ER CENTER Series 1 For HEALTH Number 4 STATISTICS plan and initial program of the Health Examination Survey U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service This report was originally published in the series '"Health Statistics from the U.S. National Health Survey," which has since been replaced by the "Vital and Health Statistics'' series. This particular report is of continuing interest in relation to the reports now being published in Series 11 of the Vital and Health Statistics reports. It provides relevant background information for use in connection with the reports of findings. It is therefore, being reprinted in its present form. Public Health Service Publication No. 1000-Series 1-No. 4 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price 35 cents. NATIONAL CENTER| Series 1 For HEALTH STATISTICS | Number 4 VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES plan and initial program of the Health Examination Survey A description of the first-cycle program of the Sur- vey, including the statistical design, the pattern of examination, and the field procedures, Washington, D.C. July 1965 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Anthony J. Celebrezze Luther L. Terry Secretary Surgeon General cat. © BE aus 1 1C NATIONAL CENTER FOR HEALTH STATISTICS FORREST E. LINDER, Pu. D., Director THEODORE D. WOOLSEY, Deputy Director O. K. SAGEN, Pu. D., Assistant Director WALT R. SIMMONS, M.A., Statistical Advisor ALICE M. WATERHOUSE, M.D., Medical Advisor JAMES E. KELLY, D.D.S., Dental Advisor LOUIS R. STOLCIS, M.A., Executive Officer OFFICE OF HEALTH STATISTICS ANALYSIS Iwao M. Moriyama, Pu. D., Chief DIVISION OF VITAL STATISTICS RoBERT D. GrovE, Pu. D., Chief DIVISION OF HEALTH INTERVIEW STATISTICS Puirie S. LAWRENCE, Sc. D., Chief DIVISION OF HEALTH RECORDS STATISTICS Moxrok G. SIRkEN, Pu. D., Chief DIVISION OF HEALTH EXAMINATION STATISTICS ARTHUR J. McDoweLw, Chief DIVISION OF DATA PROCESSING SipNEY BINDER, Chief Public Health Service Publication No. 1000-Series 1-No. 4 CONTENTS Page Preface----====mmommmm mmo eee - iii Introduction =----=-cc mmm eee meme eee 1 The Role of the Health Examination Survey in the National Health Survey- 1 General Plan of First-Cycle Examinations---===ccecmaccmmcmccmcomcaao 2 Concepts and PUrpoSes-=-=-=— =m 2 Logistic Considerations-----===--cmemmmme comme 3 Methodological Studies in Planning----=---ccc--cmcmmmmmmmo eee 4 Advance Arrangements in Each Area---------cocommmmmmmmmcmcceeoo 4 Professional Relationg-======ccccmem mmc 4 General Publicity==-====--ccmcmmm mmm 5 Other Advance ArrangementsS-----—---- momo m meee meme eee mem 5 Selecting and Contacting the Sample Persons--------ceocmmmmmmmmomooono 5 Identifying the Sample Persons-=----cocemme mmm ccc eee eee 5 The Household Interview=-----ecee momma 5 The Appointment Procedure=-------ce- mmm meee meee 6 The Examination and Examining Process---=----cccommommmmmmmmaamnnoo 8 Pattern of the Examination------ccccmmm mmm 8 Measures to Insure Standardized Examinations----------ccecmcccmaaaoo 10 Post-Examination Procedures at the Examination Center--------=--------- 11 The Data Collected-=--=====-m mmm meme ee eee ee 11 The Medical History Data-----==----ccmmmmmm mmc meme moo 11 Medical Data Related to Special Interest Conditions--=--==-cceceeeeeaaoo- 11 Additional Data From the Examination--------cccccmmmmmmmmmmm ceo 12 Other Data Collected in the HES Operations-----=-=-c-ccmmommommmooo 32 Quality COontrol---== == mmm meee eee 13 Study of Characteristics Associated With Nonresponse-----=---==-ocou-- 13 Measures to Insure Uniformity and Reproducibility of Data-------------- 14 Special Calibration Studies------==ccmommmm eee 14 Statistical Design and Estimation--------ccmommmmm mmc 15 Introductory NOte-=== == mcm moomoo 15 The Design Problem----c-cccm mmm eee eee 15 Summary of the Sample Design--—---===- common mmm m em eee ee 16 Estimation Technique------==--c cmon 18 Reliability and Evaluation of Results-==-cemccmmm mmm cee 19 Plans for Analysis and Publication of Data--=----=-c--ccccmmmmmmmoa 20 Appendix I. Appendix IL. Appendix III. Appendix IV. Appendix V. Appendix VI. Appendix VII. Appendix VIII, CONTENTS—Continued Areas in the Health Examination Survey's Sample--=-=------- Routes Followed by Mobile Health Examination Centers in Moving From One Location to Another----------------- A. Floor Plan—Mobile Examination Center —Caravan [----- B. Floor Plan—Mobile Examination Center—Caravan Il---- Example of Leaflet Distributed in Advance of Interviewer's Household Interview Questionnaire of the Health Exam- ination Surveys--------cc-emmcecmemmmmmccoocoooooomonn- Leaflet Given Examinee When Appointment is Made---=----- Selected Medical History Questions---------=---==e--o-a- Notes on Statistical Design-----======cememmeacacaoonomoo Outline of Design Development--=-===----=---=========--=-= Definition of Universe--------- seco mmmmacccacoonnx On Basic Estimation Technique- --======c-ceceecmccoaao—- Within PSU Sampling Variations --==-=======-ceccccecom-o- The Master Control Card-------c-cecccmmmccccmccc mena Illustration of Selection of a Stand-------------ccceeecaan- Page 22 23 26 28 34 35 40 40 41 41 41 42 42 rr) ), “Ff 7 PUBLIC HEALTH LIBRARY PREFACE A description of the Health Examination Sur- vey plan and the "first-cycle" program is pre- sented in this report. The Health Examination Survey is a part of the program of the U. S. Na- tional Health Survey. The first cycle consists of the administration of a specialized health exam- ination to a probability sample of the adult, civilian, noninstitutional population of the United States. This will be succeeded by other cycles dealing with different age groups of the population or different types of examination, but all making use of the same general procedure—direct ex- amination of national probability samples of persons, The impetus for and direction of the Health Examination Survey's first-cycle plans and oper- ations was initially in the hands of Dr. Oswald K, Sagen, who has since been succeeded by Mr. Arthur J. McDowell as Chief, Health Examination Survey Branch. The examination phase of the plan was worked out by Dr. Alice M. Waterhouse, Medical Advisor to the U. S, National Health Survey, Dr. James ELE. Kelly, Dental Advisor, and Dr. Lawrence E. Van Kirk, of the Division of Dental Public Health and Resources, Public Health Service. Mr, Walt R, Simmons, Statistical Advisor, was responsible for the sample design. Many other aspects of the plan and the field procedures were developed, tested, and carried out by Dr. Ruth E, Dunham, Assistant Medical Advisor, Mr. Marshall C, Evans, Chief Health Survey Representative, and Mr. Elijah White, Survey Statistician. In the planning and operation of the first cycle, valuable assistance was received from many individuals and groups within the Public Health Service and elsewhere. In particular, how- ever, mention should be made of the staff of the Bureau of the Census who participated in building the survey design and have since been carrying out several important parts of the Survey on be- half of the National Health Survey, as will be de- tailed later. Special acknowledgment also is made of the contributions to the Survey from Dr. Joseph J. Bunim, Clinical Director of the National Institute of Arthritis and Metabolic Diseases, National Institutes of Health, and mem- bers of his staff; Dr. R. C. Arnold, Former Chief, and Dr. Arthur Rikli, Chief, of the Heart Disease Control Branch, Division of Chronic Diseases, Bureau of State Services; Dr. Gerald R. Cooper, Chief, Standardization Laboratory of the Heart Disease Control Branch, and his staff; Mr. Ad Harris, Director, Venereal Disease Re- search Laboratory, Communicable Disease Cen- ter, and his staff; Dr. Thomas R, Dawber, Di- rector, Framingham Heart Project, National Heart Institute, National Institutes of Health, and his staff; and Dr. Aram Glorig, Director of Research, Subcommittee on Conservation of Hearing, American Academy of Ophthalmology and Otolaryngology. A large share of the staff nursing services in the field operation of the Survey was pro- vided on a reimbursable arrangement with the Division of Hospitals and with the Medical Of- ficer in Charge and the Director of Nurses of the San Francisco Hospital of the Public Health Service. Through their co-operation, staff nurses were detailed on a rotating basis, thus providing a source of nursing personnel for the Survey, and a unique experience for the nurses who participated. Space does not permit acknowledgment, either individually or by organizational affiliation, of all of the many persons who have given advice and assistance in the work of the Survey. Mention must be made, however, of the outstanding con- tribution of one group whose excellent perform- ance was a sine qua non of success, namely, the field staff of the Health l * The Health Records Survey, which willutilize da- ta from the third source described above, is still in the planning and pretesting phase. The Health Examination Survey (HES), follow- ing three field pretests, began the examination of a sample of the civilian, noninstitutional, adult population of the United States in November 1959. At the time of this writing more than half of the first sample, or ''cycle,' has been examined. How- ever, the rate at which persons in the sample were being examined did not reach the planned full-scale level until the spring of 1961. Comple- tion of field work on this cycle is expected in the last part of 1962, Statistical processing of data is underway, but final analysis will not begin until all the data are collected. The tempo of field work, analysis, and publication is slower in the Health Examination Survey than in the Health Interview Survey. This report depicts the sampling plan, exam- ination, and other field procedures as they were being carried out in the latter part of 1961. There were minor differences in plan when the exami- nation for the first cycle began on a small scale in November 1959. No further changes of any con- sequence are contemplated before the first cycle comes to an end late in 1962. GENERAL PLAN CF FIRST-CYCLE EXAMINATIONS Concepts and Purposes The over-all plan of the Health Examination Survey is to identify separately specific segments of its broad goal and to concentrate on these seg- ments through separate cycles of examinations. Thus, the broad primary purposes are: (1) topro- vide statistics on the medically defined preva- lence in the total U. S. population of a variety of specific diseases, using standardized diagnostic criteria; and (2) to secure distributions of the general population with respect to certain physi- cal and physiological measurements. The segment selected for study in the first cycle of examina- tion, however, is limited to the adult population, defined as those persons between the ages of 18 and 79, inclusive. Moreover, this first cycle focuses attention particularly upon certain cardio- vascuiar diseases, arthritis and rheumatism, and diabetes. This, of course, in no way implies lack of, or less, interest in other groups in the popu- lation or in other diseases. Successive cycles in the program will study other segments. A key characteristic of the plan of the Health Examination Survey is to make actual physical 13. s. National Health Survey. The Statistical Design of the Health Household-Interview Survey. Health Statistics. Series A-2. PHS Publication No. 584-A2. Public Health Service, Washington D.C., July 1958. 2, S. National Health Survey. Concepts and Definitions in the Health Housebold-Interview Survey. Health Statistics. Series A-3. PHS Publication No. 584-A3. Public Health Service, Washington, D.C., September 1958. examinations of, and tests upon, the individuals selected in the sample. Such examinations and tests can yield morbidity information unobtainable through the other mechanisms of the National Health Survey. They can provide information not only about diagnosed conditions which persons fail to report or are incapable of reporting in a sur- vey based upon individual interviews, but they can also reveal previously undiagnosed, unattended, and nonmanifest chronic diseases. In addition to serving this primary purpose, the first-cycle ex- aminations are intended to obtain baseline data on certain physical and physiological measure- ments, such as blood pressure, serum cholesterol, auditory and visual acuity, skinfolds, various heights, weight, and electrocardiographic trac- ings. Data such as these on a defined population have been either nonexistent or inadequate. They are needed to understand departures from normal, as well as to carry out certain specific programs dependent upon human engineering information. Another key characteristic of the Health Examination Survey, one which is shared with other NHS programs, is the use of a nationwide probability sample of the population in order to obtain the desired statistics in an efficient way, and in such a manner that the statistical reliabil- ity of results is determinable. A description of the sample design and the sampling method is given elsewhere in this report. Here it need be described only in terms of the general concepts. The basic decision to limit the first-cycle examinations to the adult population was followed by decisions on certain additional limitations. Persons on active duty with the Armed Forces were not to be included, nor were persons in Alaska or Hawaii. Likewise excluded were per- sons resident in institutions (penitentiaries, hos- pitals for long-term treatment of chronic disease, etc.). The size of the sample to be selected was keyed to the numbers necessary to yield reliable data on the conditions studied. Actually, of course, the determinations of the size of sample and of the conditions to be studied were interrelated and interdependent, and a factor in these determina- tions was the number of examinations which could be accomplished within three years. The sample size is also a function of the available budget and of the structure of the examining process and of the statistical design. The selection process pro- vided that the sample be stratified with respect to broad geographic region and size of place of resi- dence (rural areas, smallcities, etc.). The method is generally like that used for the Health Interview Survey, and, in fact, the sample is drawn by the Bureau of the Census from among the Primary Sampling Units (PSU's) used for this Survey. The national sample selected for the first cycle of examinations is a probability sample representative of the adult, civilian, noninstitu- tional population. It includes approximately 7,500 individuals, a number which should resultin about 6,300 examinations of sample persons after al- lowance is made for persons who will not be examined, These individuals are located in 42 different areas, with each area consisting of a county or a small group of contiguous counties. These 42 areas in which the examining is done are located in 29 different states. They are group- ed into three subsamples of 14 areas, each rep- resentative of the total population. The plan of the first cycle calls for special, single-visit examinations of each individual se- lected in the sample. It also provides that data like those collected in the Health Interview Survey be obtained for the households which include each of the sample persons. These interviews are con- ducted prior to the special examination and, in fact, the interview process is used as the means for the last stage of selection of the sample of persons included in the Health Examination Sur- vey. This process is described in more detail later in this report. Logistic Considerations The logistic problems involved in conducting the examinations are considerable. It isnecessary to carry out special medical examinations in a standardized manner, involving tests and pro- cedures requiring special equipment, and to do this on thousands of persons located from one end of the United States to the other. About 150 of these examinations are accomplished in each of the 42 different areas (or ''stands'' as they have been designated) throughout the country. The examining is done in a Mobile Health Examination Center which is moved into the area for a period of about three weeks. The Health Examination Sur- vey has two such Centers in operation simultane- ously. The routes followed in making the moves are shown in Appendix II. One consists of three specially built tractor-drawn trailers, one of which contains the X-ray and laboratory facili- ties. The other, containing the same facilities, consists of two somewhat larger specially de- signed tractor-trailers. The floor plans of each of these mobile centers are shown in Appendix III. A Mobile Health Examination Center is manned by a staff consisting of two physicians, one dentist, two nurses, two X-ray-laboratory technicians, and two receptionist-interviewers. The above staff constitutes what is referred to as a full team. For the two Centers there areonly one and one-half full teams. This is made possi- ble by a carefully planned ''leap-frog'' pattern of scheduling. It involves grouping the staff into three "half teams," each consisting of one of each of the above kinds of personnel, except thatone of the half teams has no dentist. One of these two Health Examination Centers, say Caravan I, will operate on a full-examination schedule with a full team (two of the three half teams, but only one dentist) for roughly the first half of the three- week period it is at a particular stand. Meanwhile, at another stand, the other Health Examination Center, Caravan II, is in the last half of its examining period and is operating on a reduced schedule with only a half team. Then, one half team from Caravan I will move to a new stand to join there the half team with CaravanlIlwhich has now completed operations at its previous stand, and together they will conduct full-schedule opera- tions at the new stand. The pattern is then re- peated. The above description is, of course, over- simplified; for example, it does not consider such factors as travel time between stands. It will, however, suggest the kind of carefully scheduled pattern which has made it possible to operate effectively with a limited staff. The field staff which accomplishes the Health Examination Survey is a team composed of three elements. One of these is the examining staff which has already been described. A second ele- ment is the Bureau of the Census interviewer group, while the third isthe HES field administra- tive staff, The Census interviewer group includes from four to seven individual interviewers and a supervisor. The personnel vary from stand to stand. They are selected from among the experi- enced Census interviewers used on the Health In- terview Survey, and receive additional training for the special problems of the Health Examina- tion Survey. Their task is to complete the last stage of the sample selection process, to conduct the household interview, and to invite the selected sample persons to arrange an appointment for examination. The logistics of the survey make it desirable that the interviewing be conducted with- in the space of a few days immediately prior to the period scheduled for the examinations. The third component of the field team, the HES field administrative staff, consists of an Administrative Officer in Charge, an Administra- tive Assistant, and from two to five Health Exam- ination Representatives. The scheduling of the ad- ministrative staff represents a ''leap-frogging" arrangement similar to that described for the examining staff. In the first part of the period of the Survey in a particular location, more Health Examination Representatives are needed; then some move on to join others at another loca- tion, while part stay until the examining in the area is completed. These Health Examination Rep- resentatives complete any unfinished portion of the Census interviewers' work and—most im- portant—assist in producing the maximal exami- nation response by rescheduling broken appoint- ments and making additional efforts to explain the Survey to, and obtain the co-operation of, those persons who have not initially accepted an appointment. The Administrative Officer in Charge carries out extremely varied and com- plex duties, such as completing all of the arrange- ments for the trailer site, contracting for the utilities, supervising the work of the administra- tive staff, and acting as administrative officer for the entire field staff. Methodological Studies in Planning Prior to undertaking the first cycle of exam- inations, it was recognized that certain method- ological studies needed to be made to provide the basis for planning the survey. Moreover, the sur- vey plan needed to be pretested and modified on the basis of actual experience, and the plan, fi- nally designed, tried out in pilot studies. Four such methodological studies were carried out prior to commencing operations, and have been reported separately. One was concerned with the development of a medical-history questionnaire and appropriate interviewing techniques for use in this first cycle of examinations.” A second study was aimed at the development of a single- visit cardiovascular examination. The other two studies were concerned with the problems of re- sponse, co-operation, and attitudes toward co- operation in examination surveys.” 6 On the basis of the findings of the methodo- logical studies and general knowledge of the prob- lems involved, tentative plans for the first cycle were developed and pretested in Washington, D.C., in June 1958. The results of this pretest were carefully studied and some modifications of the survey plans were made on the basis of this ex- perience. Pilot studies of the revised survey plan for the first-cycle examinations were made in 1959 in Ft. Wayne, Indiana, and Cresco, Iowa, after which the final survey plan was formulated. Actual operations in examining sample persons selected for the first cycle of the Health Exami- nation Survey were begun shortly thereafter. ADVANCE ARRANGEMENTS IN EACH AREA Professional Relations The first step toward conducting the Survey in any given sample area consists of fully in- forming the health professions at the state level and in the particular locality selected. Typically, this takes the form of a series of meetings with representatives of the State Health Department, Medical Society, Osteopathic Society, and Dental Society, and with counterpart local organizations. At these meetings a complete description of the objectives and method of operation is given. The individual private practitioners in the sample area are also informed of the Survey by means of an article in their own state or county profession- al society publication or by individual mailings, according to the advice of the professional. so- cieties. In addition to a detailed description of the content of the special examination, operating pol- 4 icies of the survey are presented at these pro- fessional meetings. Several of these policies have proved to be important factors in eliciting the co- operation of the professional organizations as 3 : U. S. National Health Survey. A Study of Special Purpose Med- ical-History Techniques. Health Statistics. Series D-1. PHS Pub- lication No. 584-D1. Public Health Service, Washington, D. C., January 1960. 4. S. National Health Survey. Evaluation of a Single-Visit Cardiovascular Fxamination. Health Statistics. Series D-7. PHS Publication No. 584-D7. Public Health Service, Washington, D.C., November 1961. 5 U. S. National Health Survey. Co-operation in Health Examina- tion Surveys. Health Statistics. Series D-2. PHS Publicatien No. 584-D2. Public Health Service, Washington, D.C., June 1960. U.S. National Health Survey. Attitudes Toward Co-operation in a Health Examination Survey. Health Statistics. Series D-6. PHS Publication No. 584-D6. Public Health Service, Washington, D. C. July 1961. f ‘ well as that of the sample peréons, The policies include: (1) confidentiality, guafantged to all par- ticipants in the Survey; parey or other informa- tion which would identify individyal participants cannot be revealed; (2) information is not givento examinees on any findings of their examinations; (3) each examinee is encouraged to sign an au- thorization to have a report of the findings of his examination sent to the physician and dentist whom he names; (4) these reports are objective rather than interpretative (e.g., simultaneous duplicate electrocardiograms are obtained, and one complete tracing, rather than an interpreta- tion, is sent to the private physician); and (5) the private physician is notified by telephone in the event of any finding which the examining physician believes is "urgent." General Publicity In addition to this publicity directed toward members of the health professions, moderate amounts of general publicity are obtained through the news media in each area. Because volunteers cannot be accepted for examination, and because a relatively small number of sample persons are involved, no attempt is made to obtain large amounts of space or long series of articlesin the local newspapers. However, a release is pro- vided to the newspapers, timed to appear justbe- fore the visits to the households begin. Besides serving the usual purpose of providing general information, the resultant articles provide clip- pings from a local source for the Survey staff to use in contacts with the sample persons. The persons who are in the neighborhoods of the population segments from which the sample persons will be chosen also receive advance pub- licity in the form of a leaflet announcing the fact of the Survey and giving some general information about it. Such a leaflet, specific to the particular stand area, is distributed, either by mail or by direct-to-door distribution, a few days before the start of the Survey in each of the neighborhoods selected for household interviews. An example of these leaflets is shown in Appendix IV. Other Advance Arrangements Prior to operations at each of the stand areas, letters are sent to various authorities in the area (e.g., the Chief of the Police Department) to inform them about the pending activities. A member of the HES staff also makes advance ar- rangements for space for trailers, utilities, other office space, and other administrative matters, SELECTING AND CONTACTING THE SAMPLE PERSONS Identifying The Sample Persons The operation which identifies specific sam- ple persons might be regarded as the first step in the process of data collection. As noted above, this operation is one in which selected households are visited and the interviews are conducted and this process is used as the means of the last stage of selection of the sample persons. The entire sampling process is described in more detail later in this report. At the time the first element of the HES field team moves into a particular location, this process has produced a list of households in particular subsegments of the PSU, which is the area for that stand or lo- cation. The list which the HES field team takes into the location will include about four house- holds for each of the subsegments. It is the ad- dress, the house, or other dwelling unit in which each of these households lives, that is the starting point of the Survey. The households currently re- siding at each of these addresses are the ''sample households'' to be interviewed and out of which the sample persons are to be selected. The sample households are visited by spe- cially trained Census Bureau interviewers who conduct an interview to determine who lives in the households and to gather information on the personal characteristics, health status, and atti- tudes toward health surveys of these persons. Everyone living in the sample household at the time of the interview is eligible to be a sample person if he meets the criteria of the Survey (18- 79 years of age, not an active member in any mil- itary service, etc.). Of those eligible, every other one is designated as a sample person. The Household Interview The household interviewing begins about nine days before the date of the first examination. The Census interviewer knocks on the door, intro- duces herself, and asks for the head of the house- hold. If the head of the household is not present, she will conduct the first portion of the household interview with any responsible adult member of the household. The questionnaire used is shown in Appendix V. It contains four kinds of questions: (1) household, (2) personal, (3) health, and (4). attitudes. The interviewer will have entered information , for some of the household questions beforehand. After necessary additional questions about the household as a whole have been asked, the inter- viewer asks questions about the individuals whose names appear on the second page of the form. After she has asked questions 1-7 and written down the name, relationship, age, and other per- sonal information for each member of the house- hold, she pauses to check those who are eligible, and, in addition, to circle every alternate eligible, thus indicating that they are sample persons. She then asks questions 8-17, which arerelated to the health of members of the household. Each adult person who is at home is interviewed for himself. Any responsible adult, however, can answer these questions for children and for other adults who are not at home, provided they are related. Unrelated household members who are not at Home must be interviewed for themselves on return visits by the interviewer. The general interview ends with questions 18-21 which cover some additional per- sonal information, and question 22 on the total family income. If there are no sample persons in the house- hold, the interview is terminated. The remaining questions, 23-34, are asked only of sample per- sons and each sample person must be interviewed for himself, Questions 23-33 concern his atti- tudes and background knowledge about health and health surveys. One purpose of this series of questions is to create the necessary rapport for a favorable response to question 34, the invitation to come to the Health Examination Center for an examination. Another important purpose is toob- tain some insight into the attitudes of those who at first refuse the offer of an examination. This may be of use in the follow-up efforts to persuade aim to accept. The questions on health, attitudes, etc., are all asked before the person is informed thathe is a sample person; this order is followed to avoid bias in the answers. The household interviews are conducted in the same manner as those in the regular Health Interview Survey of the National Health Survey. The basic core questions from the questionnaire of the regular Health Interview Survey have been incorporated in the questionnaire for the Health Examination Survey with the wording unchanged. The HES questionnaire (Appendix V) differs in that questions on attitudes have been added, and questions on special subjects such as X-rays, medical insurance, etc., have been deleted. Since the Census interviewers who administer the household questionnaire are selected