Howard E. Freeman

Inequities in Health Services among Insured Americans

To determine whether groups other than the elderly and the uninsured have difficulty obtaining access to medical care, we studied 7633 adults nationwide. As we expected, the insured had much greater access than the uninsured, but among the insured there were substantial disparities in access to care. Insured adults of working age were 3.5 times as likely (95 percent confidence interval, 2.7 to 4.4) as the elderly to have needed supportive medical services (including medications and supplies) but not to have received them, and 3.4 times (2.3 to 4.4) as likely to have had major financial difficulties because of illness. Among insured, working-age adults, the poor were 4.4 times (3.5 to 5.3) as likely as those who were not poor to have needed supportive services but not to have received them, and 5.2 times (3.6 to 6.8) as likely to have had major financial problems because of illness. Apart from insurance status and income, blacks were 1.7 times (1.1 to 2.2) as likely as whites to have needed supportive services but not to have received them. Hispanics with a medical illness were 2.2 times (1.3 to 3.2) as likely as whites not to have seen a physician within the past year. We conclude that insured, working-age adults have less access to medical care than the elderly, and that poor, black, or Hispanic persons in this group are at risk for even greater problems with access to care. Current policy strategies are unlikely to improve the ability of these groups to obtain care.

Uncompensated Care by Hospitals or Public Insurance for the Poor

Results from two recent surveys of access to medical care, one nationwide and the other in Arizona, were analyzed to determine the consequences of reductions in Medicaid coverage for low-income Americans and the accompanying shift of responsibility for their health care to clinics and hospitals that provide uncompensated or subsidized care. The analysis indicated that in 1982, low-income persons received substantially less care from physicians if they resided in states without Medicaid programs or with only limited programs. In Arizona, the only state at the time without a Medicaid program, poor children saw physicians 40 percent less often, and poor rural residents saw physicians 22 percent less often, than poor residents of states with Medicaid programs; the proportion of poor Arizona residents refused care for financial reasons was almost double that in states with Medicaid programs. In addition, poor residents of states with the highest proportions of their low-income populations covered by Medicaid fared better than those in states with less extensive coverage. Moreover, poor elderly Americans were found to have comparable access to health care, regardless of where they lived, as a result of almost universal coverage under Medicare. Thus, this analysis suggests that the growing reliance on uncompensated care provided by hospitals and clinics may not be an effective substitute for public insurance and may adversely affect the health care received by the poor.

Relations between nutrition and cognition in rural Guatemala.

The nutritional status of three and four year old children, as measured by height and head circumference, is related to cognitive performance in four rural Guatemalan villages. The relationships persist when social factors are taken into account. Families in two of the villages participate in a voluntary, high protein-calorie supplementation program. In the other two villages, the families receive a vitamin and mineral supplement with one-third of the calories. Although the longitudinal study still is ongoing there is some evidence that the children who receive the higher calorie supplement (or whose mothers received it during pregnancy and lactation) are most likely to score high in cognitive performance. The results support other animal and human studies that report an association between nutrition and cognitive development. The findings, while not diminishing social environmental explantions of differences in cognitive function, suggest the worth of nutrition intervention programs in rural areas of lesser-developed countries.

Measuring the impact of water conservation campaigns in California

The reductions in water use achieved by urban households in California during the recent drought are well documented. What is not documented is how those reductions were achieved. In this paper, we report on survey data from the Los Angeles and San Francisco Bay Areas describing the water conservation activities undertaken. We also examine variation in water conservation activities across households and adjust statistically for social desirability biases in the self-reports.

The impact of a program to enhance the competencies of primary care physicians in caring for patients with AIDS.

The authors evaluated the impact of a continuing education program on the AIDS-related competencies of primary care physicians in Los Angeles County. In the fall of 1984, telephone interviews were conducted with a random sample of general internists and family and general practitioners. Interviews were completed with 635 physicians, or 63% of the original sample. Less than 30% demonstrated adequate knowledge or practices necessary to deal with patients’ AIDS-related symptoms and concerns. These physicians were randomly assigned to one of three treatment groups receiving materials presenting similar content about AIDS in printed, audiocassette or videocassette formats. Follow-up interviews with 81% of the study group revealed significant increases in competence but this was unrelated to the use of the educational materials. Several descriptors of physicians and their practices were significant predictors of competence as assessed on pre- and post-test interviews.

Concepts of success and failure

In this paper, we present a method for eliciting and describing indigenous concepts of success and failure. The domains of success and failure are first identified by obtaining from respondents a large number of statements that describe people in terms of perceived “success” and “failure.” This pool of statements is systematically reduced and the final items are submitted to similarity judgments by additional respondents. Multidimensional scaling and cluster analysis techniques are used to analyze the similarity data. The final success and failure schemes are represented by three-dimensional models. The results are highly robust and reliable. Reliability is above .90. The methods for the collection and analysis of data are applied to four samples in the Los Angeles area. The results constitute a cultural description of the domains of success and failure that should be valid for comparable populations in the United States. The results have “external validity” since the methods are “respondent centered” and free from any researcher-imposed categories or structure. For this reason, the approach is suited for use in other cultures.

