $4,000- Unknown P Male Head $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 Under 4 4.4 2.5 9.5 0.0* 9.1 .05 4-8 9.1 7.4 9.3 12.2 5.3 -- 9—12 19.5 6.4 16.5 28.4 21.9 .01 1-3 college 27.9 25.0* 23.2 32.4 40.0* -- 4 college-up 45.5 0.0* 32.4 49.6 37.5* —— Others*** 12.8 7.3 12.3 31.0 30.8 P .001 .05 .001 .001 *Rate is based on less than 10 individuals. **There were no individuals in this cell. ***This category includes no answer, no male head, and male head not living. Table 99. Rates of dental care by income and by education of female household head. Income Education of Total Under $1,500- $4,000- Unknown P Female Head $1,500 3,999 up Total 16.2 6.1 14.0 31.2 20.8 .001 Under 4 3.1 1.4 2.4 28.6* 0.0 --— 4—8 8.4 6.5 7.7 3.3 27.3 ——- 9—12 17.7 5.7 15.8 28.4 17.5 .001 1-3 college 36.6 27.8 21.5 48.6 40.0* .01 4 college—up 35.5 14.3* 37.5 36.1 33.3* —-- Others** 11.0 2.0 14.1 12.5* 22.2 P .001 -- .001 .001 *Rate is based on less than 10 individuals. **This category includes no answer, no female head, and female head not living. 192 Summary and Conclusions. Dental practice, which was once devoted almost exclusively to performing extractions of badly infected or decayed teeth, has become a highly skilled profession with extractions only one of several specialties. With the advanced knowledge and understanding of oral hygiene have also come new norms or standards governing the care of the teeth and the mouth. One of these norms involves daily care of the teeth in the home, namely, brushing the teeth after every meal and massaging the gums regularly each day. Another norm involves professional care of the teeth twice each year. Other norms pertain to the diet and its relation to healthy teeth and gums. The findings of this study show that dental rates are highest in those age groups in which one would expect the great- est need to exist, namely, between the ages of 6 and 65 years. Also, as would be expected, females report more dental care than do males. However, regardless of age and sex differences, the people with high socio-economic status receive the most dental care. Dental rates increase with increasing income, health environment index, communication—participation index, and education of household heads. The rates are also higher for white people than for nonwhite people, for owners than for renters (especially in low income groups), for urban residents than for rural (especially in high income groups), and for the smaller households than for the larger households. 193 Although family income is clearly associated with the rates of dental care, the fact that the relationship is not consistent when certain other factors are held constant in- dicates that certain social and psychological factors are also important. The evidence of this and other studies pre- sented here indicates that there is a pronounced cultural lag in the acceptance and internalization of the norms of dental care. Although this lag is especially evident in the lower socio-economic groups, the higher groups also fall consider— ably short of the recommended goals. 194 CHAPTER VII EYE CARE Eye care has received very little attention in the vari- ous surveys which have been made to date. However, a few studies have treated various aSpects of eye care, and the results of these studies will be reviewed and compared with the present study where appropriate. Kaufman reports 5.9 cases of optical care per hundred persons in five representative counties of Missouri during a period of one year.1 Another Missouri study reports that 7.4 percent of the people used optical services in a 12-month period.2 The rate of eye care during the six months prior to the present study was 3.4 for the entire sample pOpulation. The yearly rate would be 6.8, a figure comparable to the results of the Missouri studies. However, it is considerably higher than the 3.8 percent per year reported by the Committee on the Costs of Medical Care for the years 1928 to 1931.3 1. Harold F. Kaufman, "Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricultural Ex- periment Station, Research Bulletin 400, Rural Health Series No. 2, April, 1946, p. 19. 2. Ronald B. Almack, "The Rural Health Facilities of Lewis County, Missouri,? Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943, p. 31. 3. C. Rufus Rorem (Editor), "The Economic Aspects of Medical Services," A reprint of two chapters of Publication 27 Table 100 reveals that the service most commonly re— ceived by the people was "eyes examined and glasses fitted." The rate of use of other kinds of eye care was inconsequential. Even this service was seldom received by the nonwhite portion of the sample. The frequency of this combined service of ex- amining theeyes and fitting glasses is an indication that the people tend to delay seeking eye care until their vision is noticeably impaired. There is little evidence of a periodic checkup or other preventive measures of a professional kind. Table 100. Rates of eye care by color and type of care. Color Type of Care Total White Nonwhite Total 3.4 4.2 1.4 Eyes examined and glasses fitted 2.3 2.9 .8 Eyes diseased .6 .5 .6 New glasses-—no examination .3 .5 .0 Eyes examined and other .2 .3 .0 Age and Sex. Kaufman reports that those persons above the age of 40 years made the greatest use of an Optician, and of the Committee on the Costs of Medical Care, Chicago: The University of Chicago Press, 1935, p. 9. An earlier report states that there were 39.6 refractions per 1000 population (3.96 per hundred). See Selwyn D. Collins, "Frequency of Eye Refractions in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928—31," Public Health Reports, Vol. 49, No. 22, June 1, 1934, p. 651. that the maximum use was obtained between the ages of 40 and 59 years.4 Twelve percent of the people in this age group used an Optician during the year, contrasted with only 1 per- cent of the children below 5 years of age. The Committee on the Costs of Medical Care reports practically no eye examinations for those individuals under 3 years of age.5 However, such examinations rise to a peak of 87.1 per 1000 (8.7 per hundred) at 50 to 54 years of age. Beyond this maximum, examinations decline to 33.0, the approxi- mate level of the age group from 18 to 39. In reporting on a survey of several thousand white school boys and male industrial workers, Collins and Britten indicate that the percentage of individuals with markedly defective vision (20/50 or less in one or both eyes) increases steadily after 6 years of age.6 They also indicate that the proportion of persons with normal vision (20/20 in both eyes) declined much more rapidly beyond the age of 45 years.7 4. Kaufman, op, cit., p. 30. 5. Collins, op. cit. 6. Selwyn D. Collins and Rollo H. Britten, "Variations in Eyesight at Different Ages, as Determined by the Snellen Test," Public Health Reports, V01. 29, No. 51, December 19, 1924, p. 3194. 7. Ibid. 197 Table 101 shows that eye care tends to increase with increasing age up to age group 65 and over; at this age level there is a slight decline. No eye care was reported for any of the 316 children under 6 years of age. When children reach school age and from then on into youth and adulthood, they begin to have increasing amounts of eye care. Nevertheless, the rates of eye care found in this and the studies reviewed fall far short of the standard suggested by Kempf and Jarman, that "all school children should have the simple Snellen test twice a year."8 They base their conclusion on the frequency of myopia among school children and the rapidity with which it may develop.9 Table 101. Rates of eye care by age. Age Total Under 6 6-13 14—17 18-44 45-64 65-up P Total 3.4 0.0 1.4 2.1 3.5 7.1 5.1 .001 A number of factors account for the age trend shown here. As the child begins to use his eyes day after day in his school work, this constant use not only has an effect on his eyes, but defects are often discovered which before may have 8. Grover A. Kempf and Bernard L. Jarman, "A Special Study of the Vision of School Children," Public Health Reports, Vol. 43, No. 27, July 6, 1928, p. 1738. 9. Ibid. 198 gone undetected. Certain defects are often ignored among young children on the assumption that they may "grow out of them." Furthermore, there is a certain apprehension about having a young child wear glasses because of the constant danger of his falling or otherwise injuring himself with them, the pos- sibility of his losing them, or perhaps developing emotional insecurities because of them. Many of these fears are being allayed and it is becoming increasingly common for young children to be fitted with glasses. A further explanation of the higher rates with increasing age is that nervous tensions and emotional upsets have often been known to affect the focus of the lenses of the eyes. If such a condition proceeds over a period of time, the individual has increasing difficulties in obtaining clear vision without the aid of glasses. Also, as the individual grows older the eyesight generally tends to ,wane, as do the other senses and one's physical prowess general— ly. Those whose daily activities demand considerable use of the eyes, especially for close or detailed work, will tend to notice failing eyesight somewhat more readily than others. Therefore, with other things being equal, such individuals will require more eye care. As one reaches the age of 60 or 65 years he begins to be less active. He also has a greater tendency to accept poorer eyesight and to adjust to it. His demand for eye care begins to level off and even to decline. Probably of greater importance, however, is the fact that the rather abrupt increase in eye care in the middle ages tends to coincide with the onset of presbyopia. This condition appears in individuals 199 in the middle or later middle ages and gradually increases until the age of 60 years where it tends to remain rather stationary.10 With regard to sex differences in the use of an Optician, Kaufman reports that over twice as many females as males used optical care.11 Female rates were higher in all age classes. The Committee on the Costs of Medical Care also reports a greater use by females above 10 years of age.12 In the present study, females above 18 years of age tend to report higher rates of eye care than males. The difference is not large and is only of borderline significance. The rates are 3.6 for males and 5.7 for females. The P value is only .10. The rates were so low that detailed comparisons could not be made with reliability. Further observation would be necessary before more definite conclusions could be drawn. However, it has been shown that ". . . the onset of presbyOpia begins 5 years earlier among women than among men,"13 a con- dition which would tend to produce some difference between the sexes o 10. "Presbyopia and the Duration of Life," Editorial in The Journal of the American Medical Association, October 14, 1933, p. 1239. See also Collins, op. cit., p. 664. ll. Kaufman, 22, cit., p. 32. 12. Collins, 32. cit., p. 651. 13. Ibid., p. 664. 200 Income. Various studies have indicated a rather marked increase in the amount of eye care received as family income increases.14 Isabella Wilson states that in families with in— comes below $250 per year there are 17.7 percent more persons with eye defects than in those with incomes above $750.15 This statement is probably just an indication of the existence of more untreated eye conditions rather than more defects, for she goes on to state that the lower income people are more like- ly to postpone the purchase of glasses.16 It can readily be seen in Table 102 that rates of eye care increase with increasing income. The trend is significant, although not highly so. In the two upper income groups the rates show a rather general increase with increasing age up to age 65 years. However, in the lower income groups the age dif- ferences are practically nil, which may be an indication that lower income groups are having some difficulty in meeting their needs. PeOple with the higher incomes not only have greater l4. Kaufman, op. cit., pp. 20-21; Rorem, op. cit.; and Marie Mason, "Rural Family—Health in a Selected County—In Kentucky," Lexington: University of Kentucky, Agricultural Experiment Station, Bulletin 538, June, 1949, p. 24. 15. Isabella C. Wilson, "Sickness and Medical Care Among a Rural Bituminous Coal-Mining Population of Arkansas," Fayetteville, Arkansas: University of Arkansas, Agricultural Experiment Station, Bulletin No. 394, June, 1940, p. 25. 16. Ibid. 201 financial means at their disposal with which to purchase care, but are more inclined to be engaged in activities which demand greater use of the eyes. These factors, of course, create greater demand for such care. In recent years there has been a considerable change in the design of eye glasses. Although there has been rather widespread acceptance of the new styles, those in the higher income groups already wearing glasses would be more inclined to be refitted for the express purpose of getting the new style than would the lower income groups. Table 102. Rates of eye care by income and age. Income Age Total Under $1,500- $4,000— Unknown P $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 Under 6 0.0 0.0 0.0 0.0 0.0 ** 6-13 1.4 1.1 1.7 2.0 0.0 ** 14-17 2.1 0.0 1.7 6.5 0.0 ** 18-44 3.5 1.6 3.7 4.9 3.3 -— 45-64 7.1 5.1 7.2 9.5 3.4 —- 65-up 5.1 1.9 6.8 0.0 50.0* ** P .001 ** .01 .10 ** *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Color. Little has been written on color differences with regard to eye care. However, one study has indicated that among the rural Negroes of a county in Mississippi poor vision 202 was the most common symptom reported.17 It accounted for 12.7 percent of all the symptoms reported. Poor vision was also mentioned by a higher prOportion of people in the Michigan survey than any other symptom.18 However, no color comparisons were made. The rate of eye care for the nonwhite population in the present study was only 1.4 cases per hundred, in contrast with 4.2 for the white people. The highest rates for the non- white group were found in the age groups 18 to 44 and 65 and up. The rates were 2.7 for the former and 3.8 for the latter. The age group 45 to 64 reported a rate of 1.0, and the age group 6—13 reported a rate of .9. The other groups reported no eye care. Table 103 reveals that the white people reported the most eye care within every income class. However, the rates of eye care were so small that expected frequencies fell below 5 cases;19 therefore, computation of chi square in the high and low income groups was not justified. Color differences in the 17. Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural Negroes in Bolivar County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 3, April, 1951, p. 5. 18. Charles R. Hoffer, et alii, "Health Needs and Health Care in Michigan," East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 365, June, 1950, p. 16. 19. See statement on determining expected frequencies in the section on the statistical methods used in the study. 203 middle income group were not statistically significant. Although the rates for the white group tend to increase with increasing income, the differences are not significant. There is no consistent income trend for the nonwhite group. The low expected frequencies prohibited calculation of chi square, but the differences were obviously insignificant. Table 103. Rates of eye care by income and color. Income Color Total Under $1,500— $4,000- Unknown P $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 White 4.2 3.0 4.0 5.3 3.5 ~— Nonwhite 1.4 1.1 2.0 0.0 0.0* ** p .01 ** -- ** *There were no individuals in this cell. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Both color and income are influential in the rates of eye care. However, on the whole, color differences appear to be greater. Explanation of such differences must be sought in the values and norms of the two groups. It cannot be con— cluded at this point that the nonwhite people have less need for eye care. Home Tenure. Table 104 reveals no tenure differences in the rates of eye care. The rates are practically identical in every income group. For both owners and renters the rates 204 increase with increasing income, but in neither instance does the trend show up as being statistically significant. However, in View of the fact that the rates are so similar and that the income trend for the total is significant, this lack of signifi-' cance for owners and renters separately is no doubt due to the smaller number of cases that result when the sample is divided into the two groups. Table 104. Rates of eye care by income and home tenure. Income Tenure Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 Owners 3.6 1.3 3.4 5.1 2.5 -- Renters 3.2 2.0 3.5 5.1 4.6 -- p -- * -_ -_ *The expected frequencies were not large enough to warrant computing chi square, but the difference is obviously not significant. Place of Residence. The Committee on the Costs of Medical Care indicates that the city residents have more eye 20 Wilson also indicates refractions than rural residents. that more town and village people in a bituminous coal-mining section of Arkansas had their eyes tested and wore glasses than the people in the "country."21 However, a large proportion 20. Collins, op. cit., pp. 658—659. 21. Wilson, op. cit., p. 30. 205 of village peOple also stated the need for glasses. The dif- ferences appear to be too small to be significant. Tests of significance were not reported. Table 105 reveals that the residence differences were not significant.unless the rural nonfarm and urban, which have practically identical rates, are combined. Even then the P value is only .10. The rural farm residents reported consistently lower rates in each age group up to age 45 where even this slight trend disappeared. Table 105. Rates of eye care by place of residence. Residence Total Rural Farm Rural Nonfarm Urban P Total 3.4 2.3 4.0 3.9 —-* *Whgn rural nonfarm and urban are combined the P value is Table 106 shows the relationship of rates of eye care to both place of residence and income. The residence differ- ences are not significant in any income group. The rates are slightly higher among the higher income groups, but the dif- ferences are significant only among rural farm residents. The urban group shows little income variation. The relation— ship shown here indicates that income tends to be more of a factor among rural residents than among urban in terms of the amount of eye care received. 206 Table 106. Rates of eye care by income and residence. Income Residence Total Under $1,500- $4,000— Unknown P $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 Rural Farm 2.3 0.6 2.7 6.8 4.3 .02 Rural Nonfarm 4.0 2.5 4.9 4.9 1.8 —- Urban 3.9 3.9 3.2 4.8 4.9 -- p __* ** -- _- *When rural nonfarm and urban are combined the P value is .10. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Health Environment Index. Table 107 reveals that the higher health environment index groups report higher rates of eye care than the lower groups. The differences are highly significant. The rates level off from the index value of 19 and up. Those individuals with an index value of 23 have a slightly lower rate than the next highest index group. How- ever, the slight difference between these two groups is proba- bly due to chance fluctuations in sampling. The rates of eye care were so small that detailed comparisons between income and health environment index could not be made with any degree of reliability. However, both factors are obviously influential. 207 Table 107. Rates of eye care by income and health environment index. Income Health Environment Total Under $1,500— $4,000- Unknown P Index $1,500 3,999 up Total 3.4 1.8 3.’ 5.1 3.5 .02 0-10 0.4 0.3 0.8 0.0 0.0 ** 11-18 2.8 3.3 2.5 7.0 0.0 ** 19-22 5.4 2.2 5.6 5.8 5.6 ** 23 4 7 50.0* 4.2 3.9 12.5* ** p .001 ** ** ** *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Communication-Participation Index. There was a consistent increase in rates of eye care with increasing communication- participation index score. See Table 108. The rates leveled off at the two upper index groups. The most noticeable differ- ence, however, is between the lowest index group which reported a rate of only 0.3 and the other index groups. The former re- ported only one case of eye care out of a total of 313 indi- viduals. Income differences within communication-participation index are also shown in Table 108, but the expected frequencies were so low in certain cells that chi square was not computed. Nevertheless, certain trends are rather apparent and should be pointed out. In the first place, the general lack of eye care in the lowest index category, which was noted above, shows up 208 in every income group, even in the highest income class. With this one exception, those persons with either a high index score or a high income, or both, reported the highest rates of eye care. These trends are undoubtedly not due to a differ- ence in need for eye care. Such trends reflect both a differ- ence in financial ability to pay for such care and a difference in standards. Table 108. Rates of eye care by income and communication- participation index. Income Communication- Participation Total Under $1,500- $4,000- Unknown P Index $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 0-3 0.3 0.0 1.1 0.0 0.0 ** 4-7 3.4 2.8 3.6 5.1 1.8 ** 8-13 4.1 1.8 3.7 5.5 6.0 ** 14—25 4.8 7.1 4.3 5.2 0.0* ** p .01 ** ** ** ** *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Size of Household. As revealed in Table 109, rates of eye care decrease with increasing size of family. This trend also tends to hold true within each income group. However, the households with from 3 to 6 members were the only ones whose rates consistently increased with increasing income. 209 Table 109. Rates of eye care by income and size of household. Income 'Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 3.4 1.8 3.5 5.1 3.5 .02 1-2 7.4 4.3 10.3 7.9 0.0 -- 3-6 3.1 1.1 2.8 5.1 4.5 .02 7-up 0.7 1.2 0.6 0.0 0.0 * P .001 * .001 *The expected frequencies were not large enough in certain cells to warrant computing chi square. This trend for the rates of eye care to decrease with increasing size of household is partly a reflection of the high proportion of younger children in the larger households. However, it cannot be taken as the full explanation, because even in the age groups from 18 to 65 years the rates consist- ently decrease with increasing size of household. The trend is no doubt also due to the lower socio-economic status of the larger households and the attitudes and practices associated with that status. Education of Household Heads. Table 110 reveals a significant increase in the rates of eye care as education of both the male and female household heads increases. It is ob— vious that the education of the household heads has considerable influence on rates of eye care. This tendency is no doubt due, at least in part, to the fact that the higher educated also tend to have higher incomes. Furthermore, the more highly 210 educated groups tend to make greater use of their eyes over prolonged periods of time for close-up work of a detailed nature. Such use of the eyes places a greater strain on them; hence, eye deficiencies show up more readily. This group is also more conscious of health needs and tends to be more con- cerned over the care of the eyes. The rates of eye care tend to increase with increasing income within each level of education. They also increase with increasing education within each income group. These trends indicate the combined influence of both education and income. However, they cannot be explained solely by the fact that edu- cation and income are highly correlated, because the rates of even the low income people remain relatively high in the higher education groups. Table 110. Rates of eye care by education of male and female household heads. Education of Household Heads House- 4 hold Total Under 4-8 9-12 1-3 college- Others* P Head 4 college up Male 3.4 2.2 1.6 3.7 7.3 7.8 3.1 .001 Female 3.4 0.8 2.0 4.1 4.7 6.4 3.9 .01 *This category includes no answer, no male (or female) head, and male (or female) head not living. ~ ' o v u . n I o u u - . . - .- ._ ‘ . . . u b o u . - u I ' ’ ‘ 0 h v - . A , 1 a 211 Summary and Conclusions. The most frequent type of eye care reported in the study was "eyes examined and glasses fitted." It has been seen in this chapter that the rates of eye care in- crease with increasing age up to age groups 45 to 64 and 65 and up, where they level off. This trend is largely a reflec- tion of need, which increases as one grows older.’ There is some evidence that the rates of eye care tend to be slightly higher for females than for males, but the data are not conclusive. The slight differences which were observed may be due to differences in the rate of maturity of the two sexes; this rate, in turn, is related to the onset of presby- opia and other factors affecting the eyes. There is a general increase in eye care with increasing income, health environment index, communication-participation index, and education of household heads. The rates are higher for the urban and rural nonfarm residents combined than for the rural farm residents, and higher for the white people than for the nonwhite people. Eye care decreases with increasing size of family, a tendency which appears to be due largely to the younger average age of the larger households as well as their lower family incomes. There are no tenure differences. From the data presented here it can be inferred that, in general, eye care is sought only when vision is impaired or other defects become noticeable. There seems to be little emphasis on regular eye examinations or check-ups as preventive measures. Most of the care received was in connection with the fitting of glasses. 212 The rather low rates of eye care which were reported lead one to suspect that there is considerable need which is going untreated. This tendency appears to be especially evi- dent in the lower socio—economic groups and among the nonwhite group regardless of economic standing. The evidence suggests the need for a greater dissemination of information on the prOper care of the eyes and the desirability of periodic eye examinations. 