Personal constitution and health status among Chinese elderly in Taipei and Los Angeles.

This paper reports ethnographic and statistical data on the indigenous Chinese concept of constitution (ti-zhi) and its association with health status. The data were obtained through in-depth interviews with 203 Chinese elderly residing in Taipei and Los Angeles. The informants used several dimensions to characterize their constitutions. They also described how their constitutions originated and were expressed over the lifecourse. The association between these characterizations of constitution and reported number of symptoms/diseases, self-rated health status and satisfaction with health were examined statistically. These analyses indicate that characterizations of constitution as strong/weak or as hot/cold, have significant but moderate associations with the indicators of health status.

Health education goes Hollywood: working with prime-time and daytime entertainment television for immunization promotion.

This article presents an entertainment education strategy used to influence Hollywood prime-time and daytime television programs to add storylines on the importance of immunizations to their shows. Rather than giving information about immunizations to show producers, directors, actors, and writers, we furnished "log lines" and true stories about immunizations that could be used to inspire scripts that included immunization themes. By working through personal contacts within the entertainment television industry's closed system of networks, we were able to gain entree and some airtime for our campaign agenda. Embedded messages aired on eight popular shows in the 1996-1997 broadcast season, with five scheduled to air in the 1997-1998 season. These efforts were evaluated qualitatively, focusing on issues of personal networks, content of aired messages, and comparative costs for paid airtime. The strategy developed can be adapted for a range of entertainment education interventions.

A multi-disciplinary curriculum for 11- to 13-year-olds: immunization, plus!

A sixth grade curriculum entitled "Immunization, Plus!" Was developed to promote adolescent immunization. This targeted immunization curriculum utilized contemporary learning theory and innovative teaching approaches and styles to maximize acceptability among educators. Because instructional time in school was limited, a thematic curriculum was created to embed immunization and communicable disease content within mathematics, science/health, and language arts units. The curriculum, which reflected the theory of multiple intelligences among students, offered an array of different learning formats, including linguistic, logical-mathematical, spatial, and bodily-kinesthetic. The curriculum was made available free of charge to school districts in California, and its evaluation was planned to track distribution, utilization, and changes in students' knowledge, attitude, and behavior.

The relationship between socioeconomic status and recently diagnosed rheumatoid arthritis.

OBJECTIVE: To examine the role of socioeconomic status (SES) in physical functioning, pain, and depressive symptoms among newly diagnosed rheumatoid arthritis (RA) patients with severe disease. METHODS: Data are from 118 non-Hispanic patients of European origin at baseline of a longitudinal study of early, severe RA. Outcome measures with the Health Assessment Questionnaire (HAQ) functional disability index, the HAQ visual analog pain scale, and the Center for Epidemiologic Studies Depression Scale. Hierarchical regression analyses were conducted using a health status block (disease activity and comorbidities), a non-SES related social structure block (age, sex and Lubben Social Network Scale), and indicators of SES (income and education). RESULTS: Non-SES related social structure and SES were important independent determinants of functional disability and depressive symptoms, but both they and the health status variables were unrelated to pain. Further, neither income nor education was related to disease activity or comorbidities. CONCLUSION: It cannot be argued from these data that poorer health status explains the link between SES and disability and depressive symptoms. Although, at baseline, the psychosocial effects of early RA are more severe for those with SES, the disease does not appear to be more severe. It may be that the biologic impact of status differentials will become clearer as the effects of treatment and the course of the disease unfold over time.

Physician visits by rheumatoid arthritis patients: a prospective analysis.

OBJECTIVE: To examine prospectively, using the behavioral model of health service utilization, patient-initiated physician visits, physician-requested visits, and visits for disease flares by 270 patients with rheumatoid arthritis (RA). METHODS: Four waves of telephone interviews were conducted over 2 years. Hierarchical regression analyses were used to assess the relative contributions to variance explained by blocks of variables indicating need for care and predisposing and enabling factors. RESULTS: Predisposing and enabling factors accounted for 50-67% of the explained variance in the 3 types of visits, while need accounted only for 33-50%. CONCLUSIONS: Studies seeking to identify factors other than need for care that facilitate or inhibit physician visits among RA patients are essential to analyzing the costs of care.