from those who are working on the regular Health Inter - view Survey, "a have already had intensive training and experience in maintaining standard procedures and in \asking the questions uniformly. Those selected are interviewers expected tohave the aptitude for handling the complicated proce- dures of this survey and tor establishing rapport while inviting the sample person to come in for an examination. At each stand, the first effort is to borrow qualified interviewers from the Census Regional Office in which the stand is located, in order to minimize travel costs. It is often nec- essary, however, to bring others from nearby regional offices. Good interviewers may be kept on for more than one stand so that there is some continuity in the interviewing staff. However, be- cause of the constant turnover in a large portion of the staff, special efforts are taken to achieve homogeneity by training. One full day is devoted to training on the day before interviewing begins. The purpose of this training is not only to famil- iarize these experienced interviewers with the de- tails of this particular survey, but also to estab- lish and maintain standardized procedures. After the interviewers have completed one day ofinter- viewing they meet for a half day of discussion of the problems encountered, inorder to standardize the way in which the problems are tobe met. The Census operation in all stands is supervised cen- trally from the Washington office of the Census Bureau and there is a Census supervisor at each stand who co-ordinates the work with the Wash- ington office. This supervisor is one of a small group of three or four persons that the Census Bureau has designated as eligible to be a field supervisor for this operation. Thus, the supervi- sor at a stand is usually a person who has had considerable experience in this work. In those stands where the supervisor is new, a Census representative is sent from the Washington office to teach him the procedures. The Appointment Procedure If the sample person accepts the offer to make an appointment for a survey examination, the Census interviewer telephones the Health Examination Center and confirms arrangements for a time that is convenient to the sample per- son. She then fills out an appointment slip and leaves it with the sample person. This slip shows the date and time of the appointment and the ad- dress of the Health Examination Center. A dupli- cate copy of this appointment slip is mailed to the sample person, as a reminder, two days be- fore the date of his appointment. Duplicate copies of the appointment slips are also used for rec- ord-keeping purposes at the Health Examination Center. At the time the appointment is made, the sample person is also given a leaflet containing J some general information on what the examina- tion is like (see Appendix VI). ' In order to provide maximum convenience for the sample persons, many of whom are em- ployed, the Health Examination Center is open on Saturdays, and, on some days, in the evenings. There are about 14 examiningdays at a stand out of which the sample person usually can select a convenient time. An attempt is made, however, to schedule appointments during the early part of the two-week period, insofar as possible. This is done so there will be more time in which broken appointments can be rescheduled. The examining hours are from 9 a.m, to5p.m.on some days and from 1 p.m. to 9 p.m. on others. During the in- terviewing operation there is someone available at the Center from 9 a.m. to 9 p.m. to receive the calls from the interviewers andtokeepa cen- tral record of appointment times filled and the ones still available. For each appointment that is phoned in, two kinds of records are made. The name and address of the sample person, the date and time of the appointment, and the name of the interviewer, all are entered in an "Appointment Log," along with a notation concerning the mode of transportation the sample person has chosen to use. (Frequently, transportation by taxi is pro- vided by the Survey, although in some instances the individual chooses to provide his own trans- portation.) The second entry is in the '"Schedule of Appointment' where the fact that this particu- lar appointment time has been filled by the spe- cific sample person is recorded. If the sample person is not at home at the time of the household interview the interviewer makes return visits in an attempt to interview him. Since the Census interviewing work is limit- ed to a period of about five days, there may be some sample households and some sample per- sons for whom the interviewing is still incom- plete at the end of this phase of operations. The Census supervisor refers uncompleted work to the HES Administrative Officer in Charge so that the Health Examination Representatives may make further follow-up visits. In instances where the sample person does not accept the Census In- terviewer's offer to arrange an appointment, the interviewer makes no effort to persuade the sam- ple person. It is recognized that many of the per- sons who show initial reluctance cannevertheless be examined, but the process of resolving their doubts and misapprehensions may require con- siderable time and skillful handling and this fol- low-up effort is made by the Health Examination Representatives. The Health Examination Representatives per - form three principal functions. The firstis tocon- tinue and complete the unfinished portions of the —— work of the Census interviewers. The second and most important is to contact the persons who have been interviewed but have not agreed to come for an examination, The third function is to visit and reschedule for examination those persons who made but did not keep their appointments. Itis ex- pected that at the average stand between two thirds and three fourths of the sample persons will accept the initial offer of an appointment. The majority of the remaining sample persons will agree to be examined after one or more visits by the Health Examination Representative. Perhaps 15 percent of all those who make an appointment will fail to keep it, sometimes telephoning to can- cel the appointment and sometimes simply not appearing; more than one half of these persons can be rescheduled (perhaps several times) and finally examined. Thus the work performed by the Health Examination Representatives greatly lessens the possibility that the findings of the examination will be markedly biased by nonre- sponse. It was recognized, a priori, that the propor - tion of persons willing to be examined and the ex- tent to which appointments would be broken would vary considerably from one stand to another. There is, however, a compelling reason for want- ing to know what the response characteristics are at a specific stand at the time operations at that stand are in an early stage. This reason is that the number of PSU subsegments assigned at a particular stand is variable, depending in part upon the number of eligible households and eligi- ble sample persons per subsegment, and in part upon the proportion of the selected sample per- sons which will be examined. It is desired to ob- tain approximately 150 examinations at each lo- cation. This will be accomplished at a stand at which 90 percent of the sample persons are examined if the total number of sample persons is only 165, but if the response rate falls to, say, 75 percent, this number of examinations requires that there be about 200 sample persons. The sub- segments within the PSU's have been randomly ordered and as many as are required can be in- cluded in the sample, but each one which is added must be completed. Thus the critical determina- tion desired is the number of subsegments which will yield approximately the required number of examinations without overtaxing the capabilities of the Health Examination Center andthe examin- ing staff, and without spreading too thinly the efforts of the Health Examination Representatives, The more sample persons there are to be visited, the less time per person is available for the re- peated visits often necessary to obtain a high re- sponse rate. The day-by-day reports of early stand operations are watched very carefully and projections, based on the experience at the stand considered along with all the previous experi ence, are made in order to determine how many, t } . additional subsegments (beyond the initial sure- ' to-be-needed ones) are to be assigned. THE EXAMINATION AND EXAMINING PROCESS Pattern of the Examination The special examination was developed dur- ing the presurvey period of planning, consultation, methodologic studies, and pilot studies. It is not intended to be a complete physical examination, but is tailored to the objectives and the limita- tions of the Survey. These include: (1) interest in chronic conditions and in certain physical and physiological measurements; (2) examination pro- cedures which can be performed in a standardized way and which can produce medically significant information from a single-visit examination; (3) exclusion of procedures to detect conditions which occur too rarely to provide reliable prevalence data from a sample of the given size (about 6,000); (4) exclusion of certain procedures which are not acceptable to some of the public (e.g., genital Table 1. examination), and which might therefore decrease participation in the Survey; and (5) limitation to an average of two hours for the entire examina- tion of each individual. The procedures included and the approximate time required for each group of procedures are shown in table 1 in the sequence usually followed in this examination. The basis for groupingis that all of the procedures in a group are performed at one examination station, or location within the Mobile Health Examination Center. The following is a brief description of each procedure of the examination. Identification data.—The information col- lected is minimal, limited to verifying name and address, and adding sex and date of birth. Other identifying information has been recorded incon- nection with the household interview, Approximate time required for examination, by procedure group Specific procedure, or part of examination Time in minutes Group number Obtain identification data Obtain authorization for M.D.-D.D.S. reports Take glucose drink Medical history—self administered and supplemental------------- x 25 X-rays, chest, hands, and feet Height and weight Audiometry-===mcomemc ccc cece ee Body measurementS---=-e-scececmcmcemc cee Physician's review of history Physician's examination Venipuncture Electrocardiogram Collect urine specimen-----=secemccccmcencax Dental examination Vision examinatione---==-cceccccccmccncnccanaa Exit interview------ceccccccncccc cn crcccena Total examination=--=-=cececmcmccncaa"- a J —— IT 15 111 10 Iv 40 Jp Sy ——— VI 5 mmm 120! includes an additional 10 minutes allowed for dressing and undressing and for movements between examination stations. Authorization to send findings to personal physician and dentist.—Each examinee is en- couraged to sign such an authorization. Names and addresses of physicians and dentists named by the examinees are verified by means of direc- tories and local contacts. Glucose drink.—The first medical question asked is about a history of diabetes. All exami- nees except known diabetics under regular care (as determined by the examining physician) are given a modified glucose tolerance test—50 grams of glucose solution diluted to 150 cc. are admin- istered orally. Since the examinations occur with- out control of previous intake of food, this glucose administration occurs at various times after eat- ing. Time elapsed since the most recent meal, and broad categorization of content of that meal and of any subsequent ''snack,'" are recorded, however. A venous blood specimen is obtained one hour later, and a urine specimen froml1% to 2 hours after the glucose challenge. History.—This is in two parts: several ques- tions asked by the receptionist-interviewer, and a larger number of items included in a self-ad- ministered history. The examinee is shown how to indicate his answers by checkmarks. The his- tory is not a complete one, since it is tailored to the special examination. When necessary, there- ceptionist-interviewer reads the questions to the examinee; she does not provide help in the way of defining terms, etc. Provision is made for the examinee to indicate "Don't Know'' or '?" when this is appropriate. Questions so marked will be explored with the examinee later by the physician during his examination. The receptionist-inter- viewer reviews the completed history for com- pleteness only, and asks and records the answers to any overlooked questions. Examinee undresses.—Since the examination is not a general one and does not include abdomi- nal or internal examinations, the examinee un- dresses (in the examining room) only down to the waist, and wears a short patient gown and paper slippers for the rest of the procedures. At this point the nurse describes to the examinee the content of the several parts of the examination to follow. X-rays of chest, hands, and feet." —A 14 x 17 P-A film of the chest is takenata 6-foot distance; * pregnant examinees are not x-rayed. The recommendations of the American College of Radiology for the control of radiation haz- ards have been followed in the X-ray equipment and procedures. The X-ray unit has a short exposure time and the primary beam is confined to the x-rayed area. The aluminum filter has been in- creased to a thickness of 3 mm. Lead rubber shielding protects the gonadal area of the examinee during the chest X-ray. Shielding is also used in the X-rays of the hands and feet. Periodically, radia- tion surveys of the equipment are done to guard against excess stray radiation. a film of both hands and one of both feet are made. A bone standard is x-rayed with each of these latter two films, for comparison of bone density with the standard. The three X-ray films for each examinee are developed immediately, while he moves on to other parts of the examina- tion. At a later time, a copy of the chest film is made and sent with other findings to the exami- nee's physician. Height.—This is automatically recorded. A camera which produces a finished print inl0 sec- onds records the height and the identifying num- ber of the examinee, for later reading under office conditions. The height of the examinee is meas- ured without shoes, Weight.— An automatic-balancing, automatic- printing scale is used to print the weight directly on the examinee's record. The weight is taken with the examinee partially dressed and without shoes. Audiometry.—A pure-tone audiometer is used to measure air conduction hearing thresh- olds at. five frequencies in each ear. The exami- nee is seated in a soundproof booth during the pro- cedure. Body measurements.—In addition to height and weight, 16 other body measurements are made. In the standing position these include girths of the right upper arm, chest and waist, and skinfolds of the right upper arm and the right infrascapular area. A series of anthropometric measurements are also taken—(standing) bia- cromial diameter; (seated, in a very precise po- sition), sitting height normal, sitting height erect, knee height, popliteal height, thigh clearance height, buttock-knee length, buttock-popliteal length, seat breadth, elbow-to-elbow breadth, and elbow-rest height. Physician's review of history.—The physi- cian goes over the completed history before he sees the examinee, then reviews significant answers with him to get additional data and, if necessary, clarification. Physician's examination.—As is true for all other parts of the examination, standardized techniques are used for the physical examination, The examination is concentrated on cardiovascu- lar disease and the arthritides. The cardiovascu- lar examination includes: (1) three blood pres- sure determinations spaced over about 30 minutes; all are performed on the same arm, with the examinee in a sitting position; the arm is sup- ported at atrial level, and the sphygmomanometer is supported at eye level for accurate reading by the physician; the systolic and both diastolic readings are recorded in intervals of two milli- meters of mercury; (2) funduscopic examination; (3) palpation of peripheral arteries for sclerosity, tortuousity, and quality of pulsation; and (4) pal- pation and auscultation of the cardiac area in a very thorough, detailed, and standardized way. The arthritis examination progresses joint by joint, and includes inspection, palpation, percus- sion, active and passive motion to detect tender- ness, swelling, deformity, limitation of motion, pain on motion, and other manifestations of arth- ritis and periarthritic diseases. Other portions of the physical examination are an otoscopic pro- cedure and palpation of the thyroid gland. Addi- tional abnormalities noticed during the examina- tion are also recorded. Venipuncture,—The time of the glucose drink has been recorded and a timer set when the exam- inee enters the examining room, so that the exam- ination can be interrupted for the one-hour venous blood specimen for glucose determination. At the same time, blood specimens are obtained for de- termination of serum cholesterol, serum bento- nite flocculation test for rheumatoid factor, se- rologic tests for syphilis, and microhematocrit. Electrocardiogram.—A 12-lead electrocar- diogram is obtained. A dual-writing instrument is used, which provides two simultaneous trac- ings of each lead. One tracing is used for survey purposes, and the other is sent to the examinee's physician as part of the objective report of the findings of the examination. Examinee dresses—urine specimen.—At this point, the patient dresses and a urine specimen is taken. Later, the presence of sugar is deter- mined by the Testape method, and, in males only, the presence of albumin, using the Bumintest method. Dental examination.— The dental examination consists of determining the condition of each tooth, and of assessing through theuseof indexes, periodontal disease, oral hygiene, and malocclu- sion. To determine the condition of the individual teeth on a uniform basis, objective criteria have been established and are followed throughout the entire examination procedure. The indexes that are included in the exami- nation are objective assessments of the oral hygiene status and of the severity of malocclusion and periodontal disease in individuals. The oral hygiene assessment is based upon the amount of debris and calculus on selected teeth. The assess- ments of malocclusion and periodontal disease are based, respectively, upon the number of mal- aligned teeth and their degree of malalignment, and upon the presence and extent of gingival in- flammation and pocket formation. The presence or absence, of fluorosis and nonfluoride opacities of the maxillary anterior teeth is also recorded. A portable dental chair and a standard source of light areused during the mouth mirror and explorer examination of the teeth and gums. 10 Vision examination,— Visual acuity is meas- ured with the Sightscreener. Both monocular and binocular acuity are obtained, for far and near distances. The examination is made without glasses, and appropriate parts are then repeated if the examinee wears glasses and has them with him. Exit interview.— The examinee is offered re- freshments before leaving the Examination Cen- ter, and is asked a few questions about his re- actions to the examination, and his reasons for and any problems about coming for the examina- tion. Throughout the examination, stress is put on cordial handling of examinees. Many favorable comments are received from the examinees on this point. It is another partof the essential effort to build and to keep good will and co-operative relationships in the Survey areas. Measures to Insure Standardized Examinations All the examining team members are Public Health Service staff, with the exception of the examining physicians, who are recruited on a temporary basis. They are residents or fellows in internal medicine in medical teaching centers throughout the United States. Usually they have just had at least two full years of residency, or have completed such a residency within the past few years. The usual arrangement with a medi- cal teaching center allows the residents to work with the Survey during their vacations, which might cover all or parts of one, two, or three stands. Thus, there is a constant turnover of examining physicians; e.g., 18 consecutive stands in one calendar year had 27 different physicians, All new examining staff members are trained in the particular techniques developed for the Sur- vey. Since relatively few examining dentists are used in the Health Examination Survey—only 5 in the first 18 stands—the reduction of examiner differences is an unusually important considera- tion. Before joining the examining staff, each dentist is trained intensively in the various pro- cedures of the examination. A final part of his training, the independent examination of at least 150 persons by the new examiner and by an original examiner, provides a means both of attaining greater uniformity in the examination procedures and of measuring persisting inter- examiner differences. Except for this specialized training of the dentists, most of the training of new staff mem- bers is provided by medical staff from headquar- ters and is given at the Mobile Health Examina- tion Center. Any experienced personnel in the same category are included in the training, in order to provide refresher training; however, to avoid drifts in technique, examining staff mem- bers do not train each other, Typically, for example, for the new examining physician, this consists of one day of training and practice in examination techniques, in recording, and in re- view and probing of the medical history. The fol- lowing day the entire team participates in ''dry- run'' examinations, for the practice of all team members and for testing equipment. These are actual examinations but are scheduled with more than the usual 30-minute interval, and the exam- inees are not sample persons. The ''dry-run" examinees may be members of local health de- partment staffs who are often asked to assist the Survey in this way. The headquarters medical ad- visor observes and supervises the dry-runexam- inations and the first few days of sample-person examinations at a stand. In the training and retraining of all examining staff members, stress is repeatedly put on (1) collection of high quality data in a uniform, standard, and prescribed way, and (2) accurate, complete, and legible recording. Each staff mem- ber who records data reviews that section of the basic document immediately for omissions; in addition, at the completion of an examination the entire individual record is reviewed for omissions and for legibility. POST-EXAMINATION PROCEDURES AT THE EXAMINATION CENTER Blood specimen.—The venous blood samples are refrigerated in the Examination Center over- night. On the following day, the hematocrit is de- termined by the micromethod. Two capillary tubes are filled at the time of venipuncture in case of breakage of one tube. The clotted specimen is centrifuged and the serum separated. The portion for serum cholesterol is frozen; those for serum bentonite flocculation and for the serologic tests for syphilis (STS) are kept refrigerated, as isthe fluoridated specimen for glucose. Twice a week these specimens are airmailed to central labora- tories for determinations; the serum cholesterol with dry ice, the serum bentonite flocculation and the glucose with water ice. Urine specimen.—The determinations for presence of sugar (Testape method) and for the presence of albumin in males (Bumintest method) are made in the Examination Center shortly after the specimen is obtained. THE DATA COLLECTED The Medical History Data As noted in the previous section, the medi- cal examination is initiated by a brief history (HES-203) obtained by the receptionist-interview- er. The first questions asked concern diabetes. After this the examinee is handed a question- naire (HES-204) to complete. This questionnaire is the chief means for obtaining the medical history. It contains 74 questions which are, in general, completed by checking the appropriate entry. The chief areas of the questionnaire are the following: 1. Cardiovascular disease—23 questions (see Appendix VII, A) 2. Arthritis and rheumatism—7 questions (see Appendix VII, B) 3. Diabetes—4 questions (see Appendix VII, C) 4. Mental health—9 questions 5. Vision and hearing—6 questions 6. Miscellaneous diseases and conditions— 25 questions The questions in this last group are scattered through the history; a large proportion are de- signed to parallel the information on chronic diseases and conditions obtained for the same person by the household interview. If a "yes" or "7?" is checked by the exam- inee for any of the key questions on cardio- vascular disease or arthritis and rheumatism, the examining physician probes the answer, first using a standard probe question and then querying as he judges appropriate. He then modifies the record accordingly. He also com- pletes any history questions which have been missed, resolves inconsistent entries, and tries to convert any entries of "?" to a definite "yes" or 'mo' by additional questioning. Other- wise, the examinee's undiscussed entry con- stitutes the source of historical information. Medical Data Related to Special Interest Conditions The medical examination focuses on two main areas of chronic disease—the cardiovas- 1 \ cular diseases and arthritis and rheumatism. The cardiovascular diseases that are the chief objectives of this examination are the heart diseases, hypertension, peripheral vascular dis- ease, and cerebrovascular disease. Rheumatoid arthritis and osteoarthritis are the chief diagnos- tic categories on which the arthritis and rheuma- tism examination concentrates. In addition, tests are made to detect cases of diabetes. For the heart diseases the chief sources of diagnostic information are the history, the phy- sical examination of the heart, the chest X-ray (for heart enlargement), and the electrocardio- gram. The three blood pressures taken during the physical examination will serve as the pri- mary basis for diagnosing hypertention, sup- plemented by the history and the findings of the funduscopic examination. Peripheral vascular disease will be diagnosed chiefly by an exam- ination of the peripheral arteries, but the his- tory will provide a supplementary basis for diagnosis. The history will constitute the chief basis for diagnosing cerebrovascular disease, but it will be supplemented by whatever find- ings are noted on the physical examination; this part of the physical examination, however, is not standardized. For rheumatoid arthritis, information ob- tained by the history is supplemented by the findings from the inspection and examination of the joints, the X-rays of the hands and feet, and the bentonite flocculation test of the serum. The X-rays of the hands and feet provide the primary information on the presence of osteo- arthritis, but this is supplemented by the phy- sical examination and history. As already noted, a blood specimen is ob- tained from most examinees, one hour after glucose challenge. This is measured for blood glucose concentration, and this measurement is supplemented by a test for urine sugar. These findings, together with the information obtained from the history, provide an index of the prevalence of diabetes in the population. Additional Data From the Examination The dental examination will yield consider - able detailed information not heretofore avail- able on a representative sample of the total adult population, This examination has already been described. The data it yields will include, in addition to a determination of the condition of each individual tooth, an assessment of perio- dontal disease, the oral hygiene status, an indi- cation of the severity of malocclusion if present, and the presence or absence of fluorosis and nonfluoride opacities. 