213 CHAPTER VIII PREVENTIVE CARE The concept of preventive medicine involves more than the services of the Public Health Service. The difference between preventive medicine and public health is clearly out- lined by the Committee on Medicine and the Changing Order of the New York Academy of Medicine in a book entitled, Medicine and the Changing Order.1 The Committee makes the point that: while the two are interrelated, "public health deals with those phases of disease prevention and disease control which are amenable only to social controland which are applicable mainly to the large group. Preventive medicine, on the other hand, primarily embraces those practices which only the in- dividual is capable of applying to his own benefit."2 Al- though it is agreed that the distinction which the Committee makes has considerable merit, preventive care, as used in this study, refers almost exclusively to the services rendered by the Public Health Service. For that reason, the following analysis will be built primarily in relation to the activities of that service. 1. Committee on Medicine and the Changing Order of the New York Academy of Medicine, Medicine and the Changing Order, New York: The Commonwealth Fund, 1947:1pp. 143LI44. 2. Ibid., p. 143. 214 Charms, fetishes, and other magical devices have long been known and used as a means of warding off sickness and disease.3 Such methods have been deeply imbedded in the folk practices and culture of society. Even the early beginning of the Public Health Service left much to be desired. This fact was brought out by William Cochrane, who made the follow- ing statement: "Illustrative of the emergency nature of their (county boards of health) work were cases upholding their power to remove smallpox victims to the county pest house, and to feed and attend them there at the expense of the county."4 The origin of the science of preventive medicine as it is known today is comparatively recent and is still not entirely accepted. The first full-time county health service in North Carolina was established in Guilford County in 1911.5 It was not until 1949 that the state had a full—time local health service in every county.6 3. Iola Meier and C. E. Lively, "Family Health Practices in Dallas County, Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Bulletin 369, June, 1943, p. 19. 4. William M. Cochrane, "Health Law Revision in North Carolina," From an address given at the 42nd annual meeting of the North Carolina Public Health Association, September 10, 1953, Chapel Hill: University of North Carolina, Popular Govegnment, Vol. 20, No. 7, April, 1954, p. 7. 5. Ibid., p. 8. 6. Ibid. 215 Throughout the nation new codes of preventive care based on scientific information are being established both in the customs and in the legal codes of the people. These standards involve such services as communicable disease control, maternal and child care, sanitation, chest X-rays, health examinations, vital statistics, health education, and many other relating to public and private measuresof a preventive nature. How- ever, various studies have indicated that the people of the nation are still much more concerned with the curative than the preventive aspects of medicine.7 Mystical powers of magic and ceremony are still being invoked by many, while others take no precautions.8 However, in recent years, there has been "an increasing emphasis upon the prevention rather than the cure of disease."9 The need for preventive care is well known by health authorities. Collins states that health examinations have been widely advocted in recent years as a means of diagnosing 7. Marie Mason, "Rural Family Health in a Selected County in Kentucky," Lexington: University of Kentucky, Agri— cultural Experiment Station, Bulletin 538, June, 1949, p. 12; Ronald B. Almack, "The Rural Health Facilities of Lewis County, Missouri," Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943, pp. 27 and 41; Meier and Lively, pp. 233,, p. 22. 8. Ibid., p. 19. 9. C. Rufus Rorem (Editor), "The Economic Aspects of Medical Services," A reprint of two chapters of Publication 27 of the Committee on the Costs of Medical Care, Chicago: The University of Chicago Press, 1935, p. 16. 216 incipient pathological conditions.10 He also states that early attention to minor diversions from normal may prevent the development of a serious condition. Further verification of this statement by Collins is the point made by Quick who, in a discussion of cancer, said that "routine health examina— tions carefully and seriously done, will contribute greatly toward early diagnosis of many malignant growths."11 Comparisons of the results of the present study with those of other studies are quite difficult due to the fact that most studies report on various specific aspects of pre- . ventive care, such as immunizations, physical examinations, dental examinations, school health examinations, X-rays, and others. However, the results of the various studies will be discussed and compared with the present study where feasible. The rate of preventive care reported for residents of Wake County was 9.6 per hundred for the six-month period. This rate, which would be 19.2 on an annual basis, is a little below the 24.3 percent of the peeple in the Michigan state-wide study who reported having been "personally examined or advised by a public health nurse or officer within the past year."12 10. Selwyn D. Collins, "Frequency of Health Examinations in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928- 31," Public Health Reports, Vol. 49, No. 10, March 9, 1934, p. 321. 11. Douglas Quick, "The Care of the Cancer Patient," Bulletin of the New York Academy of Medicine, July, 1933, Quoted in Cellins, ibid. 12. Charles R. Hoffer, et alii, "Health Needs and Health Care in Michigan," East Lansing: Michigan State College, Agri- cultural Experiment Station, Special Bulletin 365, June, 1950, p. 32. 217 Age and Sex. The Committee on the Costs of Medical Care reports that children under five years of age have a higher physical examination rate for preventive purposes than any other age group.13 The Committee attributes this higher rate largely to the high examination rate for children under one year of age. The Committee indicates further that less than four percent of adults had had an examination of any kind during a twelve-month period.14 However, the most fre- quent contacts with the Public Health Department which were reported in the Mississippi studies were among the school- age children.15 Among the most active programs of the Public Health Service affecting the individual in Wake County are the Maternal and Prenatal Clinic, Infant and Preschool Program, Immunization and Communicable Disease Control, Public Health Nursing, 13. C0111DS, 22. Cit. , pp. 326-327. 14. Ibid., p. 345. 15. Robert E. Galloway and Harold F. Kaufman, "Health Practices of Rural PeOple in Lee County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 1, December, 1950, p. 9; Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural Negroes in Bolivar County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 3, April, 1951, p. 10; Robert E. Galloway and Marion T. Loftin, "Health Practices of Rural people in Forrest County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 4, July, 1951, p. 9. 218 Tuberculosis Control, Venereal Disease Control, and Public Health Nursing.16 Two of the major health problems in the Raleigh area in 1949 were communicable disease control and school health and hygiene, according to a survey report made at that time.17 On the basis of this information, therefore, the highly significant negative association between preventive care and age shown in Table 111 is about what one would expect. Table 111. Rates of preventive cases by age. Age Total Under 6 6-17 18-up P Total 9.6 24.4 18.5 3.5 .001 Evidence of the work of the maternal and prenatal pro- gram shows up in the age group 18 to 44 years where females report a preventive rate of 5.2 as contrasted with 2.2 for males. 16. See A. C. Bulla (M.D.), "Survey of Public Health Facilities," A typed report of the Wake County Health Depart- ment, Raleigh, North Carolina, May 27, 1949. For a graphic summary of the range of health practices during the years 1943 through 1946 among communities in 34 states, one terri- tory, and four Canadian provinces, see: Committee on Administrative Practice, Health Practice Indices 1943-1946, New York: American Public Health AssoEiation, November, 1947. 219 There is no preventive care reported for males beyond 44 years of age, and the rates for females are too small to be of any consequence. The Committee on the Costs of Medical Care also reports more health examinations for females under 55 years of age than for males of the same age group.18 Two of the Mississippi studies also report more contacts by females with the Public Health Department; one of these studies attributed this higher rate for females to the maternity care program.19 Income. Since the services of the Public Health De- partment are rendered free of charge to the individual, one would expect to find no difference in the use of such services if family income were the sole barrier between man and preven- tive health care. However, many studies have shown that, even with regard to services which involve no cost, the lowest in- come groups still report less care. For example, Meier and Lively found that the "families claiming no preventive measures were generally families of small economic means."20 Larson and Hay, in their study of rural health in New York, found that the percentage of low income families using certain specified public health services was only half that of the higher income families.21 18. Collins, 22. cit., p. 327. 19. Galloway, Sociology and Rural Life Series, No. 3, 22. cit., and No. 4, 22. cit. 20. Meier and Lively, 22. cit., p. 19. 21. Olaf F. Larson and Donald G. Hay, "Hypotheses for Sociological Research in the Field of Rural Health," Rural Sociology, V01. 16, No. 3, September, 1951, p. 234. 220 Since these services were rendered free of charge, the authors conclude that the "use of health resources is not only a mat- ter of availability and dollars."22 In their investigation of health examinations, the Committee on the Costs of Medical Care found such examinations to be more frequent among the higher income groups.23 Kaufman also points out that the pro- portion of peOple immunized is definitely related to income, and that it increases with increasing income.24 He indicates that the difference is greatest for persons 16 years of age and under, the age group which received the most immunizations. Galloway shows a positive association between the use of the county health department and level of living among both Negroes and white people.25 In treating the consumption of foods as a preventive measure, Marie Mason has pointed out that the consumption of certain essential foods was positively associ- ated with income.26 Mickey indicates that the wrong choice of food is a matter which can be remedied only by public edu- cation.27 22. Ibid. 23. Collins, 2p. cit., p. 330. 24. Harold F. Kaufman, "Use of Medical Services in Rural Missouri," Columbia: University of Missouri, Agricul— tural Experiment Station, Research Bulletin 400, Rural Health Series, No. 2, April, 1946, p. 22. 25. Galloway, Sociology and Rural Life Series, No. l, 22. cit., p. 15. 26. Mason, gp. cit., DP. 12-15 and 32. 27. Karl B. Mickey, Health from the Ground Up, Chicago: International Harvester Company, 1946, p. 31. 221 Table 112 reveals a tendency for those with incomes of $4,000 and over to report slightly higher preventive rates than those below $4,000; however, the rates are significantly higher only in the age group under 6 years. The inconsistency in the income trend among those individuals from 6 to 17 years of age is probably due to the school health program and to the influence of the nonwhite group which, as will be shown later, reported comparatively high preventive rates for school- age children. the low income category. The nonwhite group is heavily concentrated in Fifty-nine percent of the nonwhite individuals were in families with incomes of less than $1,500, while only 17.3 percent of the white group were in this income class. Table 112. Rates of preventive cases by income and age. Income Age Tbtal Under $1,500- $4,000- Unknown P $1,500 3,999 up Tbtal 9.6 8.9 8.8 12.1 9.7 -- Under 6 24.4 15.9 25.2 39.6 15.0 .05 6-17 18.5 21.3 14.5 25.9 10.0 .10* 18—up 3.5 2.1 3.1 4.5 8.5 -— P .001 .001 .001 .001 *The P value in this instance was only .23 short of the .10 level. The highest rate of preventive care was reported for the preschool children in households with the highest family incomes. 222 Those persons with the lowest rates were adults above 17 years of age in households with the lowest family incomes. Preven- tive rates decreased with increasing age in every income group. The evidence suggests that, even when various kinds of health services are offered on a free basis, the lower income groups do not avail themselves of such services as readily as the higher income groups. In fact, Meier and Lively indicate in their study that 20 percent of the families were Opposed to immunization as a means 0f preventing disease.28 The authors state that the proportion of families opposed to such measures increased with decreasing income.29 The explanation must be sought in the complex of social-psychological factors which underlie the motivations of the people.30 Kaufman states, for example, that "persons of higher social and economic stand- ing are more likely to be aware of the causes of illness and disease and to have a better understanding of the health practices and medical treatment necessary to maintain good health."31 £2123. Although the Mississippi studies treated the color factor, the data are in such form as to make color com— parisons rather difficult. However, it appears that the Negro 28. Meier and Lively, op. cit., p. 20. 29. Ibid. 30. For essentially the same point of view see: Larson and Hay, op. cit. 31. Kaufman, op. cit., p. 28. 223 population was on a par with the whites with regard to certain services, but slightly below with regard to others.32 As shown in Table 113, there is no significant difference between the color groups with reference to preventive care when age is not taken into consideration. However, except for ages 6 to 17 years, the white population reported higher rates than the nonwhite. This exception is due to the comparatively high rate reported for the nonwhite school children, which is a reflection of the school health program. This program not only facilitates reaching the children but the parents as well, Table 113. Rates of preventive cases by color and age. Color Age Total White Nonwhite P Total 9.6 10.2 8.3 -- Under 6 24.4 30.0 13.8 .01 6-17 18.5 17.5 20.2 —- 18-up 3.5 4.4 1.1 .01 P .001 .001 .001 both directly and indirectly. The programs of the school 32. Galloway, Sociology and Rural Life Series, No. 1, op. cit., p. 9f; No. 3, op. cit., p. 10f; No. 4, gp. cit., p. 9f; and Robert E. Galloway and Harold F. Kaufman,‘ Health Practices in Choctaw County," State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 2, December, 1950, p. 9f. 224 itself often do a great deal to supplement the educational and preventive work of the Public Health Service. Among both the white and the nonwhite groups the major portion of preventive care is concentrated in the preschool and school-age children. Out of 355 nonwhite individuals above 17 years of age, there were only 4 cases of preventive care reported, all of which were females. No nonwhite males above 17 years of age received any preventive care, and only 9 cases were reported for the 497 white males. The total rates for white and nonwhite persons are practically identical in both the rural farm and urban areas.33 However, among rural farm individuals under 6 years of age the white rate is considerably higher than the nonwhite. Com- pare Tables 114 and 115. In the rural nonfarm areas the white group reports a significantly higher rate than the nonwhite group. The rates are 11.9 and 1.3, respectively. In the rural nonfarm areas the only nonwhite persons who received pre- ventive services were the school-age children. In the white group, preschool children received the greatest amount of pre— ventive care in all residence areas. Among the nonwhite group, 33. It is interesting to note that in 1950 there were 5.9 percent of the rural farm households of Wake County which did not have any kind of toilet, not to mention the number whose toilet facilities did not meet even minimum standards of sani- tation and fly protection. The correSponding percentage for the nonwhite households was 8.4. See: C. Horace Hamilton, "Sta- tistics on Rural P0pu1ation and Rural Family Living," Raleigh: The North Carolina Agricultural Extension Service, Compiled from the 1950 U. S. Census of P0pu1ation in the Department of Rural Sociology, North Carolina State College, November, 1953. the school children received the most care. 225 However, in the urban areas the preschool and early school rates were very similar. Table 114. Rates of preventive cases of whites by place of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban P Total 10.2 9.5 11.9 9.5 -- Under 6 30.0 26.4 31.6 30.8 -- 6-17 17.5 15.5 13.5 22.8 —- lS-up 4.4 4.1 6.6 3.1 .10 P .001 .001 .001 .001 Table 115. Rates of preventive cases of nonwhites by place of residence and age. Residence Age Tbtal Rural Farm Rural Nonfarm Urban P Total 8.3 9.6 1.3 8.9 .10 Under 6 13.8 9.6 0.0 23.3 .10* 6-17 20.2 19.2 8.3 25.0 --* 18-up 1.1 1.7 0.0 1.1 ** P .001 .001 ** ** *The expected frequencies were not large enough to include the rural nonfarm area in this computation of chi square. **The expected frequencies were not large enough in certain cells to warrant computing chi square. 226 Preventive rates are arrayed by color and family income in Table 116. While the preventive rates increase with increas- ing income in the white group, the reverse was found for the nonwhite group. Both trends are on the borderline of signifi- cance.34 White rates are significantly higher than nonwhite rates only in the highest income group. Table 116. Rates of preventive cases by income and color. Income Color Total Under $1,500— $4,000- Unknown P $1,500 3,999 up Total 9.6 8.9 8.8 12.1 9.7 —- White 10.2 7.0 9.7 12.6 9.7 .10 Nonwhite 8.3 10.0 6.5 0.0 0.0* .10 P -- -- —- .05 *There were no individuals in this cell. The white people, especially those with the highest in- comes, tend to direct considerable attention toward preventive care for their children even before they begin school. When children reach school age, the school health program tends to 34. In the study of rural Negroes in Mississippi, Gallo- way reports a positive association between use of the County Health Department and level of living. The differences appear to be rather small, but tests of significance were not reported. See Galloway, Sociology and Rural Life Series, No. 3, 22..gi£., p. 15. 227 narrow the difference between the white and nonwhite groups. The difference between the color groups in all three areas is negligible in these ages. Beyond school age the white group again reports higher rates of preventive care. These differences tend to illustrate the Operation of the norms and values of the two groups. The children Of both groups are compelled to go to school, and, as members of this in- stitution, they are involved in the public health program designed for schools. In this instance, neither the individual nor his parent is the major deciding factor as to whether or not he receives care. The decision depends on the Operation Of the Public Health Department and the extent to which it brings its services to the child. Outside of the formal organ- ization of the school, the influence of these services on given individuals is dependent upon the efforts Of the Public Health Service, the values of the peOple, in addition to their knowl- edge and awareness of the Service and their image Of what it is and what it does. Home Tenure. The preventive rates reported for individu- als in owner and renter households were 9.7 and 9.6, respective- ly. There were no significant differences within any age group nor within any income group. Both groups showed a slight tendency for their rates to increase with increasing incOme, but neither trend was significant. Place of Residence. Hoffer has shown that there was no difference in the prOportion of Open country and urban peOple 228 who had been personally advised or examined by their local health department during the year.35 However, he reported that prOportionately more people in metropolitan areas had such contacts than those persons in other areas.36 In three Of the Mississippi studies it is reported that the nonfarm peOple had more contacts with the Public Health Department than the farm peOple.37 However, the authors state that the peOple receiving such services constitute more nearly a cross section of the pOpulation than was the case for other health services. The Committee on the Costs of Medical Care reports that town and city housewives had about twice as many health exami- nations for preventive purposes as farm housewives.38 In terms of immunizations, however, the Committee found the rural areas had more Of certain kinds Of immunizations than the urban, less Of others, and about the same Of still others.39 35. Hoffer, 22° cit., p. 32. 36. Ibid., pp. 32 and 34. 37. Galloway, Sociology and Rural Life Series, NO. l, 93. cit., p. 9; NO. 3, op. cit., p. 10; NO. 4, op, cit., p. 9. 38. Collins, gp. cit., p. 331. 39. Compare the following reports: Selwyn D. Collins, "History and Frequency Of Smallpox Vaccinations and Cases in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928- 31," Public Health Reports, Vol. 51, No. 16, April 17, 1936, p. 477; Selwyn D. Collins: "History and Frequency of Typhoid Fever Immunizations and Cases in 9,000 Families, Based on Nation— Wide Periodic Canvasses, 1928-31," Public Health Reports, Vol. 51, NO. 28, July 10, 1936, p. 924; and Selwyn D. Collins, "History and Frequency of Diphtheria Immunizations and Cases in 229 Table 117 reveals no significant difference between residence groups in the rates of preventive care which they reported. The urban rates among the preschool and the school children are slightly higher than those in the other residence groups, but these rates are not high enough to be statistically significant. Above 17 years Of age the urban people report the smallest rate. Table 117. Rates of preventive cases by residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban P Total 9.6 9.5 10.4 9.3 -- Under 6 24.4 18.1 26.7 28.1 -- 6-17 18.5 17.3 12.8 23.6 -- 18-up 3.5 3.3 5.6 2.5 .05 P .001 .001 .001 .001 Table 118 reveals no significant residence differences in any income group. On the other hand, there are slight in- come variations in the rural farm and the rural nonfarm areas, with the general tendency for the higher income groups to re— port the highest rates. The comparatively low rate among low income, rural nonfarm residents is probably due to the low rate for nonwhite people in that area, which was pointed out 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928- 31," Public Health Reports, Vol. 51, NO. 51, December 18, 1936, p. 1771. - . U ‘ O Q 0 u . 0 D c L | l . . . . . n a I . v f . ‘ , I t u 4 ‘ a . . 7 a . c , I . . 230 earlier. Income differences among urban residents were not significant. Table 118. Rates Of preventive cases by income and residence. Income Residence Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Tbtal 9.6 8.9 8.8 12.1 9.7 -— Rural Farm 9.5 10.4 6.8 17.6 6.5 .05 Rural Nonfarm 10.4 4.1 11.7 11.6 15.8 .10 p -_ -_ -- -- The evidence of the present study, along with that Of other studies, indicates that rural or urban residence is probably not as important in the determination of the rates of use of public health services as are the services which are offered and the activeness with which they are promoted by the various health departments. Health Environment Index. Table 119 reveals that the people in the two highest index groups tend to report higher preventive rates than those in the two lowest groups. There are some minor variations within age groups, but the relation- ship is consistent and significant throughout the age distri- bution. -v‘. Table 119. Rates of preventive cases by health environment index and age. Health Environment Index Age Total 0-10 11-18 19-22 23 P Total 9.6 8.0 6.5 12.7 13.7 .001 Under 6 24.4 13.1 18.9 37.4 38.7 .01 6-17 18.5 16.0 11.3 26.6 40.0 .001 18-up 3.5 1.7 2.3 5.2 4.6 .05 P .001 .001 .001 .001 .001 Table 120 shows that the high health environment index groups rather consistently report the most preventive care with- in each income group. On the other hand, the only preventive care reported by the high income peOple was among those in the two highest health environment index categories. A greater health awareness seems evident among those peOple with a high index score than those with a low index. The differences un— doubtedly would be even greater if members Of the Public Health Service were not consciously attempting to reach the public with their services. It appears that greater efforts on the part of the health service would stimulate greater use of preventive measures. However, long-time gains will require a more intensive educational program designed to create a felt need in the minds Of the peOple for such services. Such a program would also tend to stimulate more effective use Of other community health facilities within the limits Of the eco- nomic ability of the reSpective families. 