Medical Sociology: A Review of the Literature

telligence is related to both types of aspirations.10 This conclusion is specific to persons from nonfarm families. Within this group, however, the relationship of level of aspiration to social status with intelligence controlled holds for both sexes and for both educational and occupational aspirations. Because the sample was drawn randomly from a broad population of high school seniors (the entire state of Wisconsin), and because the effects of measured intelligence and sex were controlled, the present tests lend support to the sociological claim that values specific to different status positions are important influences on levels of educational and occupational aspiration. This does not deny the importance of intelligence to educational and occupational aspirations, but suggests that status makes an independent contribution to these aspirations. 10 Following the procedure used in testing the hypotheses in the body of this article, chi-square values were computed so as to test within each sex category the association of levels of educational and occupational aspiration to measured intelligence with social status controlled. One such test was made for each of the four tables in the article. The results of these tests are as follows. Table 1: X20(20) -223.94 > X2t(20)05 = 31.41; Table 2: X2D(20) 61.27 > X2t(20).05 31.41; Table 3: %20( 230.12 > X 2t.31.41; Table 4: X20(20)127.59 > X2t(20).05 = 31.41. In each instance the null hypothesis must be rejected. Thus, for the present study, it is concluded that within either sex group, levels of educational and occupational aspiration are associated with measured intelligence when social status is controlled. This finding corroborates previous research concerning the relationship of levels of educational and occupational aspiration to intelligence (see note 4).

Collecting evaluation data : problems and solutions

Perspectives on Data Collection in Evaluations - Leigh Burstein and Howard E Freeman PART ONE: DATA SENSITIVITIES Data Collection Strategies in the Minneapolis Domestic Assault Experiment - Richard A Berk and Lawrence W Sherman Observer Studies - Lee Sechrest Data Collection by Remote Control Data Collection Issues in the Evaluation of the Effect of Television Violence on Elementary School Children - Ronald C Kessler et al PART TWO: MOUNTING LARGE-SCALE FIELD STUDIES A Tale of Two Surveys - Ronald M Anderson, Lu Ann Aday, and Gretchen Voorhis Fleming Lessons from the Best and Worst of Times in Program Evaluation Field Sampling Problems in Data Collection for Evaluating Research - Sandra H Berry Measuring Unfiled Claims in the Health Insurance Experiment - William H Rogers and Joseph P Newhouse Issues of Data Collection in Assessing Programs Involving Crime Reduction - Charles Mallar and Irving Piliavin The Job Corps and Supported Work Evaluations Some Failures in Designing Data Collection That Distort Results - Albert J Reiss Jr PART THREE: USE OF RECORD INFORMATION Program Evaluation and the Use of Extant Data - Eleanor Chelimsky Identification of Treatment Conditions Using Standard Record-Keeping Systems - J Ward Keesling Using Longitudinal Earnings Data from Social Security Records to Evaluate Job-Training Programs - Howard S Bloom An Information System for Planning and Evaluating Geriatric Care - George L Maddox The Duke Older Americans Resources and Services Program From Science to Technology - William D Neigher and Daniel B Fishman Reducing Problems in Mental Health Evaluation by Paradigm Shift REPRISE Data Quality Issues in Evaluation Research - Peter H Rossi Summary Comments

Telephone Sampling Bias in Surveying Disability

Results of the California Disability Survey indicate that telephone interviewing is well suited for undertaking disability studies that provide (1) estimates of subgroups of the disabled population, including those that are statistically rare: (2) information on current and anticipated areas of policy concern; and (3) information for geographic areas important in rehabilitation program planning. Although these objectives necessitated a large sample size and a complex instrument, the costs and timeliness of telephone interviewing enabled the survey objectives to be reached. This paper discusses the advantages of telephone interviewing, as well as biases inherent in its use. The magnitude of the bias from the omission of nontelephone households is assessed, and the results confirm that the omission of nontelephone households introduces only minor biases into estimates for the total working-age population. A method of weighting is developed and illustrated.

Data Collection The Achilles Heel of Evaluation Research

Recent advances in design, measurement, and analysis can have only a marginal impact on the integrity of evaluation studies because the evaluation of social programs is fundamentally dependent on the quality of the collected data. The effects of data collection procedures and their consequences on the integrity of evaluation conclusions are explicated. Data collection faults occurring in evaluation studies are enumerated and illustrated. A research agenda is proposed for improving data collection in social program evaluations.