12 In addition to the medical and dental exam- inations, some supplementary determinations are made during the course of the examination. These will make possible a scaling of the population by acuity of hearing and of vision, and distri- butions of some basic anthropometric measure- ments. There will be interest in relating some of these characteristics—in particular, height, weight, and skinfold thickness—to various medi- cal findings, but a description of these popula- tion characteristics will be of interest by itself, The foregoing account of the examination has already indicated the specific measurements which are made. Other Data Collected in the HES Operations Certain demographic data are available from the interview questionnaire. Each household is designated as ''rural' or ''other" before the interview, on the basis of the area in which it is located. During the interview, data are gathered on whether the house is on a farm and, if so, the size of the farm. For each per- son, there are data on age, sex, race, marital status, family composition and income, schooling, and military experience. In addition, there are data on whether the person is working and if so, the occupation and industry in which he is en- gaged. Certain health data are also available from the interview questionnaire. For each acute or chronic condition elicited by the exploratory questions 8-17, a line entry is made in Table I of the questionnaire. For each such condition, there are data on the number of days of restricted activity, number of days of bed disability, and number of days of work loss during the pre- ceding two weeks. For each chronic condition, additional data are gathered on the number of bed-disability days over the past year, and the limitation of activity due to the condition. For each condition listed, the person is asked whether it was medically attended and, if so, the diagnosis given by the physician. For each hospitalization during the past year that is elicited by question 15, a line entry is made in Table II, For each such entry, there are data on the duration of the hospitalization, the date of entry to the hospital, and the name of the hospital. The person is also asked about the diagnosis which was made for the condition. If any operations were performed, he is asked the names of them. The health data described above are similar to those collected in the Health Interview Survey. Thus, some comparisons may be made, and de- termining the extent to which the HES interview data reproduce certain findings of the larger study may aid in evaluating the effectiveness with which the representative probability sample design has been carried out in the Health Exam- ination Survey. These data will also aid in the analysis of some of the parts of the sample, as for example, the nonrespondents. Perhaps the principal utilization of the HES interview data, however, will be in conjunction with corresponding HIS data to improve the process of estimating from the HES examination data. This possibility is discussed in more detail in the section, "On Basic Estimation Technique," in Appendix VIII, The attitude questions on the interview ques- tionnaire are asked only of those persons who have been selected to be in the sample. Data are gathered on the sample person's opinion about the state of his own health and about the impor- tance of regular checkups. There are data on whether the sample person has a physician and how often he consults him. Then there are data on the person's attitude toward health surveys and the need for co-operation in such surveys. J / he interview questionnaire provides data on whether the sample person made an appoint- ment with no persuasion. Auxiliary records are kept to show the appointment record of the sample person. These records provide data on the number of appointments made, the number kept, and the number which resulted in can- cellations or which the sample person did not keep. There are data on the number of contacts made with the sample person for the purpose of persuasion. Special effort is made to gather data on the circumstances of the first appoint- ment, such as: day of week, time of day, and date of the appointment, and the number of days between the date the appointment was made and the date of the appointment. All of these data related to response are analyzed for two dif- ferent purposes: to guide the conduct of the survey in subsequent operations by providing more insight into the response problem, and to aid in evaluation of the impact of nonresponse on sample data. QUALITY CONTROL The Health Examination Survey is unusual, if not unique, not only in the group studied (a probability sample of the entire U, S. pop- ulation) but also in the amount of effort de- voted to problems of standardization of obser- vations, validation of the measurement processes, and other aspects of quality control. Because this effort extends to all phases of the operation, it has been partially described in many parts of this report. The attention given to the sam- pling problem is discussed later in considerable detail. The response problem has received, deservedly, much attention. But even if the sample were perfectly representative of the total population and if every one of the sample persons could be examined, there would re- main, of course, many problems in the area of standardization of the data collected and valida- tion of the measurement processes used. Study of Characteristics Associated With Nonresponse It has been pointed out that methodological studies were conducted to help design the sur- vey to maximize response and that the field staff of the Health Examination Survey is con- stantly concerned with this same effort. It is recognized, however, that in this Survey as in any such voluntary survey, there will be some persons who fell into the sample but were not included in the data collected, that is, in this case, were not examined. It was expected on the basis of previous survey experience and from the findings of the methodological studies that response would vary with the size of the place of residence, with better response in rural areas and small towns, and poorer response in large urban centers. Experiences also indicated that response would probably be better in the western and central parts of the United States and poorer in the eastern portion. Differences of this kind can be allowed for, quantitatively, in the estimating procedures, but no procedure will remove all risk from nonresponse. If the not- examined persons differ from the comparable examined persons with respect to any charac- teristic covered by the examination, the usual estimating procedures will lead to a biased esti- mate for that characteristic. In addition to attempting to minimize the size of the non- response group, therefore, it is necessary to be able to make some evaluation of the extent to which it differs, qualitatively, from the exam- ined group. Some information on this can be obtained from the household interview data referred to above. Comparisons will be made of the inter- view (household questionnaire) data collected in the course of the Health Examination Survey for the examined part of the sample and for the not-examined part, since questionnaire in- formation is available on nearly all of the sam- ple persons. These comparisons will be made with respect to the demographic data included (age, sex, etc.) and with respect to the health data (recent history of illnesses, etc.). For all of the examined sample persons and for 13 Y W vo the great majority of the not-examined, \the data produced by the attitudinal questions an also be compared. These include such items as the individual's evaluation of his own ‘health and his statements as to regularity of visits to a physician. (This last category of informa- tion is not available on as high a proportion of not-examined persons as the other question- naire information.) From the comparisons of the interview data it may be possivle to reach some conclusions about differences between examined and not-examined persons. Even more relevant information concerning possibly biasing differences is obtained by means of a special study of the not-examined group. At the conclusion of the household interview, amedi- cal authorization is usually obtained which names the individual's physician and permits him to release information from the particular patient's medical records for use in the Health Examination Survey. Thus, for most of the not-examined per- sons, some information that is directly relatedto their health can be sought from the physicians. This is done for all not-examined persons for whom a medical authorization could be obtained. In the remaining instances the not-examined per - son is asked to forward the request for this information to his physician. In addition, for comparison, inquiries are sent to the physicians of a matched sample of examined persons. Measures to Insure Uniformity and Reproducibility of Data While the microhematocrit test for packed cell volume of the blood and the tests on the urine are performed in the Mobile Health Ex- amination Centers, the other laboratory tests are performed for the Health Examination Sur- vey at central laboratories. The serological tests for syphilis are performed by the Ve- nereal Disease Research Laboratory, Communi- cable Disease Center, Public Health Service. Each specimen is tested by the VDRL, Mazzini, and Kolmer methods. The serum cholesterol determinations are made at the Standardization Laboratory of the Heart Disease Control Branch, Division of Chronic Disease, Bureau of State Service; Public Health Service. A ferric chloride method is used. The laboratory of the Arthritis and Rheumatism Branch, National Institute of Arthritis and Metabolic Diseases, Public Health Service, determines the serum bentonite floc- culation. Blood glucose is determined by the Somogyi-Nelson method at the Diabetes Research Unit, of the Diabetes and Arthritis Branch, Division of Chronic Disease, Bureau of State Services, Public Health Service. Periodically, aliquots of the blood specimens taken from 14 ) # examinees are Aent to an independent laboratory for a parellel measprement of serum cholesterol or blood glucose. Thus, in the case ofthese tests, the procedure and the interpretation is carried out in a standard, highly controlled manner. There are a great many quality control steps taken in the course of the examining op- eration in addition to such measures as re- training of examining staff referred to in the description of the examining process. Thus, for example, the audiometers are checked and recalibrated regularly, the scales are checked at each stand, the anthropometry measurements are made by one person and recorded by another who is also familiar with the technique, and the X-rays are reviewed before the examinee leaves the Center. The fact that consultants have been brought in periodically to observe specific as- pects of the examination (e.g., audiometric meas- urements) might be mentioned as another ex- ample of the efforts to insure that the recorded data will be of high quality. The X-rays and electrocardiograms taken in connection with the Health Examination Sur- vey are read and interpreted centrally by panels of expert consultants according to established classifications and defined criteria. In the case of the chest X-ray films, each member of a panel of three specialists independently reads each film for pulmonary and cardiovascular pathology. The electrocardiograms are eachread independently by three readers; any disagree- ments are resolved in conference with a con- sulting cardiologist. A panel of three specialists in arthritis read the hands and feet X-ray films on each examinee, each reading independ- ently, and then again review and resolve in con- ference any disagreements among the three re- sults. Through these safeguards it is hoped to obtain an unusually high degree of standardized precision in the results of these examinations. Despite the fact that many measures are taken throughout the Survey to insure that the findings are arrived at in a standardized and correct manner, it may be assumed that some amount of variability in the findings will be due, not to real differences in the subjects examined, but to differences in the examining physicians. Despite the safeguards to prevent or minimize the physician's contribution to variability in the data, some will inevitably remain. The specific examining physician is identified in the record and the analysis of the collected data will in- clude consideration of this variable. Special Calibration Studies The tests for visual acuity are made by using a Sightscreener machine which eliminates the examinee and the letters read. In order to . the need for the usual Slur between / / dd fiometric testing is calibrated and checked be able to interpret the re juts of these tests in a standard manner, a spevial methodological study was arranged. This study, made with the Pennsylvania State College of Optometry, cali- brates the results obtained by this kind of a test in terms of the results one would get with Snellen-type charts. The equipment used for regularly after each stand; the soundproofed booth in each of the mobile examination units has been tested by means of a special sound survéy. The modified test for glucose tolerance is the subject of a special calibration study being conducted by the School of Public Health of the University of Michigan. STATISTICAL DESIGN AND ESTIMATION Introductory Note The statistical design of the Health Exam- ination Survey is almost classic in the sense that it is a blend of substantive purposes, ex- plicit specifications, budgetary resources, logis- tical considerations, formal mathematical mod- els, and organized speculation concerning pop- ulation parameters and unit operating costs, Any comprehensive account of the design process would be much too extensive for inclusion in this report. The present chapter exhibits an outline and most of the key features of the design. Other chapters of the report discuss more fully several of the factors that had a significant influence on the design. Appendix VIII offers additional detail on a group of tech- nical aspects of sampling and estimation. The Design Problem A rational survey design rarely if ever springs full-blown into existence at some instant in time. Yet if the undertaking is to be efficient in any useful sense, it must be planned in con- siderable detail prior to inauguration of opera- tional stages. A project is likely to be success- ful to the degree that initial planning and design can take account of relevant factors and cir- cumstances. There is no simple formula by which this accounting can be done, particularly for an undertaking as complex as the Health Examination Survey. From the statistician's point of view, the Health Examination Survey is an especially attractive problem because of the variety of conditions or specifications that en- compass the subject. Leaving aside the broadest of administrative considerations, the leading characteristics or general specifications for the Health Examination Survey were these: 1. The coverage should be the entire adult, civilian, noninstitutional population of the United States. 2. The primary products should be of two kinds: (1) distributions of the population by specified characteristics such as height, weight, and blood pressure; and (2) es- timates of prevalence in the population of selected chronic conditions, particu- larly those in the arthritic and cardio- vascular groups. 3. The measurement processes mainly should be those obtained from a limited very highly standardized clinical exam- ination. 4. The first cycle should be completed in approximately two to three years, al- though the Health Examination Survey is a continuing activity. 5. Results should be interpreted as being national averages for the two- to three- year period, rather than as showing trend - over time, or differentials among geo- graphic, economic, or sociological sub- groups of the population. Yet it was apparent that analysis and understanding of collected data would be possible only in terms of age and sex of persons, and probably only when persons examined were classified by other sociodemo- graphic factors. 6. Despite extensive efforts to standardize the examination process, it might be ex- pected that substantial measurement var- iation would remain in collected data. For some of the measures there might be biases when compared with other measurement criteria. 7. While total budget was not rigidly speci- fied, the general dimension of available resources was fixed. From the design point of view, an important fact was that the unit cost for examining an individual per- son was certain to be relatively great as compared with the cost of obtaining a single measurement in most social surveys. 15 10. 11, 12. All evidence pointed to a variety of\, difficulties in securing the co-operation \ \ of a representative sample of persons, and accordingly indicated the heavily weighted desirability of a design which provided data for a maximum number of persons chosen in the sample, or at least did not inhibit response. . Maximum target tolerances for sampling variability were set for several key sta- tistics. The Health Examination Survey definitely was not to be considered a technique for evaluating the Health Interview Survey of the National Health Survey. But there were compelling reasons for so planning the Health Examination Survey that some of its measurements could be relatable to those of the Health Interview Survey, since such a course might lead to better estimates or to better-understood esti- mates in either or both of the surveys. The above requirements made it essential that the Health Examination Survey be conducted under a probability sampling design, in contrast to some possible alternative of a more subjective or vol- unteer selection of examinees. Perhaps the unique contribution of the Health Examination Survey would be that it would present findings that were carefully stand- ardized measurements for a probability sample of the national, civilian, noninsti- tutional adult population. An added specification—or planning de- cision perhaps—was that the design have flexibility. This was the label given a re- quirement that the over-all sample be divided into three subsamples in such a way that any one of the three was a representative sample of the defined pop- ulation for the United States. There were several reasons for this requirement. One was that one subsample—to be ex- amined early in the cycle—should be used experimentally to discover methods of maximum effectiveness in processing data and preparing estimates, A second reason was that this first third might produce highly preliminary estimates for a few characteristics common in the population. Such an outcome would be desirable since data from the entire cycle would not be available until perhaps five to six years after the project was initiated. A third reason was the possibility in a multiyear project that expected appropriations might not become available, or that costs might unduly exceed expectation. The three-part A design would fnake it possible to salvage something( frém the undertaking if it had to be curtailed at the point of one third or two thirds of completion. 13. Study of examining requirements and available facilities for examination led to another major logistic decision which initially had not been a design speci- fication. This added condition was that the examinations would have to be conducted in mobile trailer caravans, and that funds available for capital expenditure, along with associated availability of professional personnel, gave considerable weight to the use of precisely two caravans. No effort is made here to show exactly how each of these specifications made its impact on the design. But each was taken into con- sideration. The reader will be able to see most of them reflected in the final statistical pat- tern. The pattern became a highly stratified multistage probability design with clustered groups of examinees, randomized in several dimensions. Considerable effort was devoted to optimization of design in the sense that maximum reliability of estimates would be secured within budgetary limitations. In the basic design every eligible person in the defined population had an equal chance for inclusion in the sample. Rel- atively minor modifications of this self-weighting feature were introduced to handle particular situations in the population, but in all situations adjustments were made so that the probability of inclusion of every sample person was known over the entire population. Summary of The Sample Design Building blocks.—The design is most easily understood when described in terms of a set of defined building blocks which are associated with the different stages of sample selection. The first of these is the Primary Sampling Unit. For use in the Health Interview Survey, the geo- graphical territory of the mainland United States had been divided into 1,900 areas. Each area is a county or a small group of contiguous counties. With minor modifications, these areas became the PSU's of the Health Examination Survey. The PSU was divided geographically into segments, each containing an expected six households. From a listing of households within the segment, a random sampling procedure created a sub- segment of approximately four households, each of which was interviewed. Every alternate per- son in the sample households who was an eligible adult (civilian, in the age range 18-79, etc.) be- came a sample person for inclusion in the HES panel. Thus the successive building blocks are \ person, household, subsegment, segment, and PSU, and the sampling progeys was applied in successive stages to these “Blocks in reverse order to that just listed, Stratification.— For use in the Health Inter- view Survey, the 1900 PSU's had first been classified into 372 strata, and later into 500 strata. Details of this stratification have been published in reference 1. For the Health Ex- amination Survey, these 372 strata were grouped further into 42 new strata. The latter strati- fication emphasizes geographic location and pop- ulation density of the PSU's in the stratum. As nearly as was feasible, each stratum con- tained 3.5 million persons in 1950 (1960 Census data were not available when the sample was designed. This was unfortunate, but was treated in a manner which produced no bias in the results). The boundaries of these strata had been chosen so that the strata were approxi- mately equal sized, and so that there were approximately equal numbers of strata in each of five population-density classes, in each of three geographic classes, and roughly in each of the 15 superstrata obtained from the cross- classification of density and geography. The stratification pattern is shown in table 2. Selection of PSU's.— Appendix VIII outlines the route by which it was determined that there should be 42 PSU's in the Health Examination Survey. That decision, and the associated one that in order to take maximum advantage of the stratification there should be as many strata as PSU's, determined the number of strata. J , oo , The 3 by 5 matrix of strata shown in table 2 had / its origin in the flexibility requirement of the specifications. Within each of the three geo- graphic categories, for the total sample, and with the strata quotas by population density, a sample of 14 PSU's was drawn by a modified Goodman- Kish controlled-selection technique, in such a way as to maximize spread among the States, and still to draw each PSU with probability pro- portionate to its 1950 population. After the 42-area total sample had been drawn, it was divided randomly into three rounds, using the 3 by 5 matrix. This latter step was accomplished effectively by exhausting the matrix through three replications of a pseudo-Latin-square se- lection of PSU's. To close approximation, each subsample, or round consisted of one third of each of the occupied 14 superstrata in the matrix. Each round is a probability sample of the population. The sample PSU's for each round are shown in table 3. The name given to each PSU is that of a principal town or city within the PSU. Selection of sample persons.— Appendix VIII sketches the derivation of a total sample size of approximately 6,300 persons to be examined. This means an average of 150 examinees in each of the 42 PSU's or stands. A feature of the plan is that the details of a probability selection of a sample of about 150 examinees were adapted to the characteristics of the PSU, and varied from one place to another. Typical main features are set forth here. Some variations are noted in Appendix VIII, Table 2. Number of strata in the Health Examination Survey, classified by geographic location and population density Number of strata Population density U. Se North- South West total east All strata-----memmm eee 42 14 14 14 Giant metropolitan areas---~~=msmecceeccommccmaann 9 6 - 3 Other very large metropolitan areas (mostly over 500,000 population) =--=-mm-mee-m- 6 2 2 2 Other Standard Metropolitan Statistical Areas--- 9 3 3 3 Other urban areas----=--cemoooomcmcec maa. 8 2 4 2 Rural (typically 40 percent or more ED's classified as rural) -=--=-ecmcommmoeo_ 10 1 5 4 Table 3. List of sample PSU's in Health Examination and size Survey, arranged by round number Round I New York, N.Y.-A Philadelphia, Pa. Chicago, Ill.-A Baltimore, Md. Minneapolis, Minn. Akron, Ohio Nashville, Tenn. San Jose, Calif. Muskegon, Mich. Midland, Tex. Valdosta, Ga. Oxford, Miss. Butler, Mo. Grand Coulee, Wash. Round II Los Angeles, Calif. New York, N.Y.-B Detroit, Mich. Pittsburgh, Pa. Louisville, Ky. Savannah, Ga. Ft. Wayne, Ind. York, Pa. Eufaula, Ala. Kennett, Mo. Biddeford, Maine Clinton, La. Newport, Ark. Washburn, Wis. Round III New York, N.Y.-C Boston, Mass. Chicago, Ill.-B San Francisco, Calif. Columbus, Ohio Providence, R.I. San Antonio, Tex. Topeka, Kans. Newport News, Va. Carbondale, Ill. Auburn, N.Y. Conway, S.C. Rocky Mount, N.C. Winslow, Ariz. NOTE: The New York-Northern-New Jersey territory was divided into three synthetic PSU's and the Chicago Standard Metropolitan Statistical Area into two PSU’s. Some 60 geographically bounded segments were drawn by systematic selection from the PSU, using a serpentine path throughout the area, so that all parts of the PSU were given an equal chance of inclusion in the sample. These segments were reduced to subsegments of an expected four households each, by arandom two-in-three selection of listed households in the segment, Within the chosen households, every alternate person in the defined population be- came a potential sample person. The alter- nation began with the first person in an ordered sequence in one subsegment and with the second person in the next subsegment, in order to avoid bias of sample person in relation to the head of household. The term ''potential sample person'' was used for a specific reason. For operational reasons, it was desired that the number of actually ex- amined persons be close to 150. This was a consequence of the fact that movement of per- sonnel and equipment was tightly scheduled, not more than about 16 persons could be ex- amined in one day, and it was inefficient to have the examining staff idle for any extended period. Yet the vagaries of housing construction and demolition, population mobility, household size and composition, and response rates, meant that it was not possible to predict the exact number of examinees which would be produced by a fixed number of land segments. Accordingly, a second element of flexibility was introduced into the design. The 60 subsegments were ran- domized in sequence. On the average, it was found that about 50 subsegments would produce 150 examinees. First field assignments to inter- viewers included 40 subsegments. Progress through these segments in terms of apparent number of examinees determined whether 0, 1, 2, 3...20 additional subsegments would be as- signed and included in the sample. Since the subsegments had been randomized in sequence, the only effect of this procedure on design, was to alter the within-PSU sampling fraction and weight. Estimation Technique Conceptually, the estimation process in the Health Examination Survey may be identified in terms of three routines. Summary routine,—Suppose the survey and its basic estimation technique produce for the h ; : att age-sex population class an estimate of y. persons in the population, of which x3 have a specified characteristic. Suppose further that Ya is the official Census independent estimate of population in the +B age-sex class. The HES final estimate of total number of persons in the population with the specified characteristic will 1 a mn i = be x' = = x 5 and if y ZY, 3 the proportion of population with the characteris- $ tic is estimated as R' = § . More generally, if x) A is the basic estimate th for any aA— subgroup of the population, and if Ya = x" — then x' A= = Xx' a ' 3 aa aA ye ’ an ° he X final estimate for the A-class of the population, x! A and R'.x = is the proportion of Z¥aA Ja a the population in the A-class with the character- istic. Thus the purpose of the summary routine is to make the sample more closely repre- sentative of the population with respect to sex and age and thus reduce variance. Basic routine.—The basic routine is the estimation technique which produces within the n age-sex cell the estimates x] s y , and x" the proportion Ry = i : Exact method- oO ology for producing these estimates will be determined from experimental studies conducted with data from the Round I—the "first third" of the cycle of 42 stands. A prominent pos- sibility is described in Appendix VIII, in the section "On Basic Estimation Technique." Editing and imputation routine.—In a survey of the type of the Health Examination Survey, the procedures adopted for editing reported data and for handling instances of missing data can be critical. These topics are not treated in the present report despite their importance. The primary reason for this course ‘is again that final decisions await investigation of Round I data, Two comments are in order at this point. The first of these relates to the general matter of nonresponse and missing data. If there are missing measurements in a set of data, there is, of course, no way in which a risk of bias can be entirely avoided. All schemes of estimate must include either explicit or implicit imputation for missing measurements. In the Health Examination Survey two courses are being taken to minimize difficulties in this area. The first is assignment of extensive re- sources to cut nonresponse to a manageable size. Ever-present attention is being given to the nonresponse problem, since substantial non- response had been the experience in earlier studies offering clinical examination to sample groups. The other course is assembly of aux- iliary data on both respondents and nonrespond- ents through household interview and reports from solicitant's personal physicians, in order to facilitate the residual imputational process. A second comment is that in accord with policy of the National Health Survey, every effort will be made in publications of data from the Health Examination Survey to convey to users of the data an understanding of how the estimates have been produced, including the nature of all significant adjustments. Reliability and Evaluation of Results How good will the data from the Health Examination Survey be? This is a question to which there is, of course, no unique answer. Perhaps the most significant answer will be found over a period of time in the collective judgments of students and users of the data, It can be stressed, a priori, that the results will be the product of highly standardized meas- urements on a probability sample of the popu- lation, and that these measurements were se- lected initially because a good many qualified people thought them relevant to a wide variety of purposes. Standard errors of published statistics will be presented by the National Health Survey. The standard error, as calculated, will include sampling error, and a portion of the measure- ment error, or measurement variation. It will not include any biases that may reside in the data. The design is such that good approxima- tions can be secured for a number of com- ponents of variation. For example, it is ex- pected that it will be possible to determine what proportion of the variance comes from the between-PSU component and what proportion from the within-community component. It is hoped that a rough estimate can be made of the contribution to variability of some items that arises from residual differences among physicians, despite efforts at standardization. Elsewhere in this report there are brief descriptions of efforts being made to calibrate and to validate some of the measurement proc- esses. As all investigators in health and medi- cine know, this latter work is in an area in which there is much to be done. PLANS FOR ANALYSIS AND PUBLICATION OF DATA All of the data collected in the first cycle of examinations are coded and punched into cards, transferred onto magnetic tape, and then tabulated by an electronic computer in the Na- tional Center for Health Statistics. The coding of the data is done by personnel of the Bureau of the Census under a contract with the Na- tional Health Survey. In accordance with the general policies of the NHS program, the findings of the Health Examination Survey will be made available to interested governmental and other public and private agencies, to organizations or groups, and to the general public, as rapidly as possible. The size of the sample, however, and the plan of the first-cycle examinations require that most of the analysis must await collection of the data for the entire sample. The processing operation with respect to the early stages (e.g., coding) is going on simultaneously with the data collection. Likewise, the plans for the tabula- tions are being developed and preliminary tabu- lations are being made to aid in planning the final process of tabulation and analysis. The findings of the first-cycle examinations made in the Health Examination Survey will be published in a separate series of health sta- tistics reports. These will include presenta- tion and analysis of the frequency distributions of the population for the various kinds of data which have been recorded in the survey; e.g., blood pressure readings, dental findings, serum cholesterol determinations, etc. In addition they will include estimates, derived from the exam- ination findings, of the prevalence in the popu- lation of cardiovascular disease, arthritis, dia- betes, etc. There are still decisions to be made with respect to the way in which final deter- minations are made of the diagnoses indicated by the findings. Consideration is being given to consultant panel review of the entire relevant portion of each of the records in order to arrive at a standard and valid diagnosis. The pre- liminary work to be done with the tabulations of data for the ''first round" of the first cycle will aid in making the final plans in this phase of the operation. The diagnostic goal is a sta- tistically satisfactory diagnosis, rather than a diagnosis sufficiently established in the individ- ual case to govern the course of treatment for the patient. This means that the HES diagnostic procedure needs to be such that its expected value over a group of examinees is near the average that would be obtained for the group if all the individuals in the group were given a more comprehensive series of similar clinical examination—although the two sets of procedures would not necessarily produce identical results in each individual instance. 