232 Table 120. Rates of preventive cases by income and health environment index. Income Health Environment Total Under $1,500— $4,000— Unknown P Index $1,500 3,999 up Total 9.6 8.9 8.8 12.1 9.7 -— 0-10 8.0 10.2 4.2 0.0 0.0 .05 11—18 6.5 4.8 8.7 0.0 0.0 -— 19-22 12.7 19.8 9.0 14.2 19.7 .10 23 13.7 0.0* 16.7 13.2 0.0* ** P .001 ** .05 .02 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Communication-Participation Index. Table 121 shows a consistent increase in preventive rates as communication— participation index increases. There is a general tendency for high index groups to report higher rates than low index groups at all ages. Table 121. Rates Of preventive cases by communication- participation index and age. Communication-Participation Index Age_ Total 0-3 4-7 8-13 14-25 P Total 9.6 4.8 7.8 11.7 14.1 .001 Under 6 24.4 6.3 22.3 34.5 31.8 .01 6-17 18.5 12.7 17.2 13.1 43.1 .001 18-up 3.5 1.6 1.7 6.1 3.2 .001 P .001 .01 .001 .001 .001 233 Income trends within index groups are not consistent. However, with some minor variations, the tendency is for the highest index groups to report the highest rates within each income group. On the whole, the highest rates were reported for the peOple with both a high index and a high income. Hoffer and Jane indicated in their study that over half Of the informants were not even acquainted with the work of the county health department.40 Larson and Hay point out that, in the New York study, the prOportion Of peOple who had heard Of the county health department increased with increasing in- come.41 The authors state that 56 percent Of the low income families had heard of the county health department, as con- trasted with 73 percent for the high income families. These findings indicate that merely raising the level Of one's income or making certain health services available without charge does not automatically change the health behavior Of the peOple. 0n the whole, the low income peOple are not as fully aware Of the services available to them. However, the results Of this study show that persons who have a high index Of communication and community participation tend to make the greatest use of preventive measures regardless Of income. This greater access to information appears to exert considerable influence on the use which these groups make Of preventive health services. 40. Charles R. Hoffer and Clarence Jane, "Health Needs and Health Care in Two Selected Michigan Communities," East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 377, June, 1952, p. 5. 41. Larson and Hay, 9p. cit., p. 234. 234 Size of Household. As would be expected, the individuals in the two largest household sizes report the highest preventive rates. See Table 122. These higher rates are a reflection Of the greater prOportion Of children in these households. The individuals in households with 3 tO 6 members report higher rates than the individuals in the largest households, especial- ly the preschool children. This tendency is probably a reflec- tion of the higher socio-economic status of the former group. At the school-age level there is little difference between them. This lack of difference is another indication of the influence Of the school health program and the way it tends to reach the children of varying family backgrounds with about equal fre- quency. However, prior to entering school, whether or not the child receives preventive service is determined largely by his family background. Table 122. Rates of preventive cases by size Of household and age. Size of Household Age Total 1v2 3-6 7—up P Total 9.6 3.7 11.4 8.9 .001 Under 6 24.4 0.0* 30.6 8.1 .001** 6-17 18.5 11.1* 19.8 17.2 ——-** 18-up 3.5 3.5 4.0 1.2 --- P .001 *** .001 .001 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough to include households with 1—2 members in this computation of chi square. ***The expected frequencies were not large enough in certain cells to warrant computing chi square. 235 Among those households with 1 to 2 and 3 to 6 members the rates increase consistently with increasing income. The trend is reversed among those households with 7 or more members. The data dO not reveal sufficient explanation Of these trends. Nevertheless, it is Obvious that many individuals do not seek various kinds Of health care even when the economic barrier is removed. Education of_Household Heads. Marie Mason has indicated a positive association between education and the utilization Of certain specified preventive measures in the age group above 19 years.42 She found no consistent differences in the age group 15 tO 19 years. In the present study, rates Of preventive care were found to increase as the education of household heads increased, as is shown in Table 123. The same relation- ship was found within each age group. The highest rates were found among children of preschool and school ages whose house- hold heads had one Or more years Of college. The lowest rates were reported among those age groups 18 years of age and over, whose household heads had less than a high schOOl education. 42. Mason, 9p. cit., p. 32. 236 Table 123. Rates of preventive cases by education of male and female household heads. Education of Household Heads Household Total Under 9-12 1 college- Others* P Head 9 up Male 9.6 6.6 ‘ 11.4 17.2 7.8 .001 Female 9.6 6.5 11.7 15.5 3.9 .001 'TTKis category includes no answer, no male (or female)—head, and male (or female) head not living. Tables 124 and 125 reveal that within income groups the rates tend tO increase with increasing education, except in the lowest income group. The educationtifferences within the lowest income group are not significant. Within education levels incOme differences are not consistent. However, on the whole, the highest rates are found among those persons in households with the highest incomes and whose household heads have the highest education. It is evident that preventive care was influenced some- what by both family income and the education of household heads. These groups tend to be more fully informed concerning the programs Of the Public Health Service and the need for preven- tive health measures in general. 237 Table 124. Rates of preventive cases by incOme and by education Of male household head. Income Education of Total Under $1,500- $4,000- Unknown P Male Head $1,500 3,999 up Total 9.6 8.9 8.8 12.1 9.7 -- Under 9 6.6 9.3 5.2 4.9 0.0 .02 9-12 11.4 8.5 12.0 7.1 20.3 —- l college-up 17.2 0.0* 12.9 21.1 0.0 .10 Others** 7.8 8.5 8.9 0.0 3.8 P .001 -- .01 .001 *Rate is based on less than 10 individuals. **This category includes nO answer, no male head, and male head not living. Table 125. Rates of preventive cases by income and by education Of female household head. Income Education Of Tbtal Under $1,500- $4,000- Unknown P Female Head $1,500 3,999 up Total 9.6 8.9 8.8 12.1 9.7 —- Under 9 6.5 9.3 4.8 2.5 3.6 .05 9-12 11.7 12.3 11.4 9.5 19.0 -- 1 college-up 15.5 4.0 14.2 18.6 0.0* ~- 0thers** 3.9 2.0 5.1 12.5* 0.0 P .001 -- .01 .01 *Rate is based on less than 10 individuals. **This category includes no answer, nO female head, and female head not living. 238 Summary and Conclusions. The concept Of prevention Of sickness and disease is not a new concept. It has long been deeply rooted in the customs and folk practices of the peOple. Until recent years it took the form Of magical devices and ceremonies as a means Of warding Off sickness and maintaining good health. Although vestiges of such practices still remain in many segments Of society, the concept Of prevention has be- come a highly technical and complex field involving both public health and preventive medicine. Standards of good preventive care have evolved which include such measures as immunizations for certain kinds of contagious diseases, periodic X-rays of the chest, codes of sanitation, annual physical examinations, maternal and child care, and others. Many Of these standards or norms are becomming legalized and considerable emphasis is being placed on the educational aspects of preventive care. However, studies have shown that greater emphasis is still being placed on the curative rather than on the preventive aspects of health care. This chapter has shown that for the sample pOpulation of Wake County the rate Of preventive care during the six months prior to the survey was 9.6 per hundred population. The rates were highest among the preschool and the school-age children. This trend corresponds rather closely with the emphasis Of the programs of the Public Health Service at that time. Also, the fact that females received more preventive service than males 239 is an indication of the influence Of the maternity program being carried on by the health department. The rates of preventive care were shown tO increase with increasing income, but the differences were significant only for preschool children. Apparently the school health program narrowed the gap between income groups. The rates also in- creased with increasing health environment index, communication- participation index, and education of household heads. Although income differences are not consistent within certain Of these measures, in general, those persons who had high status with regard to these reSpective measures, and whose family income was also high, were the individuals most likely to have the highest rates of preventive care. Other findings of this chapter can be summarized as follows. The white people reported higher rates than the non- white peOple in each age group, except those Of school age. The greatest color differences were found among the rural non- farm residents and in the highest income group. There were no appreciable residence or tenure differences. The rates were higher among individuals in the two largest household groups where the relative prOportion Of children is high. The fact that the second largest household group had a higher rate than the largest households is undoubtedly due tO its higher socio- ' economic status. Differences in the use Of preventive measures were not as divergent among the various socio—economic levels as they 240 were in the use Of certain other health facilities. This greater similarity of rates is the result of the combined in- fluence Of the lack of expense connected with such services and the efforts put forth by the Public Health Service. How- ever, even though these services were provided without charge, the persons in the higher socio-economic levels received the greatest amount of care. This tendency appears to be due to the fact that they are more fully informed, and that they tend to be more concerned with health and health care. Greater efforts in the area of health education would undoubtedly narrow these differences even further. 241 CHAPTER IX DIAGNOSTIC SERVICE According to a representative Of the North Carolina Insurance Commission, most, if not all, insurance companies exclude diagnostic services from their contracts. Such services are Omitted by implication, if not by a Specific exclusion clause, since the policies are issued to insure against the cost Of sickness and accidents. A representative Of a local health insurance agency expressed the Opinion that diagnostic services were not included in insurance contracts since practi- cally all calls to a medical practitioner involve diagnosis Of one kind or another. He felt that if such services were included every call could result in a claim. If such were the case, insurance rates would have to be raised to pro- hibitive levels. Only one study was found which even remotely dealt with diagnostic services. The study was that Of Almack in Missouri.1 Almack refers to the service as "consultation," which he defined as consulting "a practitioner for purposes other than the treatment of illness, or disability, or for 1. Ronald B. Almack, "The Rural Health Facilities Of Lewis County, Missouri," Columbia: University Of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943, p. 27-28. 242 physical examination."2 The service may or may not have in- cluded diagnosis, but in view Of the definition used there would be little else left. In any event, 10 percent of the sample population received consultation service during the course of a year. In the present study the rate of diagnostic services for the six months prior to the survey was 5.4, which would amount tO a rate of 10.8 on an annual basis. Age and Sex. Since the rates were generally quite low, the age distribution was combined into larger groupings, as shown in Table 126. This table shows a general decline in diagnostic rates with increasing age, but the differences are tOO small to be statistically significant. Table 126. Rates of diagnostic cases by age. Age Total Under 18 18-44 45—up P Tbtal 5.4 6.2 5.4 4.2 -- It was found that females reported higher rates than males, especially in the age group 18 to 44 years. This was the only age group in which females were significantly higher 2. "Physical examination" apparently refers to a "check- up" or an examination for the purpose of detecting possible in- cipient conditions. It does not appear to include known physi— cal impairments. 243 than males. This tendency is undoubtedly related tO conditions incident tO childbearing. Income. Income has a highly significant association with the use Of diagnostic services. Table 127 shows that there is a marked increase in reporting Of the use of diagnostic services as income increases. It is most pronounced among those in the younger ages, but it becomes decreasingly less prominent with increasing age. Table 127. Rates Of diagnostic cases by income and age. Income Age Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Tbtal 5.4 1.1 5.5 10.0 6.2 .001 Under 18 6.2 0.9 4.8 18.7 6.0 .001 18-44 5.4 0.5 5.9 8.3 6.6 .01 45-up 4.2 2.0 5.7 3.8 6.1 -—- P -- -- -- .001 The tendency for the use Of diagnostic services to de- crease with increasing age is quite pronounced among those with incOmes of $4,000 and above. Age differences are not significant for either of the lower income groups. This trend coincides with the greater emphasis of the high income people on the health needs of their children, an emphasis which has been pointed out in previous chapters. 244 92125. The association between the use Of diagnostic services and color is highly significant. White persons report- ed four times as much diagnostic service as nonwhite. The rates are significantly higher at all ages. Table 128 shows that the white group reported higher diagnostic rates than the nonwhite group at all income levels. Furthermore, the rates for white persons increase with increas- ing income, but there is no consistent trend for the nonwhite group. It should also be pointed out that the rate Of 3.2 for the nonwhite middle income group involved urban residents entirely. The other nonwhite rate involved only rural farm residents. NO diagnostic services were reported for nonwhite rural nonfarm residents. White rates were also consistently higher than nonwhite rates in all places of residence. Table 128. Rates Of diagnostic cases by income and color. Income Color Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 White 6.9 2.0 6.3 10.4 6.2 .001 Nonwhite 1.6 0.6 3.2 0.0 0.0* ** P .001 ** .10 ** *There were no individuals in this cell. **The expected frequencies were not large enough in certain cells to warrant computing chi square. 245 The difference in the rate Of use Of health services between the white and the nonwhite people has been shown re- peatedly throughout this study. The white group quite con- sistently reports the highest rates regardless Of income levels. The reason for this difference lies in the cultural backgrounds Of the two groups, i.e., the customs, norms, values, and attitudes. I Tenure. Individuals in owner households reported high- er diagnostic rates than those in renter households. The dif- ference between them is not large, but it is significant. This tendency is found at all ages except the age group 18 to 44. This trend is not consistent when income is considered. See Table 129. The owner group reported slightly higher rates in the middle income group, but among those with incomes of $4,000 and over the renters have a rate more than double that of the owners. There is no significant difference between them in the lowest income level. Among both owner and renter households the diagnostic rates increase with increasing income. This tendency is more pronounced among the latter group. 246 Table 129. Rates Of diagnostic cases by income and home tenure. Income Tenure Total Under $1,500— $4,000- Unknown P . $1,500 3,999 ~up Total 5.4 1.1 5.5 10.0 6.2 .001 Owners 6.5 1.9 6.9 6.9 11.4 .10 Renters 4.4 0.7 4.3 17.5 0.0 .001 P .05 -- .10 .001 Place Of Residence. When rates of diagnostic services are related to residence, as shown in Table 130, it is readily seen that diagnostic rates increase with increasing urbanity. This trend is consistent in every age group except those 45 years Of age and up, where the rates for the various residence groups are practically identical. Table 130. Rates Of diagnostic cases by place Of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban P Total 5.4 2.2 4.2 8.5 .001 Under 18 6.2 1.3 5.1 12.5 .001 18-44 5.4 1.7 3.4 8 8 .001 45-up 4.2 4.4 4.3 4.0 -—- p -- -- —- .01 247 Among urban residents the rates of diagnostic service tend to decrease with increasing age. This tendency is not evident among the other residence groups. Age differences dO not appear to be of much consequence among the other groups. Table 131 reveals that the high income, urban residents report the highest rates Of diagnostic service. The urban people are the only residence group whose rates increase con— sistently and significantly with increasing income. Table 131. Rates Of diagnostic cases by income and place Of residence. Income Residence Total Under $1,500- $4,000- Unknown P $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 Rural Farm 2.2 1.0 1.1 6.8 8.7 * Rural Nonfarm 4.2 1.6 6.9 1.0 3.5 .02 Urban 8.5 0.8 7.3 13.9 7.3 .001 P .001 * .01 .01 —- *The expected frequencies were not large enough in certain cells to warrant computing chi square. Health Environment Index. The relationship between diagnostic rates and health environment index is highly sig- nificant. The rates increase from a rate Of zero in the lowest index group to 17.1 in the highest group. Within the highest index group the rates decrease with increasing age, from 32.8 for those under 18 years Of age to 4.4 for those 243 45 and above. It will be remembered that this same trend existed for the highest income group. However, for those persons under 18 years of age the rate for the high health environment index group is almost double that Of the high in- cOme group. On the other hand, the rates are almost identical for those persons 45 years Of age and above. Table 132 reveals that the highest diagnostic rates were reported among those with a high health environment index and a high income. While both factors are influential, the evidence indicates a greater influence Of the health environ- ment index. Table 132. Rates of diagnostic cases by income and health environment index. Income Health Environment Total Under $1,500- $4,000- Unknown P Index ' $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 0-10 0.0 0.0 0.0 0.0 0.0 ** 11-18 2.2 2.4 2.1 0.0 3.6 ** 19—22 8.3 2.2 9.0 8.5 8.4 ** 23 17.1 0.0* 19.4 16.4 12.5* ** P .001 ** .001 .01 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. Communication-Participation Index. There is a positive association between the rate Of diagnostic care received and communication—participation index. However, the differences are somewhat smaller than those found for health environment index. Although there is some evidence Of decreasing diag- nostic rates with increasing age in the two highest index categories, it is Of slight significance in the second high- est category and of no significance in the highest. When communication-participation index is considered in relation to income, as shown in Table 133, it can be seen that income has a slightly greater influence upon diagnostic rates than does the communication-participation index. How- ever, both are influential. Table 133. Rates of diagnostic cases by incOme and communication— participation index. Income Communication- Participation Total Under $1,500- $4,000— Unknown P Index $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 0-3 1.0 0.5 2.1 0.0 0.0 ** 4-7 4.0 1.2 4.8 10.3 3.5 .01 8-13 6.1 1.8 6.6 6.9 7.5 —- 14-25 11.9 0.0 6.5 15.5 22.2* .05 P .001 ** -- .05 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells tO warrant computing chi square. Size of Household. Size of household and rates of diagnostic services are negatively associated. This holdstrue 250 generally for each age group. However, in the smallest house- holds there was no diagnostic care reported for persons under 18 years Of age. This absence Of diagnostic care in this group is probably due largely to the small number Of individu- als in this category. With this one exception, the difference between the smallest and the middle sized households is prac- tically nil. The major difference, therefore, is between those with less than 7 members per household and those with 7 or more members. While there is some evidence Of decreasing rates with increasing age, it is not very pronounced in any household group. It is most evident in the households with 3 to 6 members. Contrary tO what would be eXpected, in families with 7 or more members there was no diagnostic care reported for females above the age of 17 years. One would expect some diagnostic care during the childbearing ages, 18 to 44 years. On the other hand, in this age group the females in the smaller households reported twice as much diagnostic care as males. It is rather evident that factors in addition to Ob- jective need are influencing the rates Of diagnostic service. Table 134 reveals, as have other tables above, that income is one of those factors. That there are other factors Operating is further evidenced by the fact that diagnostic rates increase with increasing income in each household size except among households with 7 or more members. In this instance there was 251 no diagnostic service reported for either the highest or the lowest income group. Table 134. Rates of diagnostic cases by income and size of household. Income Size of Total Under $1,500- $4,000- Unknown P Household $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 1-2 6.8 3.4 6.6 12.4 0.0 .10 3-6 6.1 0.7 5.6 10.7 8.0 .001 7-up 1.7 0.0 4.0 0.0 0.0 * P .01 * -- .10 *The expected frequencies were not large enough in certain cells to warrant computing chi square. Education Of Household Heads. There is a significant increase in diagnostic rates as education of both the male and female heads increases. This increase is consistent in all age groups. The higher education groups report the highest rates for individuals below 18 years of age with decreasing rates as age increases. This tendency has been consistent among all Of the higher socio-economic groups. Among those individuals whose household heads have less than a high school education the age differences are not significant. Tables 135 and 136 show that diagnostic rates increase with increasing education of both male and female household heads as well as with family income. Those with the highest incomes and whose family heads have had 1 year or more Of 252 college report the highest rates. Out Of 225 individuals whose male household heads had less than 4 years Of schooling there was only 1 case of diagnostic care reported, and that was in the lowest income group. There were only 6 cases Of diagnostic care reported among the 560 individuals in the lowest income group. Table 135. Rates of diagnostic:casesby income and by education Of male household head. Income Education Of Total Under $1,500- $4,000- Unknown P Male Head $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 Under 4 0.4 0.6 0.0 0.0* 0.0 ** 4-8 3.3 1.1 5.0 1.0 10.5 ** 9-12 6.2 2.1 6.8 7.8 3.1 ** l college-up 13.3 0.0* 7.8 17.1 7.7 .05 Others*** 3.8 1.2 4.4 3.4 15.4 P .001 ** -- .001 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells tO warrant computing chi square. ***This category includes nO answer, no male head, and male head not living. 253 Table 136. Rates of diagnostic cases by income and by education Of female household head. Income Education Of Total Under $1,500- $4,000- Unknown P Female Head $1,500 3,999 up Total 5.4 1.1 5.5 10.0 6.2 .001 Under 4 0.0 0.0 0.0 0.0* 0.0 ** 4-8 2.3 1.3 2.6 1.4 9.1 ** 9-12 5.9 0.9 6.6 6.8 6.3 .10 l college—up 13.3 4.0 9.4 17.0 12.5* .05 Others*** 3.9 0.0 7.7 0.0* 0.0 P .001 ** .01 .001 *Rate is based on less than 10 individuals. **The expected frequencies were not large enough in certain cells to warrant computing chi square. ***This category includes no answer, no female head, and female head not living. Summary and Conclusions. The rate Of diagnostic care received by the individuals Of this study during the six months prior to the survey was 5.4 cases per hundred pOpulation. The highest rates were found among the younger ages, white peOple, urban residents, owners, the members Of the smaller households, and females (especially those from 18 to 44 years of age). The rates increased with increasing income, health environment index, communication-participation index, and education Of household heads. It has been indicated that seeking diagnostic service is not simply a matter Of need nor of financial ability to pay for such services. It is also related to the differences in 254 the health norms and standards of the higher socio-economic groups as contrasted with the lower groups. These norms have not been isolated as such in this study. But it is through them that a more complete understanding Of behavior as related to diagnostic health care will be had. 255 CHAPTER X COST OF HEALTH CARE Many studies have been made Of the cost Of various aspects Of medical care. Such studies are Of considerable value locally as well as nationally as an aid in planning health programs and in anticipating the needed financial re- sources for adequate health care of a pOpulation. There is no question that the cost Of modern medical care has exceed- ed the ability Of many peOple to pay.1 The Serbein report shows that personal expenditures for medical care in the United States were three times as high in 1951 as they were in 1929, and more than four times as high as the low reached in 1933 during the depression years.2 Sound programs Of fi- nancing health care can be formulated only on the continued accumulation of Objective information on the costs of health services and facilities and the relative financial ability Of the peOple to pay for such services, as well as their buying habits and budget priorities.3 1. Charles E. Lively, "Some Problems Warrant Study for Continuing Health Improvement," The Journal of Osteopalhy, November, 1953, p. 17. See also Alfred E. COhn and—Claire Lingg, The Burden of Diseases in the United Spgtes, New York: Oxford University Press, 1950, p. v. 2. Oscar N. Serbein, Paying for Medical Care in the United States, New York: Columbia Press, 1953, p. 48. 