Clyde R. Pope

Gender, psychosocial factors and the use of medical services: a longitudinal analysis

Many researchers have reported gender differences in levels of reported symptoms, morbidity, mortality and medical care utilization, but the debate continues about the underlying causes of these differences. Some have argued that women use more medical services because they are more sensitive to symptoms and interested in health, while others believe that womens greater service utilization arises from the fact that women experience more morbidities than do men. To date, these questions have not been studied prospectively. Using data from a household interview survey carried out in 1970-1971 and linked to 22 years of health services utilization records, we explored the effects of gender, self-reported health status, mental and physical symptom levels, health knowledge, illness behaviors and health concerns and interest on the long-term use of health services. After controlling for the aforementioned factors, female gender remained an independent predictor of higher utilization over the 22-year period studied, and psychosocial and health factors measured at the initial interview predicted service use even 19-22 years later. Controlling for factors identified as likely causes of gender-related differences in healthcare utilization, gender remains an important predictor of medical care use before and after removing sex-specific utilization. In addition, the consistent predictive ability of attitudinal and behavioral factors, combined with the finding that health knowledge did not predict utilization, indicates that efforts to help patients assess their service needs should target the attitudinal and behavioral factors that vary with gender, rather than health-related knowledge alone.

Social networks as predictors of ischemic heart disease, cancer, stroke and hypertension: Incidence, survival and mortality

Three social network measures were obtained from a randomly sampled cohort of 2603 HMO members in 1970-71. Mortality and first incidence of ischemic heart disease, cancer, stroke, and hypertension were assessed over the next 15 years. Outcome data were adjusted for age, sex, smoking, SES, and baseline health status. Persons with histories of a given morbidity at or prior to baseline were excluded from the analyses of that morbidity. Social network measures, particularly network scope (a measure of the number of different domains in which a person has social contacts), were powerful predictors of 15-year mortality hazard, but weak predictors of incident disease. Only network scope predicted IHD incidence, and none of the other morbidities was predicted by the social network measures. However, social network measures were strong predictors of both cause-specific and all-cause mortality among persons who had incident cases of IHD, cancer, and stroke. These data suggest that social networks may be more effective in supporting recovery after illness has occurred than in preventing the incidence of new disease.

Gender differences in the relationship between social network support and mortality: A longitudinal study of an elderly cohort

Despite well-recognized gender differences in patterns of social network support, few studies have explored whether the pathways by which social support affects mortality risk differ for men and women. In a 15-year follow-up study of elderly HMO members, we found that network size affected mens mortality risk indirectly, through their health status, while no such indirect effect was found for women. The data also suggested that network size had a direct protective effect on mortality risk for both men and women, with men gaining protection at a lower level of network size than women. These findings confirm the need for a gender-specific approach to further research on this subject, and suggest the need to measure variables that capture the different meaning and value of social network participation for men and women.

Gender roles, illness orientation and use of medical services☆

The study investigates illness orientation as a factor which may account for sex differences in the utilization of medical care. First, sex differences in the way symptoms are perceived, evaluated and acted upon (illness orientation) are analyzed. Then gender role factors which may account for sex differences in illness orientation are examined. Finally, the degree to which gender role factors and illness orientation account for sex differences in medical care utilization are assessed. The study population includes 1648 adults between the ages of 18 and 59. Medical record data covering 7 years of outpatient services are linked with survey data on the respondents. The findings show that while females are more likely to perceive symptoms than males, there is no apparent sex difference in a tendency to adopt the sick role when ill. In addition, results indicate that gender role factors such as level and type of role responsibility and concern with health are related to female though not male symptom reports. Illness orientation variables are related to rates of medical utilization for both sexes. However, it is primarily the perception of symptoms and an interest and concern with health which contributes to sex differences in utilization rates. When examining respondents who report either a very low or very high number of symptoms, sex differences in utilization rates fall below statistical significance.

The quality of social roles as predictors of morbidity and mortality

This study uses a longitudinal design to examine the health effects of the quality of social roles among a cohort of women and men. The specific roles of interest are the spouse role, the parent role, and the worker role. The cumulative and interactive effects of role characteristics and role satisfactions and stresses are also examined. The study population was randomly selected from among members of a large HMO and were part of a household interview conducted in 1970-71. Medical records for the 2 years prior to the interview and for 15 years after the interview for the cohort members are linked with the survey data. The findings show that for women, particular qualities of the marital and work roles are predictive of subsequent morbidity and mortality. For married women, equality in decision making and companionship in marriage are protective against death. None of the marriage characteristics are predictive of health outcomes among men. Work support is protective against death, malignancy, and stroke among employed women, and work stress increases the risk of ischemic heart disease among employed men. None of the parental role characteristics were significant predictors of health outcomes for men or women. No interactions were found.