20 Ti an a APPENDIX | AREAS IN THE HEALTH EXAMINATION SURVEY'S SAMPLE Caravan I Caravan II Philadelphia, Pennsylvania (During the early part of the Health Exami- nation Survey only one Mobile Examination Cen- 22 10. 11. 13. 14. 15. 16. 18. 21, 22. 23. 24. 27. 28. 30. 32. 35. 37. 39. Valdosta, Georgia Akron, Ohio Muskegon, Michigan Chicago, Illinois Butler, Missouri Midland, Texas Los Angeles, California San Jose, California San Francisco, California ter was used,) Grand Coulee, Washington 12. Washburn, Wisconsin Minneapolis, Minnesota 13. Minneapolis, Minnesota Chicago, Illinois 14. Chicago, Illinois Detroit, Michigan 15. Detroit, Michigan Fort Wayne, Indiana 17. Auburn, New York York, Pennsylvania 19. Biddeford, Maine New York, New York 20. New York, New York New York, New York 23. Baltimore, Maryland Baltimore, Maryland 25. Oxford, Mississippi Nashville, Tennessee 26. Savannah, Georgia Eufaula, Alabama 29. San Antonio, Texas Clinton, Louisiana 31. Kennett, Missouri Newport, Arkansas 33. Louisville, Kentucky Topeka, Kansas 34. Providence, Rhode Island Boston, Massachusetts 36. Carbondale, Illinois Conway, South Carolina 38. Columbus, Ohio Winslow, Arizona 40. Pittsburgh, Pennsylvania 41. Newport News, Virginia 42. Rocky Mount, North Carolina ee ROUTES FOLLOWED BY MOBILE HEALTH KEY ---Route of Caravan I ---Route of Caravan II QFirst Round Stand [J second Round Stand () Third Round Stand Number enclosed in Round symbol indicates stand order in entire first cycle. APPENDIX II EXAMINATION CENTERS IN MOVING FROM ONE LOCATION TO ANOTHER 24 APPENDIX ll A. FLOOR PLAN -MOBILE EXAMINATION CENTER—CARAVAN | 8' X 35 Interview Room [Interview Room © Emergency Door \ Emergency Door eight Scal : ® J Removable Lead Rubber Shields Dental Roor Heras 1 9 mm Scale ® gg a 3 2 : Visual Acuity " X-ray Machine 8 Reception oO Lead Lined Wall — I ————— Door X-ray Developing Door 3 | | Wash | ashroom d | | Door ! ~~] L Door Door Door Door So Emergency Door \ Washroom ® A yy c Door Door $3 Ss Door a : i Office and Staff Room 3g § ES Records Files Lo. ° Preliminary Examining Room B Examining Statistical Room A Work (3) 8x3 8' X 35° B. FLOOR PLAN—MOBILE EXAMINATION CENTER—CARAVAN II g! Vv ENTRANCE EX LEAD LINED WALL [] OFFICE and STAFF Room RECORDS & 41 =>) FILES Preliminary 1 Statistical ! Work 1 — ee \ | LL | THRU. | | WAY | RECEPTION | I | py — ———_ INTERVIEW INTERVIEW ROOM ROOM X-RAY \ DEVELOPING I THRU- | ] way X-RAY HEIGHT MACHINE SCALE MOVABLE LEAD RUBBER / SHIELDS [yf J WEIGHT Ens SCALE Scale - Width |" 3! Length I" 5! Y DOOR AMINING ROOM A ® DENTAL AREA VISUAL ACUITY WASHROOM WASHROOM ® a— LABORATORY AREA AUDIOMETER o SOUNDPRQQF BOOTH ¥00a AON39¥3IW3 EXAMINING B ® EE es EMERGENC A 451 25 26 APPENDIX IV EXAMPLE OF LEAFLET DISTRIBUTED IN ADVANCE OF INTERVIEWER'S VISIT HEALTH 1S NEWS i. Bexar County ll WL LEN | He TE “mr ny ia REN pz 2 Y A i - ] A HEALTH EXAMINATION CENTER will be brought to San Antonio for the Health Examination Survey to begin February 16 U. S. Department of Health, Education, and Welfare Public Health Service U. S. National Health Survey Washington, D. C. TURN THIS PAGE FOR THE STORY A MESSAGE FROM THE PUBLIC HEALTH SERVICE Bexar County is especially distinguished out of the 3,076 counties in the United States, because it is among the 109 counties which have been selected by the U. S. National Health Survey for its Health Examination Survey. The 109 counties, taken as a group, constitute a representative sample of the entire United States popula- tion, balanced between urban and rural, North and South, East and West, large cities and small cities. The Health Examination Survey will soon give health examinations to about 150 adults from households in the County. To reach these people, interviewers from the U. S. Bureau of the Census are visiting the particular households in the sample to invite the selected persons to the health examinations. The purpose of these health examinations is to answer the question: "How healthy are the people of the United States?" In 1956 the U. S. Congress thought this question so important that it passed a special law, which was supported by members of both major political parties, to set up the National Health Survey and get at the facts. Some of the facts can be learned by asking people questions about their health. However, actual tests and measurements from a health examination are needed to get much of the information. The examinations done by the U. S. Public Health Service in the Health Exami- nation Survey are focused on some of our most important health problems, such as heart trouble, diabetes, and arthritis and rheumatism. Information is collected on dental conditions, hearing, and vision. Also, there are various other scientific measurements made and laboratory tests performed by the specially trained team of physicians, dentists, nurses, X-ray and laboratory technicians, and medical- history interviewers. The examination is not a substitute for a check-up by one's own physician or dentist. While the examination is quite thorough in some respects, it is not a com- plete examination; it does not require undressing below the waist, and no internal examinations are done. It is not painful or embarrassing in any way. None of the information collected about a person is revealed to anyone other than the person's own physician or dentist, and then only if the person specifically requests that the physician or dentist be given a report. A good many of the people who read this handbill will either themselves be in- vited, or will be living close by people who will be invited, to take the health exam- ination. It is very important that all the people invited—that is, all the people who are part of the sample—accept the invitation. No other persons can be accepted for the examination, no matter how much they would like to be examined. If you are one of those chosen, you will be personally informed of this fact. Everyone is given free transportation to and from the examination, and every- thing about the examination itself is free. The examinations take place in a mobile Health Examination Center operated by the U. S. Public Health Service and are given at convenient hours during the day and in the evening. The center will be brought to Bexar County and set up in a convenient location, where examinations will be given beginning Friday, February 16. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE 27 28 APPENDIX V HOUSEHOLD INTERVIEW QUESTIONNAIRE OF THE HEALTH EXAMINATION SURVEY The National Health Survey is authorized by Public Law 652 of the 84th mit identification of the individual will be held strictly confidential, will be used only by pers and will not be disclosed or released to others for any other purposes (22 FR Congress (70 Stat. 489; 1687). 42 U.S.C. 305). All information which would per- ons engaged in and for the purposes of the survey, Form HES-1 U.S. DEPARTMENT OF COMME RCE 1. Questionnaire (3RD REVISION) BUREAU OF THE CENSUS (8-9-61) ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE of HEALTH EXAMINATION SURVEY Questionnaires 2. (a) Address or description of location 3. Iden. Code 3a. R.O. Code 4. i weigl 5. Sample [* PSU No. |” Segment =F Serial No. (b) Mailing address if not shown in (a): Include city and State (c) Type of | : it | (d) Name of Special Dwelling Place | Code living | = a 2 ! 9. Is this house on a farm or ranch? [| Yes [J No quarters 1 Ask Items 10 and 11 only, if ‘rural’ box is checked: 10. Do you own or rent this place? L [7] Rural J All other [] Own [J Rent free 11. If “Own’’ or "rent free’’ in question 10, ask: (a) Does this place have 10 or more acres? If “‘rent’’ in question 10, ask: (b) Does the place you rent have 10 or more acres ? (c) During tl of crops $50 or more? [J Yes | | | | products from the place amount to i | [] Rent I [] Yes. I he past 12 months did sales 1d) During the past 12 months did sales of crops, livestock, and other farm roducts from the place amount to 250 or more? [2] Yes , livestock, and other farm | I$ [I No | [I No CO No 12. Are there any other living quarters, occupied or INSTRUCTIONS FOR Q. 12, 13, AND 14 vacant, in this building (apartment)? .............. [JYes [JNo If "Yes," to questions 12, 13, or 14 apply definition of a nousiig i unit to determine whether one or more additional questionnaires B. DT Tuas ding in his building ua «..JYes [No should be filled and whether the listing is to be corrected. Ask at all units except apartment houses: 18: Jhot ts the telephone number | 16. neces ig overlooked any thing best time to call? 14. Is there any other building on this property for "we Bh what is the people to live in - either occupied or vacant?...... . [JYes []No Noriphone 17. RECORD OF CALLS AT HOUSEHOLDS Item 1 Com. 2 Com. 3 Com. 4 Com. 5 Com. Date Entire household Rr) TT || {[e. a et ni} [rEnm-— [eC 1 ee] Time why [Beet 1 peed fee 1 pee 1 s as Time £85, TJ No one home TJ No one home [] No one home [1 No one home 200.Y Sample P. not home Sample P. not home [[T) Sample P. not home Sample P., not home 2 Col. No. TILT ps [J] Unrel. P. not home |) Unrel. P. not home |] Unrel. P. not home |[=] Unrel. P. not home £8 Ly ® Dat S32 Lp! Som—— — d fosmid Joc 2Ees Time S=t8 TJ No one home TJ No one home TJ No one home TJ No one home Tete Col. No [] Sample P. not home [[—] Sample P. not home |=] Sample P. not home [—) Sample P. not home : * [Z] Unrel. P. not home [] Unrel. P. not home |[7] Unrel. P. not home [] Unrel. P. not home 18. REASON N-INTERVIEW TYPE A B Cc Zz [] Refusal (Fill 1tem 19) [J Vacant - non-seasonal [J Demolished Interview not obtained for: [CJ No one at home - [] vacaat - seasonal [J In sample by mistake Reason: tepested cals [] Usual residence elsewhere [] Eliminated in sub-sample | Cols. — — — [] Temporarily absent [] Armed Forces [] Other (specity) [J Other (specity) [] Other (Specity) because: 19. Reason for refusal Footnotes and comments 20. Signature of interviewer 21. Code 1. (u) What is the name of the head of this household? (Enter name in first column) (b) What ash the names of all other persons who live here? (List all persons who live here.) (c) Do any (other) lodgers or roomers live here? [Ne [2] Yes (List) —————— (d) Is there anyone else who lives here who is now temporarily in a hospital? CI No [C] Yes (List) ep (e) Away on business? [JINeo [C] Yes (List) mp (f) On a visit? [J Neo [] Yes (List) =p (9) Is there anyone else staying here now? [CJ Ne [] Yes (List) ——————————— No (leave on questionnaire) Last name (1 First name and initial 2. How are you related to the head of the household? (Enter relationship to head, for example: head, wife, daughter, Relationship grandson, mother-in-law, partner, lodger, lodger’s wife, etc.) Head Age 3. How old were you on your last birthday? (Check ““EA’’ box in question 1 for all persons 18-79 years old) 3 Jie White Negro 4. Race (Check one box for each person) 0 3 oe E 5. Sex (Check one box for each person) [] Male [] Female If 17 years old or over, ask: [] Under 17 years 6. Are you now ied, wid d, divorced, d or never ried? 0 Married [Divoreed [] Widowed [|] Separated (Check one box for each person) [] Never married If 17 years old or over, ask: 7. (a) What were you doing most of the past 12 months -- (For males): working, or doing something else? (For females): working, keeping house, or doing something else? If “‘Something else’’ checked, and person is 45 years old or over, ask: (b) Are you retired? [] Under 17 years [] Working [] Keeping house [] Something else NOTE: Determine which adults are at home and record this information. Beginning with question 8 you are to interview [] Under 17 years for himself or herself, each adult person who is at home. [] At home J Noe at ome 8. Were you sick at any time LAST WEEK OR THE WEEK BEFORE? (That is, the 2-week period which ended [C] Yes [1 No last Sunday)? == (a) What was the matter? (b) Anything else? 9. Last week or the week before did you take any medicine or treatment for any condition (besides . . . which [] Yes [CJ No you told me about)? (a) For what conditions? (b) Anything else? 10. Last week or the week before did you have any accidents or injuries? (a) What were they? i [] Yes [CJ No (b) Anything else? 11. Did you ever have an (any other) accident or injury that was still bothering you last week or the week before? [C] Yes [CJ No (a) In what way did it bother you? (b) Anything else? 12. AT THE PRESENT TIME do you have any ailments or conditions that have lasted for a long time? [0 Yes [CJ No (If *'No’’) Even though they don’t bother you all the time? (a) What are they? (b) Anything else? 13. Has anyone in the family - you, your --, etc. - had any of these conditions DURING THE PAST 12 MONTHS? [] Yes [J] No (Read Card A, condition by condition; record any conditions mentioned in the column for the person) 14. Does anyone in the family have any of these conditions? [C1 Yes [T1No (Read Card B, condition by condition; record any conditions mentioned in the column for the person) 15. (a) Have you been in a hospital at ony time DURING THE PAST 12 MONTHS? [] Yes [No If “Yes,” [oo ee 8 2 ia (b) How many times were you in the hospital overnight or longer? Wo: of tims 16. If baby under one year listed as a household member, ask: : . (0) Was the baby born in a hospital or at home? (Check proper boxes for WY espe Teme If **hospital’’ in q. 16(a) and 1 or more in q. 15(b), ask: both mother and child.) y Ni (b) Was this hospitalization included in the number you just gave me? [3 Yes ZI Re 17. a During the past 12 months has anyone in the family been a patient in a nursing home or sanitarium? 1 Yes [I No If *'Yes,” ask: oT css es im ew (b) Who was this? (c) How many times were you in a nursing home or sanitarium? No. of times For persons 17 years old or over, show who responded for (or was present during the asking of) q. 8-17. R (For Pp Pp 8 q a 8-17) If persons responded for self, show whether entirely or partly. For persons under 17 show who responded t Be for them. [_JResponded for self-entirely [_JResponded for self-partly Col. was respondent 29 30 Table | - ILLNESSES, IMPAIRMENTS, AND INJURIES Col. |Ques- {Rid you|Ask for all illnesses and Ask if the entry in Ask only if {Ask for any entry in Ask only for: Co No. Yon EVER [present effects of old injuriesy Col. (d-1) is: 6 years old|Col. (d-1) or Col. (d-2)| Impairments and injuries of Ts oh ony (3/12 doctor talked tor An Impairment of over and|that includes the words: | And for. * indness, “lm Abscesses Inflammation per- talk to | what did the doctor say or poor vision |Allergy* Tumor Aches Neuralgia son @ dweto} it was? - - did he give it a Symptom, or eye Asthma ‘“Condition’" | Bleeding Neuritis about a medical name? or trouble of Cyst Disease’ | Blood Clot Pains nd. i (5 If doctor not talked tor | came from question 11 or 14: Stroke» ‘Trouble’ | Boils Sores Record original entry and Can you Concer Soseness 5 askafd- 2) (4-5) a What was the cause of . ..7 |ses well |What kind of ... is it? | Vol, haar £ » tS o i td navi *Por an allergy or stroke Infection Weakness 3 sk tor all injuries during to rea i 2 past 2 weeks: dary ask: What part of the body is affected ?| v newspaper Show detail for: A What part of the body was print with |How Joes the allergy Ear or eye - (one or both) hurt? } glasses? |(stroke) affect you? Head - (Skull, scalp, face) What kind of injury was it? Back - (Upper, middle, lower) Anything else? Arm - (Shoulder, sept, elbow, lower, wrist, hand; one or both) Leg - (Hip, upper, knee, lower ankle, foot; one or both) (a) (b) (c) (d-1) (d-2) (d-3) (d-4) (d-5) x x x [3 Yes [] Yes : i [CI No [No [1] Yes 1) Yes * x x 2 [CJ No [J No x x x x [C] Yes [7] Yes 3 [INo [No x x x x [Yes [] Yes 4 [CINo [CINo x x x x TI Yes [] Yes ’ CiNe Ne s [Yes 10 Yes 2 * 2 No [No Table Il - HOSPITALIZATION DURING PAST 12 MONTHS Qo. Ques- | When did [How To Interviewer What di they say uj the hospita) the condition was -- No. tion you enter | many i ey give it a medical name? of No. the hos- nights How many | Will you | How many] Was this a [per pital? were you |of these | need to [of these |person (If ‘they’ didn’t say, ask): L]son in the -- nights | ask Cols.|-- nights | still in E (Month, hospital? | were in | (f) and were last | the hos- What did the last doctor you talked to say it was? 2 year) the past (8)? week or ital on 12 the week [last (Entry must show ‘Cause,’ ‘Kind,’ and "‘Part of £ months? before? Siaday Body’ in same detail as required in Table I) night? (a) (b (©) (d) (e) . (x) fH (8) (h) A Mo: =. [1 Yes FTIR [] Yes 1 crimes ights Yr: Nights | “Nighes | CON | None | Ne All Mo Ca | CO Yes |r| OI ves 2 EL. re N Nights CIN Yr: Nights Nights [CINe [_] None © 3 Mo: | 14 [] Yes [1 Yes : Nights —_——— No No Yr: | Nights |" Nights - [_] None tl Table | - ILLNESSES, IMPAIRMENTS, AND INJURIES How [How many [If 6-16 [If 17 years| Did you first notice . . . To About If 1 or Ask after completing last SA Een many |of these [years old | old or over|(did it happen) during the inter: how more days| condition for Sh person WEEK BE days, |-- days ask: ask: past 3 months OR before ; . | many in Col. FORE did |inclulfwere you gl viewerildoys (mand logue |1frar [if yes” ...cause you a9 in bed ay How many | LAST ua I Col ts) look at 2” or |in Col. to cut down or most of | jays did WEEK or heck id . [this card |"'3"" in |(q): Satur- | the day? Check one |Did... start CON- 12 ed, ask: on your usual d ...keep |the WEEK during the past |TINUE | months and read |Col. (p): activities for [39 you from | BEFORE, [1 o00%s or JNUE | mands, 1" 12% Which? as muchos ao | school how many [F€7¢1 TE |b ofore that time?[(k) is | kept you [many of [Statement ls this day? Son last week [days did | 3 ig checked | inbed [there |Then tell [because |(gnter or the ... keep "mos. |(1f during past Jor the for all day: me which of any |x oq week you from "| 2 weeks, ask): |condi- |ormost |were statement of the line for before? work? ’ "tion of the during [fits you |condi- each Check one (For (Go Which week, is on day? last est, in | tions condi- 0 females {i last week of [Card A week ~~ |rerms of | you ton | § No | Yes add) Col. the wesk or is an orthe freslth. have named | not count- | (n)) efore? impair- eek eld. me. (Go ing work rap ment; ey Cards D- about? Ss to around the other- G, as £ Col. ee house? wise, appros - (Kk) STOP priate) (e) (f) (8) (h) (i) () | (m) (aa) (n) (0) ®) (9) (r) Last week Days Days Days » Week before 1. Days{ —— Days [C1] Yes 1 p— or or or - Bef 2 k or or MM No Days [J None |[["]None |[_]None [CJ Before 2 wks} [7] None |[] None Days Days Daye [C] Last week Days Days [J Yes or or or [] Week before or or Cl No 2 Days |["] None |] None |[] None [] Before 2 wks [] None |[_] None k Days Days Days fg Lud: wed Days Days [] Yes y= + -D =] Week before Db 4D) One 3 Days |™] None |[]None |] None [1 Before 2 wks [] None |[_] None Days Days Days [1 Lag week Days Days = Yes pee or or or [] Week before or or [No 4 Days [| None |[]Nene |[_] None [] Before 2 wks [] None |[] None Days Days Days [C] Last week Days| —— Days [] Yes EA or or or [_] Week before or or “IN 5 Days |—None |] None |[] None [7] Before 2 wks [] None |] None aw Days Days Days [CJ Last week Days| —— Days [C] Yes rr — or or or [] Week before or or [TNeo 6 Days | None None |[_] None [] Before 2 wks [] None |[] None Table Il - HOSPITALIZATION DURING PAST 12 MONTHS Were any operations performed on To Interviewer you during this stoy at the hos- Whar is the name and address of the hospital you were in? Carry this condition through Table I, pital? if it does not appear there « » AND 3 If “Yes, (Enter name, city and State; if city not known, enter county) 1 or more nights in Col. (f), 2 OR . (a) What was the name of the condition is on Card A, or is an 5 operation? impairment ¢ (b) Any other operations? Will you need to fill Table I? wl (i) 0) (xx) [J Yes [J No en os o_o [] Yes [No | 1 M1 Yes [Neo gS tt sn, tn pv [] Yes (JNo | 2 Y No C1 Yes Ne | eee meee ] Yes [CINo |3 32 If 17 years old or over, ask: [] Under 17 years 18. (a) What is the highest grade you attended in school ? Elen: : : 2 $ 5 E75 (Circle highest grade attended or check ‘*None’’) College: 1 2 3 4 5+ [] None (b) Did you finish the - - grade (year)? = Yes ji = No If Male and 17 years old or over, ask: [[) Fem. or und. 17 yrs. 19. (a) Did you ever serve in the Armed Forces of the United States? If ‘'Yes," ask: [J Yes [J No (b) Are you now in the Armed Forces, not counting the reserves? (If ‘Yes, delete this person from questionnaire) — [a] Yee F CJ No (c) Was any of your service during a war or was it peace-time only? [= Var ese El Peace If "War," ask: time only (d) During which war did you serve? I wv TT CJ Korean If ‘'Peace-time’’ only, ask: [C] Other (e) Was any of your service between June 27, 1950, and January 31, 1955? Ask for all persons 17 years old or over: 20. (a) Did you work at any time last week or the week before? If “'No,”” ask 20(b) and (c). (b) Even though you did not work last week or the week before do you have a job or business? (c) Were you looking for work or on layoff from a job? 21 . If "Yes," in question 20(a), (b), or (c), ask: (a) For whom did you work? If “Yes in q. 20(c); (b) What kind of business or industry was this? q. 21(a) - (e) applies to the person's last full-time (c) What kind of work were you doing? civilian job. (d) Class of worker (Fill from information above; or, if not clear, ask): [C] Private-paid [] Govt Own Non-paid Ask only for persons 20 years old or over: | ar ar CJ! _ "pa! J (e) Have you been a --, or doing this kind of work for the past three years? [7] Under 20 years [1 Yes [J No 22. Which of these income groups represents your total family income for the past 12 months, that is, your's, your Group etc? (Show Card H.) Include income from all sources, such as wages, salaries, rents from property, pensions, from relatives, etc. Time /day S Ask only for sample persons not at home at time of interview: What is the best time to find--- at home? TO BE FILLED BY INTERVIEWER AFTER INTERVIEWING SAMPLE PERSON(S) -- NOT TO BE ASKED OF RESPONDENTS Se (a) Did anyone ask one or more questions about the health examination? ction | [] Yes [J No If “Yes,” (b) What were the questions? [Please write in below your suggestions for overcoming problems during follow-up visits. [Section 2 [J No problems observed ASK ONLY OF SAMPLE PERSON(S) Enter name and column number of sample person (from question 1). Name Name Column number Column number 23. Would you say your own health, in general, is excellent, good, fair, or poor? 1[] Excellent 2[] Good 3 [] Fair 4] Poor 5 [J] DK 1] Excellent 3 Fair 2[] Good 24. How important do you think it is for people to have a regular check-up... very important, fairly important, or hardly important at all? 1[_] Very important 2 [] Fairly important 3] Hardly important 1] Very important 2 [] Fairly important 3 [] Hardly important 4] DK 4] DK 25. (a) Do you have a doctor you usually go to? 1] Yes 2] No 1] Yes 2] No If “Yes,” (b) What is his name and address? 26. How long has it been since you last talked to any doctor about yourself? Mos. or Yrs. Mos. or Yrs. [] Less than 1 mo. [| Never [] Less than 1 mo. [] Never 27. Do you get check-ups from a doctor AS OF TEN as once every two years? |1[ |] Yes 2[] No 1] Yes 2[J No 28. (a) Do you have a dentist you usually go to? 1] Yes 2[] Neo 1] Yes 2[]No If “Yes,” (b) What is his name and address? 29. How long has it been since you last saw a dentist about yourself? Mos. or Yrs. Mos. or Yrs. [J Less than 1 mo. [_]Never [JLessthan 1 mo. [_] Never 30. Do you go to a dentist AS OFTEN as once every year? 1] Yes 2[] No 1] Yes 2] No 31. (a) Have you heard or read anything recently about the National Health 1 Yes 2] No 1 Yes 23 Noy Survey and the special health examinations being given in this area? (Show pd | (Show clipping) If “Yes,” 3 NHS newspaper 3 NHS newspaper (b) In a newspaper or magazine? On TV? Radio? From somebody J Li a *H her meme game: Jalliig you about it? (Check all that apply) EC; Rudiorouraiome a If “newspaper,” 7] Somebody telling 7] Somebody telling (c) Which newspaper? 1] Very important 1] Very important 32, How important do you think it is for people to cooperate on surveys such |, [] Fairly important 2[] Fairly important as this... very important, fairly important, or hardly important at all? 3 [] Hardly important 3] Hardly important 4] DK 4) DK 33. As you might expect, the Public Health Service cannot learn all they need to know about health in the nation just by asking questions. For some 1 [] Certainly come 1] Certainly come things they need actual measurements and tests obtained in a health 2 [] Probably come 2 [] Probably come examination, 3 [_] Probably not come 3 [] Probably not come (a) How do you think most people will feel about helping in this way -- 4] DK 4] DK will they certainly come, probably come or probably not come for such a hnalth examination? 34. Throughout the United States, the Public Health Service is giving a Preferred times: Preferred times: health examination to a sample of adults and you are in this sample. For your community, a special examination center has been set up at and the examinations will be given from . | through [7] App made: [1 App made: No. No. The examination is not painful or embarrassing in any way and free transportation to and from the center will be provided. From our past Date Date experience we know that most people are glad to come for the examina- tion. Appointment times are available during morning, afternoon and Time Time evening hours. (Specify any problems mentioned |(Specify any problems mentioned about coming) about coming) (a) We would like to make an appointment for you -- which time would be most convenient for you to come? [] Appointment not made [] Appointment not made (Specify reason for no appointment)|(Specify reason for no appointment) [] Signed [C] Refused | [] Signed [_] Refused 35. Present medical authorization for signature [] Not asked to sign [J] Not asked to sign 33 34 APPENDIX VI LEAFLET GIVEN EXAMINEE WHEN APPOINTMENT IS MADE YOU AND THE HEALTH EXAMINATION SURVEY Why you? If you have been asked to come to our examining cen- ter, you are one member of a very important group of people who, taken all together, make up a representative sample of the people of the United States. From this sam- ple will come important scientific information on the health of the entire United States. You will be the repre- sentative of thousands of others who are just like you-- the same age, same schooling, and most important of all, the same level of health, However, the fact that there are thousands of other people whom you represent does not mean that there is anyone who can take your place. The scientific sampling method has led us to YOU. If you are not there to represent those thousands, their part in the health picture is missing and the picture may be mis- leading, What to expect: The health examination which you will receive is very thorough in some respects, but is not a complete examination, For example, no internal examinations will be done. All of our staff--the receptionist, the physician, the nurse, the dentist, the technician--will do everything to make your visit to the examining center a pleasant ex- perience, At the start, you meet the receptionist who will ask if you would like the findings of the examination sent to your own physician and dentist, This is so that your own doctor can tell you about the results, Then the reception- ist gives you a sweet, lemon-flavored soft drink. After that, she helps you fill out a questionnaire that contains the kinds of questions your doctor asks when he gets your medical history. After this, the nurse will be with you during the rest of the examination, explaining each step. She shows you to an examining room, asks you to undress to the waist and put on a white gown, After you meet the doctor, he reads over your medi- cal history and asks a few questions about it, He exam- ines your eyes and ears, takes your blood pressure sev- eral times, and makes a complete examination of your heart by listening to the sounds it makes. After youmeet the dentist, he checks over your teeth and mouth, He also gives you an eye test--if you have eyeglasses, please be sure to bring them with you, be- cause we need to test your vision both with and without glasses, In another part of the examination the nurse makes a record of the impulses of your heart with an electro- cardiograph (EKG)--for this test you liedown, relax, and even go to sleep if you wish, But youcan't sleep long be- cause this test takes a very short time, Some simple body measurements, such as arm and chest size, shoul- der width, etc., will also be done, Other parts of the examination include: a hearing test; x-rays of your chest, hands and feet; height and weight; blood and urine specimens. After you have dressed, you are invited to enjoy re- freshments while you give us your opinion and reactions to the health examination, Knowing what you think about it helps us to improve and to make the examination even more comfortable and convenient. THE U. S. NATIONAL HEALTH SURVEY U.S. DEPARTMENT OF HEALTH, €DUCATION, AND WELFARE Public Health Service Washington 25, D.C. U.S. NATIONAL HEALTH SURVFY APPENDIX VII SELECTED MEDICAL HISTORY QUESTIONS (Excerpts From HES-204, Medical History—Self Administered) Cardiovascular Disease . a. In the past few years have you had any headaches? If YES b. How often? [Every few days] [Less often | c. Do they bother you [quite abit | [ just a little] . a. In the past few years have you had any nosebleeds? If YES b. How often? [Every few days] [Less often c. Do they bother you [quite a bit] { just alittle] . a. At any time over the past few years, have you ever noticed ringing in your ears or have you been bothered by other funny noises In your ears? If YES b. How often? [Every few days] [Less often] c. Do they bother you [quite a bit | ( just a little | . a. Have you ever had spells of dizziness? If YES b. How often? ( Every few days | [ Less often | c. Do they bother you [quite a bit | [ just a Tittle | . Have you ever fainted or blacked out? . a. Have you ever had a stroke? If YES b. Have you had a stroke in the past 12 months? c. Have you ever seen a doctor about it? . Has any part of your body ever been paralyzed? . Nas there anytime in your life when you had a lot of bad sore throats? 