3. The Serbein report cited above is a comprehensive analysis Of methods Of paying for medical care in the United States. This study was based entirely upon secondary source materials. See: Ibid., entire volume. 256 A separate medical case record was made for each case Of acute illness, chronic illness, dental care, eye care, pre- ventive care, and diagnostic care. Each Of these categories is mutually exclusive, and each may or may not have involved some cash expenditure. The costs Of medical care discussed in this chapter refer tO the total costs involved for the combined total Of these various medical cases, unless otherwise speci— fied. Time does not permit a detailed analysis of the cost Of each type Of medical service received. A brief summary will be made Of the cost Of health care expended by the various sociO-economic groups under study here. The cost Of insurance premiums was not included in the analysis. It should also be pointed out that there were 106 cases out Of 1737 medical cases for which costs were unknown. Therefore, the figures reported in the following pages are slightly lower than the actual amount spent by the total sample for health care. The problem of unknown and forgotten costs is one which faces all research— ers in this area unless day by day records are kept.4 The services Of M.D.'s, M.D. specialists, non-M.D.'s, and dentists combined accounted for 50.9 percent of all of the medical care costs. Hospitals were next highest with 20.8 per- cent of the costs, and drugs followed with 15.0 percent. Next in order were glasses, dentures, and appliances which accounted 4. The Canadian Sickness Survey employed a convenient technique for having informants record day to day illnesses and expenditures. See: A. F. W. Peart, "Canada's Sickness Survey Review Of Methods," Reprinted from the Canadian Jouppal Of Public Health, October, 1952, pp. 404-414. 257 for 6.0 percent Of the costs, and midwives, special nurses, and practical nurses accounted for 3.8 percent. The cost Of other services was practically oil. The results Of this study show that the total cost for all kinds Of medical care during the six-month period was $44,284 for the 2125 individuals. The mean cost was $27.15 per medical case and $20.84 per capita. Since there was an average Of 3.69 persons per household in Wake County in 1950, . the mean cost per household would amount to $76.90 for six months and $153.80 per household per year.5 As was pointed out above, since there were some cases with unknown costs in the study, these household estimates are a little low. Even so, this figure is somewhat below the estimated national average of $178.00 made in the N.O.R.C. study for the year 1952 to 1953.6 Since the mean is Often distorted by one or two cases involving relatively large costs, preference has been given tO the median in the present study. The median cost for all cases was $6.70. However, since a close approximation Of the median 5. This latter figure is about double the average of $82.10 per year estimated for Canada by the Canadian Sickness Survey. See: "Canadian Sickness Survey, 1950-51," Special Compilation: NO. 1, Family Expenditures for Health Services (National Estimates), Ottawa, Canada: The Dominion Bureau Of Statistics and the Department of National Health and Welfare, May, 1953, p. 10. 6. Odin W. Arderson, "Voluntary Health Insurance and Con- sumer Expenditures for Personal Health Services in the United States, July 1952 through June 1953," National Consumer Survey Of Medical Costs and Voluntary Health Insurance, New York: Health Information Foundation, Summary Report No. 2, 1954, p. 5. 258 can be had from simple inspection Of the tables which give the percentage Of cases involving specified costs, medians were calculated only for those cases which involved some cost. This measure gives a comparative estimate Of the expense in- curred in those cases involving some costs. The median cost for all cases with costs was $11.74. It should be pointed out that since the data on cost Of health care in this chapter are based on percentage distri— butions rather than distribution; Of ratios, the regular form Of chi square is used. Therefore, only one P value is reported for each table, since this value is based on the frequency distri- bution Of the entire table. Age and Sex. With some minor variations, Table 137 shows that as age increases there is a general decrease in the percentage Of medical cases which involve no costs. Further- more, for those cases with some cost involved, the median cost increases with increasing age, reaching a peak at ages 45 to 64. Thereafter, the median cost Of medical care declines slightly. In the age group 45 to 64, about half (49.2 percent) Of the cases involved costs above $17.00. On the other hand, among children under 6 years of age only 12.3 percent Of the cases involved that much cost. The age variations with regard to cost of health care can be explained primarily in terms Of the amount and kind Of health services used. With regard to the percentage Of cases without costs, the primary age difference appears to be between those individuals 17 years Of age and below and those above 17. .oanap magnum may we nofiwonahpmap manequHH was so comma mu osae> mun» oosfim .oHnmu some new tonnes now no osam> m one base .OAOHOHOQB .moHnma magnassou one can mane psonmsonnu poms ma unmadm “no mo EHOH amastH one .mofipmh mo mucuusnaupwwp can» monums moofipanunp Imam mososuonm so momma Ohm umpomso wage :a oamo season HO amoo so mass may oosfim** .pouzneoo on we: UHOOO .ouOmoaonp .Oam oo.wa o>ond use? assume mane* Hoo. **m oH.mH *un mw.HH mm.m om.» om.m vs.HH Anamoo aha; mommvv mpmoo :mfieoz as be an m e s mos aaocxnp mpmoo spas mommo o.om «.mv w.mm N.OH w.HH «.ma m.mm asuoo.waa o.mm m.om e.mm s.mm H.mm o.mm «.mm oo.saauoo.oa o.Hm H.NH m.om s.mm H.5m m.sm m.m~ oo.mauoo.aa c.wH m.HH m.mH ¢.wm o.mm m.wm s.Ha ocoz HHH 44m saw us «mm 4mm amps mmwao Happy o.ooH o.ooH o.ooH o.ooH o.ooa o.ooH o.ooH pcooaoa sauce asumo «also swims sauva mass m “use: Hayes pmoo omd .owe can ease spades me meO Mayo» an mommo amoepos we soapsnfiapmwo pnooaoo can mmeO cameos .uma mapme 260 Those individuals 17 years Of age and under have been shown to make greater use Of the facilities Of the Public Health Service, which are provided without cost. On the other hand, they are less likely tO require dental and eye care than the Older age groups. Furthermore, the illnesses which they re- port are Of a comparatively short duration, and the indication has been that these illnesses are Of a less serious nature ! than those in the Older ages. These factors tend to decrease g the amount Of service required per case; hence, the cost per case is lower. The Older age groups, on the other hand, tend tO report higher rates Of more serious and long term illness. They also have relatively higher rates Of dental and eye care. These factors tend to increase the percentage Of cases which require some expenditure as well as the average cost per case. The percentage Of males and females above 17 years Of age reporting cases without costs is 13.0 and 16.8, respec— tively. The proportion of females reporting cases with costs above $17.00 is also slightly higher than the prOportion Of males. Furthermore, the median for those cases with costs is $12.58 for males and $15.46 for females. The difference be- tween the sexes is more pronounced in the age group 18 to 44 years than in the other ages. The median cost is $8.98 for males and $13.66 for females in this age group, but there is little or nO difference between them in the other age groups. This sex difference in the cost of health care is Obviously due to a greater use Of health services by women than men. N 0') H Females had a higher use Of every type Of health service studied. This trend was especially pronounced in the age group 18 to 44 years Of age. The Committee on the Costs Of Medical Care found much the same trends with regard to the distribution of costs Of health care by age and sex as were found in this study.7 The Committee reported a general increase in average cost with increasing age. Furthermore, in the age groups above 14 years, females had the highest cost. The difference was greatest in the age groups 19 to 44 years Of age. It should be pointed out, however, that the Committee report was based On the aver- age cost per person rather than per medical case. Income. The Canadian Sickness Survey not only found that the percentage of family units without expenditures de- creased with increasing income, but also that the mean expendi- ture increased with increasing income.8 Both the nation—wide study conducted by N.O.R.C. and the Missouri study conducted by Almack reported a positive association between income and 7. Helen Hollingsworth, et alii, Medical Care and Costs in Relation to Family Income: _A_Statistica1 SourEe Book, Bureau MemorandumfNo. 51, Second EditiOnj’Washington: Federal Security Agency, May, 1947, p. 177. 8. "Canadian Sickness Survey, 1950-51," Special Compi- lation: NO. 2, Family Expenditures for Health Services by Income Groups (National Estimates), Ottawa, Canada: The Do- minion Bureau of Statistics and the Department Of National Health and Welfare, July, 1953, pp. 10-11. 262 family expenditure for all medical and health services.9 Various other studies have reported an increase in expenditure for health care with increasing income; however, these studies have also indicated that the expenditure does not increase prOportionately.10 Table 138 shows that in the present study as family in- come increases the percentage Of cases which involve no costs decreases., This trend is largely a reflection Of the greater use Of health services by the upper income groups. Among those cases which involved some costs, the median cost increases slightly with increasing income. This trend is also indicative Of a greater expenditure by the higher income groups for more costly medical procedures and accomodations, as well as great- er use Of health services per case. The interpretation pre— sented here is in essential agreement with that of Almack, namely, that these income differences are not a reflection Of 9. Anderson, Op. cit., Tables 4 and 5; Ronald B. Almack, "The Rural HeaIth'FEEilities Of Lewis County, Missouri," Columbia: University Of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943, p. 38. 10. Marie Mason, "Rural Family Health in a Selected County in Kentucky," Lexington: University Of Kentucky, Agri— cultural Experiment Station, Bulletin 538, June, 1949, p. 24; C. Rufus Rorem (Editor), "The Economic Aspects Of Medical Services," A reprint Of two chapters Of Publication 27 Of the Committee on the Costs Of Medical Care, Chicago: The University Of Chicago Press, 1935, p. 12; Isabella C. Wilson, "Sickness and Medical Care Among the Rural POpulatiOn in a Petroleum- Producing Area Of Arkansas," Fayetteville, Arkansas: University Of Arkansas, Agricultural Experiment Station, June, 1941, p. 27; Hollingsworth, 2p..31£., p. 154. differences in need, but rather Of differences in standards and in ability to Obtain and to pay for needed health services.11 Table 138. Median costs and percent distribution Of medical cases by total cost Of health care and income. Income Cost Total Under $1,500- $4,000- Unknown $1,500 3,999 up Total Percent 100.0 100.0 100.0 100.0 100.0 Total Cases 1737 374 723 519 121 None 21.7 35.5 21.4 13.1 17.5 $1.00-$5.00 25.6 23.4 26.1 24.8 32.9 $6.00—$17.00 26.2 19.4 25.2 32.2 28.2 $18.00-up 26.5 21.7 27.3 29.9 21.4 Cases with Costs Unknown 106 19 45 24 18 Median Costs (Cases with Costs) 11.74 11.02 11.74 12.46 8.98 P .001 Color. Table 139 shows that a much larger proportion Of the nonwhite cases involved no costs than did the white cases . medical services in time Of sickness. which involved some cost, the median cost for white and nonwhite is practically identical. ence in median cost is due to the fact that the average length ll. Almack, pp. cit., p. 39. However, This difference is a reflection Of the lower use Of for those cases At least part of this lack Of differ- of stay in a hospital was longer for the nonwhite than the white peOple. Greater color differences would probably be revealed if color groups were further subdivided into income groups. However, the number Of cases prohibits further cross- tabulation. Table 139. Median costs and percent distribution Of medical cases by total cost of health care and color. Color Cost Total White Nonwhite Total Percent 100.0 100.0 100.0 Total Cases 1737 1419 318 None 21.7 17.3 41.4 $1.00-$5.00 25.6 26.5 21.2 $6.00-$l7.00 26.2 28.5 16.2 $18.00-up 26.5 27.7 21.2 Cases with Costs Unknown 106 85 21 Median Costs (Cases with Costs) 11.74 11.74 11.50 P .001 Home Tenure. Previous chapters have shown minor vari- ations between the tenure groups in the use Of various health services. Table 140 indicates that individuals in owner house— holds have a slightly higher percentage of cases which involved some costs than dO renters. The tenure differences in this table are not large, but they are significant according to the chi square test. However, for those cases with costs there is 265 very little difference between the medians for owners and renters. The median for owners is slightly higher. Table 140. Median costs and percent distribution Of medical cases by total cost of health care and home tenure. Tenure Cost Total Owners Renters Total Percent 100.0 100.0 100.0 Total Cases 1737 877 860 None 21.7 17.8 25.7 $1.00-$5.00 25.6 25.2 25.8 $6.00-$l7.00 26.2 29.2 23.4 $18.00-up 26.5 28.0 25.1 Cases with Costs Unknown 106 72 34 Median Costs (Cases with Costs) 11.74 12.10 11.26 P .001 Place Of Residence. Studies in Pennsylvania and Arkansas have reported that the average cost per family for medical care decreased with rurality.12 Furthermore, the Committee on the 12. Ruth M. Connor and William G. Mather, "The Use Of Health Services in Two Northern Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 517, July, 1949, p. 11; W. G. Mather, "The Use of Health Services in Two Southern Pennsylvania Communities," State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 504, July, 1948, Table 17; Wilson, pp, 233,, p. 32. 266 Costs Of Medical Care found that per capita expenditure in- creased with increasing size Of community.13 The data of the present study reveal relatively little difference between residence groups in the cost of medical care. Table 141 shows that the prOportion Of cases with no costs declines slightly with increasing urbanity. However, the distribution presented in this table is not statistically significant. The median of those cases with costs increases with increasing urbanity, but differences are so slight that they tOO are probably in- significant. Table 141. Median costs and percent distribution of medical cases by total cost Of health care and place of residence. Residence Cost Total Rural Rural Urban Farm Nonfarm Total Percent 100.0 100.0 100.0 100.0 Total Cases 1737 467 463 807 None 21.7 25.4 21.3 19.8 $1.00—$5.00 25.6 25.6 26.1 25.2 $6.00-$l7.00 26.2 25.2 24.9 27.7 $18.00-up 26.5 N 23.8 27.7 27.3 Cases with Costs Unknown 106 30 26 50 Median Costs (Cases with Costs) 11.74 11.02 11.86 11.98 P 13. Rorem, 2p. cit., p. 14. 267 In order to get a clearer idea of the relationship Of the use and cost of health services to rural and urban resi- dence, other factors, such as income, color, tenure and others, need to be held constant. For example, it has been shown in another study that, while the average medical expenditure in- creased with increasing urbanity, the percentage Of the family 14 income spent decreased with urbanity. Health Environment Index. Table 142 reveals that the lowest index group had by far the largest proportion Of cases which involved no costs. Of those cases which involved costs, the median cost for this low index group is also somewhat below that Of the higher index groups. The medians tend to decrease slightly beyond the peak in the index group 11 to 18. However, the decline is small and probably not significant. The trends revealed here reflect the comparatively low rates of use of medical services by the low index group. This lower usage is due in part to a difference in ability to pay as well as differences in health standards, as has been pointed out. The fact that the low index people tend to have lower in- comes probably affects the kind of service used, in terms Of the expensiveness of the service. l4. Bureau Of Labor Statistics, Family Spgnding and Saving in Wartime, 1945, p. 71, quoted in Hollingsworth, 2p. cit., p. 154. 268 Table 142. Median costs and percent distribution Of medical cases by total cost Of health care and health environment index. Health Environment Index Cost Total 0-10 11-18 19-22 23 Total Percent 100.0 100.0 100.0 100.0 100.0 Total Cases 1737 252 470 712 303 None 21.7 41.2 21.5 19.5 10.9 $1.00-$5.00 25.6 26.0 24.0 26.4 25.7 $6.00-$17.00 26.2 17.9 25.4 25.0 37.3 $18.00-up 26.5 14.9 29.1 29.1 26.1 Cases with Costs Unknown 106 17 29 41 19 Median Costs (Cases with Costs) 11.74 7.78 12.70 12.10 11.50 P .001 Communication-Participation Index. It is seen in Table 143 that the proportion of cases for which there was no cost is greatest in the lowest index group. There were 41.0 per- cent of the cases in this group for which no cost was reported, compared with 16.0 in the highest index group. Furthermore, for those cases with costs the median cost increases with increas- ing communication-participation index. Differences in use Of health services and economic status are reflected by these trends. However, it has been pointed out in a previous chapter that the communication-participation index needs greater re— finement in order to become a more discriminating measure. 269 Table 143. Median costs and percent distribution Of medical cases by total cost of health care and communication-participation index. Communication-ParticipatiOn Index Cost TOtal 0-3 4-7 8-13 14-25 Total Percent 100.0 100.0 100.0 100.0 100.0 Total Cases 1737 182 540 727 288 None 21.7 41.0 23.8 17.5 16.0 $1.00—$5.00 25.6 21.6 26.0 27.2 23.2 $6.00-$l7.00 26.2 19.9 25.4 26.8 30.4 $18.00-up 26.5 17.5 24.8 28.5 30.4 Cases with Costs Unknown 106 11 28 42 25 Median Costs (Cases with Costs) 11.74 10.30 11.26 11.74 12.94 P .001 Size Of Household. There is a definite relationship between size of household and total cost Of health services. See Table 144. The percentage of individuals in the largest households reporting cases without costs is over three times as high as the percentage Of those in the smallest households. The respective percentages are 36.3 and 11.4. Also, for those cases which involve some costs the median cost decreases with increasing size Of household. Even though the middle-sized households have a relatively higher economic standing than the smallest households, the latter group reported somewhat more cases with costs above $17 than did 270 Table 144. Median costs and percent distribution of medical cases by total cost Of health care and size of household. Size Of Household Cost Total 1-2 3-6 7-up Total Percent 100.0 100.0 100.0 100.0 Total Cases 1737 330 1198 209 None 21.7 11.4 21.9 36.3 $1.00-$5.00 25.6 21.2 26.2 28.4 $6.00-$l7.00 26.2 29.7 27.5 13.9 $18.00-up 26.5 37.7 24.4 21.4 Cases with Costs Unknown 106 24 74 8 Median Costs (Cases with Costs) 11.74 14.74 11.14 8.50 P 0001 the former group. This greater average cost for the smaller households is probably due to the high proportion of Older peOple in such households. It has already been shown that the older people not only reported a higher percentage of cases with costs, but also that the median cost for such cases was considerablyabove that of the cases in the younger age groups. On the other hand, the largest households not only have a large prOportion of persons in the younger ages, but their use of health services generally has been shown to be lower, on the whole, than the individuals in the other household sizes. Furthermore, their economic standing is lower than the other household groups. shown here. These factors tend to account for the trends 271 Education of Household Heads. Mason found no consistent relationship between education of household heads and expendi- ture for health care.15 However, Tables 145 and 146 show that, in the present study, the persons whose household heads have the lowest level of education report the highest percentage Of cases without any cost involved. Among those individuals whose household heads have less than a fourth grade education, the median cost for those cases with costs is less than half Of the medians in every other educational level. This trend, however, is not revealed for education Of female heads. In fact, the median in the lowest educational level of female heads is slightly above those of the higher education groups. The data do not reveal sufficient explanation of these trends. They may be due tO chance variations in sampling. The trend Of greatest importance is that the proportion Of cases without any costs decreases as education Of both the male and female household heads increases. This trend is in- dicative Of the higher use Of health services and facilities by the more highly educated groups. It also reflects the higher income Of such groups and the difference in health standards which, of course, affect both the amount and type Of health resources used. 15. Mason, 2p. cit., p. 27. 272 .wsH>HH “on use: ons can .Omo: mass on .yosmsm Os mousHosa hnowoumo mane* Hoo. a mm.mH Ne.HH OH.NH mw.HH oH.mH om.m es.HH Awpmoo spas momdov mpmoo :mfiooz am 82 HH mm NH 4 mes caoaxcs mwmoo nu“? mommo m.om v.8m s.mm o.mm v.8m H.o m.mm dauoo.mse m.mH H.4m e.mm N.Hm m.Hm s.mm «.mm oo.sawuoo.ma m.Hm m.mm H.2m n.8m m.em m.em m.mm oo.mwuoo.ae o.mm m.mH m.m e.mH m.sm o.mm s.Hm . oaoz «Hm mmm mom awe mmm wHH amps mmmso fleece o.ooH o.ooH o.ooH o.oos o.ooH o.ooH o.ooH unwound Haves a: owOHHOO v *mamsuo ummmfifioo v muH «Hum mus amen: fishes pmoo Odom on2 mo :ofiumooom .Omon made we oOfiHmOSOO can ease season we pmoo Haven up mommo awesome mo :OHpsnahumHO HGOOHOQ pad mpmoo cameos .mwa OHOMB 273 .wsH>HH we: use: madam“ one .Omon onEom o: .Aosmse o: mossflosa hsowOpmo mfisea Hoo. a mm.mH mm.mH mm.m~ om.o~ mm.HH em.mfi «s.HH Ampmoo spas mommov mvmoo smfipoz ms oH ma mm mm s moH aaoasas mumoo nu“? mommu m.sm o.om m.mm o.mm H.mm m.Hm m.mm asuoo.wfiw s.om e.mm H.mm m.su o.mH m.mm «.mm oo.saeuoo.oe m.Hm m.mm o.mm e.sm o.mm o.mH m.mm oo.meuoc.ae m.om m.