Concordant and discrepant views of patients' physical functioning.

OBJECTIVE: Although considerable research has been done on patient-physician interaction, few studies have examined discrepancies between patients and physicians in their assessments of the patient's physical functioning. One recent study reports such discrepancies between rheumatologists and 41% of their rheumatoid arthritis patients. This article reports data replicating that study and examining the relationships between such discrepancies and a number of other variables. METHODS: This is a longitudinal study of 158 patients with rheumatoid arthritis who were interviewed 4 times over a 2-year period and who reported their levels of physical functioning on the Arthritis Impact Measurement Scales. At the time of the fourth interview, the rheumatologists rated each patient's physical functioning on the revised criteria published by the American College of Rheumatology. RESULTS: Rheumatologists' assessments of their patients' physical functioning were discrepant with the patient's assessment for 35% of these patients. Twenty-seven patients were rated as worse than they rated themselves and 28 were rated as better. There were no differences between the concordant and the two discrepant groups in demographic or health status characteristics.

The physical, mental, and social health status of older Chinese: a cross-national study.

This article reports data on 16 indicators of the physical, mental, and social health status of older Chinese living in Beijing, Guangzhou, and Los Angeles. Both the frequency distributions of these indicators and their factor structures are different among the three cities. These differences may have implications for the planning of public health services. Either they are the result of differences in the way in which people in each of these cities think about illness or they are the result of differential experiences with disease. Although these data cannot resolve this issue, both the frequency distributions and the severity ratings for nine chronic diseases also differed markedly among the three cities.

The stress process in rheumatoid arthritis.

OBJECTIVE: To evaluate the Stress Process Model proposed by Pearlin and colleagues by examining the role of personal and social resources in mediating the relationship between the rheumatoid arthritis (RA) related stressors of functional disability, pain, and flares, and the outcome of depressive symptoms. METHODS: Data are from 285 patients who participated in a study of the natural history of RA, comorbidity and depression. Measures include the Center for Epidemiologic Studies-Depression (CES-D) scale, the Arthritis Impact Measurement Scale Functioning and Pain scales, the Lubben Social Network scale, and items indicating sociodemographic status, health status and personal resources. A series of hierarchical regression analyses with multiplicative interaction terms were conducted. RESULTS: Substantial consistency between the Stress Process Model and relationships observed in the data was demonstrated. CONCLUSION: Although no claim is made to having demonstrated that the observed relationships are causal, the fact that the data are consistent with the model invites a prospective analysis in which the ordering of the variables over time can be established unambiguously. Because of the implications of the Stress Process Model for the design of psychosocial interventions, such a test is especially important.

Illness episodes, physician visits, and depressive symptoms.

Although there is a large literature examining the effects of distress on the demand for medical care, the data on which this literature is based are equivocal. Nonetheless, this literature is cited frequently by those who advocate a national mental health policy designed to produce a cost-effective "medical offset effect." In this study, longitudinal data on illness episodes, physician visits, and depressive symptoms were collected from 940 Medicare recipients enrolled in a health maintenance organization (HMO) under a Tax Equity and Fiscal Responsibility Act (TEFRA) contract. Seven waves of interviews were conducted over a period of 1 year. This article presents two sets of analyses. In the first, controlling for chronic conditions and demographics reported at baseline, the relationships between depressive symptoms reported at baseline, and all illness episodes and physician visits that occurred over the subsequent year are examined. In the second, controlling for depressive symptoms and demographics reported at baseline, the relationships between illness episodes and physician visits over the study year, and depressive symptoms recorded at the final interview are examined. The data indicate that, whereas depressive symptoms at baseline are virtually unrelated to subsequent illness episodes and physician visits, illness episodes and physician visits are related to subsequent depressive symptoms. These data indicate, therefore, that policies aimed at diverting the distressed from seeking medical care may result in further inequities in the receipt of needed care.

Care seeking for musculoskeletal and respiratory episodes in a Medicare population.