5. a. Have you ever been bothered by shortness of breath when climbing stairs? If YES b. How often? [ Almost everytime | { Less often | c. Does it bother you | quite a bit just a little 35 36 17. 18. 18. 21. . Have you ever been bothered by shortness of breath when doing physical work or exercising? If YES b. How often? [ Almost everytime | Less often | c. Does it bother you quite a bit just a little . Have you ever been bothered by shortness of breath when you were not doing physical work or exercising? If YES b. How often? [Every few days | [Less often | c. Does it bother you [quite a bit just a little . Have you ever been bothered by shortness of breath when you are excited or upset about something? If YES b. How often? | Almost everytime | [Less often | c. Does it bother you | quite a bit [Just a Tittle | . Have you ever waked up at night because you were short of breath? If YES b. How often? [Every few nights | [ Less often | c. Does it bother you [quite a bit just a little In the past few years, have you ever had any pain, discomfort, or tightness in your chest? IF_YES, please answer questions b through j below. b. How often? [Every few days | [ Less often | c. Does it bother you [auite a bit | [Just a little | d. Where does it bother you? (Check every place it bothers you.) Tk Waals Somewhere else | State where e. Does it usually [stay in one place | | move around | [7] f. How long does the pain usually last? [ Just a few minutes | | Few minutes to an hour | [More than an hour | a. Does it usually come [When you take a lot of exercise | or when you are quiet or is there no difference h. Does it usually come or [ doesn't this make any difference | i. Do you take any pills or medicine for it? 2. In the past few years, have you ever had any -pain, discomfort, or trouble in or around your heart? IF YES, please answer questions b through j below. b. How often? [ Every few days | [ Less often | c. Does it bother you quite a bit just a little | d. Where does it bother you? (Check every place it bothers you.) State where e. Does it usually [ stay in one place | [ move around | [7] f. How long does the pain usually last? [Just a few minutes | | Few minutes to an hour | [More than an hour a. Does it usually come { When you take a lot of exercise | or when you are quiet or is there no difference h. Does it usually come when you are upset or [ doesn't this make any difference | 23. 24. 25. 26. 65. i. Do you take any pills or medicine for it? . Sometimes, our hearts "act funny" (odd) like missing a beat, or beating real fast, or seem to turn over. Have you ever noticed your heart do anything like that? If YES b. How often? [ Every few days | [ Less often | c. Does it bother you {quite a bit | [just 3 little | . Have you ever been bothered by your heart beating hard? If YES b. How often? [ Every few days] [Less often] c. Does this bother you [quite a bit | [Just a Tittle] . Are your ankles ever swollen at bedtime? If YES b. Is the swelling gone by morning? . When you walk, do you have pains or cramps in your legs? If YES b. How often? [ Every few days | [Less often] c. Does it bother you [quite a bit | [Just a little | . Has a doctor ever told you that you have hardening of the arteries? If YES b. Have you had this condition in the past 12 months? 37 | 66. a. i pressure? | If YES or ? / If YES Have you ever had any reason tc think you may have high blood b. Did a doctor tell you it was high blood pressure? c. How long ago did you first start having it? [1 year | [1-5 years] [over 5 years | d. Have you had it in the past 12 months? LYES | [NO | e. Do you take any pills or medicine for it? f. Give name of the medicine 67. a. Have you ever had any reason to think you may have heart trouble? iT YES or ? If YES b. Did a doctor tell you that you had heart trouble? [ves] [no] If YES, what did he call it? c. How long ago did you first start having it? . Have you had it in the past 12 months? . Do you take any pills or medicine for it? ( 1 year | [1-5 years | [ over 5 years | L YES || no) 2 [es] [Mo]; BE Give name of the medicine B. Arthritis and Rheumatism 27. a. get up? If YES b. How often? C. 23. a, like that? If YES b. How often? c. Does it bother you [quite a bit | that? If YES b. How often? c. Does it bother you [quite a bit | 30. a. like that? If YES b. How often? c. Does it bother you [quite a bit | 38 Does it bother you How about swelling of the joints? . How about pain in the joints? How about tenderness of the joints? Have you ever had morning stiffness, or weakness when you | Less of ten] | Every few days | quite a bit Have you noticed anything | Less often | [just a little] | Every few days | Have you noticed anything like [ Less often | [just a Tittle | [ Every few days | Have you noticed anything | Less often | [just a Tittle] [Every few days | 61. 62. 64. 70. 71. 72. a. Have you ever had any reason to think you may have rheumatism or arthritis? If YES or ? b. Did a doctor tell you it was rheumatism or arthritis? c. How long ago did you first start having it? (1 year | [1-5 years | [ over 5 years | d. Have you had it in the past 12 months? e. Do you take any pills or medicine for it? rheumatism) |f YES b. Have you had it in the past 12 months? . Has a doctor ever said you "ad rheumatic fever (inflammatory c. Are you taking any pills or medicine for it? If YES d. What is it? Has a doctor ever said you had gout? Diabetes Have you had any recent increase in being thirsty (drink a lot of water)? Have you had any recent increase in urination (pass a lot of water)? a. Have you lost any weight recently (without trying to)? IF YES: b. How much weight have you lost? ________1bs. c. Over what period of time have you lost this weight? a. Has any of your relatives ever had diabetes? \F YES: b. Please aive relationship of this person or these persons to you: 39 tee im J—— APPENDIX VIII NOTES ON STATISTICAL DESIGN Outline of Design Development This outline is restricted primarily tothe more ex- clusively statistical aspects of the designing, and within that confine to a severely abstracted account. As already noted in this report, a survey design is the product of an iterative process in which, in suc- cessive steps, a closer and closer match is attempted among objectives, feasible operating procedures, budg- et, other resources, and idealized mathematical models. In the Health Examination Survey, this process began in the summer of 1957 with review of earlier experience of others in related matters, with many staff discus- sions of problems and possibilities, and with the initia- tion of several exploratory and developmental projects. These latter projects were to be carried out mostly by research contractors, and were intended to shed more light on specific examining and measurement techniques and on methods of securing favorable response to the offer of a clinical examination. Soon there began the specifications and procurement of needed equipment. By the fall of 1958, the general pattern of the Sur- vey was emerging. It had been decided that the exami- nations would be conducted in mobile caravans, and would, for the first cycle, cover the adult, civilian, non- institutional population. The general content of the examination itself was chosen. It seemed desirable that the regular HIS data be obtained for all prospective examinees prior to the examination, This step would be taken for two reasons: first, it was to be the funda- mental sampling procedure, and second, it would pro- vide data which might clarify the relationship between the Health Interview Survey and the Health Examination Survey. Now a streamlined statistical model was developed. It contemplated a three-stage sampling process, with the first of these stages subdivided into parts, so that four levels of units were recognized: Primary Sampling Units, locations (of examining places within PSU's), clusters (of households), and pérsons. To convert the purely algebraic model to operational indicators, it was necessary to implement the mathematical analysis with estimates of likely values of a good many param- eters. Estimation of needed parameters in a new kind of undertaking is always difficult, For this part of the job, it included determinations of total budget, overhead costs, unit costs for scores of activities, population variances for quite a variety of groups of persons, and target tolerances for typical end products. The esti- mates were made. Experience in pretests and data from the Health Interview Survey played an important role here. 40 The formal solution for this first model yielded a plan with 38 PSU's, 1,347 clusters of households, and 5,538 examinees. The scheme envisaged an average of about 4 examinees per cluster, 36 clusters per PSU, and 146 examinees per PSU. The first results also pointed to one location per PSU in areas with low den- sity of population, two locations in medium-density areas, and three locations in high-density areas. As planning work proceeded, there were many revisions of the estimated parameters, but the final design is very similar to the initial model. Of technical interest was the conclusion thatthe "optimum is broad" for the circumstances of this sur- vey. More specifically, it was decided that there was not a great difference in expected precision or cost for a design of 30 PSU's with 200 examinees per PSU, and one of 50 PSU's with about 120 examinees per PSU. Some of the scheduling and operating problems, how- ever, would be rather différent for these two situations. Many questions remained to be settled before the design was complete. Some of these were decided on the basis of administrative or supervisory judgment. But wherever possible, data from the three pretests were utilized in conjunction with principles of securing either minimum variance, or minimum cost. Among the decisions which have a distinct effect on the design are these: Making the design essentially self-weighting. 2. Introduction of the three subsamples or rounds. 3. Use of four or five interviewers at each stand. 4, Assignment of examinees alternately to each of two nurse-physician teams. 5. Selection of an average of one person per house- hold from four households in a segment, rather than two persons from each of two households in a segment, (Both schemes were tested.) 6. Insistence that there be close to 150 examinees at each location. This step was taken with some loss from unequal sampling fractions, but for the reasons indicated in another section of this report. 7. Deletion of a procedure for taking the examina- tion into the home of the sample person who would not come to the caravan center. 8. Decision to adopt but very limited use of auxil- iary medical data for nonrespondents, as distinct from other possible courses of using such data wherever they might be found. 9. Introduction of multiple reading of X-ray and EKG charts. 10. Pretest tabulation of such readings as height and weight, in order toimprove coding and recording instructions. — 11. Establishing an itinerary which is geared sub- jectively to hoped-for maximum response, and moderate travel cost, rather than random se- quencing. This meant, for example, examining all West Coast locations consecutively, avoiding northern Wisconsin in midwinter, and avoiding New York City in vacation-prevalent July and August. In addition, budget shortages at one point in time led to a rerouting which was some- what less desirable than the original choice had been. This rerouting also has delayed the com- pletion of Round I by approximately six months. Definition of Universe The universe to be covered by the Health Examina- tion Survey is the "civilian, noninstitutional, population of the United States.' But every word inthis title needs more careful definition in the conduct of the Survey. The operational definition covers many pages of field manuals. Prominent characteristics are the following: The United States is restricted for cost reasons alone to the mainland, excluding Alaska and Hawaii. The time period is considered the "average over the three-year period ending late in 1962." Noninstitutional is defined by exclusion through an extensivelist of types of places. In particular, among the out-of-scope places are correctional institutions, resident hospitals and nursing-care homes, and homes for the needy. Civilian personnel resident at a miltary base are in- cluded. There is a variety of special cases about which there may be difference of opinion as to whether they should or should not be within scope. Among these, for example, are American Indians living on reservations. It was decided that they should be included. There are several classes of cases for which inclusion or exclu- sion is largely a matter of semantics (and associated estimation procedures). These arise from the fact that the nature of the examining process is such that it is restricted to the physically available ambulatory pop- ulation. For any other person, the choice isto consider him out-of-scope, or nonrespondent. Examples of such persons are: people who die between the time they are selected for the sample and the time they are scheduled for examination; persons who are inhospitals, or other- wise physically unable to go or be taken to the caravan center; persons in jail (local jails are not considered institutions); crews of vessels and other persons who are not at their place of residence at any timeat which the HES examining team is available in their community. On Basic Estimation Technique Not so long ago estimates of population parameters were limited to inflation of sample data by the recipro- cal of the sampling fraction. A wider range of possibil- ities exists today. This greater latitude is largely a function of the doctrine of making maximum use of all relevant information. The newer methods include such processes as ratio estimation—which will be used in the HES summary routine—and regression, difference, and poststratification techniques. Data from Round I will be used to explore the applicability of some of these processes. Of particular interest is possible use of the extensive HIS data (some 360,000 persons) in conjunc- tion with the HES raw data. Consider the situation within the a™7 age-sex cate- gory. Assume that the HES interview} sample (6,300 total persons) shows Py, as the estimated relative num- ber of persons with a characteristic which is corre- lated with the x-characteristic. As an illustration, say Ps, is the estimated proportion from the HES interview of persons with one or more chronic conditions in the arthritis or cardiovascular groups, and x is a pre- liminary estimated relative number of persons in those groups with a positive cardiovascular examination sta- tistical diagnosis. Similarly Py, is the HES-interview estimate of the proportion of persons without the indi- cated condition and x, is the examination estimate of the relative number in this latter group with the cardio- vascular diagnosis. There are from the Health Interview Survey (360,000 persons) estimates Ph, and Ps which correspond, re- spectively, to Py, and Py, , and which have smaller sampling variance. It may be, then, that is a better estimate than x" = " rox! a Ya Pai ai x"! = ne 1" x? a Ya = Pai ai would be, where both Ya and y' are sample estimates of total number of persons in the 2 class. Note that X's = yt! gpl. XN is exactly the estimate a a ai “ai which would have been obtained if all interview data had been disregarded. Whether an estimate of the form xy will be utilized or the ''preliminary'' estimate xy! , will be determined from analysis of data from Round I. Within PSU Sampling Variations The typical procedure for selection of examinees within a PSU has been described previously in this re- port. It was stated that the detailed procedure varies somewhat from one place to another, Two of the varia- tions, used in several places, are described briefly here. In the later stands of the cycle, useis made of data which have become available from the 1960 Population Census. In order to reduce costs, the principal part of the sample is drawn from the address registers which were established as a part of the Census-taking proc- ess. These list samples are then supplemented with samples of new construction—obtained from building permit files—in order to cover addresses which were not in existence at the time of the Census. For the ma- jor part of the list sample, "Super-segments' of 20 adjacent addresses are drawn, and then subsampled to produce the standard HES subsegment of an expected four households. For very large metropolitan areas, even with two or more locations of the examining caravan, it is quite difficult and costly to persuade sample persons from 41 all parts of the area to come to the examining center, For such areas, an additional subsampling stage has been introduced. This has been termed the "satellite" system. It is illustrated in the stylized figure 1. The metropolitan area is divided into seven subareas: a cen- tral city, and six radial arms. The final sample area consists of the central city, and two of the six satellite areas, the latter being drawn randomly and within- sampled more heavily so that they represent the total satellite territory. Two locations of the caravans are used, at places appropriate for travel to and from the chosen subareas—in figure 1, say, at points A and B, if satellite areas II and V are drawn into the sample. CENTRAL Aa CITY Figure 1. Locations A and B for a major metropolitan area in which the sam- ple areas are the Central City and subareas Il and V of the six satellite territories. The Master Control Card With the complex survey design, and many variable factors associated with the undertaking, it isnecessary to know rather precisely the status of every sample person. For this purpose, and for ultimate use in in- structing the electronic computer for data processing, a master control card is established for each sample person, Through the common tie of examinee number (which is assigned to each sample person, whether examined or not), information on the control card can be integrated with any other data which pertain to that examinee. The master control card contains the following items: a set of eight basic design weights which ac- count for all stages of sample selection and variations in the central design; a set of four estimation weights which reflect relevant interview data and population controls; a single one-digit summary weight for use in experimental and preliminary punchcard procedures; the examinee number; stand number (PSU); segment number; superstratum number (geography and popula- tion density); first-stage type (certainty or noncertain- 42 ty); round number; second-stage selection code (satel- lite status); location code (within PSU); age; sex; and examination status (showing whether examined; if not, why; and if auxiliary data obtained, source of data). Illustration of Selection of a Stand The illustration is for the selection of one of the stands in the 15-cell matrix which represents ''Other SMSA's in the South," and more specifically that one of the 42-strata described as "southern SMSA's with less than 141,000 population in 1950 plus 6 larger southern SMSA's with similar characteristics." Table I. Data for selection ot a stand (small southern SMSA's) Substratum | 900 res Substratum population ge in 500 area design in millions 1950 in 1950 popu- lation 1. Orlando, Fla. 114 114 2. Baton Rouge, La. 156 156 3. Montgomery, Ala. 138 138 4. Lubbock, Tex. 199 101 Wichita Falls, Tex. 5. Durham, N.C. 246 101 Winston-Salem, N.C. 6. Jackson, Miss. 141 141 7. Gadsden, Ala. 192 94 Lexington, Ky. 8. Roanoke, Va. 133 133 9. Greenville, S.C. 167 167 10. Waco, Tex. 241 129 Galveston, Tex. 11. Savannah, Ga. 151 151 12. Asheville, N.C. 258 123 Raleigh, N.C. 13. Augusta, Ga. 162 162 14. Mobile, Ala. 228 228 15. Amarillo, Tex. 201 87 Laredo, Tex. San Angelo, Tex. 16. Corpus Christi, Tex. 164 164 17. Shreveport, La. 174 174 18. Macon, Ga. 134 134 Stratum total-- 3,199 Table I exhibits pertinent information. This stra- tum had 3,199,000 population in 1950. Some of the 18 substrata contain more than one PSU, but each substra- tum was represented in the 500-area design bya single PSU; namely the one for which 1950 population is shown in the right-hand column of the table. Controlled selec- tion had determined earlier that in the 42-area design this stratum was to be represented by either a Florida or a Georgia PSU. Consequently the Florida and Georgia PSU's (of the 500 area sample) were listed along with cumulative population: PSU Stratum 1950 | Cumulative population population Orlando, Fla. 114 114 Savannah, Ga. 15) 265 Augusta, Ga. 162 427 Macon, Ga. 134 561 Each of these areas had first been picked with probability proportionate to size (PPS) to represent its stratum; a single choice was made among the four, again with PPS, so that the total process is a selection with PPS. The random number in this instance was 119, and thus selected Savannah, Georgia, to represent the stratum of 25 PSU's. The reciprocal of over-all proba- bility of selection of Savannah is 3,199,000/151,000, or 21.19. It should be noted in this process that the popula- tion weight ascribed to the PSU's among which selection is made is that of the stratum (in the 500 area design) from which it came, and not just the population of the selected PSU. %U.S. GOVERNMENT PRINTING OFFICE : 1965 O - 775-521 43 REPORTS FROM THE NATIONAL CENTER FOR HEALTH STATISTICS Public Health Service Publication No. 1000 . Origin, Program, and Operation of the U.S. National Health Survey. 35 cents. Health Survey Procedure: Concepts, Questionnaire Development, and Definitions in the Health Interview Survey. 45 cents. . Development and Maintenance of a National Inventory of Hospitals and Institutions. 25 cents. Series 1. Programs and collection procedures No. 1 No. 2. No. 3 No. 4. Plan and Initial Program of the Health Examination Survey. Series 2. Data evaluation and methods research No. 1. Comparison of Two-Vision Testing Devices. 30 cents. No. 2. Measurement of Personal Health Expenditures. 45 cents. No. 3. The One-Hour Glucose Tolerance Test. 30 cents. No. No. No. No. No. . Comparison of Two Methods of Constructing Abridged Life Tables. 15 cents. An Index of Health: Mathematical Models. 4 5 6. Reporting of Hospitalization in the Health Interview Survey. No. 7. 8 9 0 Health Interview Responses Compared With Medical Records. . Comparison of Hospitalization Reporting in Three Survey Procedures. . Cooperation in Health Examination Surveys. Acute Conditions, Incidence and Associated Disability, United States, July 1961-June 1962. 40 cents. Family Income in Relation to Selected Health Characteristics, United States. 40 cents. Length of Convalescence After Surgery, United States, July 1960-June 1961. 35 cents. Current Estimates From the Health Interview Survey, United States, July 1962-June 1963. 35 cents. Impairments Due to Injury, by Class and Type of Accident, United States, July 1959-June 1961. 25 cents. . Disability Among Persons in the Labor Force, by Employment Status, United States, July 1961-June 1962. 40 cents. Types of Injuries, Incidence and Associated Disability, United States, July 1957-June 1961. 35 cents. Medical Care, Health Status, and Family Income, United States. 55 cents. Acute Conditions, Incidence and Associated Disability, United States, July 1962-June 1963. 45 cents. Health Insurance Coverage, United States, July 1962-June 1963. 35 cents. Bed Disability Among the Chronically Limited, United States, July 1957-June 1961. 45 cents. Current Estimates From the Health Interview Survey, United States, July 1963-June 1964. 40 cents. Illness, Disability, and Hospitalization Among Veterans, United States, July 1957-June 1961. 35 cents. Acute Conditions, Incidence and Associated Disability, United States, July 1963-June 1964. 40 cents. Health Insurance, Type of Insuring Organization and Multiple Coverage, United States, July 1962-June 1963. 35 cents. Chronic Conditions and Activity Limitations, United States, July 1961-June 1963. 35 cents. Cycle I of the Health Examination Survey: Sample and Response, United States, 1960-1962. 30 cents. Binocular Visual Acuity of Adults, United States, 1960-1962. 25 cents. Blood Pressure of Adults, by Age and Sex, United States, 1960-1962. 35 cents. Blood Pressure of Adults, by Race and Region, United States, 1960-1962. 25 cents. Selected Dental Findings in Adults, United States, 1960-1962. 30 cents. Weight, Height, and Selected Body Dimensions of Adults, United States, 1960-1962. Findings on the Serologic Test for Syphilis in Adults, United States, 1960-1962. No. 10. Hospital Utilization in the Last Year of Life. Series 3. Analytical studies No. 1. The Change in Mortality Trend in the United States. 35 cents. No. 2. Recent Mortality Trends in Chile. 30 cents. Series 4. Documents and committee reports No reports to date. Series 10. Data From the Health Interview Survey No.“ 1. No. 2. No. 3. No. 4. Disability Days, United States, July 1961-June 1962. 40 cents. No. 5. No. 6. No. 7 No. 8. No. 9. No. 10. No. 11. No. 12. No. 13. No. 14. No. 15. No. 186. No. 17. Series 11. Data From the Health Examination Survey No. 1. No. 2. Glucose Tolerance of Adults, United States, 1960-1962. 25 cents. No. 3. No. 4. No. 5. No. 6. Heart Disease in Adults, United States, 1960-1962. 35 cents. No. 7. No. "8. No. 9. Series 12. Data From the Health Records Survey No reports to date. Series 20. Data on mortality No reports to date. Demographic Characteristics of Persons Married Between January 1955 and June 1958, United States. 35 cents. Series 21. Data on natality, marriage, and divorce No. 1. Natality Statistics Analysis, United States, 1962. 