¢H m.wH m.om s.mm m.mm s.Hm oaoz «OH msH new one mew Ho smsfi mmmao Haves o.ocH o.ooH o.ooH o.ooH o.ooH o.ooH o.ooH unwound adage Q: omoHHoo v *mwonoo ummmafloo v mus «Hum mus amen: fleece pmoo Odom onsom mo sofipmoapm .Omon onsom mo sofivmospo pom muse season HO pmoo Haven an mommo Hmowpos mo cofipsnfiupmwo poochoa use mumoo scape: .mvH OHQsE Summary and Conclusions. A separate medical case record was made for each case Of acute and chronic illness and each case Of dental, eye, preventive, and diagnostic care received. Any given case may or may not have involved some cost. There were 106 cases Out Of 1737 for which the costs were unknown. Therefore, the figures presented in this chapter understate the total amount of cost involved. The total cost Of health services for all cases during the six-month period was $44,284. The mean cost was $27.15 per case and 20.84 per capita. The estimated average cost per household for Wake County was $76.90 for six months and $153.80 for a year, exclusive Of insurance premiums. Since the median is not distorted by extreme cases, as is the mean, the median was given preference throughout this chapter. The median cost for all medical cases was $6.70, and for all cases with costs it was $11.74. In general, as would be expected, those groups which have been shown in previous chapters to have the highest rates of use Of health services also had the highest percentage Of medical cases with costs. Such groups also reported higher median costs for those cases which involved some cost. This latter tendency appears to be a result Of a greater use of health services per case as well as the use Of more costly services and facilities. CHAPTER XI SUMMARY AND CONCLUSIONS Summary In recent years there has been greater emphasis in this country on health and health care programs than at any other period of time. In North Carolina, as in many other states, I ‘ 5:; there has been a pronounced upswing in interest and efforts in the field of health. Some examples of this interest and activity are the establishment Of the North Carolina Medical Care Commission, the hospital building program, the expanded medical school program Of the University of North Carolina, increased efforts to make health insurance available to the peOple Of the state, and the establishment of a medical edu- cation loan fund. With the rapidly expanding health programs and activities in the state, there has been a need for more detailed analyses of the factors associated with health and with the health care activities of the people. The present study was designed to provide some Of this needed information for those health agen- cies, social workers, applied sociologists, and other groups who are concerned with the health Of the people. This investigation was part Of a larger state-wide study Of health conditions and of medical services and facilities directed by Dr. C. Horace Hamilton, Head of the Department Of 276 Rural Sociology at North Carolina State College, during the latter part Of 1949. This phase of the study was based on a house-tO-house canvass Of a two percent, random sample Of the pOpulation in Wake County. The resulting sample population was composed of 588 households and 2125 individuals, including both white and nonwhite people in rural and urban areas. The Objective Of the study was to collect and analyze data which, it was judged, would be useful in planning a more effective health program for the county and which would also provide a basis whereby basic principles regarding health pro- grams may be derived. The analysis was based on three basic or dependent variables: morbidity, the use Of health services and facilities, and the cost Of health services and facilities. These variables were analyzed in relation to a set of selected social and economic factors considered as independent variables; namely, age, sex, income, color, home tenure, place of residence, health environment index, communication-participation index, size of household, crowding index, and education Of household heads. The results of the findings are summarized below. Agg. Age was found tO be one Of the major influencing factors in terms of the amount Of acute and chronic illnesses reported and the use Of various health services. The highest rates Of acute illness were reported for the youngest age groups, particularly in the highest income group. On the other hand, chronic illness rates showed a marked increase with in- creasing age. Age differences were also found in the use Of 277 health services. The highest rates Of use Of a doctor, for example, were found among the youngest and the Oldest age groups. This trend correSponds rather closely with the higher rate Of use of a doctor for acute illness in the younger ages and for chronic illness in the Older ages. Age variations in hospitalization rates were not significant. When hospitalization for acute illness was considered separately, however, the age differences were of borderline significance. Those individuals under 6 years of age and those from 18 to 44 reported the highest rates. Dental rates were lowest for those individuals under 6 years Of age and next lowest for persons 65 years Of age and over. The other age groups reported comparatively similar rates. Eye care, on the other hand, increased with increasing age up to age 65 where there was a slight decline. There was a rather pronounced decrease in the rates Of preventive care as age increased. This tendency was due large- ly to the programs of the Public Health Service which were directed specifically at the younger age groups. There was also a slight decrease in diagnostic rates with increasing age, but the trend was not statistically significant, except in the highest income group and among urban residents. The percentage Of medical cases without costs decreased with increasing age. However, the median cost for those cases with costs increased with age up to age 65 where there was a slight drop. 278 §g§, The sex variable was analyzed only for those age groups above the age Of 17 years, since it was assumed that sex differences below that age would be of little consequence in this study. It was found that there was no difference be— tween the sexes with regard to acute illness. For chronic illness, females reported higher rates in the age groups 18 to 44 and 45 to 64. They also had higher rates of use Of doctors and hospitals, and reported more dental, eye, preven- tive, and diagnostic care than did males. This tendency was manifest primarily in the age group 18 to 44 years, but in some instances it appeared in the older age groups as well. The percentage of medical cases with some costs was greatest for females. The median cost for the total number of cases with costs was also higher for females. These trends are Obviously a result Of a greater use of health facilities and a greater expense per medical case. Income. Family income was definitely associated with the rates of illness reported, with the various kinds Of health care received, and with the cost of health care. Acute illness rates reported in the study increased with increasing income. The major difference was found between those individuals whose family income was $4,000 or more and those persons with a family income below $4,000. Income differences were most pronounced in the age groups under 14 years. On the other hand, there was a decline in chronic illness rates as income increased. The primary difference was between those with a family income 279 under $1,500 and those with $1,500 or more. However, income differences for the nonwhite portion Of the sample with regard tO chronic illness rates were not statistically significant. The use of a doctor increased as family income increas- ed. However, when age was considered, this tendency appeared only in the younger age groups. There was also some indication Of higher hospitalization rates as income increased, especially for those with $1,500 or more, but the trend was only on the borderline Of significance. Further study would be necessary to confirm this result. There was a definite increase in the rates Of dental, eye, and diagnostic care received as income increased. Rates Of preventive care also increased with increasing incOme for those individuals under 6 years Of age, but incOme variations were not significant for the other age groups nor for all groups combined. 92123, Another Of the.inf1uential factors in morbidity and the use and cost Of health services was the color factor. The white people reported considerably higher rates Of acute illness, a tendency particularly marked in the lower age groups. It was also manifest in the rural farm and urban areas but not in the rural nonfarm areas. There were nO significant color differences in the rates Of chronic illness. The rate of use Of a doctor was higher for white than for nonwhite people except in the Oldest age group. The differ- ence showed up in every income group. The white people also 280 had a higher rate Of use Of hOSpitals, but the difference was ' only Of borderline significance. However, the average length of stay in a hospital was greater for nonwhite people. White peOple reported higher rates Of dental, eye, and diagnostic care than did the nonwhite people. They also re- ported more preventive care, except in the ages 6 to 17 years where the school health program was Operative. The percentage Of cases without any costs was greatest for the nonwhite people due largely to a comparatively larger percentage of unattended illnesses and the lower use of health services generally. On the other hand, for those cases which did involve some costs, the median cost for white and nonwhite cases was about the same. This lack of difference in median costs is probably due, at least in part, to the longer average length Of stay of nonwhite people in hospitals, which tends tO make up for the generally higher rates Of use Of health facili- ties by the white peOple. Home Tenure. Home tenure was one Of the least discrimi- nating of the variables examined in the study. Greater tenure differences would probably be observed if other factors such as color, place Of residence, and income could all have been held constant. However, such detailed cross-tabulations would require a very large sample. Place Of Residence. Residence differences in this study were not as pronounced as is commonly anticipated, especially when age, income, and color are held constant. However, due 281 tO the size of the sample these factors could not be held constant for every comparison. Health Environment Index. There was nO consistent re- lationship between scores on the health environment index constructed for this study and chronic illness rates. There appeared tO be a slight tendency for chronic illness rates to increase with increasing index below 18 years of age but to decrease in the age groups 18 and above. However, these trends were only suggestive and need additional study. With- in income groups differences between the rates of chronic ill- ness in the various index groups were not significant. Acute illness rates increased with increasing health environment index scores. This tendency was less pronounced as age increased. There was a consistent increase in the use Of a doctor as health environment index increased. This tendency was mani- fest among those persons in every age group except those 65 years and up. It was also consistent in every income group. On the contrary, the income differences within index groups were not significant. There was also an increase in hospital- ization rates as health environment index increased. In general, the index appeared to be more influential in rates Of hospitalization than was family income. The rates of dental, eye, preventive, and diagnostic care alSO increased with increas- ing health environment index. The percentage Of medical cases without costs decreased with increasing health environment index. This trend would [0 (X) N be expected in View of the generally greater use Of health services by the higher index groups. The lowest index group reported the lowest median cost for those medical cases with costs. The next lowest index group reported the highest median, and beyond this peak there was a slight decline with increasing index. The higher median costs of the higher index groups reflect greater use Of health facilities per case and probably more expensive care in general. The greater use of hospitals, which is generally more expensive than other kinds Of medical care, would account for at least part Of the difference. Communication-Participation Index. There was no sig— nificant relationship between rates Of acute illness and the communication-participation index. However, there was a slight tendency for chronic illness rates tO decrease with increasing index, but this tendency was evident only for the total and for the age groups 18 to 44 and 65 and up. The latter was only on the borderline Of significance. Within income groups the differencesbetween the index groups were not significant. There was a tendency for rates Of use Of a doctor to increase with increasing communication-participation index, but the trend was not consistent within either the age groups or the income groups. There was also nO significant relation- ship between the index and rates Of use of a hospital. On the other hand, there was a general increase in the rates Of 283 dental care, eye care, preventive care, and diagnostic care as communication-participation index increased. The preventive and diagnostic care trends, however, were not entirely con- sistent throughout the income groups. As the communication-participation index increased, the percentage Of medical cases with costs and the median cost for those cases with costs increased slightly. This slight trend is probably due to the generally higher use Of certain types Of health care by the higher index group. However, the relative- ly higher incomes Of the high index group are probably part Of the explanation. The communication-participation index was among the least influential factors studied. It is in need of further refinement. Size Of Household. Individuals in households with from 3 to 6 members reported the highest rates Of acute illness. This tendency was especially pronounced in the higher incOme groups and in the younger age groups. Trends were not signifi- cant beyond the age of 13 years. The rates Of chronic illness, on the other hand, decreased with increasing size Of household. This tendency was consistent throughout the income groups. However, with age held constant the differences between the rates for individuals in the various household sizes were not significant. This lack Of difference within age groups points up the major influence Of age upon chronic illness rates. In- dividuals in the smaller households reported higher rates Of 284 chronic illness than the others primarily because the relative proportion of older peOple was higher in such households. Individuals in the largest households reported the low- est rates Of use of both doctors and hospitals. The rates for the individuals in other household sizes were about the same. The rates Of dental care decreased with increasing size Of household within every income group. This tendency is due in part to the higher proportion of Older people in the small- er households. However, age is not the full explanation since the same trend was found among adults. The lower economic standing and differences in the standards Of the persons in the largest households are also responsible in part for this trend. There was a decrease in rates Of eye care with increas— ing size Of household. Individuals in the largest households reported practically no eye care. This trend was due in part to the larger proportion Of children in the largest household group and the lower economic status Of this group. However, since this tendency appeared even with income and age constant, further explanation must be sought in the health standards Of the peOple. I Diagnostic rates were also lower for the individuals in the largest households. The rates for individuals in the other two household sizes were about the same. Those persons in the largest households also reported the lowest rates Of preventive care, despite the fact that preventive care was 285 generally most prevalent in the younger age groups. Individu- als in the middle-sized households reported the highest rates Of preventive care. This trend is due primarily tO the higher social and economic standing Of this group in relation to the other groups and to the corresponding health standards of such status. Both the percentage of medical cases with costs and the median cost for those cases with costs decreased with increas- ing size of household. These trends are a reflection of the relatively lower use of health facilities by the largest house- holds and the higher proportion of adults in the smallest household group. Despite the higher average income of the middle-sized households, the median cost was higher for cases in the smallest households. This trend points up the relative- ly greater cost of illness among the older people since the proportion Of older people is higher in the smallest house- holds. Crowding Index. The least crowded and the most crowded index groups reported the lowest rates Of acute illness, while the middle groups reported the highest rates. This tendency is comparable to that Of the largest and smallest households. However, the relationship between acute illness rates and crowd- ing index was not consistent within age and income groups. The rates of chronic illness decreased with increasing index. Although this tendency was rather constant throughout the income groups, it was not consistent within any age group. 286 Crowding index trends were obscured due to the necessi- ty Of combining cells for cross-tabulations; furthermore, since the results based on the size of household were fairly similar to those based on the crowding index, further analysis Of this index was not made. Education of Household Heads. There was a general in- crease in the rates of acute illness as education increased. The major difference was between those individuals whose house- hold heads had less than 9 years of education and those who had 9 or more. When age was taken into account, it was found that this trend was manifest primarily in the two youngest age groups. This trend was not consistent throughout the income groups, and in no instance were income differences significant within educational levels. Chronic illness rates, on the other hand, decreased with increasing education of household heads, but no trends appeared either when age or when family income were held constant. There was a rather definite increase in the use Of a doctor as education Of household heads increased. This trend was especially pronounced in the younger ages, and it was con- sistent throughout the income groups except the lowest. Within educational levels there were significant income differences. Those persons whose household heads had 9 years or more of schooling had slightly higher rates of hospitalization than did those with less than 9 years. However, the differences be- tween educational levels were not highly significant. 287 There was an increase in the rates of dental, eye, pre- ventive, and diagnostic care as education Of household heads increased. This trend was rather consistent within both age and income groups. The percentage Of medical cases with costs increased with increasing education of household heads, but there was little variation in the median cost for those cases with costs. Conclusions Morbidity. The data Of this study suggest that there is more agreement among the various social and economic groups regarding chronic illness than there is in the area Of acute illness. The definitions which the people have Of illness are important in this connection. Even though an individual may, from a medical standpoint, have some morbid condition, he will not report such a condition unless he recognizes it and defines it as such. These differences are due in part to differences in health standards and in part to the nature of the illness. Due to the health standards, certain groups tend to place greater emphasis upon health and health care than do others; hence, more concern is shown over a wider variety of afflictions. This is especially true of acute conditions which are relatively short lived. On the other hand, other groups do not look upon various afflictions with as much concern. They tend to overlook many illnesses, especially those of a less serious nature. However, such chronic conditions as cancer, tuberculosis, arthritis, heart disease, and others, have been publicized considerably and have come to be widely recognized as conditions which require medical attention on the part of all groups. The Use of Health Services and Facilities. The two major factors which appear to be among the most important influences in the use Of health services and facilities are the need for such services, on the one hand, and the ability to pay for them, on the other. These factors, however, are not fixed. They both depend upon the particular circumstances and the persons involved. They are also dependent upon each other to a certain extent. - One of the vital aspects Of need in terms of the de- cision Of a given individual to seek medical care is not just need from a physician's point of View. Felt need, from the patient's point Of view, is the primary basis for action. The individual may not even be ill as far as he himself is concerned. Objective need (that is, need from the medical standpoint) is based primarily on scientific information. Need from the patient's point of view may be based in part on Objective information, and in part on customs, habits, fears, attitudes, and superstitions which have been handed down from generation to generation or which have developed from the in— dividual's own experiences. Furthermore, conflicting goals in terms of time and money as well as financial ability not only influence the use of health services directly, but they also influence the felt needs of the individual. On the basis of the information at hand, both the medi— cal profession and the layman consciously or unconsciously set up standards or norms not only concerning what constitutes need for medical care in a given situation, but also what con- stitutes the prOper means Of meeting that need. It is Obvious, therefore, that the standards Of various groups of people are not only at variance with the medical profession but also with each other. These standards are the basis for the decisions which result in action. Other things being equal, those groups whose standards most nearly coincide will be more likely to make the same decisions with regard to the use of medical services. If the standards Of the laymen vary from those Of the medical profession, their decisions and the consequent actions will vary from what would be recommended by the medi- cal profession. Even though there are differences in Objective need from one group to another, it cannot be concluded from this and similar studies that because the higher social and economic groups generally reported more acute illness and more use Of health services in this study, that they had more Objective need for health care. Although health standards were not in- vestigated as such in the study, the data presented here, along with the findings and conclusions Of other studies, suggest that the standards Of the higher social and economic groups are more nearly in line with those of the medical profession. These groups appear to be more nearly recognizing and fulfilling their objective health needs than are the other groups. The norms of the higher groups stimulate a greater awareness and concern over health and health care, and the generally higher economic status of such people permit them to make greater use of health services and facilities once the need is recognized. As a consequence, illnesses tend to be checked in their early stages, and the favorable experiences which these groups have with the medical profession develops in them a greater confi- dence in the profession and the norms of scientific medicine. The norms of lower groups, on the other hand, are at greater variance with the norms of the health profession. Further- more, being of a generally lower economic status, they are faced with greater conflict of goals in terms of the use of the income which they have. These factors lead to delays in seek- ing medical advice and attention. Such delays often postpone the treatment of an illness until it is in its advanced stages, and, therefore, mortality is comparatively high. Ability to pay for health services is related to family income and other economic resources. It is also related to other financial obligations, spending habits, the costs involv- ed, conflicting goals, and aspirations which may have higher priority. Ability to pay is also affected by felt need in the sense that budget priorities may have to be reassessed and certain goals sacrificed if the need become sufficiently pro- nounced. Although it is commonly agreed that certain groups cannot "afford" all of the medical care they need, it would be 291 difficult to draw the line at any given income level and say that those families above that level can, with prudent manage- ment, have access to all the health care they need. Sometimes expenses are too great. This problem is one of the dilemmas in the financing of medical care at the present time, and one which needs more attention. Perhaps with additional study of the value-attitude systems of the people, their health habits and expenditure patterns, a clearer understanding of the problem will be available. Cost of Health Care. In this study, groups which tended to have more medical cases with costs also tended to report a higher median cost for those cases with costs. The cost of health care for a given individual or groups is influenced not only by the rate of use of health services but also by the type of services used. Therefore, the study of costs without refer- ence to these factors is misleading. Two individuals with equal costs do not necessarily receive the same amount or kind of care. More study should be given to the cost of health care in relation to the type of service received. Health Environment Index. Good health habits are a result of health standards which are reflected in the immediate surroundings in the home. To measure these surroundings, a health environment index was constructed. The use of this index has helped to establish the fact that standards of health and health care vary within given income groups and that the use of health services is related to other health habits, N m (\D attitudes, and practices, and not just to economic factors. Simply raising an individual's income or reducing the cost of health care would not necessarily change his standards of health, nor his use of/health services. Further use of such an index as this in health research is justified, although additional standardization of the various items of the index is needed. Communication-Participation Index. A communication- participation index such as the one used in this study is a useful device as an aid in explaining the behavior of the people with regard to health and health care. However, more study must be given to the individual items of the index and the relative influence which they have on health matters. For example, one or two items of mass media may devote more atten- tion to health than any or all of the others. Therefore, an individual may have a fairly low score on the index and yet be more highly influenced in his attitudes toward health and health care by these one or two items than a person who receives a high score. Such an index would also be very useful in planning or carrying on health education programs if the individual items were studied in terms of the kinds of groups which they reach and the relative influence which they have. It is only with a knowledge of such channels of communication and participation that greater numbers of people can be reached by health in- formation. 293 Recommendations for Action. The results of this study suggest two major recommendations for action. The first of these concerns the need for greater emphasis on health education. The second concerns the need for meeting the costs of medical care. First, there is a need for greater dissemination of health information concerning: 1. Conditions which call for immediate medical attention. 2. Problems of personal hygiene and daily health habits. 3. Prevention of sickness and accidents. 4. Instruction on the availability and the most adequate use of health services and facilities, both public and private, within the limits of family financial abilities. The first recommendation is directed toward changing the health standards of the people and bringing them more nearly in line with the standards of medical science. Secoui greater experimentation is needed in methodsof financing the cost of medical care, especially for low income peOple and hardship cases who can least afford modern medical care, and who are also least likely to afford health insurance to cover their needs at the present premium rates. This recom- mendation is designed to provide the means whereby health care can be received once it is needed and desired by the people. Recommendations for Further Study. Several crucial problems need further study. They are set forth in a series of questions below. 