Mental health status as a predictor of morbidity and mortality: a 15-year follow-up of members of a health maintenance organization.

OBJECTIVES This study sought to relate preexisting depression, worries, affect balance, and mental health symptoms to subsequent risk of morbidity and mortality. METHODS A random sample of members of a health maintenance organization were interviewed at home in a 1970/71 survey. Baseline psychological measures from that survey were then related to 15-year mortality and first incidence of cancer, heart disease, hypertension, stroke, functional gastrointestinal disease, and hyperimmune diseases. RESULTS Baseline depression and the Langner Mental Health Index predicted incidence of functional gastrointestinal and hyperimmune diseases. The relationship of the Langner index to hyperimmune diseases was particularly strong; mortality, cancer, heart disease, hypertension, and stroke incidence were not related to that index. Except for affect balance, which was worst in the elderly, indications of psychological dysfunction were strongest in the young. CONCLUSIONS Psychological indices detected increased risk for functional gastrointestinal and hyperimmune diseases but were not related to mortality risk. Further research is needed to disaggregate relationships of the specific conditions that were included in the hyperimmune group. Functional gastrointestinal disease might be preventable with early attention to depressed persons and to those scoring high on the Langner index.

Effect of domestic and occupational roles on morbidity and mortality

This study examines the effect of labor force participation, occupational status and domestic roles on morbidity and mortality among women and men over a 15-year period. The main research questions address the long-term effects of multiple roles. Does the combination of domestic and work roles result in adverse health effects, or provide some health advantage? The study population was randomly selected from among members of a large HMO and were part of a household interview conducted in 1970-71. Medical records for the two years prior to the interview and for 15 years after the interview for the cohort members are linked with the survey data. The findings show that for women there is some longevity advantage in paid employment. Overall, the combination of employment and domestic roles apparently poses no health threat to women, and may provide some advantage. Multiple roles are unrelated to mortality and morbidity outcomes among men.

Consistently high users of medical care among the elderly

This study identified consistently high and low users of medical care services in a group of older HMO members continuously enrolled for six years. Consistently high users made up 26% of the sample, but accounted for more than 50% of total outpatient contacts and hospital admissions. Average ambulatory care costs were more than four times greater for the high users compared with the low users. Consistently high users were older than consistently low users, but did not differ significantly in other sociodemographic characteristics. Compared with the low users, the high users reported more total medical conditions and were more likely to indicate they had arthritis, high blood pressure, heart conditions, and other chronic problems. They perceived themselves to be in poorer health and reported higher levels of psychologic distress. The low users tended to be less satisfied, but the two user groups were not significantly different regarding use of services outside the HMO

Utilization patterns among long-term enrollees in a prepaid group practice health maintenance organization

Criteria used in this study established that 13% of long-term adult members of a prepaid group practice health maintenance organization (HMO) were consistently high users of outpatient medical care services. This population accounted for 31% of the total doctor office visits (DOVs), 35% of the hospital admissions, and 30% of the outpatient surgical services for long-term members. The most frequent reason for DOVs in this high user group was treatment and/or follow-up of chronic conditions. Patterns of utilization were unrelated to marital status, income, occupation, and perceived social class. Smoking and alcohol use also were not associated with utilization patterns. However, the consistently high users were more likely to perceive their health status as fair or poor and to report a higher number of physical symptoms. They were also more likely to be characterized by a higher degree of psychological distress, especially depression. Contacts with the HMOs mental health department constituted less than 1% of their total medical care contacts, and only 13% made at least one mental health contact over the study period. The findings are discussed in terms of their health and medical care implications.

Health Status and Social Factors in Nonprescribed Drug Use

This article examines the relationship between a set of demographic, socioeconomic, sociopsychologic, and health status characteristics of a heterogeneous adult population and their use of nonprescribed drugs. The objective is to determine whether nonprescribed drug use is best accounted for by demographic and socioeconomic factors, by health and medical beliefs, by health status, or by some combination of these. The data are derived from a personal interview survey of 2603 adult members of the Kaiser-Permanente Medical Care Program, Oregon Region. The results indicated that a combination of characteristics from among these three sets were the best predictors. Sex, income, education, mental health status, tendency toward self-treatment, and level of concern with health matters were the most important variables, although they account for only a small amount of the variation in nonprescribed drug use. A portrait of the most frequent users of nonprescribed drugs raised the question as to whether these are the classic neurotics, the “worried-well”, or persons whose medical care needs have not been adequately recognized or met.