45 cents. No. 2, Series 22. Data from the program of sample surveys related to vital records. No reports to date. PUBLIC HEALTH SERVICE PUBLICATION NO. 1000-SERIES 1-NO. 4 NATIONAL p CENTER Series 1 For HEALTH Number ) STATISTICS Plan, Operation, and LC CR ET ER EERIE] WO) Children’s Examinations U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Public Health Service Fublication No. 1000-Series 1-No. 5 For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C., 20402 - Price 40 cents NATIONAL CENTER| Series 1 For HEALTH STATISTICS Number 5 VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES Plan, Operation, and Response Results of a Program of Children’s Examinations / A description of the Health Examination Survey's second cy- cle, examinations of a probability sample of United States children 6-11 years of age. Washington, D.C. October 1967 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service John W. Gardner William H. Stewart Secretary Surgeon General NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Acting Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, PH.D.,, Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Acting Assistant Director for Research and Scientific Development ALICE M. WATERHOUSE, M.D., Medical Consultant JAMES E. KELLY, D.D.S., Dental Advisor LOUIS R. STOLCIS, M.A., Executive Officer DONALD GREEN, [nformation Officer OFFICE OF HEALTH STATISTICS ANALYSIS IWAO M. MORIYAMA, PH.D., Director DIVISION OF VITAL STATISTICS ROBERT D. GROVE, PH.D, Director DIVISION OF HEALTH INTERVIEW STATISTICS ELijAH L. WHITE, AM., Director DIVISION OF HEALTH EXAMINATION STATISTICS ARTHUR J. McDOWELL, Director DIVISION OF HEALTH RESOURCES STATISTICS SIEGFRIED A. HOERMANN, Director DIVISION OF DATA PROCESSING LEONARD D. McGANN, Director Public Health Service Publication No. 1000-Series 1-No. 5 Library of Congress Catalog Card Number 67-61853 PREFACE This report is primarily a description of one of the major programs of the National Center for Health Statistics, It is, therefore, most appro- priately classified in Series 1, It is not, however, purely a program description since it includes the results of the execution of the program with re- spect to response, Thus it represents for the sec- ond cycle of the Health Examination Survey a combination of two reports related to the first cycle—Series 1, Number 4 (program description), and Series 11, Number 1 (response results), The process of planning this program has been described in considerable detail in this re- port. This description is primarily a necessary foundation for understanding and use of the findings reports to be published later, It is hoped that it will serve also as an aid to others facing some- what similar problems in planning examination surveys, In the course of the description, acknowledg- ment is made of some of the assistance received from individuals and groups within the Public Health Service and elsewhere, Space does not per - mit anything like full recognition of those who have participated. Mention should be made here, however, of the important role played by the U.S, Bureau of the Census. Under a contractual ar- rangement they have participated in the survey planning and sample design, selected the sample, conducted the initial household interviews, and carried out part of the data processing, The exam- ination phase of the plan was worked out and generally supervised by Dr, Alice M, Water- house, then Medical Advisor to the National Center for Health Statistics, Dr. James E. Kelly and Dr. Lawrence E. Van Kirk, Jr., Dental Advisors to the Center and the Division of Health Ex- amination Statistics, respectively, and Dr. Lois R. Chatham, Psychological Advisor to the Divi- sion. This report was prepared by Arthur J. McDowell. CONTENTS PP LOIRE = = weir mmm oe mre 0 0 0 0 em Introduction ~-====-==-========-=--m-=m--o--=s--ss-SSsooSSSSoSmoSSooEETEoT General Pattern of Successive HES Programs-------=-----=--=-=-=-=-==-==--~ The Organization by Cycles --=-= === ‘=~ sm=m===========m=n==—===—==s The Three- Level Operation Concept---=--==-=-=--======--==--=--==-=---==°""~ Common Characteristics of Successive Cycles-------=-===-=-==---=--=-=-~ Developing the Detailed Plan--------=---=--=-====----=-===---o-==o=ooos Preliminary Studies And TEBlS= mm === xm mn www = mm wm mn som tm mimi mie The LOgGIStICE-===-=====n=m=m===s====mmemee=o mmm === mmo m mmm Mobile Examination Centers and Field Staff-----------------------=---~ Sequencing and Scheduling Stands--------==--=-=-==-=----==---"oooToTo Advance Arrangements and Coordination-----=--==-=--=--=---===-=-=-----°~ The Household Interview and Final Stages of Sampling--------==-------- Appointment and Transportation Procedures-----=--=-=-----====-=-=---=-= Nature of the Examination--------=--=--=========----=-====-=-=---=--===-=-=-== General Considerations -----=-=====-=====-====== —====-=c-==-==--==-=---=== The Examination by Physician and Nurse-------------------------=°°-°~ The Dental and Vision Examinations-------=-==-=-=-=--===-==-==----=---=°° Poychological ToMiNre = mam mm oon S00 a 2% wm mo iso sm 0.2 mi on Tests, Procedures, and Measurements Done by Technicians------------- aro WwW Ww NN == OO oO ONO 10 12 13 15 17 17 17 19 20 21 21 CONTENTS--Con. The Ancillary Data Collected------- General Considerations -------- Response Results ----=-----oco--- Level of Participation Achieved- - Differentials in Response Among Demographic Subgroups---------------- Reasons for Sample Persons Not Cooperatilige «www mwwsmwws sn sm REIT CIICES = mmm mom mn 0 mt im mm i i 08 0 0 mm mm Appendix 1, IA, IB. IC. ID. IE, IF, Appendix II, Appendix III, Selected Forms Used CYele I mm wm mmm me we wm wim mim sm wi National Health Survey Questionnaire ---------- cco _____ Child's Medical History-—Parent------ - «=-=coeeeoo________ Health Examination Survey II—Audiometry --------=-==couun. Health Examination Survey Il-- Body Measurements ---------- Supplemental Information From School-----=-ecooe coo. Child's Medical History-— Interviewer ----=--=-eooeoooooooooo Audiomerry Testing ProceUrege = a= www wm cme mmm wm mins Estimation Procedure 26 27 27 28 31 33 35 35 40 46 47 48 50 54 56 SYMBOLS Data not availableg=======mmemmemmeemn——- Cotagory NOL APPLCADLE mm mmm wm sit soe = QUANLIly ZErO=======mmnm==—==——==——————— Quantity more than 0 but less than 0.05--=-~- Figure does not meet standards of reliability or precision--========mwe—=-—- THIS REPORT IS a detailed description of the second program of the national Health Examination Survey. This survey involved selection and examination of a probability sample of the nation's noninstitutionalized children between the ages of 6 and 11 years. The examination focused particularly on factors related to growth and development. It included examination by a physician, a variety of tests, procedures, and measure- ments, examination by a dentist, and tests administered by a psycholo- gist, The report describes the development of the survey plan, the sam- ble design, the content of the examination, and the operation of the survey, including steps taken to combat measurement evvor. It also presents the response results of the survey, The Health Examination Survey second cycle program succeeded in ex- amining 96 percent of the 7,417 children selected for the sample. This very favorable response vate showed expected variations by population- density groups and some other variables, but the differences were slight, Thus, for example, the range of variation among the 40 locations visited was quite limited. The lowest response at any location was 90 percent, and at two locations 100 percent of the sample childven were examined. The report discusses factors related to response rates. PLAN, OPERATION, AND RESPONSE RESULTS OF A PROGRAM OF CHILDREN'S EXAMINATIONS INTRODUCTION The Health Examination Survey is carried out as one of the major programs of the National Center for Health Statistics, It is a part of the National Health Survey, authorized in 1956 by the 84th Congress as a continuing Public Health Serv- ice activity, The National Health Survey consists of three different survey programs. One of these, the Health Interview Survey, is primarily concerned with the impact of illness and disability upon people's lives and actions and the differentials observable in different population groups. It col- lects information from the people themselves by means of household interviews, A second, the Health Records Survey, actually is a family of record-linked surveys, It includes follow-back studies based on vital records, institutional sur- veys to establish sampling frames as well as to provide data, and surveys based on samples of hospital records. The third major program of the National Health Survey is the Health Examination Survey (HES). The Health Examination Survey collects data by direct physical examinations and tests and measurements performed on the sample popula- tion studied. This is the best way to obtain definite diagnostic data on the prevalence of certain medi- cally defined illnesses. It is the only way to ob- tain information on unrecognized and undiagnosed conditions—in some cases, even nonsymptomatic conditions, It is also the only way to obtain dis- tributions of the population by a variety of physical, physiological, and psychological measurements. It provides these data for a known population and simultaneously provides the demographic and socioeconomic data required for analysis, Because the Health Examination Survey col- lects a wide range of kinds of data on each of the sample persons examined, it is possible to investi- gate many different interrelationships. In addition to exploring the obvious differentials in disease prevalence related to demographic or socio- economic factors (age, sex, income, education, and the like), it is possible to relate one set of medical findings to another or to other kinds of data col- lected in the examinaton, Thus data on visual acuity can be related to school achievement, find- ings of an eye examination, scores on psycho- logical tests, and other items, The possibility of studying interrelationshipsis not limited to those already known to exist. Suspected relationships can be investigated, and examination of the col- lected data may even reveal relationships hitherto unsuspected, GENERAL PATTERN OF SUCCESSIVE HES PROGRAMS The Organization by Cycles The Health Examination Survey program is carried out as a series of separate programs, each one with a specific set of goals, These suc- cessive programs are referred to as "cycles," Each cycle is concerned with some specific seg- ment of the total U.S, population and with certain specified aspects of the health of that subpopula- tion, Thus thefirst cycle obtained data on the prev- alence of certain chronic diseases and on the distribution of various measurements and other characteristics in a defined adult population, The second cycle concerns a different population, chil- dren between the ages of 6 and 11 years, and the examination focuses on factors related to growth and development, The third cycle covers a sample of youths between 12 and 17 years of age. The first cycle began examinations in Novem- ber 1959 and completed the last of the field work 3 years later, in 1962. The examination was de- signed to determine the prevalence of the several cardiovascular diseases, arthritis and rheuma- tismi, and diabetes. Various measurement data were ' gathered, including visual and auditory acuity, blood pressures, electrocardiographic tracings, and numerous body measurements. A dentist examined teeth and mouths, The sample population was representative of the total civil- ian, noninstitutionalized U.S. population between the ages of 18 and 79 years inclusive, Reports already published from the first cycle include the program description,? various methodological reports, 310 and a growing group of reports of find- The Three-Level Operation Concept The plan of operation which has developed for the Health Examination Survey involves what is referred to as three-level operation. This ex- pression describes a pattern whereby inany given period the survey is operating simultaneously on three different levels—data collecting, cycle planning, and analysis of findings. At a particular time, for example, when the examinations are being carried out for Cycle II, the work of tabu- lation, analysis, and publication of findings from Cycle lis also proceeding. During that same period of time the planning and preparing for Cycle III is being worked on so that when all examinations are completed in Cycle Il the process of examining in Cycle Ill can begin. There are a number of reasons for this three-level operation, but the principal one is to avoid complete dismantling of a field apparatus between examining phases of successive cycles. Common Characteristics of Successive Cycles In addition to the broad mission and general operating pattern which have been described, a number of basic characteristics are common to all the cycles of the Health Examination Survey. Some of these are strengths; others are limita- tions. All HES programs make use of probability sampling. This is a sine qua non for a national health examination survey since the examination process obviously involves time, skill, and cost factors that preclude its use on any but a rather limited scale. Probability samples make possible generalizations concerning the population from which the sample is drawn with some knowledge of how reliable the generalizations are. All the programs collect cross- sectional data on a national sample of the noninstitutionalized population, The numbers involved in the national sample permit some analysis by broad geographic region or by population-density groups or other major subgroups of the total sample, but they do not permit detailed geographic breakdown of the data. No information by State, for example, will be forthcoming from these programs, The data collected relate to a particular point in time; no longitudinal data are presently being collected through any followup of examined persons. The samples studied in each of the cycles are limited to the noninstitutional population. The programs all represent a multidiscipli- nary approach to research, In each of them mem- bers of many different professions combine their efforts, including statisticians, physicians of vari- ous specialties, dentists, psychologists, nurses, educators, sociologists, and management special- ists. The programs also involve interagency collaboration, The U.S. Bureau of the Census isa partner in many phases of the survey. Many other agencies advise and assist in various ways— Federal agencies such as the National Institutes of Health, the Office of Education, and the Chil- dren's Bureau, to name but a few, and agencies outside the Government such as medical research centers, schools of public health, and survey re- search agencies, A basic premise underlying all the programs of the National Center for Health Statistics is that findings should be made available to all in- terested persons as rapidly as possible, This is done primarily through the publication of reports prepared in a form usable by large numbers of consumers of health statistics and yet at the same time organized so that a medical research worker interested in particular problems can obtain rele- vant data by looking ata minimum of data in which he is not interested, The principal reports are published in the various Vital and Health Statistics series, THE PLANNING PHASE OF CYCLE I Guidelines at Outset The foregoing description of the general pat- tern of successive cycles of the Health Examina- tion Survey indicates some of the broad guidelines that were available at the outset of the planning phase of Cycle II. Thus it was clear early in 1961 that the second cycle would study a probability sample of a segment of the national population, would exclude institutionalized persons, and would collect cross-sectional data related to health which require direct examination, testing, and measuring of the individuals in the sample. The first step in establishing the basic guidelines spe- cific to the plan for the second cycle was to add to these general guidelines the specific targets for Cycle 11. The determination of the broad targets for the second cycle, the population segment to be studied and the general objectives of the study, was made arbitrarily but only after widespread consultation with many users of the kinds of data which the Health Examination Survey is able to produce, One formally constituted body, which played animpor- tant part in the process, was the Advisory Com- mittee to the Surgeon General on the National Health Survey. This was a broadly based group of experts who represented a wide range of inter - ests in the health field. In addition advice was obtained from an advisory group composed of rep- resentatives of various agencies within the Depart- ment of Health, Education, and Welfare and a like group of representatives of many other Federal Government departments. Apart from consulting with formally established groups, there were a considerable number of contacts with individuals prominent in the field of medical and health sta- tistics throughout the country. A number of schools of public health, medical research centers, and like agencies were also contacted, “” 2 During the early stages of this consulting, .~ - the individuals contacted were asked to indicate the different kinds of studies which they felt were most needed and were appropriate to the method, They indicated their relative priorities for differ- ent kinds of studies, and these were considered along with other general guidelines to determine the broad targets, Broad guidelines for the second cycle, in addi- tion to those already discussed, included the fol- lowing: 1. The data collection mechanism developed and proved through the first cycle will be used with appropriate modifications, 2. Experienced and qualified personnel in the field staff will be retained to the extent necessary to perform the data collection operation in Cycle lI, 3. The total period of data collection for Cycle II will be between 2 and 3 years, 4, Certain cost factor limitations such as the budget loads projected for each of the fiscal years 1962 and 1963 will be ob- served, 5. The schedule developed will take account of climate and will provide a safety factor so that if the operation terminates prior to completion of all examinations, a smaller but still representative subsam- ple will have been included, 6. The Bureau of the Census will collaborate in the sample design and selection work and will carry out the first phase of the field interviewing in the survey, 7. The detailed plans developed for the study will be tried out in at least one full-scale pilot project operation prior to initiating the data collection for the sample, Se ¥ en, a Dy: TN ~ By mid-1961 a determination had been made that the second cycle program would involve the examination of a probability sample of children and that the focus would be primarily upon factors related to growth and development, The aim of the survey would be to collect considerable infor- mation on health characteristics and to obtain distributions of the population by various physical and physiological measurements. Developing the Detailed Plan Throughout the latter part of 1961 and early part of 1962 the work of planning the second cycle proceeded and intensified. The process of con- sulting with numerous interested individuals and agencies was continued, but now the inquiries were more specific, It having been determined to col- lect data on growth and development in children, such questions as these hadtobe answered: "What specific body measurements should be made and in what manner?'' "How should visual acuity be determined?’ "What kind of information should be collected in the medical history?" During the process of developing the more detailed plan, it became necessary to modify the original concept in various ways, At the beginning it had been tentatively decided that the age group to be studied in Cycle 11 would be persons between the ages of 6 and 17 years inclusive. As the de- tailed planning proceeded, however, it became apparent that the differences between persons in different age segments of this population group were so great as to require separate programs. Such matters as feasibility of self-administered tests, type of motivational approaches to be used, sizes of some of the supplies and equipment, and adverse effect on participation on the part of teenagers in a program that seemed to bea ''chil- dren's" examination—all these and other consid- erations led to a decision to limit the age range. It was decided to redefine the Cycle II target population as children between the ages of 6 and 11 years inclusive and to follow this program with a third cycle which would have youth at ages 12 to 17 years inclusive as its target population, The development of the sample design was, of course, an important aspect of the planning process. It was carried out concurrently with the determination of the content of the examination 4 and the detailing of the operating procedures. These are discussed later in this report in some detail. Here it may be noted that the specific uni- verse to be sampled was defined as consisting of . all children who were 1. Between the ages of 6 aud 11 years in- clusive regardless of whether they at- tended school. 2. Residents of the United States (including Alaska and Hawaii), 3. Not confined to an institution. 4. Not residing upon any of the reservation lands set aside for use of American Indi- ans, The determination as to appropriate status with respect to conditions 1, 2, and 3 made on the date of the household interview (the first contact in which the necessary information was obtained) was to govern in establishing sample versusnon- sample status, While the process of developing the detailed plan for the second cycle resulted in some delimi- tation of the orginal concept (as with the age range), it also produced some expanding of the goal of the examination. It was recognized from the beginning that the lowness of prevalence rates of chronic disease in the age group considered meant that the focus would have to be on measure- ments and on factors related to growth and devel- opment. As the plan focused more sharply on the most important factors to be studied, it became apparent that in this age group it would be essential to collect some data relevant to the intellectual growth and development of the children, It ap- peared desirable also to obtain some sort of measure of factors related to the development of personality. The decision to include collection of some psychometric data in the second cycle plan in- volved the addition of yet another discipline to the already multidisciplinary research team, Corn- sultations were begun with psychologists, and a number of experts in this field joined with the physicians, dentists, anthropologists, statisti- cians, management specialists, and others in de- veloping the plan, Within each of the named dis- ciplines there were various specialty subgroups involved— pediatricians, otolaryngologists, child development specialists, orthodontists, physicists specializing in the optics of vision, statisticians specializing in sample design, psychologists ex- pert in behavior of children, and anthropologists skilled in human engineering problems, The list is not complete, but it is long enough to suggest the extent to which compromises had to be made and priorities assigned since all that everyone felt was necessary could not possibly be included, Preliminary Studies and Tests The planning phase of Cycle II included a number of different kinds of preliminary studies and tests, some of them involved and some fairly limited. In a few instances it was possible to take advantage of work that had already been done in some other connection, Thus one of the important areas of interest concerned the levels of auditory acuity, It had been recognized that there was need for new standards with respect to hearing levels in children. The American Academy of Ophthal- mology and Otolaryngology had established the Subcommittee on Hearing in Children to work in the development of such new standards, This group had carried out a series of studies of school chil- dren in the Pittsburgh area, had developed the detailed content and form of the examination and the kinds of equipment required, andhad acquired considerable experience in measuring auditory acuity in children, This group was interested in the survey because it would afford the chance to establish norms for the total national population, From the viewpoint of the Health Examination Survey, the work which this subcommittee had completed provided extremely valuable develop- mental work, Arrangements were made for execu- tive director of the Subcommittee on Hearing in Children, Dr, Eldon Eagles, to serve as a con- sultant to the Health Examination Survey, The audiometric portion of the second cycle examina- tion was based on the work that had been done in the Pittsburgh studies. Dr. Eagles supervised the training of the technicians for the Health Examina- tion Survey, and the Acoustical Laboratories of the University of Pittsburgh agreed to perform the calibration of the instruments used, Various other benefits accrued to the program as a result of the cooperative arrangement, In this instance, the survey had essentially no developmental work to do because this had all been done in connection with the subcommittee activity. With respect to the medical history instru- ment to be used, a methodological study was carried out to determine the form and to develop the exact wording of the inquiries. This was done for the survey by the Survey Research Center, affiliated with the University of Michigan, and was under until the planning was fairly well under way. Because of this late start, some of the methodo- logical work in this area had to be delayed until after the second cycle was actually in the data collection phase. An example is a contract study to develop recommended methods of evaluating and analyzing the results of the modified Thematic Apperception Test which was being used. This study was undertaken by the Institute of Behavioral Research, Texas Christian University, and was under the direction of Dr, S, B. Sells, Preceding the institution of actual data col- lection in Cycle II, there were two separate pilot test operations carried out, The first of these was an early partial pilot test conducted in Decem- ber 1962 in Rocky Mount, North Carolina. This location had been the last of the 42 areas to be surveyed in connection with the Cycle I operation and the pilot test was carried out to get informa- tion on the attitudes which parents would have toward their children's participation in such a program, to gain more information on how well the children could perform certain tests, to ex- plore ways in which arrangements could be made with schools for necessary released time, to de- termine the pattern of scheduling which would be most effective, to try out the proposed medical history questionnaire, and to gain some experience in carrying out a survey in the age group 6-11 years, Approximately 70 children were examined in the Rocky Mount Pilot Test, The operation pro- vided answers to some of the questions that were being asked and gave a basis for further planning work on many other items, The work of planning the second cycle con- tinued during the next 3 months, and in March and April of 1963 a further pretest of the examination Sei. 5 the direction of Dr, Charles Cannell, .~ The determination to include psychometric tests in the second cycle program was not made = plan was carried out in Wilmington, Delaware, Certain modifications in plans that had been made on the basis of the first pretest were put into effect for this major pilot project, in which about 180 children were examined, Following this pilot study some further modifications were made and the second cycle data collection phase was initiated in July 1963. THE SAMPLE DESIGN General Plan The sample design for the second cycle of the Health Examination Survey is quite similar to that used for Cycle I, The National Center for Health Statistics set specifications for the sample, developed the overall design, and carried out some of the steps of drawing the sample. Other steps in the sample selection were performed by the Bureau of the Census under a contract arrange- ment, The sample design is that of a multistage, stratified probability sample of loose clusters of persons in land-based segments, The succes- sive elements dealt with in the process of sampling are primary sampling unit (PSU), census enumer- ation district, segment (a cluster of households), household, eligible child, and finally, sample child. The total number of children in the United States (including Alaska and Hawaii) who met the general criteria for inclusion in the universe sampled was about 24,000,000. This was the esti- mated U.S. population between the ages of 6 and 11 years inclusive as of mid- 1964 excluding small numbers who were residing in institutions or re- siding outside the United States. It was decided to select a sample of close to 8,000 persons, a sam- pling fraction of about 1/3000. The distribution of the population in the 6-11 age group is fairly even over this range, and so there should be about 1,000 persons in each of the single years of age. Since the second cycle places much emphasis on factors related to growth and development and since year-by-year change is important in this period of growth, it was felt necessary to have a large enough sample to permit analysis of much of the data by single years of age. Stratification and Selection of PSU's The first stage of this multistage process consisted of the selection of PSU's, It was in this stage that stratification was carried out, In con- nection with the Current Population Survey and the Health Interview Survey the entire United States had been divided into nearly 2,000 PSU's and these had been grouped into 357 strata. (Each PSU is a standard metropolitan statistical area (SMSA), a county, or agroup of several contiguous counties.) The sample selection process for the second cycle started with these 357 strata and grouped them into 40 superstrata which are re- ferred to as the strata of HES Cyclell. The aver- age size of each Cycle II stratum was 4.5 million persons, and all fell between the limits of 3.5 and 5.5 million. The grouping into 40 strata was done in a way that maximized homogenity of the PSU's included in each stratum, particularly with regard to degree of urbanization, geographic proximity, and degree of industrialization. The 40 strata into which they were grouped were classified into 4 broad geographic regions (each having 10 strata) and cross-classified into 4 broad population-den- sity groups (each having 10 strata). Eachofthe 16 cells resulting from the 4x4 cross-classification on geography and population density contained either 2 or 3 strata. A single stratum then might include only one PSU (or even only part of a PSU as, for example, in the New York City SMSA which was determined to represent two strata), or it might include several score PSU's. The four broad geographic regions into which the HES strata were classified were groupings of States which approximated the Bureau of the Cen- sus regional groupings. The HES nortl.castern classification was identical to the corresponding Census region, The HES midwestern group dif- fered from the Census North Central Region in that it did not include Kansas, Nebraska, and the Dakotas. The HES southern classification differed from the Census South Region in that it did not include Texas and Oklahoma, The six States speci- fied above were included in the HES western grouping along with other States in the Census West Region, Figure 1 shows the sample areas. WESTERN REGION Yq HAWAII BS nnn Caravan | wm wmm= Caravan || ems Combined Single Team NORTHEASTERN REGION MIDDLEWESTERN REGION Figure I. Map showing sample areas and itinerary: Health Examination Survey Cycle I. The four population-density groups divide the United States into four roughly equal parts, It was necessary to combine ‘some urban counties with rural areas because of the continuing dimi- nution of the rural portions of the country, The population-density groups were defined differently for the four geographic regions, the attempt being to obtain a reasonable division of each region into the following four classes: 1. The largest metropolitan areas 2. SMSA's of specified size 3. Other SMSA's or specified highly urban areas 4. Other and rural areas For the Northeast Region, New York City's two SMSA's and Philadelphia made up the entire three strata in Class 1. Class 2 in that region con- sisted of other SMSA's of over 1,000,000 population grouped in two strata, Class 3 consisted of the remaining SMSA's and Class 4 of all other urban and rural areas, For the Middle West the strata in Class 1 con- sisted solely of the Chicago and Detroit SMSA's, Class 2 was made up of the other larger SMSA's, most of them over 500,000 in population, Class 3 and Class 4 were other SMAS's and allother areas, respectively, { RN Sy In the South, the largest metropolitan areas class included all SMSA's over 700,000. Class-2__ ~~ Tt Ma eR included all other SMSA's, Class 3 consisted of a specified group of highly urban areas. The other areas made up Class 4. In the West Class 1 was defined as consisting of three strata, two of them the two Los Angeles SMSA's and the other including San Francisco and Seattle SMSA's. Class 2 included all other SMSA's over 550,000 population, The other SMSA's were grouped into two strata in Class 3, and all other areas made up Class 4. Table 1 shows the number of strata in the second cycle classified according to population- density groups and broad geographic regions. There was a third axis of stratification used in selecting the 40 PSU's for the second cycle. This pertained to the rate and direction of change in the population between the 1950 and 1960 census. The rationale here was that two localities in the same geographic region and with the same population density may differ markedly in ways related to health status if they have different rates of popula- tion change. A midwestern city of 400,000 may be quite different if on the one hand its population has remained constant over the past decade or on the other hand it has doubled its population dur- ing the past 10 years. To take account of rate of change of population, the design specifications provided that within each region the 10 PSU's would be further classified in- to four classes ranging from those withno increase in population to those with the greatest relative increase. Each such class contained either two or three PSU's, Having classified the PSU's into 40 strata with the subgroupings indicated above by region, population-density groups, and rate of change of population, the selection of PSU's for the HES sam- ple was made by selecting one PSU from each of the 40 strata. The technique used was one of controlled selection with the probability of selec- tion of a particular PSU being proportionate to its 1960 population, In the controlled selection tech- nique the attempt was made also to maximize the spread of PSU's among the States, subject however to all the limitations already laid down for the sample, It will be evident that the complete stratification implies a three-dimensional 4x4x4 grid, and that not every one of the 64 cells con- tributes a PSU to the sample of 40 PSU's, Never- theless, the controlled selection technique ensures the sample's matching the marginal