1. What are the commonly accepted standards of good health and health practices of medical science and of the layman? a. In what ways do the standards of medical science and those of the layman coincide, and in what way do they differ? b. Where did these standards originate, and on what are they based? How can the attitudes of the people be modified so that the people will make more adequate use of the health facilities available to them? Through what channels of communication do the various groups of people receive health infor- mation, and what are the most influential sources of information in terms of subsequent behavior? How are decisions made within family units concern- ing the use of health services and facilities? What are the status and role relationships in such situations? How are budget priorities set up within the family unit, and how are they rearranged to meet the de- mands of ill health? What is the image which peOple have of the various health services and facilities? That is, what are the people's attitudes and expectations concerning these services and facilities? How does having insurance influence the use of health services? For example, are those who pur- chase health insurance: a. The persons who are most able to pay for health care? b. Those persons who, for a variety of reasons, anticipate greater use of health services? What are the attitudes of the people toward and expectations of health insurance as a means of meeting the cost of health care? 295 CHAPTER XII METHODOLOGICAL NOTE Some research workers seem to proceed on the assumption that a healthy state is a goal that all men strive for with equal intensity at all times. Such reasoning has lead many to the conclusion that the only barrier between man and good health, or at least access to modern medical care, is an economic one, or perhaps one of lack of facilities and services or distance from such services.1 These factors are admittedly important, but they are by no means the only ones. The present study has indicated through actual findings and by implication of the findings what some of these addition— al factors are. It has also pointed up the desirability of analyzing data on sickness and the use of health services in terms of a theoretical framework so the results will be cumu- lative with other research in the field of health and with research in other fields as well. On the basis of the experi- ence in this study, it is believed that the action schema would be very useful in this regard. Such an approach in- tegrates the findings into a logical interdependent framework 1. For a discussion and refutation of this point of view see: Olaf F. Larson and Donald G. Hay, "Hypotheses for Sociological Research in the Field of Rural Health," Rural Sociology, Vol. 16, No. 3, September, 1951, pp. 228 and 534. not obtained at the simple descriptive level or through test- ing unrelated hypotheses. In this framework, the use of health services is only one of the elements of a total situation in which the actor is directing his efforts and attention toward the goal of good health, either in terms of relief from some morbid condition or of preservation of a healthy status. Morbidity and cost of health care are simply additional elements in the situation. The action schema is set forth in brief below as an indication of how studies such as the present one could fit into such a framework, if the research were so designed from the beginning. It can be applied to an intensive analysis of individuals, families, or communities and also to the analysis of larger sample populations. The Action Schema. An act can be analyzed into four in- separable factors or elements.2 These four elements are: an actor, an end or goal, conditions, and means. Each of these elements of action is analytically distinct, and each is neces- sary for an understanding of action. The actor is that person or group of persons who actually does the acting. In the field of health the particular actors which are studied depend on the objectives of the research. In some instances it may be medical personnel of various kinds, a health agency or group, or it may be the patient or the 2. The following discussion is drawn largely from Talcott Parsons, The Structure of Social Action, New York: McGraw—Hill Book Company, Inc., 1937, Chapter II; also Kingsley Davis, Human Society, New York: The Macmillan Company, 1949, Chapter V. _-_._,.___i 297 patient's family. In studies such as the one just concluded the actors are the household heads and the members of the households whom they represent. In any given action the actor participates only in terms of certain fairly well-defined roles, that is, in terms of "a pattern or type of social behavior which seems situation- ally apprOpriate to the individual in terms of the demands and expectations of those in his group."3 Within the health context the actor may be playing the role of the sick person, doctor, nurse, lab technician, public health specialist, druggist, parent or guardian, and many others depending upon the particu- 4 Also, one person may at various lar situation in question. stages of the action play different roles. He may, while play- ing the part of the patient, diagnose and treat his own ail— ments which, whether he uses scientific medical knowledge or not, places him in the role of the lab technician, druggist, physician, and patient. Furthermore, a given role varies from individual to individual and from situation to situation depending upon what seems to be appropriate in the given situation. For example, the role of the sick person, includ- ing his reaction to the treatment situation, may vary considerably 3. S. Stansfeld Sargent, Social Psychology: An Inte- grative Interpretation, New York: The Ronald Press COmpany, 1950, p. 279. 4. For a detailed discussion of the role of the medical practitioner and of the sick person see: Talcott Parsons, The Social System, Glencoe, Illinois: The Free Press, 1951, pp. 433ff. 298 depending upon whether the individual considers himself to be basically healthy or whether he accepts his status as being ill; whether the illness is a minor ailment or a major afflic- tion; whether sickness is sought as a refuge or whether it is a condition to be overcome. Some of the implications of these various situations are outlined by Barker and others in Adjustment to Physical Handicap and Illness: A Survey of the Social Psychology of Physique and Disability.5 The authors present a very interesting discussion largely in terms of the concepts of Lewinian field theory. More needs to be known about the various roles and role expectations with regard to sickness and the use of health services, The status of the actor is another important factor, since each status carries with it not only certain rights but also certain obligations and expected behavior. Therefore, in any given action the various statuses of the actor will have an influence in determining the availability of means, his choice of means, his norms, as well as the nature of the goal itself.6 Therefore, a knowledge of the statuses occupied by the actor is necessary for a complete understanding of his action. Statuses are of two types, namely, ascribed and achieved. The ascribed statuses which were investigated in 5. Roger G. Barker, et alii, Adjustments to Physical Handicap and Illness: A Survey of the Social Psychology of Physique and Disability, Nengork: Social Science ResearCh Council, Bulletin 55, Revised, 1953, pp. 310ff. 6. James W. Green, "The Farmhouse Building Process in North Carolina," Unpublished Doctoral Dissertation, Chapel Hill: University of North Carolina, 1953, p. 14. the present study were age, sex, and color. The achieved statuses were education, income, health environment index, communication-participation index, home tenure, place of resi- dence, and crowding index. It was considered that these vari- ous statuses would have particular value in attempting to ex- plain the behavior which was recorded in the study. However, other statuses need to be investigated, and more needs to be known about the various components of these indices of status and how they operate to influence behavior with regard to health care. For example, what is it about high or low income or education which influences the use of health services? What are the social-psychological and cultural factors involved, and how do they function? The 232 or goal refers to some future state of affairs toward which the actor is motivated. It may be conscious or unconscious, but in either case it is subjective since, by definition, there is no end unless such exists for the actor. The concept, and, implies some motivation and exertion on the part of the actor to obtain it. The particular ends which are chosen by an actor are related to his value—attitude system which has been derived from his cultural background and the social systems of which he is a part. The primary goal within the present context is the obtaining of good health. This general goal may involve many concrete acts. These acts can be classified into three types as follows: (1) those which involve seeking some kind of cure as a means of restoring health, (2) those which involve seeking diagnostic services for the 300 purpose of detecting or determining the nature of some known or suspected malfunction, and (3) those which incolve seeking services to protect and maintain a healthy condition, which is actually a long-range goal of good health. As has just been indicated, in seeking good health or the preservation of good health, major emphasis is placed upon the use of health serv— ices and facilities, that is, the means whereby the actors attempt to reach their goal. These medical services and facilities may actually be looked upon as secondary or sub- ordinate goals since, as Durkheim has stated, "Every means is from another point of view, an end."7 Illness or morbidity is investigated since it is the primary factor in the situation which motivates the individual to seek the desired end. Whether the individual has relief from ill health as a goal depends in large measure on his defi- nition as to what constitutes illness. Illness or morbidity can be defined on both an objective and a subjective level. From an objective point of view it is any state of the human biological organism for which professional medical diagnosis would indicate the need for some kind of medical attention. This definition is, of course, limited by the advancement of medical knowledge and understanding, but is the most objective basis available. From a subjective point of view illness refers to the informant's (actor's) views concerning his own state of 7. Emile Durkheim, (Translated by Sarah A. Solovay and John H. Mueller), The Rules of Sociological Method, Glencoe, Illinois: The Free Press, 1938, p. 48. 301 well—being and that of members of the household about whom he is reporting. His definitions depend on the normative order and on his value-attitude system which have been derived from his socio-cultural background. They may or may not be based on objective fact. In any event, to be most meaningful, human action must be viewed from the point of view of the actor;8 for, as W. I. Thomas has emphasized, "If men define situations as real, they are real in their consequences."9 "Every concrete activity is the solution of a situation."10 And every situation is composed of both subjective and ob- jective phenomena or events. By objective, in the present 8. In essence, the Lewinian field theory is a situation- al analysis of action from the point of view of the actor, an approach which can be put to very good use in the field of health care. Roger G. Barker and others have done some work along this line in their Ad ustment to Physical Handicap and Illness: A Survey of the ociiI'Psycholog of Physique and’Disability, op. cit., eSpecialIy Chapter VI ,—"Sbcial Psychology of Acute Iilness." For a summary and critique of the Lewinian approach see: Robert W. Leeper, Lewin's Topological and Vector Psychology, Eugene, Oregon: University of Oregon, 1943. Studying behavior from the actor's point of view has been termed by perception psychologists as the "phenomenological approach." As described by Krech and Crutchfield, this is "the systematic attempt to observe and describe the world as it appears to the experiencing individual." See: David Krech and Richard S. Crutchfield, Theory and Problems of Social PsyChology, New York: McGraw-Hill Book Company, Inc., 1948, p. 78. 9. Quoted by Robert K. Merton, Social Theory and Social Structure, Glencoe, Illinois: The Free Press, 1949, p. 179. 10. W. I. Thomas and Florian Znaniecki, The Polish Peasant in Europe and America, New York: Alfred A. Knofp, Voi. l, 1927, p. 68. *fai a discussion of the definition of the situation see the "Methodological Note"; see also "Definition of the Situation," by the same authors in Theodore M. Newcomb and Eugene L. Hartley, et alii, Readings in Social Psychology, New York: Henry Holt and Company, 1947, pp. 76—77. 302 context is meant from the point of View of the researcher 11 but it may also mean from the point as suggested by Parsons, of view of the medical profession which, in certain aspects of the health context, is probably the most objective criterion available. The subjective refers to viewing phenomena or events from the point of view of the actor, that is, the ego or self, not the biological organism. The biological organism is considered in the same relationship to the self as the physical environment. However, as has been pointed out, to be most meaningful human action must be viewed from the point of view of the actor. The components of any situation may be considered either as conditions or as mean, depending on the situation. They arise from three sources, the physical environment, the actor's innate capacity, and society. The conditions are of two kinds. They are either obsta- cles or facilitating conditions. Any given situation contains both. Since the actor must exert himself in order to obtain a given end there must be certain obstacles in the way, other— wise the end would come without any effort on his part. On the other hand, there are conditions in the situation which facilitate the achieving of the desired end or goal. To use a rather mundane example, in an isolated rural area with dirt roads, rain may impede travel and, therefore, prevent the in- dividual from attaining needed medical care. On the other 11. Parsons, The Structure of Social_Action,‘gp. cit., p. 46. 303 band, to the individual who feels the necessity of continuing his work in spite of some affliction, the rain may afford him an opportunity to leave the job and to seek medical aid. The conditions, then are those aspects of the situation over which the actor has no control. They establish the limits of action. Probably the most commonly recognized condition in the present context is the economic factor related to obtaining health care. In a given situation the cost of health services and the individual's economic resources are fairly well fixed. The actor has relatively no control over the conditions of action during the period of time in which he is attempting to reach his goal. Hence, little, if anything, can be done to allevi— ate the cost or to expand the income or other economic re- sources during this span of time. The mgag§_are those aspects of the situation over which the actor has control and which can be used, within the con- ditional limits, for the attaining of the desired goal. In the example of the isolated person above, rain may simply limit the use of the automobile as a means of travel. A horse, a boat, or other means may be used within the limits set by the conditions of the situation. In the example which relates to economic resources, while the actor's income may be rela- tively fixed during the period of action, he has considerable freedom as to how that income will be used in obtaining the desired goal. As directed by his norms and within the limits of other conditions, he may use his income for the purchase of patent medicines, ingredients for home remedies, faith healers, 304 M.D.'s, M.D. specialists, non-M.D.'s, and others. The components of the situation may be classified as relating primarily to the actor and his family or to the com- munity, and, as suggested above, they may be considered as means or conditions depending on the situation. Among those items included in the community-related components are the following: The state of advancement of medical knowledge, understanding, techniques, and equipment. Distance from medical services and facilities. Channels of communication through which medical attention or information can be received. a. Automobile and other means of transportation. b. Telephone, radio, television, and movies. c. Newspapers, bulletins, magazines, and related mass media. d. Organizational participation. Economic factors. a. Cost of health services and facilities. b. Welfare, charity, or other pro- visions for financing medical costs. Laws which affect health practices. Place of residence, although a community- related component, is related to other factors, especially to the family-related components such as psychological distance, custom, income, and others. It is only by breaking residence down into these other components that it begins to have meaning, and then only if it can be demonstrated that one residence group has more or less of a particular character— istic or combination of characteristics than another. 305 Family-related components of the situation include the following: 1. Size and composition of the family. 2. Customs, mores, folkways, superstitions, fear, and religious beliefs. 3. Knowledge, information, and understanding. 4. Distance from a psychological point of view. 5. Image of health services, facilities, and personnel, including the value plac- ed on medical care in general as well as for specific kinds of service. 6. Social stratification including both social class and caste and the values and customs associated with the differ- ential behavior of the various levels. 7. The severity of the illness, which is also influenced by objective factors. 8. Economic resources. a. Income. b. Real estate or other property which may be sold or mortgaged to provide capital. c. Insurance against the costs of ill health. 9. Other goals--competing interests in terms of time, money, or desirability. Neglect has often been stated as a factor by informants for not seeking medical attention. However, it has no meaning except as it is related to the reasons for neglect. Competing goals is, no doubt, one of those reasons. Theoretically, in any given situation the actor has an indefinite number of alternative choices with regard to means and ends. However, as a consequence of his understanding, 306 there is a possibility of error through the choice of wrong means, or of failure through lack of knowledge of available means, or through ignorance of the relationship of the par- ticular means to the ends which are sought. The actor is not only limited by his own understanding but also by the normative restrictions which are placed upon him. "A norm is an independent selective standard relating the situation and the end. A knowledge of norms answers the question 'why?' a certain course of action is chosen rather than other possible alternative courses within the area of control of the actor. It is an indispensable structural element of action without a knowledge of which concrete courses of action cannot be fully understood. Norms may be classified in three types."12 These types are efficiency norms, legitimacy norms, and norms of taste. They are discussed briefly below. Efficiency norms are the norms of rationality and utility. These norms are those standards which determine the most effective adaptation of the means to the ends in a given situation. In obtaining relief from ill health they are the standards which are derived from knowledge and experience and which govern the choice of means necessary to obtain the re- storation of health with the least expenditure of time, money, and the least inconvenience and pain.13 For example, the actor 12. Green, 92. cit., p. 20. The fdflowing discussion of norms is based on Green, p. 21ff and on Parsons, The Structure of Social Action, 22. cit., Chapter XVII. l3. Parsons has indicated that ". . . these are no simple matters of weighing a rationally understood 'need' 307 may be faced with a choice between a home remedy and going to a physician. A home remedy may be inexpensive and readily available and, though it may or may not have any real medici- nal value, it has become associated with bringing relief from the affliction. On the other hand, going to see the doctor may involve considerable expenditure of time and money not only for doctor's fees but for transportation and drugs as well. The doctor's examination and treatment may also involve considerable pain which the home remedy avoids. Of course, the situation may be completely reversed; that is, through experience one may have found that early treatment by a physician may be the most efficient and in the long run in- volve less expenditure of both time and money and perhaps even less pain. Efficiency norms are also involved in the choice of the type of practitioner whether it be an M.D., a non-M.D., a specialist, public health nurse, faith healer, or others. Legitimacy norms are the standards of moral obligation. "The attitude of the actor to these norms may vary; that is, they may, on the one hand, be morally neutral conditions to which he orients his action, as he would to the availability of any technical means, or, on the other hand, his attitude may be a 'moral' one of acceptance and hence an obligation to live up to them, or rejection and a correSponding obligation against an equally assessed 'cost' in the form of discomfort or inconvenience." Parsons, The Social System, 22. cit., p. 452. 308 to combat them."14 In the field of health there are certain legal codes and restrictions governing not only the medical profession but the layman as well. Such things as licensing, laws governing the practice of euthanasia, certain doctor— patient relationships, and codes of sanitation are among those included. These restrictions may compel the individual to orient his action in certain ways, but may not involve moral obligation. Such restrictions, therefore, are more accurately classified as conditions. However, if a moral acceptance is involved these restrictions are classified as norms which govern the choice of means. For example, a doctor may avoid the practice of euthanasia solely because of the legal restric- tions placed on such action. On the other hand, he may avoid it because of a moral aversion to the taking of a human life. Other examples can be found in certain superstitions and religious beliefs and practices which are nonlegal but which carry a strong moral obligation. For example, the Hopi Indians of Arizona have a variety of taboos which a woman must observe during pregnancy and childbirth. These norms, which are not observed by the medical profession, have been one of the major stumbling blocks in getting these people to use the hospital during childbirth.15 The deep-rooted aversion which some people have toward cutting human flesh and certain faith healing prac- tices, taboos, and rituals can all be classed as legitimacy norms. l4. Parsons, The Structure of Social Action, 2p. cit., p. 652. \ ""‘ 15. Sheldon G. Lowry, "The Major Rites of Passage of 309 Norms of taste operate within the limits established by the efficiency and legitimacy norms, but they are not bind- ing in the same way as the other two types.16 These norms do not denote standards of "right" nor of utility as do the other types, but rather standards of beauty, appreciation, and "taste." Such norms are greatly affected by the indi- vidual's status positions. Among the many examples which can be chosen in the field of health and health care are: having lar-u -.n IA — «a teeth filled with gold when the choice is made on the basis of "show" rather than the utility or durability of the sub- stance, wearing braces on the teeth for the purpose of beauti- fying the mouth by straightening the teeth, performing certain kinds of plastic surgery, removal of various growths on the skin, avoiding Operations because of the scar which it might leave, and others. The selection of a private room in the hospital, special nurses, a suite of rooms, and similar items can often be classed as norms of taste depending upon the situation. It should be pointed out that it very often happens that all three of these types of norms are involved in the same con- crete situation. Therefore, one need not feel the necessity to ascribe all norms in a particular action to any one type. In fact, in any complex of action more than one type is usually the Hepi Indians," An unpublished paper based on secondary sources, 1948, p. l. 16. See Parsons, The Structure of Social Action, gp. ci ., pp. 677ff. . r , o T o 4 w l l . a r r I o , I v D : . . . n . ‘ Q , r I' r . o . . . 