Responses to episodes of musculoskeletal illness, musculoskeletal injury, and respiratory illness are examined separately. Data are from a 1-year longitudinal study of the illness experiences of 885 Medicare recipients. Unlike studies examining aggregate use of medical services, this study examines both episodes for which medical care was sought and episodes for which no medical care was sought. Both factors associated with the decision to seek medical care for each type of episode and the illness response patterns associated with whether medical care is sought are analyzed. The three types of episode have different characteristics and profiles of illness response. Perceived seriousness and duration of the episode are the best predictors of physician visits for all episode types. However, the relative effect of predisposing and need variables on the decision to seek medical care is greatest for musculoskeletal illness episodes. These data also bear on the relationship between self-care, informal care, and the use of formal medical care. Use of nonprescription medications is shown to substitute for medical care in a significant number of illness episodes. Lay consultation and restricted activity are often linked with physician visits; however, they cannot be assumed to precede care seeking. The analytic strategy of examining responses to specific types of episodes suggests that both characteristics of the person and characteristics of the illness affect how people respond to illnesses and that the relative importance of each type of characteristic is specific to each illness type. Implications of these findings for health education are discussed.

Rheumatoid arthritis and the use of medical services.

Although there have been several studies examining the direct and indirect costs of rheumatoid arthritis (RA), no studies have analyzed the group and individual factors that are associated with the use of services among RA patients. The present study applies the behavioral model of health services utilization developed by Andersen to data derived from interviews with 288 RA patients. The behavioral model proposes that the use of services is related to predisposing, enabling, and need variables. All visits within 6 months of the interview that were initiated by the patient, requested by the physician, in response to RA flare-ups and/or for physical therapy were analyzed. Ever having had surgery for RA also was analyzed. The results indicate that predisposing and enabling variables are related to use among these RA patients and, therefore, use is not a simple function of need.

Rheumatoid arthritis and comorbidity.

Data collected from 288 patients with rheumatoid arthritis (RA) indicated that 54% of respondents also reported other chronic conditions, and that 20% rated at least one of these other conditions as severe. Both the frequency and severity of these comorbidities affected scores on measures of depressive symptoms, social connectedness and on the Arthritis Impact Measurement Scales. These findings suggest that the absence of controls for comorbidity may bias measures of functional status among patients with RA.

Psychological distress and the decision to seek medical care among a Medicare population.

Although there have been a number of studies linking psychological distress to the demand for medical care, few studies have examined this relationship among the aged. The issue is important, however, partly because it has been suggested that distress might cause some individuals to seek unneeded medical care. The financial impact of the aged seeking unneeded care on Medicare is, thus, a matter of public concern. This study presents results from a prospective investigation of the impact of psychological distress on the seeking of medical care among a sample of 1,009 Medicare recipients. Following a baseline interview that assessed, among other things, psychological distress, the respondents were reinterviewed six times over the course of one year. Respondents reporting episodes of illness at each interview were asked a series of questions regarding how they responded to the episode. The present analysis examines the impact of a series of variables, including psychological distress, on the decision to seek care for each of the episodes about which the respondent was queried. It also examines the impact of psychological distress on the total number of physician visits requested by the respondent over the study year. Finally, since a panel of 22 geriatricians rated whether or not the episodes reported by the respondents should have resulted in a physician visit, the impact of psychological distress on the medical necessity of the visits made by these respondents is analyzed. The analyses found no relationship between psychological distress and any of these outcomes. Thus, it does not appear that, among these respondents, psychological distress has any impact either on the frequency of physician visits or the medical necessity of visits made for episodes of illness.

Psychological distress and the decision to seek medical care.

There have been a number of studies linking psychological distress with the demand for medical care. The importance of these studies lies in the finding that the distressed use of services more frequently than the non-distressed. To the extent that many of the visits of the distressed are for medically trivial reasons, which is the most frequent interpretation of this finding, there may be an argument in favor of cost containment strategies aimed at diverting the distressed away from seeking 'unneeded' medical attention. There are, however, a number of difficulties both with most of the studies that have been done to date and with how the finding of more frequent visits among the distressed is interpreted. The present study examines the reporting of illnesses, disability per illness reported, patient initiated physician visits per illness reported and physicians' judgement regarding the medical necessity of the visits reported for a representative sample of the Los Angeles metropolitan area. The 950 respondents in this analysis were divided into groups by three levels of psychological distress. Illnesses reported both prospectively and retrospectively to the measurement of psychological distress are analyzed. The data indicate that, although the distressed report more illnesses, they are no more likely either to report disability per illness or to initiate medical care per illness. Further, the distressed are no more likely either to initiate unnecessary physician visits or to avoid initiating necessary visits. The implications of these findings for the impact of cost containment strategies on equity in the delivery of medical services are discussed.