distributions in all three dimensions and being closely rep- resentative of all cross-classifications. Further Stages of Sample Selection Having selected the 40 sample PSU's, the further successive stages of sample selection called for selecting census enumeration districts (ED), segments, households, eligible children (EC), and finally, sample children (SC). All but the last two of these steps were carried out at headquarters prior to actually beginning the sur- vey in a particular PSU. In selecting the ED, segments, and house- holds, account was taken of the PSU's 1960 popula- tion in the age group 5-9 years, Thus the prob- ability of selection of a particular one of the ED was proportional to its population in that age group at the 1960 census date, which by 1963 roughly Table 1. Number of HES Cycle II strata, by population-density group and geographic area, 1963-65 Number of strata Population-density group North- | Middle Total east West South | West TOLER Lr wee wv cr cs mm mm om am wt 0 0 mr me 40 10 10 10 10 Largest metropolitan areas-----========-====-----= 10 3 2 2 3 SMSA's of specified size-=-====mmmm=-===--mecean=— 10 2 3 3 2 Other SMSA's or specified highly urban areas------ 10 3 2 3 2 Other and rural areas-==-==-==-==---c-c---=-com=o=- 10 2 3 2 3 approximated the population in the age group that is the target of the second cycle. (The use of the 5-9 group was, of course, dictated by convenience since information about this group was readily available.) Generally in a particular PSU, 10 ED were selected by a controlled selection technique. Then a similar selection was made of two segments in each one of the ED. Each of the resultant 20 segments was either a bounded area or a cluster of households (or addresses), The size of a seg- ment was variable and was related to the 1960 population of children aged 5-9, It was expected to yield approximately 10 children in the age range 6-11 years at the time of the survey, Thus the expected yield per PSU was approximately 200, This feature of the sample design resulted in con- siderable variation among the PSU's in the number of households selected. In many of the sample PSU's this number was about 500, or about 25 per segment; in some, the number was more than dou- ble this. Thus, for example, in Sarasota, Florida, the sample design produced more than 1,000 households, and in Grand Rapids, Michigan, it produced fewer than 500. The total number of EC in each of these locations, however, was nearly the same, The final stages of the sample selection, identification of EC and designation of SC, were carried out in the field immediately prior to the start of examinations in the particular PSU, The earlier steps in the sample selection process generally produced lists which identified each individual household selected in terms of the ad- dress and the name of the head of the household at the time of the 1960 census, (This last item was for convenience in those cases where it was still relevant; the household presently occupying that address was the one within scope of the sur- vey.) Each of the households was visited and a listing of all members of the household provided the information on EC. All children in the age range properly resident at the address visited were EC, When the visits to households had been completed to the point where the total number of EC could be estimated fairly closely, a determina- tion was made as to the pattern to be followed in reducing that number to the desired number of SC. The EC to be excluded from the SC group were determined by systematic subsampling. Special Problems Early in the work of planning the second cycle it became apparent that the schools should play an important role in the program. Almost all of the population in the age group 6-11 years are in school for a large part of the time they could be examined. Thus, at a minimum, it would be nec- essary to have cooperation of school officials in releasing the children chosen to participate in the program, Beyond this, however, it was felt that a sample design which used the school populations as an element of stratification might have opera- tional advantages, If, for example, in a particular PSU it was possible to classify the total 6-11 population according to various groups of schools attended (including, of course, as one group the not-in-school children), a sample consisting of some appropriate number of sample children from one or more schools in each group might minimize the number of specific locations from which the sample children would come, It would, of course, be necessary to take proper account of various types of schools (public, parochial, private, and the like), of school size (number of students), and of some kind of socioeconomic classification of the schools (in terms of the predominant socioeconomic characteristics of the students enrolled), as well as other factors such as segregation in the regions where schools are segregated. Although some consideration was given to using the schools in this way as a sam- pling frame, the idea was abandoned, The principal reason for this decision was the unavailability of the necessary classificatory data concerning the schools. Another scheme considered in the early stages of planning was to utilize two different size samples with the smaller one a subsample of the larger. The concept was that it might be desirable to select an original sample of 15,000 to 25,000 children and to make certain observa- tions on all of this sample, The simpler elements of the examination—certain body measurements, for example—might be done on the larger sample, The smaller sample would be selected from this group and would be subjected to the additional examination and tests which require pediatrician time or special equipment and elaborate testing (e.g., audiometric tests). An important advantage of such a scheme is that it would permit a two- phase selection of the smaller sample and would provide poststratifying information that would re- duce sampling variance, In the further develop- ment of the plan this idea was dropped, however, largely because of the operational problems which it seemed to present, One other modification of the basic sampling designed to minimize the geographic spread of the sample persons was considered and was ac- tually used in a number of PSU's where examining was carried out in the first months of the second cycle. This was a subsampling stage involving the subdivision of a PSU into a number of dis- tricts—usually one central city area and four to six satellite areas. A random selection of some of the satellite districts was then made and all the sample in the central city and in the selected subareas or satellite districts was used for the household visit and final sampling. It was decided after a number of months' experience that the operational gains (in terms of further concentra- tion of sample persons in limited areas) were not essential to carrying out the survey, and so this subsampling stage was abandoned in later stands. Another special problem considered in the design of the HES sample for the second cycle concerns one of the effects of the clustering in- volved in the multistage sampling process, The sample children were chosen from among those in particular segments, those segments had been selected from sets of similar segments which taken together constituted the selected ED, the selected ED in turn had been chosen trom among the sets of ED which taken together constituted the PSU's, and so on, Typically, the result of cluster- ing of this type is to produce a sample having a somewhat higher sampling error than would be expected from a simple random sample of the same size. The introduction of clustering, how- ever, reduces unit costs and this permits an in- crement in sample size which more than offsets the loss in sampling efficiency. While there was no question but that clustering should be used in the survey, some consideration was given to whether the design should include some provision to control the selection of siblings. Since the household is one of the elements of the sample design, the number of related children in the resultant sample is greater than would come 10 from a design which sampled children 6-11 years old without regard to household. This merited some special attention since many of the statistics collected in the survey are affected by genetic factors. If a sample child is small of stature, say, or is myopic or is high on an IQ scale, a sibling of that child is somewhat likely to deviate in the same direction, Under the design used, it was necessary to visit about five households to obtain one house- hold with any eligible children, Of the households having children in the 6-11 years range, a little less than half had two eligible children or more. If only one of these had been taken in each case and if overrepresentation of one-child households were to be avoided, it would have been necessary to increase the original group of households visited by moré than 100 percent and would have considerably increased work of picking up and delivering the children, It was decided the advan- tage of obtaining a somewhat smaller variance by doing this was not great enough to justify the increased cost and difficulty. The chosen design contains the correct proportion of children from families having only one eligible child, from those having two eligible children, and so forth. The sample as a whole is properly representative of average measurement of the total population 6-11 years old, The fact that the sample contains a higher proportion of siblings than there would be in a systematic sample of every kik child does lead to some increase in variance but should pro- duce no bias in the various estimated mean meas- urements, for example, THE LOGISTICS Mobile Examination Centers and Field Staff The examinations in the first cycle had been carried out in specially constructed mobile ex- amination centers and it was decided to use the same plan for the second cycle, Eachof these two centers consisted of a set of specially designed trailers. The individual trailers making up a set were drawn by detachable truck tractors in making the move from one area to another, Then the trailers were set up side by side and covered passageways connected them to make the examina- tion center (fig. 2). Floor plan VITAL GAPAGITY PHYSICAL WASHROOM | EXAMINATION PSYCHOLOGICAL GRIP [STRENGTH J EXAMINATION sooy — MEASUREMENTS PHONO - CARDIOGRAM X-RAY DARK | DENTAL ROOM WEIGHT EXAMINATION HEIGHT VISUAL ACUITY PHOTOGRAPH RECEPTION WASH STAFF ROOM ROOM PSYGHOLOGICAL EXAMINATION || exercise | AUDIOMETRY TEST EXAMINEE ENTRANGE Caravan | - 4 trailers - each 35'x 8' Figure 2. Mobile examination center. The trailers which had been used in Cycle 1 were renovated and modified for the Cycle II ex- aminations. In addition it was found necessary to add a new trailer to each set in order to provide a better environment for carrying out the hearing test. The decision to cooperate with the Subcom- mittee on Hearing in Children has already been noted, Their work had established that the expected hearing levels in the age group 6-11 years were substantially below (better than) those for adults and that precise measurement of these levels would require a soundproof room-—not merely the soundproof booth that had been used for adult test- ing. The Subcommittee made available tothe sur- vey two specially constructed trailers (one for each set) which included a soundproof room along with other examining space. The field staff of the second cycle consisted of three elements. One of these elements was the examining staff operating within each of the mo- bile examination centers, This included a physi- cian, a nurse, a dentist, two psychologists, two technicians, atechnician'saide,anda coordinator, The second element of the field staff consisted of field office managers, administrative assist- ants, and HES representatives, all of whom worked either in or out of an office established near the site of the mobile examination center. This second element of the field team arrived earlier than the examination period, carrying out certain house- hold visits, scheduling, and related activities which are described later, There were one field office manager, two or three HES representatives, and one administrative assistant on duty at each location. Since some operations at a new stand began before all examinations ata preceding stand were concluded, the staffing patternhad to include some extra persons to provide for this overlap period. The third element, which also arrived ahead of the examining group, was a team of Census interviewers (usually five to seven per- sons) and a supervisor, Their work was completed during the week before the start of the examina- tions, The examining physician was in all cases either a senior resident or fellow in pediatrics. This staff member, unlike the others, was gen- erally employed only for a particular location, al- though some served later at other locations, Following visits by HES medical staff members 12 to numbers of medical schools and madical cen- ters, arrangements were made well inadvance for a physician to examine at a future stand, He was then given special training in the techniques of the particular survey. The examining dentist was a commissioned officer of the Public Health Serv- ice who continued on duty for 1 or 2 years in this position. The psychologists were temporary civil- ian employees of the Public Health Service and generally served from 3 to 9 months at various locations. Other members of the field staff (except for the Census employees) were full-time regular civilian employees of the Public Health Service. Sequencing and Scheduling Stands Among the general guidelines set forth above as constraints upon the plan of the survey were the requirements that the schedule take account of climatic variation and that it insure against the possibility of unrepresentativeness in the event the entire survey could not be completed. The former is a fairly obvious operational neces- sity; it would be impractical to conduct an ex- amination survey such as this in the northern parts of the United States in the middle of the winter. The sample areas in the northern states were scheduled for completion during the mid- summer months, and the areas in the Deep South were visited in the winter. This characteristic of the stand sequencing pattern is advantageous from an operational view- point, but it produces certain limitations in the resultant data. Because the sequencing of stands is controlled in this way the survey data cannot yield valid comparisons by geographic region for conditions which have a seasonal pattern, This is, perhaps, not too serious a limitation for many of the characteristics of particular interestinthe second cycle because they are not likely to exhibit seasonal variations, It seems likely that visual acuity levels, for example, will not be much dif- ferent regardless of the season of the year in which they are measured, It is obvious that this could not be said for such conditions as acute respiratory disorders. Even some of the body measurements taken such as weight may exhibit some seasonal variation, and this possibility must be taken into account in analysis of these data. The other major consideration which entered into the determination of the sequence and schedule of the various locations or stands was provision against possible termination of the program before all of the locations had been visited, The action taken was to make a subsample selection of 32 of the 40 stands which would provide a less desirable but somewhat representative smaller sample and then to aim ata schedule which would include most of those stands in the first three quarters of the schedule, Then if it had become necessary to cut back the total sample it would have been possible with very little rescheduling to end up having completed all of those 32 stands along with a minimum number of other stands. Another main constraint on the schedule and sequence was economy of operation, An effort was made to minimize the amount of travel nec- essary in moving from one stand to the next by sequencing with regard to geographic proximity, The map (fig, 1) and the schedule (shown be- low) which was followed in the survey illustrate the moves, Cycle II used two caravans, two com- plete examining teams, and two administrative teams, It will be noted that during the latter part of the survey only one mobile examination center was used, Advance Arrangements and Coordination The conduct of the survey in any specific location is, of course, a responsibility of the Public Health Service, not shared with States or local health authorities or with others inthe area, As a matter of policy, however, steps were always taken to fully inform the State and local health departments, and the medical, dental, and osteo- pathic professional organizations in the States and in the communities, In addition, since this pro- gram involved school children, the State and local officials concerned with public schools were al- ways contacted, as were the appropriate local and diocesan officials of the parochial schools, Typically, these contacts were made initially by a letter or telephone call giving a little informa- tion about the program and arranging an appoint- ment for a personal visit to discuss the plan in detail, The representative of the survey who vis- ited the health officials was usually a medical advisor to the program. The dental advisor always wrote the dental association in the area and fre- quently arranged a visitas well, The visits to State school officials were always preceded by a general information and introductory letter from the Office of Education, which had been kept informed throughout the planning of the program, The assistance given by Dr, Fred F, Beach, Director of Elementary and Secondary School Organization and Administration Branch, is gratefully ac- knowledged. Visits to the various officials at the State level were followed by visits at the county and city levels, The success of the survey owes much to the generous support it was given by health and edu- cation officials at every level, both public and private, This is exemplified, for example, in the June 1964 resolution passed by the House of Dele- gates of the American Medical Association ''to express its approval of the program of the U.S, National Health Survey and to recommend cooper- ation by State medical associations and component medical societies." At the State and local levels support was manifested in the cooperation obtained in informing physicians of the survey, Frequently this was done by means of an article in a pro- fessional publication distributed to all the physi- cians in the area such as the monthly bulletin of the county medical society; sometimes it was done through individual mailings of a leaflet provided by the survey. Correspondingly, communication from the dental society usually went to its mem- bers and the superintendent of schools sent letters to school officials who might be contacted individ- ually later, All of these steps increased the likeli- hood that the occasional inquiry about this program directed by a parent to the family physician or to the school principal, for example, would receive an immediate informed and favorable response, The staff in the Washington headquarters routinely prepared professional releases con- cerning the program and provided them for the uses described above in informing physicians and dentists, In addition general news releases were prepared concerning each location operation and distributed to local news media timed to precede by a few days the beginning of the field operation in that area. As a result at most of the locations there were from one or two to half a dozen or more news items or feature stories published con- cerning the program, In some areas local radio Cycle II schedule of stand operations Stand # Caravan I 1 Portland, Maine----====--~- 3 Poughkeepsie, New York---- 5 Boston, Massachusetts----- 7 Philadelphia, Pennsylvanig==—r=immwm=me= 9 Charleston, South Carolina----==-=--- 11 Sarasota, Florida--<==w==~- 13 Atlanta, Georgla~===wmmem=- 15 Baltimore, Maryland------- 17 New York, New York----=-=--- 19 New York, New Yorkl----=--- Cycle III pretest New York, New York--==-=-=-- 21 Grand Rapids, Michigan---- 23 Chicago, Illinois2-------- 25 Barbourville, Kentucky---- 27 Marked Tree, Arkansas----- 29 Houston, TeXage--===wwew=m= 31 Detroit, Michigans===wwmw- Cycle III pretest Detroit, Michigan--==-===-~- 32% Lapeer & Marysville, MAC LAT = ew mm iv id hm 0 me 34% West Liberty and Beattyville, Kentucky---- 335 Allentown, Pennsylvania--- 36% Manchester & Bristol, Connecticut-=--=-========== 38 Jersey City, New Jersey--- 40 Columbia, South Carolina-- Igoth examining and administrative teams, at 3 separate locations. team was used. set up while examinations were in process NO sisted of the PS 2Both examining and administrative teams,Caravans I and II,in Chicago; Beginning with Stand #28, The additional Date Caravan II Stand # July-Aug. 1963- Ashtabula, Ohio----=====--- 2 Aug.-Sept------ Ottumwa, lowa--=---=-==---- 4 Sept ~0ct= s=iwmm Denver, Colorado---------- 6 Oct.-Nov=--=-==-=-- Lamar, COloraqo- i= m=w=mms 8 Nov.-Dec-=-=--=-=-~- Los Angeles, California--- 10 Jan.-Feb. 1964- Los Angeles, California--- 12 Feb.-Mar------- San Francisco, California- 14 Mar .-Apr------- Mariposa, California------ 16 Apr.-May---=---- Moses Lake, Washington---- 18 May-June-July July-Aug-=------ Minneapolis, Minnesota---- 20 Aug .-Sept------ Neillsville, Wisconsin---- 22 Sept.-Oct=====~ Chicago, Illinois--------- 23 Oct .-Nov=-=-=-=---- Des Moines, Iowa----=-=----- 24 Nov.-Dec--=-=---~- Wichita, Kansas----------- 26 Jan.-Feb. 1965- Brownsville, Texas---=---< 283 Feb.-Mar.-Apr-- Birmingham, Alabama-=------ 30 Apr.-May------- Lapeer & Marysville, Michigane=m=====o ummm =—en 32% May-June-=--=--- Cleveland, Ohio~==~=wmuiniss 33 West Liberty and June-July------ Beattyville, Kentucky---- 34% JUly~Aug === ume Manchester & Bristol, Connecticut w= wemwamwwa~= 36% Aug .-Sept------ Newark, New Jersey-------< 3 Sept .-Oct.-Nov- Georgetown, Delaware------ 39 Nov .-Dec. use was made of both Caravans, but administrative staff enabled the succeeding stand to be at a given location. *Examinations held at 2 locations. Typical schedule for a stand Office setup----=-====-==-= Census interviewing------- HER followup-=-=-========== Trailer arrival----------- Trailer setup«~=======w===- Staff setup and training-- DEY TUNS»= = minim onion eis ion wm ExaminationSewnme==cwwwwn== Dismantle--=--m=======m=-- Trailer and staff move---- 1/22 Friday 1/25 Monday-1/29 Friday (5 days) Monday-To close of stand Tuesday Wednesday Thursday Friday Monday-3/1 Monday (16 days) Tuesday 3/3 (Number of TE: Stand locations are cities in which trailers were located. U's which may have included several counties. Caravan I only, in New York. Trailers were two locations. only one examining days dependent on distance) Sample areas con- or television stations initiated contacts and the survey staff cooperated in providing the basis for programs concerning the survey or participating in them, The publicity efforts were kept ata fairly low-key level since volunteers not only were not sought but could not be accepted and since coopera- tion of parents was excellent without any extensive publicity, It did prove useful occasionally, how- ever, for the interviewer tohavea clipping from a local newspaper to quickly indicate the authenticity of the program. Another kind of advance arrangements also had to be made in each area, These involved a visit by a survey staff member to determine an appropriate location for the mobile examination center and to initiate the many logistical actions required to conduct the survey, Arrangements were made for necessary electrical, plumbing, telephone, laundry, and other contractual serv- ices, Information on possible living arrangements was obtained and made available in advance to the staff, who then individually arranged their housing, Various local authorities such as the mayor and the chief of police were informed concerning the pending activities, The list of logistical measures which were required was a long one and the scheduling of the various steps had to be set far in advance to insure the smooth operation of the survey, The Household Interview and Final Stages of Sampling The foregoing discussion of the sampling plan had indicated that at the time the survey began operation at a particular location there was a list of addresses of households in particular clusters throughout the area, The Bureau of the Census sent a letter to each of these households informing them that they would shortly be visited by an interviewer collecting some information in connection with a health survey being made by the Public Health Service. At each of the listed households a Census interviewer made a visit and asked certain questions, The questionnaire used is shown as Appendix IA, Its contents are discussed in more detail later, but it may be noted here that the first group of questions asked of all households identified the composition of the house- hold. If there were no eligible children in the household (no children between the ages 6 and 11 years), the interviewer completed the interview with a few questions related to the possible pres- ence of another household on the premises. These abbreviated interviews required only about 5 min- utes, In the households in which the interview in- dicated there were eligible children, additional information was collected. The full interview usually required about 15 to 20 minutes, The final questions were asked only of the parent or guardian of the eligible child, the interviewer going back again if a parent was not present ini- tially, At the end of the full interview the inter- viewer gave the parent a medical history form to complete for each eligible child, She explained that a representative of the Public Health Service would come to the house in about a week to pick up the completed medical history, This form is shown as Appendix IB, When the household questionnaires have been completed by the Census interviewers, they are edited by the census supervisor for omission or inconsistencies and then turned in to the HES field management office. At this point the final stage of sample selection is carried out, A master list of all eligible children is prepared and is ordered according to segment and serial number, It will be recalled that the sample design provided for a variable number of households per segment, with the total number for any given location expected to yield approximately 200 eligible chil- dren, The actual number of eligible children was a variable which ranged from about 150 to 250. While the survey could tolerate some varia- tion in numbers of sample children at a location, operational considerations limited the maximum to about 200. At this final stage of sampling there- fore the actual yield of eligible children was the basis for a decision as to further sampling to re- duce the size to manageable limits, If the number was 200 or less no further reduction was made and all eligible children were regardedas sample children, If onthe other hand the number of eligible children was over 200, the rule for random reduc- tion in sample size was used, (The rule prescribed the deletion of every nth name in the list as or- dered above, starting with the yth name, y being a number between 1 and n selected randomly.) SITTING WEIGHT - ONE OF THE SERIES A TAPE RECORDING OF OF BODY SIZE MEASUREMENTS THE WEART SOUNDS. MEASURING VISUAL ACUITY MEASURING THE WEART RATE Arren exencise MEASURING BREATHING CAPACITY THE HEALTH EXAMINATION SURVEY The Health Examination Survey is part of the U.S. National Health Survey authorized by Congress in 1956. The purpose of the National Health Survey is to collect information about the health of Americans. This information will be used by medical researchers, educators, physicians, dentists, and many public and private agencies. Some information is collected by asking people questions about them- selves and their health. Other needed information can be obtained only by an actual health examination. In 1962 the Health Examination Survey completed a survey of health conditions of persons 18 through 79 years of age. About 7,000 adults throughout the United States participated in the special health exami- nation which was a part of that survey. During 1963 through 1965, the Health Examination Survey is con- ducting a survey of the health of children who are 6 through 11 years of age. Thousands of parents throughout the Nation will be asked questions about their children's health. Many of these parents wall be asked to have their child come toa Health Examination Center for a specia health examination. This examination is designed to provide infor- mation about the growth and development and the health of children at ages 6 through 11 years. The examination is given in a Health Examination Center which consists of several specially built mobile trailer units. Transpor- tation to and from the Center is provided by members of the Health Examination Survey. Arrangements are made with school officials when examinations are scheduled during school hours. All information obtained in the interview and in the health exami- nation is held in confidence. DESCRIPTION OF THE HEALTH EXAMINATION The special health examination of the Health Examination Survey is designed to provide information about the growth and development of children. It consists of the following: An examination by a pediatrician of eyes, ears, nose and throat, heart, and nerve and muscle systems. An electrocardiogram and a phonocardiogram of the heart. YOUR CHILD and the Health Examination Survey U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Center for Health Statistics National Health Survey WASHINGTON, D.C. 20201 An examination by a dentist of the teeth and mouth. Psychometric measurements by a psychologist. Tests of vision and hearing. X-rays of the chest, hand and wrist An exercise test, pedaling a bicycle-like machine. A grip-strength test. Measurement of breathing capacity. Height, weight and other body measurements. The examination lasts about 3 hours. Each day there will be two examining periods—morning and afternoon. Six children will be examined during each period. Usually, the children will be from the same school and will know each other. Children who are examined during the morning period will be served lunch. Children who participate in the special health examination will find it an interesting and enjoyable experience. HOW YOUR CHILD WAS SELECTED TO PARTICIPATE IN THE SURVEY The U.S. Bureau of the Census, working with the Health Examination Survey, has selected 40 areas in the United States which, taken al- together, are representative of the entire Nation. Each of these areas consists of one or more counties. These areas are located in the North, South, East and West. Some are urban and others are rural. Within each of