310 involved.17 As indicated above, a definite action can only appear as a result of a definition of the situation, and, hence, the selection of the particular means to be used in attaining the desired end. This reduction of alternatives to a single course of action which predominates over the others is reached only after an interpretation of the existing conditions that must be overcome and the selection and special combination of the individual's values and attitudes. Although at times a certain attitude or value imposes itself seemingly unreflectively and leads immediately to action, there is usually a period of reflection, after which either a ready-made social definition is applied or a new personal definition is constructed. Since the various socio-economic groups in this country share a common culture, they also have many characteristics in common. However, much of their socio-cultural background is different because they are actually subcultures within the larger culture. To the extent that this background is different, there will also be a difference in the normative orders, the value-attitude systems, and the relative knowledge and under— standing of the various groups. Moreover, the extent to which these factors vary in the area of health and health care the definitions of morbidity, the goals with regard to health care, and the means of attaining these goals will also vary. There is considerable need for a clearer understanding and a greater elaboration of these various factors as they relate to the total health situation of the nation. 17 Ibid-- 0. 651. 311 BIBLIOGRAPHY Works Cited Almack, Ronald B. "The Rural Health Facilities of Lewis County, Missouri." Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 365, May, 1943. Anderson, Elin L. "Adequate Medical Care for Rural Families." Reprinted from the Journal of Home Economics, Vol. 36, No. 7, September, 1944. Anderson, Odin W. "The Health Insurance Movement in the United States: A Case Study of the Role of Conflict in the Development and Solution of a Social Problem." Ann Arbor: University of Michigan, Published Doctoral Dissertation, Publication 959, 1948. Anderson, Odin W. "Voluntary Health Insurance and Consumer Expenditures for Personal Health Services in the United States, July 1952 Through June, 1953." National Consumer Survey of Medical Costs and Voluntary Health Insurance. New York: Health Information Foundation, Summary Report No. 2, 1954. Anderson, Odin W. "Voluntary Health Insurance and Utilization of Personal Health Services in the United States, July 1952 Through June 1953." National Consumer Survey of Medical Costs and Voluntary Health Insurance. New York: Health Information Foundation, Summary Report No. 3, 1954. Anderson, Odin W. "Debt Among Families in the United States Due to Costs of Personal Health Services as of July 1953." National Consumer Survey of Medical Costs and Voluntary Health Insurance. New York: Health Information Foundation, Summary Report No. 4, 1954. Avnet, Helen Hershfield. Voluntary Medical Insurance in the United States: Major Trends and Current Problems. New York? iMedical Administrative Service, Ific., 1944. Barker, Roger G., et alii. Adjustment to Physical Handicap and Illness: A Survey of the SocialPsychology‘of Physique and ‘Disability. New York: Sociai_Science ResearchICouncil, ' BuIIetin 55, Revised, 1953. "Basic Rules Apply to Dental Health for All Ages." Skilled Techniques in Building Group Action. New York: The Education Service of J. walter—Thompson Co., Vol. 4, No. 1, May, 1953. Bird, Bedford W. and Paul H. Landis. "Planning the Rural Hospital and Health Center," Pullman: State College of Washington, Agricultural Experiment Station, Popular Bulletin No. 181, August, 1945. Bright, Margaret L. and Donald G. Hay. "Health Resources and Their Use by Rural Peeple: Ulster County." Ithaca: Cornell University, (U. S. Department of Agriculture c00perating), Department of Rural Sociology Mimeograph Bulletin No. 32, July, 1952. Britten, Rollo H. "A Study of Dental Care in Detroit." National Health Survey, Public Health Rgports. Vol. 53, No. 12, March 25, 1938, pp. 446-459. Bulla, A. C. (M.D.). "Survey of Public Health Facilities." A typed report of the Wake County Health Department, Raleigh, North Carolina, May 27, 1949. Bureau of Labor Statistics. Family Spending and Saving in Wartime. 1945. "Canadian Sickness Survey, 1950-51." Special Compilation: No. 1, Family Expenditures for Health Services (National Estimates). Ottawa, Canada: The Dominion Bureau of Statistics and the Department of National Health and Welfare, May, 1953. "Canadian Sickness Survey, 1950-51." Special Compilation: No. 2, Family Expenditures for Health Services by Income Groups (National Estimates). Ottawa, Canada: The Dominion Bureau of Statistics and the Department of Nation— al Health and Welfare, July, 1953. Cochrane, William M. "Health Law Revision in North Carolina." From an address given at the 42nd annual meeting of the North Carolina Public Health Association, September 10, 1953. Chapel Hill: University of North Carolina, ngular Government, Vol. 20, No. 7, April, 1954. Cohn, Alfred E. and Claire Lingg. The Burden of Diseases in the United States. New York: Oxford University Press, 1950. 313 Collins, Selwyn D. "Cases and Days of Illness Among Males and Females, With Special Reference to Confinement in Bed, Based on 9,000 Families Visited Periodically for 12 months, 1928-31." Public Health Reports. Vol. 55, No. 2, January 12, 1940, pp. 47-94. Collins, Selwyn D. "Frequency and Volume of Doctors' Calls Among Males and Females in 9,000 Families, Based on Nation- Wide Periodic Canvasses, 1928-31." Public Health Reports. Vol. 55, No. 44, November 1, 1940, pp. 1977-2020. Collins, Selwyn D. "Frequency and Volume of Hospital Care for Specific Diseases in Relation to all Illnesses Among 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928-31." Reprint No. 2405 from the Public Health Reports, Vol. 57, No. 38, September 18, 1942, pp. 1399-1428, and No. 39, September 25, 1942, pp. 1439-1460. Collins,-Selwyn D. "Frequency of Dental Services Among 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928- 31." Public Health Reports. Vol. 54, No. 16, April 21, 1939, pp. 629-657} Collins, Selwyn D. "Frequency of Eye Refractions in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928— 31." Public Health Repprts. Vol. 49, No. 22, June 1, 1934, pp. 649:666. Collins, Selwyn D. "Frequency of Health Examinations in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928- 31." Public Health Reports. Vol. 49, No. 10, March 9, 1934, pp. 321-346: Collins, Selwyn D. "Frequency of Surgical Procedures Among 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928-31." Public Health Reports. Vol. 53, No. 16, April 22, 1933, pp.i5874628. Collins, Selwyn D. "A General View of the Causes of Illness and Death at Specific Ages Based on Records for 9,000 Families in 18 States Visited Periodically for 12 Months, 1928-31." Public Health Re orts. Vol. 50, No. 8, February 22, 1935, pp.i23 — 55. Collins, Selwyn D. "History and Frequency of Diphtheria Immunizations and Cases in 9,000 Families, Based on Nation- Wide Periodic Canvasses, 1928-31." Public Health Reports. Vol. 51, No. 51, December 18, 1936, pp. 1736—1773. 314 Collins, Selwyn D. "History and Frequency of Smallpox Vacci- nations and Cases in 9,000 Families, Based on Nation-Wide Periodic Canvasses, 1928-31." Public Health Reports. Vol. 51, No. 16, April 17, 1936, pp. 443-479. Collins, Selwyn D. "History and Frequency of Typhoid Fever Immunizations and Cases in 9,000 Families, Based on Nation-Wide Periodic Canbasses, 1928-31." Public Health Reports. Vol. 51, No. 28, July 10, 1936, pp. 897-926. Collins, Selwyn D. "Sickness and Health: Their Measurement, Distribution, and Changes." Reprinted from The Annals of the American Academy of Political and Social Science, January, 1945, pp. 152-163. Collins, Selwyn D. and Rollo H. Britten. "Variations in Eye- sight at Different Ages, as Determined by the Snellen Test." Public Health Reports. Vol. 29, No. 51, December 19, , pp. 31 - 194. Committee on Administrative Practice. Health Practice Indices 1943-1946. New York: American Pubiic Health Association, November, 1947. Committee on Aging and Geriatrics. Fact Book on Aging. Washington: Federal Security Agency, no date. Committee on Medicine and the Changing Order of the New York Academy of Medicine. Medicine in the Changing Order. New York: The Commonweaith Fufid, 1947. Committee on the Costs of Medical Care. Medical Care for the American People. Chicago: Universify of Chicago Pfess, "Publication No. 28, 1932. Connor, Ruth M. and William G. Mather. "The Use of Health Services in Two Northern Pennsylvania Communities." State College: The Pennsylvania State College, Agricultural Experiment Station, Bulletin 517, July, 1949. Davis, Kingsley. Human Society. New York: The Macmillan Company, 1949. Downes, Jean. "Causes of Illness Among Males and Females." The Milbank Memorial Fund Quarterly. Vol. XXVIII, No. 4, Ofitbber, 1950, pp. 497-428. Durkheim, Emile. (Translated by Sarah A. Solovay and John H. Mueller) The Rules of Sociological Method. Glencoe, Illinois: The Free Press, I938. 03 H 0'] Ewing, Oscar R. "The Nation's Health--A Ten Year Program." Washington: United Stated Government Printing Office, September, 1948. Falk, I. S., M. C. Klem, and N. Sinai. The Incidence of Illness and the Receipt and Costs of Medical Care Among Representa- tive Families. Chicago: ‘University of Chicago—Press, Publication No. 26 of the Committee on the Costs of Medical Care, 1933. Falk, I. S., C. Rufus Rorem, and Martha Ring. The Costs of Medical Care. Chicago: University of Chicago—Press, Publication No. 27 of the Committee on the Costs of Medical Care, 1933. Frankel, Lee K. and Louis I. Dublin. "A Sickness Survey of North Carolina." Public Health Reports. Vol. 31, No. 41, October 13, 1916, pp. 2820-2844. Gafafer, W. M. "Results of a Dental Examination of 1,908 White and Colored Males at the Ohio State Reformatory." Public Health Reports. Vol. 51, No. 13, March 27, 1936, pp. 32I- 332. Galloway, Robert E. and Harold F. Kaufman. "Health Practices of Rural PeOple in Lee County." State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 1, December, 1950. Galloway, Robert E. and Harold F. Kaufman. "Health Practices in Choctaw County." State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 2, December, 1950. Galloway, Robert E. and Harold F. Kaufman. "Use of Hospitals by Rural Peeple in Four Mississippi Counties." State College: Mississippi State College, Agricultural Experi- ment Station, Circular 174, July, 1952. Galloway, Robert E. and Marion T. Loftin. "Health Practices of Rural Negroes in Bolivar County." State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 3, April, 1951. Galloway, Robert E. and Marion T. Loftin. "Health Practices of Rural People in Forrest County." State College: Mississippi State College, Agricultural Experiment Station, Sociology and Rural Life Series, No. 4, July, 1951. 316 Graham, Frank Porter. "A Challenge to the Medical Schools and the Medical Profession." Reprinted from Pediatrics. Vol. 13, No. 1, January, 1954, pp. 92-100. Green, James W. "The Farmhouse Building Process in North Carolina." Chapel Hill: University of North Carolina, Unpublished Doctoral Dissertation, 1953. Gregory, C. L., et alii. "The Health of Low-Income Farm Families in Southeast Missouri." Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 410, August, 1947. Grisette, Felix A. "North Carolina Facts." Raleigh: North Carolina Research Institute, Vol. II, No. 14, April 3, 1954. Hamilton, C. Horace. "Many Family Incomes in Wake County too Low for Good Health Care." News and Observer. Raleigh, North Carolina, February 15, 1950. Hamilton, C. Horace. "Rural Health and Medical Service in North Carolina: Papers and Preliminary Reports of Surveys, 1944-1949." Raleigh: North Carolina State College, Agricultural EXperiment Station, Progress Report RS-9, August, 1950. Hamilton, C. Horace. "Statistics on Rural Population and Rural Family Living." Raleigh: The North Carolina Agricultural Extension Service, Compiled from the 1950 U. S. Census of Population in the Department of Rural Sociology, North Carolina State College, November, 1953. Hay, Donald G. and Margaret L. Bright. "Health Resources and Their Use by Rural People in Clinton County, New York, 1951." Ithaca: Cornell University, (U. S. Department of Agriculture cooperating), Department of Rural Sociology Mimeograph Bulletin, No. 33, August, 1952. Hay, Donald G. and Olaf F. Larson. "Use of Health Resources by Rural Peeple in Two Western New York Counties, 1950." Ithaca: Cornell University, (U. S. Department of Agricul- ture cooperating), Department of Rural Sociology Mimeo- graph Bulletin, No. 31, June, 1952. "Health Information Foundation Survey of Medical Costs and VOluntary Health Insurance." (Highlights from a National Survey.) New York: Health Information Foundation, January 24, 1954. 317 Hoffer, Charles R. "Health and Health Services for Michigan Farm Families." East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 352, September, 1948. Hoffer, Charles R. "Health and Health Services in Three Michigan Communities." East Lansing: Michigan State College, Agricultural Experiment Station, Quarterly Bulletin, Article 31-12, August, 1948. Hoffer, Charles R. and Clarence Jane. "Health Needs and Health Care in Two Selected Michigan Communities." East Lansing: Michigan State College, Agricultural Experiment Station, Special Bulletin 377, June, 1952. Hoffer, Charles R., Edgar A. Schuler, et alii. "Determination of Unmet Need for Medical Attention Among Michigan Farm Families." The Journal of the Michigan Medical Society, Vol. 46, April, I947, pp. 443-446. Hoffer, Charles R., et alii. "Health in Michigan." East Lansing: Michigan State College, COOperative Extension Service, Extension Bulletin 319, June, 1953. Hoffer, Charles R., et alii. "Health Needs and Health Care in Michigan." East Lansing: Michigan State College, Agri- cultural Experiment Station, Special Bulletin 365, June, 1950. Hoffman, Frederick L. More Facts and Fallacies of Compulsory Health Insurance. New Jersey: ‘Prudentiaiipress, I920. Hollingsworth, Helen, et alii. Medical Care and Costs in Relation to Fapily Income: A StatiStical Source Bock. Washington: Federal Security Agency, Bureau Memorandum No. 51, Second Edition, May, 1947. "Hospital Resources and Needs." The Report of the North Carolina Hospital Study, 1951. Jackson, Elizabeth H. "Morbidity Among Males and Females at Specific Ages--Eastern Health District of Baltimore." The Milbank Memorial Fund Quarterly. Vol. XXVIII, No. 4, October, 1999. Kaufman, Harold F. "Extent of Illness and Use of Medical Services in Rural Missouri." Columbia: University of Missouri Agricultural Experiment Station, Progress Report No. 5, April, 1945. rm 318 Kaufman, Harold F. "Use of Medical Services in Rural Missouri." Columbia: University of Missouri, Agricultur- al Experiment Station, Research Bulletin 400, Rural Health Series No. 2, April, 1946. Kaufman, Harold F. and Marion T. Loftin. "Differentials in Health Practices Among Socio-Economic Groupings in Rural Mississippi." State College: Mississippi State College, (Mimeographed), no date, 2pp. Kaufman, Harold F. and Warren W. Morse. "Illness in Rural Missouri." Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 391, August, 1945. Kempf, Grover A. and Bernard L. Jarman. "A Special Study of the Vision of School Children." Public Health Reports. Vol. 43, No. 27, July 6, 1928, pp. 1713-1739. Kirck, E. C. "Dentistry." Encyclopedia Britannica. 13th Edition, Vol. 8, pp. 50-54} Klein, Henry and Carroll E. Palmer. "Studies on Dental Caries VII. Sex Differences in Dental Caries Experience of Ele- mentary School Children." Public Health Reports. Vol. 53, No. 38, September 23, 1938, pp. 1685-1690. Kleinschmidt, L. S. "How Can Better Rural Health Be Developed?" Reprinted from Rural Sociology. V01. 9, No. 1, March, 1944. Klem, Margaret C. "Medical Care and Costs in California Families in Relation to Economic Status." San Francisco: State Relief Administration, 1935, Processed. Krech, David and Richard S. Crutchfield. Theory and Problems of Social Psychology. New York: McGraw-HiIl—BOOR Company, Ific., 1948. "Large Accident Toll Among Women." Statistical Bulletin. New York: MetrOpolitan Life Insurance Company, VOI. 35, No. 3, March, 1954. Larson, Olaf F. and Donald G. Hay. "Differential Use of Health Resources by Rural PeOple." Reprinted from the New York State Journal of Medicine. Vol. 52, No. l, Januaryil, 1952. Larson, Olaf F. and Donald G. Hay. "Hypotheses for Sociological Research in the Field of Rural Health." Rural Sociology. Vol. 16, No. 3, September, 1951, pp. 225-237. M qr- - . a . y ' o . . . . - - . . . . . . . . , , . , . c . . o - . . . , u o . . , - . . n . . . . . i ~ ~ I . . . . ~ o v v v . . v - l o - v u . . , . . . . - - c - o n . - a y . . u , ‘ . - o . A . . p . 319 Leeper, Robert W. Lewin's Topological and Vector Psychology. Eugene, Oregon: UniveiiSty of Oregon, 1943. Lively, Charles E. "Some Problems Warrant Study for Continuing Health Improvement." Reprinted from The Journal of OsteOpathy. November, 1953. Loomis, Charles P., et alii. Rural Social Systems and Adult Edpcation. East Lansing: The Michigan State College Press,1953. Lowry, Sheldon G. "Attitudes of Michigan Residents waard Government-Sponsored Prepayment Plans for Health Care." East Lansing: Michigan State College, Unpublished Master's Thesis, 1950. Lowry, Sheldon G. "The Major Rites of Passage of the HOpi Indians." An unpublished paper based on secondary sources, 1948. McMahan, C. A. "Personality and the Urban Environment." In T. Lynn Smith and C. A. McMahan. The Sociologyyof Urban Life: A Textbookygith Readings. NEw‘YErk: ‘The Drydéfi‘ Press, Inc., 1951, pp. 748-760? McNamara, Robert L. "Illness in the Farm Population of Two Homogeneous Areas of Missouri: Its relation to Social and Economic Factors and Its Susceptibility to Small- Sample Study." Columbia: University of Missouri, Agri- cultural Experiment Station, Research Bulletin 504, July, 1952. Maes, Urban. "Aseptic Surgical Techniques." Hagerstown, Maryland: Practice of Surgepy, Vol. 1, Chapter 7, 1937. Mason, Marie. "Rural Family Health in a Selected County in Kentucky." Lexington: University of Kentucky, Agri- cultural Experiment Station, Bulletin 538, June, 1949. Mather, W. G. "The Use of Health Services in Two Southern Pennsylvania Communities." State College: The Pennsyl- vania State College, Agricultural Experiment Station, Bulletin 504, July, 1948. Mayo, Selz C. "Post War Planning for North Carolina: Rural Health Services and Facilities." Raleigh: North Carolina State College, Department of Rural Sociology, Report No. 12 (Mimeographed), October, 1945. v r O c a . o r . c o . . . \ n . , u u s o . n a s 320 Mayo, Selz C. and Kie Sebastian Fullerton. "Medical Care in Greene County." Raleigh; North Carolina State College, Agricultural Experiment Station, Bulletin 363, November, 1948. Meier, Iola and C. E. Lively. "Family Health Practices in Dallas County, Missouri." Columbia: University of Missouri, Agricultural Experiment Station, Bulletin 369, June, 1943. Merton, Robert K. Social Theory and Social Structure. Glencoe, Illinois: The Free Press, 1949. l - Mickey, Karl B. Health from the Ground Up. Chicago: if Internationaiiflarvester Company, 1946. F _ Miljis, Harry Alvin. Sickness and Insurance: A Study of the lie Sickness Problem and Health Insurance. Chicago: ‘The r Universiiy Of Chicago Press, 1937. Lk>tt, Frederick D. and Milton I. Roemer. Rural Health and Medical Care. New York: McGraw-Hill‘BoOk Company, Inc., 1948. 3National Health Survey: 1935-1936. "Illness and Medical Care in Relation to Economic Status." Washington: U. S. Public Health Service, Bulletin No. 2, 1938. 3Natdonal Health Survey: 1935-1936. "The Magnitude of the Chronic Disease Problem in the United States." Washington: U. S. Public Health Service, Bulletin No. 6, 1938. lhitional Health Survey: 1935-1936. "Significance, Scope and Method of a Nation-Wide Family Canvass of Sickness in Re- lation to Its Social and Economic Setting." Washington: U. S. Public Health Service, 1938. lfiewcomb, Theodore M. and Eugene L. Hartley, et alii. Readin s in Social Psyghology. New York: Henry Holt and Company, 19472 Parsons, Talcott. The Social System. Glencoe, Illinois: The Free Press, 1951. Parsons, Talcott. The Structure of Social Action. New York: McGraw-Hill Book Company, Ihc., 1937. Peart, A. F. W. "Canada's Sickness Survey Review of Methods." Reprinted from the Canadian Journal of Public Health. October, 1952, pp. 494-414. 321 Perrot, George St. J., et alii. "The National Health Survey: Scope and Method of the Nation-Wide Canvass of Sickness in Relation to Its Social and Economic Setting." Public Health Reports. Vol. 54, No. 37, September 15, 1939, pp. -1 . Phillips, Joseph. "The Revolution in Hickory Nut Gorge." Reader's Digest. November, 1952, pp. 117-121. "Presbyopia and the Duration of Life." Editorial in The Journal of the American Medical Association. October 14, 1933, pp. 1239-1240. 5;. _ The President's Commission on the Health Needs of the Nation, Dr. Paul B. Magnuson, Chairman. Building Amepica's Health. Washington: U. S. Government Printing Office, Volume I, Findings and Recommendations, 1952. WI‘il‘l The President's Commission on the Health Needs of the Nation, Dr. Paul B. Magnuson, Chairman. Building Americgls Health. Washington: U. S. Government PrihiingOfiiée,VolumeiII, America's Health Status, Needs and Resources, 1952. The President's Commission on the Health Needs of the Nation, Dr. Paul B. Magnuson, Chairman. Building America's Health. Washington: U. S. Government PrintingOffice, Vqume III, America's Health Status, Needs and Resources--A Statistical Appendix, 1952. The President's Commission on the Health Needs of the Nation, Dr. Paul B. Magnuson, Chairman. Building America's Health. Washington: U. S. Government Printing Office, Volume IV, Financing a Health Program for America, 1952. The President's Commission on the Health Needs of the Nation, Dr. Paul B. Magnuson, Chairman. Buildin America's Health. Washington: U. S. Government Printing 0 iEe, VOIhme—V, The Peeple Speak--Excerpts from Regional Public Hearings on Health, 1952. Quick, Douglas. "The Care of the Cancer Patient." Bulletin of the New York Academy of Medicine. July, 1933. "Record High Longevity at the Mid-Century." Statistical Bulletin. New York: MetrOpolitan Life Insurance Company,V61ume 34, Number 7, July, 1953. Rorem, C. Rufus (Editor). "The Economic ASpects of Medical Services." Chicago: The University of Chicago Press, A reprint of two chapters of Publication 27 of the Committee on the Costs of Medical Care, 1935. 322 Sargent, S. Stansfeld. Social Ppychology: An Integrative Interpretation, New York: The RonaId Press Company, 1950. Schuler, Edgar A., Selz C. Mayo, and Henry B. Makover. "Measuring Needs for Medical Care: An Experiment in Method." Rural Sociology. Vol. XI, No. 2, June, 1946, pp.152-158. Serbein, Oscar N., Jr. Paying_for Medical Care in the United States. New York: *COIumbia University Press, 1953. "Sickness Survey of Principal Cities in Pennsylvania and West Virginia." New York: Metropolitan Life Insurance Company, Sixth Community Sickness Survey, 1917. Simons, A. M. and Nathan Sinai. The Way_of Health Insurance. Chicago: The University of Chicago Press, 1932. Smith, 0. Norris (M.D.), Chairman Medical Advisory Committee to Hospital Saving Association (North Carolina Blue Cross). "Hospital Insurance Discussed." News and Observer. Raleigh, North Carolina, March 15, 1954. Smith, T. Lynn. The Sociolog of Rural Life. New York: Harper and Brothers PubliShers, . Sorokin, Pitirim A. and Carle C. Zimmerman. Principles of Rural-Urban Sociology. New York: Henry Holt and Company, 1929. Sorokin, Pitirim A., Carle C. Zimmerman, and Charles J. Galpin. A Systematic Source Book in Rural Sociology. Minneapolis: UhiVersiiy othinneso a Press, V01. III, 1932. Stern, Bernard J. Society_and Medical Progress. Princeton: Princeton University Press, 1941. Sydenstricker, Edgar. "Economic Status and the Incidence of Illness." Hagerstown Morbidity Studies No. X. Public Health Reports. Vol. 44, No. 30, July 26, 1929, pp. 1821- T823 0 Sydenstricker, Edgar. "Physical Impairments and Occupational Class." United States Health Reports. Vol. XLV, 1930. Sydenstricker, Edgar. "A Study of Illness in a General POpu- 1ation Group." Hagerstown Morbidity Studies No. I: The Method of Study and General Results. Public Health Reports. V01. 41, No. 39, September 24, 1923, pp. 2969- 2088. fl’.‘ .‘J ‘. 'i'il’n‘. 3 ' Taylor, Carl C., et alii. Alfred A. New York: Thomas, W. I. and Florian Znaniecki. Europe and America. 1927. "United States Census of of Commerce, Bureau Government Printing "United States Census of of Commerce, Bureau Government Printing Williams, Pierce. Periodic ngmeht. 323 Rural Life in the United States. Knopf, 1949. —F The Polish Peasant in New York: Alfred A. Knopf: Vol. 1, Population: 1940." U. S. Department of the Census. Washington: U. S. Office. P0pu1ation: 1950." U. S. Department of the Census. Washington: U. S. Office. The Purchase of Medical Care Through Fixed New‘York: National Bureau Of Economic Rbsearch, Inc., 1932. Wilson, Isabella C. "Sickness and Medical Care Among a Rural Bituminous Coal-Mining Population of Arkansas." Fayetteville, Arkansas: University of Arkansas, Agricultural Experiment Station, Bulletin No. 394, June, 1940. Wilson, Isabella C. "Sickness and Medical Care Among the Rural Population in a Petroleum-Producing Area of Arkansas." Fayetteville, Arkansas: University of Arkansas, Agri- cultural EXperiment Station, June, 1941. Selected Works Not Cited Anderson, Odin W. "The Extent of Voluntary Health Insurance in the United States as of July 1953." National Consumer Survey of Medical Costs and Voluntary Health Insurance. New York: Health Information Foundation, Summary Report No. l, 1954. Bigelow, George H. and Herbert L. Lombard. Cancer and Other Chronic Diseases in Massachusetts. New York: Houghton Mifflin Company, 1933. Blackwell, Gordon W. "Behavioral Science and Health." Forces. Vol. 32, No. 2, December, 1953. Social "America's Greatest Opportunity." Reprinted from New York, November, 1945. Boas, Ernst. the Reader's Scope Magazine. 