Mexican-American, black-American and white-American differences in reporting illnesses, disability and physician visits for illnesses.

This paper presents data on the reporting of illnesses, disability due to illnesses and the decision to seek medical attention for illnesses among a representative sample of Mexican-Americans, Black-Americans and White-Americans in Los Angeles. Few differences were observed among these groups with respect to the reporting of illnesses, disability due to illnesses or in the frequency with which illnesses were brought to medical attention. Hierarchical stepwise multiple regressions were run for each of these variables within each of these subgroups. Some differences were found among these groups in the variables that predicted illness reporting, disability and the use of physician services for illnesses. These differences indicate that ethnicity affects health behavior through its interaction with other variables. Speculations are offered regarding the meaning and historical sources of the differences observed.

Worker Training in Job Safety and Health: how do we know it Works?

Two methods of occupational disease and injury prevention specifically required by Federal law are education and training of workers in job safety and health. Basic assumptions underlying these strategies are that they will increase safe behavior thereby reducing health risk. However, questions continue to arise regarding the effect of ongoing training as a preventive measure and, therefore, about the practical usefulness of these assumptions. The purpose of this study was to examine the extent to which evaluations of ongoing training programs can provide information to test the basic assumptions. A self-administered mail survey concerning the evaluation practices of occupational health professionals responsible for the evaluation of health and safety training programs was conducted. Results suggest that for many evaluations the information collected is inappropriate for the uses to which it is put. Furthermore, the results also suggest that measurement validity is a problem. Thus, in effect, we have no way of knowing whether or not the majority of training programs are effective.

Mass media based health behavior change: televised smoking cessation program.

This report describes the 1-year follow-up assessment of a television-based smoking cessation program shown as a part of local news in the Los Angeles area. The post-broadcast experiences of two distinct samples was considered: individuals who wrote in for additional materials (Registrants) and a cross section sample (CS) contacted by a random survey method. Results showed significant between-group differences in demographic characteristics and smoking behavior outcomes. Compared to the CS sample, registrants displayed more quitting attempts during the 1-year follow-up period (70.7% and 49.8%) and more abstinence (6.2% and 2.4%, respectively). When compared to results from a comparison survey, both registrant and CS subjects made significantly more quitting attempts in the three week period following broadcast. In terms of abstinence, only registrant results significantly differed from the comparison survey (6.2% vs. 2.9%). Few correlates of outcome were identified. Overall, analyses suggest that the televised quit smoking program encouraged viewers to initiate more numerous attempts to quit smoking than otherwise would have been expected. In terms of maintaining nonsmoking over time, however, only registrants experienced significantly greater success than might have been observed in the general population. Implications for research and policy recommendations of televised health promotion programs are proposed.

The evaluation of health and safety training.

A national survey of individuals responsible for health and safety training at the workplace was conducted by self-administered mailed questionnaires in 1982-83. This analysis examines the responses to the questions on evaluation. Descriptive data on the extent to which health and safety training programs are being evaluated, the types of evaluation that are done, and the technical approaches used are presented. Results suggest that the majority of current training programs are being evaluated in some way, but also that a substantial portion of these evaluations are not rigorous and do not validly assess the extent to which training is effective.

Smoking and television: review of extant literature.

Smoking cessation programming is appearing with increasing frequency over the medium of television. This report reviews those television quit smoking programs that have been described in the literature. Programming features (e.g., program timing, content, utilization, and cost-effectiveness) are examined in addition to the assessment of the impact on viewers' smoking behavior. Overall, published reports have described a host of intriguing ways the TV medium can be used to encourage widespread smoking cessation. To date, however, there has been relatively less innovation and thoroughness in terms of assessing program impact. Implications are discussed for the burgeoning realm of health promotion programming via the electronic media.