324 "Canadian Sickness Survey, 1950-51." Special Compilation: No. 3, Family Expenditures for Health Services by Ex- penditure Group (National Estimates). Ottawa, Canada: The Dominion Bureau of Statistics and the Department of National Health and Welfare, September, 1953. "Canadian Sickness Survey, 1950-51." Special Compilation: No. 4, Family Expenditures for Health Services (Regional Estimates). Ottawa, Canada: The Dominion Bureau of Statistics and the Department of National Health and Welfare, January, 1954. "Canadian Sickness Survey, 1950-51." Special Compilation: No. 5, Volume of Sickness (National Estimates). Ottawa, Canada: The Dominion Bureau of Statistics and the Department of National Health and Welfare, April, 1954. "Changing Africa: New Deve10pments in the British Dependencies." New York: British Information Services, 1953. Commission on Financing of Hospital Care. "Prepayment and the Community." New York: The Blakiston Company, Inc., Vol. 1, Publication set for 1954. Commission on Financing of Medical Care. "Financing Hospital Care for Non-Wage and Low Income Groups." New York: The Blakiston Company, Inc., Vol. II, Publication set for 1954. Commission on Financing Medical Care. "Factors Affecting the Costs of Hospital Care.” New York: The Blakiston Company, Inc., Vol. III, Publication set for 1954. Commission on Hospital Care. "Hospital Care in the United States." New York: The Commonwealth Fund, 1947. Committee on Medical Care. "Report of the Committee to Review the Medical Care Program." Baltimore: Maryland State Planning Commission, Publication No. 77, February, 1953. Davis, Michael M. and Hugh H. Smythe. "Providing Adequate Health Service to Negroes." Reprinted from the 1949 Yearbook Issue of the Journal of Negro Education for the Committee on Research in Medical Economics, New York, May, 1949. Downes, Jean and Selwyn D. Collins. "A Study of Illness Among Families in the Eastern Health District of Baltimore." The Milbank Memorial Fund Quarterly. Vol. XVIII, No. 1, "January, 1940, pp. 5-26. -27 "" r o u . o - . . o I r . . . , , . . o u s - , n o . . c . n - v I o . o - o : a . . : . . 1 c - 0 ~ - I ‘ - o s . . . - . ‘ , o . | u a ; ‘ I o ‘ . v o . . s . 325 Duncan, Otis Durant. "Some Social and Economic Aspects of the Problem of Rural Health in Oklahoma." Stillwater: Oklahoma Agricultural and Mechanical College, Agri- cultural Experiment Station, Experiment Station Circular No. 78, September, 1931. "Financing Hospital Care in the United States." (A Summary Report.) Chicago: The Commission on Financing of Hospital Care, January, 1954. Foster, George M. "Relationships Between Theoretical and 5 Applied Anthropology: A Public Health Program Analysis." Rel Human Organization. Vol. 11, No. 3, Fall, 1952. Frankel, Lee K. and Louis I. Dublin. "Sickness Survey of West , Virginia Cities." New York: MetrOpolitan Life Insurance L. Company, 1917. Hagood, Margaret Jarman and Daniel 0. Price. Statistics for Sociologists. New York: Henry Holt and C0mpany, 1952. Hamilton, C. Horace. "P0pu1ation Density and Size of Hospital Communities." Reprinted from Hospitals. November, 1945. Hay, Donald G. and Olaf F. Larson. "Medical and Health Care Resources Available in Cortland County, New York, 1949." Ithaca: Cornell University, (U. S. Department of Agri- culture cooperating), Department of Rural Sociology Mimeograph Bulletin No. 24, July, 1950. Hay, Donald G. and Olaf F. Larson. "Medical and Health Care Resources Available in Chautauqua County, New York, 1950." Ithaca: Cornell University, (U. S. Department of Agriculture cooperating), Department of Rural Sociology Mimeograph Bulletin No. 29, February, 1952. Hay, Donald G. and Olaf F. Larson. "Medical and Health Care Resources Available in Livingston County, New York, 1950." Ithaca: Cornell University, (U. S. Department of Agri- culture cooperating), Department of Rural Sociology Mimeograph Bulletin No. 30, February, 1952. Hay, Donald G. and Olaf F. Larson. "Medical and Health Care Resources Available in Oswego County, New York, 1949." Ithaca: Cornell University,(U. S. Department of Agriculture c00perating), Department of Rural Sociology Mimeograph Bulletin No. 25, July, 1950. Hepple, Lawrence M. "Selective Service Rejectees in Rural Missouri, 1940-1943." Columbia: University of Missouri, Agricultural Experiment Station, Research Bulletin 439, April, 1949. 325 Hilleboe, Herman E. "Social Science and Public Health." Health News. Vol. 31, No. 3, March, 1954. Lively, C. E. and P. G. Beck. "The Rural Health Facilities of Ross County, Ohio." Wooster: Ohio Agricultural Ex- periment Station, Bulletin 412, October, 1927. "Maternal Mortality Can Be Lowered." Statiotical Bulletin. New York: MetrOpolitan Life Insurance COmpany,_VoI. 35, No. 2, February, 1954. "Old Age in Rhode Island." Chronic Illness News Letter. Maryland: Commission on Chronic Illness, Vol. 4, No. 8, October, 1953. Page, Robert Collier. "Doctors and the Federal Medical System: The Problem, the Findings and the Solution." Reprinted from The Journal of the Michigan State Medical Society. V01. 51, January, 1952, pp. 41-48. Page, Robert Collier. "Health Maintenance of Key Personnel." Reprinted from Industrial Medicine and Surgery. V01. 20, No. 7, July, 1951, pp. 325-3301 Robinson, G. Canby. The Patient as a Person. New York: The Commonwealth Fund, 1939. Stieglitz, Edward J. (Editor). Geriatric Medicine Diagnosis and Manogement of Disease in the Aging and in the Aged. Philadelphia: “W. B. Saunders Company, 1934. '— Sydenstricker, Edgar. "The Incidence of Various Diseases According to Age." Hagerstown Morbidity Studies No. VIII. Public Health Reports. Vol. 43, No. 19, May 11, 1928, pp. 1124-1156. Sydenstricker, Edgar. "Sex Differences in the Incidence of Certain Diseases at Different Ages." Hagerstown Morbidity Studies No. IX. Public Health Reports. Vol. 43, No. 21, May 25, 1928, pp. 1259-1276. Reference Lists Folsom, J0siah C. (Compiler). "Social Security and Related Insurance for Farm People: An Annotated Bibliography of Selected References." Washington: U. S. Department of Agriculture, Library List 50, 1949. JP 1 Q . ;IJ . an; a v r n . . . . c v u . n 1 n a . ‘ . a ~ 4 ‘ . . . p I . . . "An Inventory of Social and Economic Research in Health." New York: Health Information Foundation, 1953. Note: This is the second in a series of such annual releases. Locke, Joseph H. (Compiler). "Community Organization for Health--Selected References." East Lansing: Michigan State College, Social Research Service, (Sponsored by the Farm Foundation, Chicago), 1950. "The National Health Survey 1935-36: Sc0pe, Method, and Bibliography." Washington: U. S. Public Health Service, Public Health Bibliography Series, No. 5, (1936-1950), Fr! 1951. L Otto, Margaret M. "Community Organization for Health and 5 Welfare Services." New York: Russell Sage Foundation, Ll Bibliography 5, 1948. "Rural Health Annotated List of Selected References." Washington: U. S. Department of Agriculture, Bureau of Agricultural Economics, Library List No. 60, June, 1953. "Sources of Morbidity Data." Washington: Public Health Service, U. S. Department of Health, Education, and Welfare, Listing No. 1, 1953. Turner, Violet B. "Chronic Illness: Digests of Selected Refer- ences." Washington: U. S. Public Health Service, Bibliography Series No. 1, 1951. Turner, Violet B. "Chronic Illness: Digests of Selected References 1950-52." Washington: U. S. Public Health Service, Bibliography Series No. 1, Supplement, 1953. Turner, Violet B. "Hagerstown Health Studies: An Annotated Bibliography." Washington: U. S. Public Health Service, Public Health Bibliography Series No. 6, 1952. Watrous, Roberta C. and John M. McNeill (Compilers). "Rural Community Organization, A List of References." Washington: U. S. Department of Agriculture, Library List 46, 1949. . . . . . . . . .. , ' u . o o , , . - I r o u - - e , . - c . e . o . . . o . , . . . . \ v D u . . s c . v . , . <‘ o r r v \ a . . . . a ' . a p ~ . . APPENDIX A STATISTICAL METHODS USED IN THE STUDY 328 q L. *1 Li“ Han-u.— I 329 STATISTICAL METHODS USED IN THE STUDY In the chapter on the cost of medical care, and in one or two other instances which are specifically stated, percent- ages were used. In the remainder of the study rates have been used throughout. The rates are simply ratios of cases of ill- nesses (or cf use of health services) to pOpulation. The rate in each cell of a given table, therefore, is based on the num- ber of cases of illness (or use) and the number of individuals in that cell, and is reported as so many cases per hundred pOpulation. Of course, the rates can go above 100 since a given individual may report more than one case of illness or of use of health services. To test the association between two characteristics or variables, the chi square test was used throughout the study.1 When percentages were involved, the traditional chi square formula, 2 2 2 (f ’ fc) f X - E or Z - N fc ’ fc ' was used and was applied to the frequency distributions from which the percentages were computed. In this instance only one P value is reported for the entire distribution of each table. 1. For a detailed discussion of the chi square test the reader is referred to Margaret Jarman Hagood and Daniel 0. Price, Statistics for Sociologists, New York: Henry Holt and Company, 1952, and to other general statistics texts. ‘ ‘m ‘F 330 For those tables involving rates the following deri- vation of the above formula, as develOped by Dr. C. Horace Hamilton, was used. The test was applied to each row and to each column in the tables where appropriate, and a separate P value is reported for each. The formula implies expected frequencies based on the populations in the given cells and on the ratio of the total cases to the total pOpulation in g the given row or column. The expected frequency of each cell, therefore, is obtained as follows: [ ifc' rpi in which ifc - the expected frequency of the ith cell, Zfi 23p1 r = or the total frequency of the column divided by the total pOpulation of the column, and pi = the pOpulation base of the ith cell. Therefore, the conventional formula for chi square, 2 1’1 Z-——— - N becomes: ifc 2 2 2 f f p f X2 = Z.__l - N - -1 E._l - N - 2: 1 E .1. - szi rpi r pi 2 T1 pi The degree of freedom for a given column is one less than the number of cells in the column. It should also be pointed out that those cells with expected frequencies below 5 were combined with other cells, in which case, one degree of 331 freedom was lost for each combination. However, when such combinations did not seem to be logical or if they appeared to distort or change the general trend of the data, the chi square test was omitted and this fact was reported. The chi square test in this instance is a test of the null hypothesis that in the population from which the sample has been drawn, there is no association between two given variables, i.e., the variables are independent. To test this hypothesis the observed distribution is compared with an ex- pected distribution (which in this case is based on the margin- al totals, since they are the best available estimate of the universe) to determine "if the discrepancies between the two distributions are greater than could have been explained by chance variations in sampling."2 The hypothesis is that there is no difference between them. In other words, the observed deviations could have occurred by chance alone. In this study, if the probability that such discrepancies could have occurred by chance is 5 or less in 100, the null hypothesis that there is no difference between the two variables is rejected, and the observed variations are said to be significant. A proba- bility of 10 or less but greater than 5 in 100 is said to be on the borderline of significance, and that the data are in need of further study. Since the chi square test does not show direction, con- clusions which involve direction are derived from empirical 2. Ibid., p. 364. 332 observation of the data rather than from the statistical test. Furthermore, the chi square test does not single out individual cells as being more influential in the distribution than others. However, there is justification for calling attention to the peculiarities of individual cells, such statements merely being suggestive of possible trends and areas which need further study. Observations based on the chi square test are not con- clusive anyway; the test simply adds some assurance as to the accuracy of the empirical observations. Only the following probability values have been reported in the study: .001, .01, .02, .05, and .10. T0 avoid the cumbersome use of the phrases "greater than" and "less than" and the symbols which represent these phrases, the actual probability values in the study are less than the value report- ed but greater than the next lower value. For example, a P value reported as .05 is actually less than .05 but greater than .02; similarly, a value reported as .02 is less than .02 but greater than .01, etc. In one or two instances the P value was almost exactly the value reported. Any value which went above .10 is not considered to be significant, and this fact is represented with a dash (--). Chi square was not computed on the "unknown," "no answer," and similar categories since it was felt that nothing would be added to the value of the analysis by so doing. _‘ ’h. 'A~__--1-_ I l '1» 333 APPENDIX B THE INTERVIEW GUIDE 334 THE INTERVIEW GUIDE The interview guide used in the study is reproduced be- low. Detailed instructions to the interviewers for the study as a whole and for each individual question are on file in the Department of Rural Sociology at North Carolina State College. Map No. Enumerator Date Edited by Date WAKE COUNTY HEALTH SURVEY North Carolina Agricultural Experiment Station Department of Rural Sociology Head of Household Informant Address W Column Item and Data Code 1 Card Set 2-4 Record Number 5 Residence: Rural Farm Rural Nonfarm Urban 6 Color: White Nonwhite 7 Home tenure: Owners Renters 8 Family Income 3 9 Occupation: 10 Industry: 335 Column 11 12 13 14 15 16 17 18 19 20-21 22-23 24 25~ 26-27 28-29 30 31 32 33 34 35 36 Item and Data Farm tenure: NUMBER OF PERSONS IN THIS HOUSEHOLD WHO WORKED AND/OR RECEIVED AN INCOME DURING THE PAST YEAR Total Agricultural Nonagricultural Both Age of male head Age of female head Education of male head Education of female head Number rooms in this house Number persons in this house Crowding index Movedz. '45 '46 '47 '48 '49 Health environment index Communication-participation index AGE DISTRIBUTION Children under 6 Children 6-13 Children 14-17 Males 18—44 Females 18-44 Males 45-64 Females 45-64 Column 37 38 39-40 41 42 43 30 31 32 33 34 35 36 37 38 39 40 41 42 Item and Data Males 65-up Females 65-up Number living children Number infant deaths Deaths of other children Stillbirths HEALTH ENVIRONMENT (Card Set 2) Condition of structure: (4) Excellent (3) Good (2) Fair (1) Poor (0) Bad Entrance not in alley Dual egress Living room One or more bedrooms per two peOple Windows for all rooms Insect-proof screens Safe water supply (Public system or private drilled well, covered and prOperly located.) Running water in house Carry water less than 50 feet Kitchen sink Sanitary sewage diSposal (Public system, septic tank or approved pit privy.) Private bath and toilet 336 . "I" 1.1fifin- " 0 1 4 I}. .g——=_———=L_ st_ Column Item and Data Code 43 Private kitchen ____ 44 Running hot water ____ 45 Central heating system ____ 46 Electric lights ____ 47 Mechanical refrigerator ____. 48 Ice box ____ 49 Rats and insects under control _____ COMMUNICATION AND PARTICIPATION (Card Set 2) 5O Automobile for family use ____ 51 Radio in operating condition ____ 52 Telephone ____ 53 Daily newspapers .____ 54 Weekly or local newspapers _____ 55 Farm magazines .____ 56 Other magazines ____ 57 Encyc10pedia _____ 58 Home Health Guide '____ 59 Government pamphlets on infant and child care ____ 60 Other government pamphlets _____ Attend and Work in Following Opganizations Much Some None 61 Church, Sunday School, etc. M S N ____ 62 Lodges and fraternal orders M S N _____ 63 Civic and luncheon clubs M S N 337 Column 64 65 66 67 68 69 7O 71 72 30-31 32-35 36-37 38-39 40-41 42-43 44-45 46-47 48-49 50-51 52-53 54 55 Item and Data Business and professional Labor unions Cooperatives General farm organizations P. T. A. Home Demonstration Clubs Other educational organizations Social and recreational Boards and committees of any organizations HEALTH INSURANCE AND RELATED SUBJECTS (Card Set 3) M M M Number of individual medical care records Total cost of medical care How Paid: Percent by: Cash Credit Insurance (Blue Cross) Insurance (Other) Government Organized philanthrOpy Friends and relatives Unpaid Discount allowed Family Blue Cross Hospital Insurance Is surgery included? mmmmmmmm 22222222 338 Column 56-57 58 59 60 61 62-63 64-65 66 67 68 69 70 71-72 73-74 75 76 77 78 79 80 Item and Data Number of persons covered Commercial health, hospital or accident insurance included Include surgery? Include hospitalization? Disability clause? Number of persons covered Health insurance premiums per year Miles from nearest doctor Miles from nearest hospital Usual fee for call in doctor's office $ Usual fee for home call by doctor Usual fee for night home call Number office calls Number home calls 35 35 Have you heard any talk on radio, or read anything about National Health Insupance? Have you made up your mind on the matter? Attitude: For it Against it Undecided No Opinion Group coverage Number in household covered Include surgery? 39 340 INDIVIDUAL RECORD FOR ALL TYPES OF ILLNESS AND MEDICAL TREATMENT (Card Set 4) Includes dental work, fitting glasses, vaccinations, diagnostic work, preventive and educational clinics, as well as acute and chronic illness. Must include all acute illnesses which began or ended during the preceding pig months. Column Item and Data Code 30 Name No.____ .____ 31 Age Sex ‘____ 32 Cause _____ 33 Acute Chronic ___ _____ Dental Eyes Diag. Preventive 34 Disability: None____ Partial____ Fu11___ ‘____ 35 Present Condition: Well Ill Conv. Dead 36 Date terminated_o 37-38 Length of Illness: Years Months Days 39-40 Days in hospital 41-42 Days in home bed 43 Doctor: None M.D. M.D. Spec. Non-M.D2____ Dentist____ 44 Home calls by doctor 45-46 Office calls 47-48 Hospital calls 49-50 Total calls It"; -‘ _— Column 51 52-54 55-57 58-60 61-63 64-65 66-67 68-70 71-72 73-74 75-78 79-80 Visits by patient to out-patient department, to clinic, or to Public Welfare Department m Item and Data Cost byType of Service General M.D. $ NOD-M Q D o Midwife Prac. Nurse Attendant Hospital Rx drugs ‘69 Specialist M.D. $ Dentist Spec. Nurse Servant Other drugs Diagnostic (X-ray, Lab., etc.) Glasses Appliances Ambulance Other Total Wages lost Dentures $._____ $ {F} Code 341 if“ APPENDIX C BASE SAMPLE POPULATION TABLES .TTfl-I, “or” - . O . ‘ 343 Table 1. Frequency distribution of sample population by in- come and age. Income Age Total Under $1,500- $4,000- Unknown $1,500 3,999 up T0tal 2125 560 950 471 144 1 L-, Under 6 316 88 155 53 20 “1 6-13 282 93 119 50 20 { 14-17 144 43 60 31 10 18-44 856 184 405 206 61 1 45-64 410 98 167 116 29 65-up 117 54 44 15 4 Table 2. Frequency distribution of sample population 18 years of age and over by sex and age. Sex Age Total Males Females Total 18-up 1383 658 725 18-44 856 410 446 45-64 410 191 219 65-up 117 57 60 Table 3. Frequency distribution of sample pOpulation by color and age. Color Age Total White Nonwhite Total 2125 1498 627 Under 6 316 207 109 6-13 282 176 106 14-17 144 87 57 18-44 856 632 224 45-64 410 305 105 65-up 117 91 26 Table 4. Frequency distribution of sample pOpulation by in- _come and color. Income Color Total Under $1,500- $4,000- Unknown $1,500 3,999 up Total 2125 560 471 144 White 1498 201 451 144 Nonwhite 627 359 20 0 ‘ fix” an...“— a Table 5. Frequency distribution of white sample pOpulation 18 years of age and over by sex and age. Sex Age Tbtal Males Females Total 18-up 1028 497 531 18-44 632 310 322 45-64 305 143 162 65-up 91 44 47 Table 6. Frequency distribution of nonwhite sample popu- lation 18 years of age and over by sex and age. Sex Age T0ta1 Males Females Tbtal 18-up 355 161 194 18-44 224 100 124 45-64 105 48 57 65-up 26 13 13 Table 7. Frequency distribution of sample pOpulation by home tenure and age. Tenure Age Total Owners Renters Total 2125 1005 1120 Under 6 316 118 198 6-13 282 105 177 14-17 144 70 74 18-44 856 372 484 45—64 410 257 153 65-up 117 83 34 346 Table 8. Frequency distribution of sample population by in- come and home tenure. . Income Tenure Total Under $1,500- $4,000- Unknown $1,500 3,999 up Total 2125 560 950 471 144 Owners 1005 157 435 334 79 Renters 1120 403 515 137 65 Table 9. Frequency distribution of sample population by place of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban Total 2125 692 530 903 Under 6 316 105 w 90 121 6-13 282 127 56 99 14-17 144 69 30 45 18-44 856 233 238 385 45-64 410 115 89 206 65-up 117 43 27 47 “. it... “up ‘ .. .- Table 10. Frequency distribution of white sample pOpulation by place of residence and age. Residence Age Total Rural Farm Rural Nonfarm Urban Tbtal 1498 421 454 623 Under 6 207 53 76 78 6—13 178 62 47 67 14-17 87 35 27 25 18-44 632 152 207 273 45-64 305 84 76 145 65-up 91 35 21 35 Table 11. Frequency distribution of nonwhite sample popula- tion by place of residence and age. Residence Age Tbtal Rural Farm Rural Nonfarm Urban Total 627 271 76 280 Under 6 109 52 14 43 6-13 106 65 9 32 14-17 57 34 3 20 18-44 224 81 31 112 45-64 105 31 13 61 65-up 26 8 6 l2 348 Table 12. Frequency distribution of sample pOpulation by in- come and place of residence. Income Residence Total Under $1,500- $4,000- Unknown $1,500 3,999 up Total 2125 560 950 471 144 Rural Farm 692 309 263 74 46 Rural Nonfarm 530 122 248 103 57 Urban 903 129 439 294 41 Table 13. Frequency distribution of sample population by health environment index and age. Health Environment Index Age Total 0-10 11-18 19-22 23 Total 2125 448 742 701 234 Under 6 316 99 95 91 31 6-13 282 91 93 77 21 14-17 144 28 75 32 9 18-44 856 161 291 299 105 45—64 410 48 151 151 60 65-up 117 21 37 51 8 Table 14. come and health environment index. Income Health Environment Total Under $1,500- $4,000- Unknown Index $1,500 3,999 up Total 2125 560 950 471 144 0-10 448 303 119 16 10 11-18 742 209 435 43 55 19-22 701 46 324 260 71 23 234 2 72 152 8 Table 15. Frequency distribution of sample pOpulation by communication-participation index and age. Communication-Participation Index Age Total 0-3 4—7 8-13 14-25 Total 2125 313 741 801 270 Under 6 316 63 112 119 22 6-13 282 49 94 103 36 14-17 144 14 51 57 22 18-44 856 122 311 329 94 45-64 410 42 130 158 80 65-up 117 23 43 35 16 349 Frequency distribution of sample population by in- 350 Table 16. Frequency distribution of sample population by in- come and communication-participation index. , Income Communication- Participation Total Under $1,500- $4,000- Unknown Index $1,500 3,999 up Total 2125 560 950 471 144 0-3 313 187 95 20 11 4-7 741 249 357 78 57 8-13 801 110 406 218 67 14-25 270 14 92 155 9 Table 17. Frequency distribution of sample pOpulation by size of household and age. Size of Household Age Total 1-2 3-6 7-up Total 2125 351 1370 404 Under 6 316 1 229 86 6-13 282 4 173 105 14-17 144 5 87 52 18-44 856 157 591 108 45-64 410 141 225 44 65-up 117 43 65 9 351 Table 18. Frequency distribution of sample population by in- come and size of household. Income Size of Total Under $1,500- $4,000- Unknown Household $1,500 3,999 up Total 2125 560 950 471 144 1-2 351 116 136 89 10 3-6 1370 282 641 335 112 7-up 404 162 173 47 22 Table 19. Frequency distribution of sample population by crowding index and age. Crowding Index Age Total Under .50- 1.00- 1.50- 2.00- .50 .99 1.49 1.99 up Total 2125 258 826 550 229 262 Under 6 316 2 100 83 59 72 6-13 282 5 76 95 50 56 14-17 144 10 45 43 20 26 18-44 856 81 378 231 84 82 45-64 410 122 183 71 12 22 65-up 117 38 44 27 4 4 352 Table 20. Frequency distribution of sample population by in- come and crowding index. Income Crowding Total Under $1,500- $4,000- Unknown Index $1,500 3,999 up Total 2125 560 950 471 144 Under .50 258 53 87 101 17 .50-.99 826 113 373 272 68 1.00-1.49 550 143 296 80 31 1.50-1.99 229 115 101 O 13 2.00-up 262 136 93 18 15 Table 21. Frequency distribution of male sample population 18 years of age and over by crowding index and age. Crowding Index Age Total Under .50- 1.00- 1.50- 2.00- .50 .99 1.49 1.99 up Total 18-up 658 105 289 166 47 51 18-44 410 38 182 112 40 38 45-64 191 50 84 41 6 10 65-up 57 17 23 13 l 3 353 Table 22. Frequency distribution of female sample population 18 years of age and over by crowding index and age. Crowding Index Age Total Under .50- 1.00- 1.50- 2.00- .50 .99 1.49 1.99 up Total 18-up 725 136 316 163 53 57 18-44 446 43 196 119 44 44 45-64 219 72 99 30 6 12 65-up 60 21 21 14 3 1 Table 23. Frequency distribution of sample population by education of male household head and age. Education of Male Head 4 Age Total Under 4-8 9-12 1-3 college- Others* 4 college up Total 2125 225 628 518 165 167 422 Under 6 316 42 97 91 26 20 40 6-13 282 33 110 59 12 23 45 14-17 144 17 55 26 6 7 33 18-44 856 74 228 255 64 73 162 45-64 410 39 111 71 44 42 103 65-up 117 20 27 16 13 2 39 *This category includes no answer, no male head, and male head not living. Table 24. Frequency distribution of sample population by in- come and by education of male household head. Income Education of Total Under $1,500- $4,000- Unknown Male Head $1,500 3,999 up Total 2125 560 950 471 144 Under 4 225 157 42 4 22 4-8 628 188 323 98 19 9-12 518 47 266 141 64 1-3 college 165 4 82 74 5 4 college-up 167 0 34 125 8 Others* 422 164 203 29 26 head not living. *This category includes no answer, no male head, and male Thble 25. Frequency distribution of sample pOpulation by edu- cation of female household head and age. Education of Female Head 4 Age Total Under 4-8 9-12 1-3 college- Others* 4 college up Total 2125 129 735 752 213 141 155 Under 6 316 15 119 126 30 19 7 6-13 282 16 119 107 15 12 13 14-17 144 8 75 40 10 2 9 18-44 856 41 259 339 86 67 64 45-64 410 31 134 107 61 35 42 65-up 117 18 29 33 ll 6 20 *This category includes no answer, no female head, and female head not living. 355 Table 26. Frequency distribution of sample pOpulation by in- come and by education of female head. Income Education of Total Under $1,500- $4,000- Unknown Female Head $1,500 3,999 up Total 2125 560 950 471 144 Under 4 129 69 42 7 11 4-8 735 309 310 72 44 9-12 752 106 393 190 63 1-3 college 213 18 79 111 5 4 college-up 141 7 48 83 3 Others* 155 51 78 8 18 *This category includes—no answer, no female head, and female head not living. .1- 4. 714.1! 3 (PM; rt»; CféiiY 13.41.23“; L INTER-MERRY LOAN JE 19 "35 INTER-HENRY mu JE 19 '55