these 40 areas, approximately S00 houses are selected by scientific sampling methods. Every child in the 6-through-11- year age group living in one of these houses automatically becomes a part of a national sample group of about 9,000 children on whom health histories are obtained. The sample is then reduced by another sampling operation to give a sample of about 8,000 children to be examined. This national sample is representative of the roughly 25,000,000 children in the United States in this age group. The information obtained from the examinations of children in this sample will make it possible to make good estimates of what infor- mation would have been obtained if all children in the 6-through-11 year age group had been examined. rigure 3. Leaflet describing the program. The remaining names were then taken as the group of sample children, Appointment and Transportation Procedures About a week after the Census interviewer had left a medical history form with the parents of each eligible child, an HES representative (affec- tionately called a HER, and appropriately so since most of these individuals are women) visited the household to pick up the form. That visit was de- signed to accomplish a number of things, If the form had not been completed, the HER attempted, usually successfully, to assist the parent in com- pleting it at that time, If it had been completed or partly completed, the HER performed a quick review and edit and classified any incomplete or patently inconsistent entries, The HER then ad- ministered an additional interview, collecting a number of bits of information which it had been decided could be obtained better by an inter- viewer than by means of a self-administered questionnaire, If the eligible child had been determined to be a sample child, the HER also explained the plan and nature of the examination program, She obtained the written consent of the parent for the child's participation in the examination, for the survey to transport the child to and fromthe mo- bile examination center, and for the survey to obtain additional information from school person- nel, from a physician's, dentist's, or hospital's records, and from other official sources such as State registrars, She also indicated to the parents that the Public Health Service would be glad to forward to their physician and dentist the findings of the medical and dental examinations if the parents so wished and recorded such a request if it was made, Finally she explained that survey personnel would notify the parent of the date and time of the child's examination and she lefta leaf- let which described the program (fig. 3). The field management office worked out the examination schedule, consulting with the various school principals whose students were involved concerning times when the children might be per- mitted to be away from school. In the scheduling, attempts were made to arrange the appointments so that transportation workload was minimized, A note was sent to the parent both to inform him as to the specific examination time and to serve as a reminder of the program. On the appointed day a representative of the survey, usually one of the HER's, called for the sample child either at home for morning appointments or at school in the after - noon and drove him to the mobile examination cen- ter, After the examinationhad been carried out the child was taken back to school or to his home, NATURE OF THE EXAMINATION General Considerations It has been pointed out that the primary focus of Cycle Il was on measurements and health factors related to growth and development. The low inci- dence of chronic disease inthe age group examined resulted in some lessening of the relative impor- tance of the physician's role compared with the roles of other members of the examining team (technicians, dentist, psychologist, and so forth), This is reflected in the time allocations for the examination seen in the flow chart (fig, 4). The physical examination by the physician (assisted by the nurse) required about 30 minutes of the total time of approximately 3 hours, About the same amount of time was required for the work of the dentist, which, in addition to the dental examination, included certain tests and measure- ments related to vision, The other 2 hours were equally divided between the battery of tests admin- istered by a psychologist and the series of tests, procedures, and measurements carried out by specially trained technicians, The pattern of scheduling examinees with respect to time of day differed in Cycle II from that used in the earlier adult examination program, In Cycle I examinees were brought into the mobile examination center on a staggered pattern, with two examinations beginning at half-hour intervals, Each examinee went through the same sequence of examination elements. In the early pilot test work for Cycle II it was decided that the child would be more at ease if a number of children came in for examination at the same time, After some exper- imenting it was decided to bring inatone time all six children who would be examined in each half- day. It then became necessary to vary the sequence of their examinations since, for example, the six Date A. M.0O P. M.O 1! pe 111! Iv! v VI T T T x HEART 2 T HEART 2 I HEART 0 hour Vision Audio Physical Body %. Psych Psych Dental Jay Sudio Bye sye en Bike Vision Xray Physical Body M. Dental Bike 1 hour J J J Dental ig Xray Physical Viglon ; Bike Paya Pgyed Body M. Vision Physical Body M. Audio Dental 2 hours J J Audio Physical Jray Dental D D Xray Body M. Vision Body M. Vision Bike Bike Dental Audio Physical Psych Psych D D D D HEALTH EXAMINATION SURVEY Daily Flow Chart 'T and II the youngest, III and IV next ’11, IV, and VI must have preliminary heart examination Xray includes height and weight Body Measurement includes vital capacity and may include grip strength T includes temperature and undressing may J-juice, D-dress be done at 0 hour or later, Physical includes ECG and phonocardiogram Dental and vision may include grip strength Figure 4. could not be examined by one physician at the same point in the sequence of examination elements if all examinees started together. In determining the sequence, a number of factors in addition to staff composition had to be considered. It was neces- sary, for example, to have a preliminary heart examination carried out for those examinees whose sequence called for the exercise tolerance test (shown as ''bike'" onthe flow chart) in advance of the physician's examination. Another consider- ation was the desirabilitv of having the younger 18 In A.M. an additional 10-15 minutes is required for lunch Daily flow chart. children take the psychological tests early in their sequences so that their responses would be less likely to be affected by physical weariness. When the children first arrived at the mobile examination center, they were greeted by the nurse and the coordinator, a staff member with special responsibilities in the area of management of flow of examinees, records preparation, and the like. A brief explanation of the examination was given. Temperatures were taken and name tags provided. The children changed from their street clothes into the examination uniform provided. It consisted of gymnasium-type shorts and a terry-cloth robe for the boys, The girls were provided with similar shorts, a specially designed blouse, and a terry- cloth robe, The examinees wore cotton socks on their feet, This uniform was designed to facilitate and standardize various elements of the exami- nation such as the physician's examination, body measurements, and X-rays, The Examination by Physician and Nurse Each "Child's Medical History-Parent'" form (Appendix IB), which had been completed in the household prior to making the appointment, was reviewed by the examining physician on the day before the scheduled examination, He paid special attention to any entries which suggested any lim- itation on the child's ability to perform any of the tests or procedures and to medical history items which required further followup in the course of the examination, Before the standardized physical examination was begun, the physician examined any child whose temperature was 100° or over, If he determined the child was too sick to be examined further or if he suspected a contagious disease, the child was taken home without further examination, (In such cases the examination was rescheduled for another date.) Before the exercise tolerance test was taken by the child, the physician listened to the heart in order to exclude from exercise any child who might have heart disease, The pediatrician's examination included a general inspection, examination of joints and muscles and neurological examination, eye exam- ination, ears, nose, and throat examination, and cardiovascular examination, The nurse was pres- ent during the examination and assisted the phy- sician, The examining procedure followed was a standardized one, but after the physician had com- pleted the prescribed elements, he was free to follow leads or pursue particular points as he judged appropriate, The general inspection included observation of gait, general appearance, and observable phy- sical deformities, observation for tics or man- nerisms and for evidence of finger sucking or nail biting, and notation as to evidence of breast devel- opment and presence of axillary hair, With regard to examination of joints and muscles, the examinee performed various spec- ified movements and the physician watched espe- cially for any evidence of abnormality, When abnormality was noted or suspected the physi- cian introduced additional procedures to confirm or rule out the condition, The eye examination included careful in- spection for evidence of styes, conjunctivitis, blepharitis, nystagmus, ptosis, and strabismus. In testing for strabismus, the pediatrician used the Hirschberg's method (corneal light reflex), the moving light test, and the cover test, When strabismus was found, the location, type, and confirming tests were recorded, The examination of the ear, nose, and throat was the subject of special interest because of the possible relevance of findings in this exam- ination to the audiometric data, The pediatrician was provided with a Welch Allyn pneumatic otoscope (in addition to a Siegle's otoscope and headlight) and had been given specific train- ing in this particular technique. The examination included evaluation of the condition of the drum, auditory canal, and external ear, as well as inspection of the oral pharynx, tonsils, and nose, The cardiovascular examination included the pediatrician's listening for and recording a de- tailed description of the heart sounds, innocent as well as significant murmurs, It also included recording a phonocardiogram and a 10-lead electrocardiogram, Two blood pressure readings were taken in a specified manner by the nurse (fig. 5). The physician prepareda summary of findings and a report form to be used in sending a summary report on the examination to the child's physi- cian, The selection of findings to be reported to the physician was limited to the results of proce- dures not ordinarily done in the usual pediatric examination such as electrocardiogram and audi- ometric examination and any medical conditions which were not already reported as known in the parent's medical history for the child, On occa- sions when the physician tentatively diagnosed a previously unsuspected condition which he felt required special followup (e.g., heart disease with X-ray or electrocardiogram findings), he communicated by telephone with the child's own 19 Blood pressure reading. Figure 5. physician to apprise him of the findings. This, of course, was done only if the parent had given the signed consent to contact the physician. If not, the parent was notified by telephone if some acute condition requiring medical care was found in the examination, The Dental and Vision Examinations The dental examination was conducted in a standardized manner by the examining dentist, a PHS commissioned officer, It included deter- mining and recording the status of each tooth space or of each tooth occupying a tooth space. Objective criteria for the examination were established to classify teeth as normal, carious, filled, filled-defective, nonfunctional carious, re- tained deciduous teeth and roots, missing, miss- ing-space closed, or replaced. In addition, the eruption status of each permanent tooth not scored on the above scale was noted. An eval- uation of oral hygiene was made based on amounts of debrisand calculus on selected tooth surfaces. A periodontal index score was recorded for each 20 tooth determined by the presence and extent of gingival inflammation and pocket formation, A rating was given for nonfluoride opacities and fluorosis. Any fractures of permanent incisors were noted. Finally a detailed assessment of the status of occlusion was made (fig. 6). An adjustable examining chair and a standard light source were used in the examination by mouth mirror and explorer of the teethand gums. A staff member recorded the observations called out by the dentist. The examination required about 10 minutes. The procedure differed in several respects from that given patients seeking dental care. Teeth under inspection were not dried or isolated, oral calculus and debris were not removed, and tooth surfaces were not generally probed. All of these differences tend to produce some understatement in the number of defective teeth found. The examining dentist completed a report form to be sent to the child's private dentist if such a report had been requested and authorized by the parent. Dental assessment of the status of oc- clusion. Figure 6. The fact that the administration of certain vision tests was by the examining dentist reflected operational considerations, since this member of the examining team had the requisite available time, Its effect, however, was to have these pro- cedures carried out by a professional person who, once the necessary special training had been given, was highly adept at administering the test. The vision examination included tests for color vision (Ishihara's screening test followed by Hardy-Rand-Rittler's test to establish fact, type, and degree for children failing), tests for monocular and binocular visual acuity at near and far distances (Bausch and Lombe Orthorater instrument with special Armed Forces plates supplemented by Landolt ring charts for illit- erates), tests for distant and near lateral phoria and for distant vertical phoria, a test for accom- modation (diopter test), and tests for binocularity (orthorater plates and "Worth 4-dot" tests). Except for color vision tests, the tests were made without glasses for those children who normally wore glasses. Administration of these tests usu- ally required about 15 minutes, Psychological Testing The decision to include some measures rel- evant to intellectual and personality growth and development has already been mentioned, When this decision was reached, the staff survey sought advice from persons skilled inthe area of psycho- logical testing of children. With the assistance of the National Institutes of Mental Health, a meeting was arranged at which child psychologists from five leading universities considered the kinds of psychological data which a program such as the Health Examination Survey should attempt to collect, The consensus of this group was that the survey should include some measures of intelligence, including but not limited to verbal tests, along with some tests designed to get at some personality factors. After first performing some pilot test work, it was decided to adopt the following tests as the battery for the survey: 1. Vocabulary subtest from the Wechsler Intelligence Scale for Children 2. Block design subtest from the Wechsler Scale 3. Human figure drawing 4, Selected cards from the Thematic Apper- ception Test 5. Wide Range Achievement Tests (1963 revisions of the arithmetic and reading sections) The psychometric battery was administered by psychologists who had been trained at least at the level of the master's degree and who had had some experience in administering tests to chil- dren. The time required to test a single child was approximately 1 hour, None of the tests required the use of specially developed Health Examination Survey forms. Except for the Thematic Apper- ception Test, the test forms which are commer- cially available include space for the required answers or entries, In the case of the stories produced on the basis of the Thematic Apper- ception Test cards, the psychologist made tape recordings which were later transcribed and available for reading and evaluation, A methodological study was carried out in order to obtain a critical objective evaluation of the psychological procedures chosen for the second cycle, This study included a literature review concerning each test component, recom- mendations concerning the kinds of inferences which | could appropriately be made from the test results, and recommendations for further research which were felt necessary in order to make proper use of the data collected. This study was done on a contract basis by Dr, S, B. Sells of the Institute of Behavioral Research, Texas Christian University, and the results have been published in the Center's methodological series? Tests, Procedures, and Measurements Done by Technicians Each of the two field teams of the survey had two technicians who carried out the following oper - ations: audiometric test, X-rays of chest and of hand and wrist, recordings of height and weight, spirometry, grip strength test, a series of body measurements, including skinfold thickness, and an exercise tolerance test, Each of the two tech- nicians was trained to carry out all these opera- 21 Figure 7. Audiometric testing. tions, and the children were assigned toone or the other by the coordinator, A third staff member, a technician aide, assisted the technicians in some of the procedures requiring services of a second person, The audiometric testing was done in a spe- cially constructed soundproof room large enough for ihe technician to be in the room with the child being examined (fig. 7). Each child was tested at eight different frequencies, and the 4000-c.p.s. frequency was repeated a second time, However, when the child showed fatigue, testing at the last two frequencies was omitted, For each frequency the sound was presented separately to each ear in the order prescribed on the recording form (Appendix IC), This was arranged so that for about half the children the first ear tested was the right and for the others it was the left, The technician recorded for each frequency the lowest decibel level at which a response was obtained in at least 50 percent of the trials (two out of three trials or three out of five), The audiometry testing procedures shown as Appendix II are part of the instructions to the technician contained in the staff instruction manual, Two X-ray films were taken by the tech- nicians; one was a 14x17 posterior-anterior 22 film of the chest at a distance of 2 meters, and the other was a 10x12 film of the right hand and wrist for the determination of skeletal age. All recommended precautions to minimize radiation hazard were taken, including use of a special ''no scatter'' cone, use of lead-rubber apron shields, conduct of dosimetry field surveys, and wearing of film badges by technicians, The X-rays were immediately developed inthe mobile examination center to permit a retake of any film judged to be technically inadequate. No reading or interpretation of the X-rays was done at the mobile examination center, however, the physician looked at the chest film prior to recording his summary of findings. The reading of both chest and hand-wrist X-rays was done by special readers after the records had been transmitted to the Washington headquarters office, Spirometry was administered by a technician using a Collins 6-liter vitalometer. The examinee was instructed to take as deep a breath as pos- sible and blow it all back through the tube. The vitalometer traces the maximal forced expir- atory volume (or vital capacity) on a timed ro- tating cylinder which can be measured to show the desired parameters such as peak flow rate, Three separate recordings were made for each examinee, The examining room temperature and barometric pressure at the time of examination were recorded, A test of grip strength was made, using a dynamometer--three separate tests for each hand. The examinee's statement as to his "hand- edness'' was recorded at this time. The survey used a special self-balancing scale to record the examinee's weight directly on the record form, A special device was also used in measuring height, The examinee stood on a platform; he was backed against a vertical bar to which an adhesive strip with his exam- ination number was fastened (fig. 8). He stood under a movable horizontal arm which was adjusted to fit snugly on top of the examinee's head while he stood up straight with feet together and head in the Frankfort plane, When the tech- nician had positioned the examinee, he pressed the button attached to a camera mounted on the movable arm and focused on the scale and pointer arrow, This camera delivered a finished print 10 seconds later which became part of the Figure 8. Measuring standing height. examinee's record. The measurements of height and weight were made with the examinee wearing the special uniform and only the socks provided on his feet, Body measurements on each examinee were made by one of the technicians with the technician aide serving as recorder, In addition to the stand- ing height and weight measurements already described, they made 30 separate measurements, Sixteen of these had been made in the adult program of Cycle I; the other fourteen were new. The measurements made included a wide variety of skinfold thicknesses, girths, heights, breadths, and lengths. The recording form used indicates the specific items (Appendix ID), The equipment used included several anthro- pometers (Siber Hagner & Co., Inc., New York, New York), sliding calipers (Hudlicka type, 30 cm.), skin calipers, steel tape measures, foot- stools, and a specially designed body measurement table for examinations requiring that the examinee be seated. Measurements were recorded to the nearest millimeter, Finally anexercise tolerance test was carried out, This test made use of a bicycle ergometer, a bicycle-like device on which the examinee sat and pedaled while holding onto handlebars. The equipment could be set for the desired workload, and the amount of work being performed was thus a known quantity, The end point of the test was the examinee's pulse rate, which was moni- tored and recorded by means of special equipment (Kenelco) fastened to the examinee by an electrode attachment. A reference table specific for age, sex, and weight of the child was provided so that the technician could determine the appropriate load setting for the equipment, The examinee made a 1l-minute-test run; then if the pulse rate had advanced appropriately, he continued for the 2-minute-test ride. If the test run indi- cated underloading or overloading, the load was adjusted, and then the test was continued, Vari- ables recorded directly on the Gase record included the pulse rate before exercise, the pulse rate at 2 minutes after end of exercise, the maximum pulse rate during the 5 minutes directly after exercise, and the rate at the end of the 5-minute rest after exercise, The tech- nician also recorded the workload adjustment and the temperature and humidity of the exam- ining room at the start of the test. In addition, the equipment traced a timed graph of the pulse rate throughout the test, THE ANCILLARY DATA COLLECTED General Considerations In describing the logistics of the survey, mention has been made of several question- naires: the household questionnaire administered by the Census interviewer at all households visited and the child's medical history and the HER interviewer-administered questionnaire for sample children. An attempt was made to obtain information for sample children on a question- naire sent to the schools (Appendix IE), In addi- 23 or tion a copy of the birth certificate of each sample child was requested from the appropriate State office, It should be recognized that data obtained on the questionnaires were intended to serve various purposes. In some cases the data were desired to classify health information and exam- ination findings such as data on income or edu- cational class of the parent, In other cases the information was requested to facilitate subsequent survey operations, Examples of this are informa- tion on the grade and school of the child or on the name and address of the child's physician. Other items were included to assist the physician inhis examination of the child, Thus the physician was alerted to the occasional child who had some physical limitation which would require special handling in the examination (e.g., a limitation ~on physical exercise imposed by the child's physician would be a contraindication for the exercise tolerance test). Sometimes the medical history suggested to the physician the necessity for his paying particular attention to some part of the clin- ical examination, It was recognized that this would result in the physician's examination not being quite the same thing for every examinee, A blind-type design in which the physician did not see the medical history would produce some- what different results in some cases, It was felt, however, that the advantages of an examination procedure more nearly like that in clinical prac- tice outweighed any disadvantages. So the phy- sician not only reviewed the medical history in advance of the examination, but he was instructed to go onto administer further special examinations in some instances where his initial examination made him suspect the presence of a defect such as a neurological abnormality. Frequently the reason for collecting data on the questionnaires was the desire to relate that information to some specific part of the exam- ination findings, Thus the child's medical history provides information concerning injuries to the ear, past operations, earaches, and the like which can be examined in relation to the results of the audiometric testing, Relatively few items were collected on the questionnaire in order to describe the total universe sampled with respect to the character- 24 istic covered by a specific question, but there are some such items, An example of sucha ques- tion is the one which asks whether the parent feels that the child's teeth need straightening. Of course, here there was also interest in relating the response to this question to the findings on the child's dental examination with respect to occlusion status, Description of Separate Source Documents The household questionnaire was the basic source document which provided required demo- graphic data concerning the population sample as well as serving in the final stage of sample selec- tion. This form, which has already been referred to briefly, is shown as Appendix IA. The form was administered by a Census interviewer who had already filled in the identifying numbers of the PSU, segment, and so forth (items 2-6, page 1) prior to visiting the household. The interviewer began with question 1 on pages 2and 3 of the form and inquired about the household composition. A column was completed for each member of the household, and age, sex, race, and relationship to household head were recorded, For all children between ages 5 and 12, the exact date of birth was recorded, The target population was children between 6 and 11 years of age, inclusive, but pilot studies indicated the desirability of special checking on the ages of children within 1 year above or below this range. For households in which there was one eligible child or more, the additional information called for in questions 6 through 14 was obtained. These include infor- mation on the school attended and the grade for each eligible child as well as information on education, county of birth, handedness, working status, and marital status for each of the parents, In addition, questions were asked which provide total family income and a basis for further ques- tions in a subsequent interview to elicit a com- plete history of all marriages for each of the parents, Another question (No. 13 on page 2) gets at the occurrence of certain specified events such as a death in the family which might be regarded as potentially traumatic in the child's life. At the conclusion of the interview the interviewer leaves the medical history form to be completed by the parent (Appendix IB). This form was designed to be self-administered, The operation plan, however, provided that it would be picked up personally by one of the HES inter- viewers, This afforded an opportunity for the staff member to do an on-the-spot edit of the completed form and to ask about any missing or questionable entries, In something like 10 percent of the cases, the form had not been filled out when the interviewer called back. In such cases the interviewer assisted the parent in completing it then and there, and in those instances the form was regarded as HER interviewer-administered, In all the other cases the interviewer reviewed the form and asked about any problem entries, The instructions for completing the interviewer- administered questionnaire indicate how this was done (see Appendix IF for both form and instruc- tions). The HER interviewer-administered question- naire collected four kinds of data: (1) some infor- mation on the child's eating habits and the parent's perception thereof, (2) a record of all marriages with dates and reasons for terminationin the case of broken or multiple marriages of either parent, (3) characterization of twins as identical or fra- ternal, and (4) a number of items concerning the behavior of the child and the parents perception of that behavior (e.g., tense or relaxed, strong temper, and time spent in watching TV), The par- ticular characteristic of questions included in this group, as distinct from those on the self- administered child's medical history-parent form, was that they either required special handling on the part of the interviewer or concerned subjects which were thought to be sensitive and so better handled through discreet personal inquiry. Another set of ancillary data was contained in a questionnaire obtained from the school at which the sample child was a student (Appendix IE). This form was intended to serve several purposes, For one, it provided official infor- mation on the child's grade placement, an item collected from the parent but subject to poten- tial error, More important, it served as a measure of the child's success in a major part of his real life situation (going to school) and so afforded an independent evaluation of the child which could be compared with the findings of the examination, It attempted to identify the child whose health (including mental ability) problem or difference had come to the attention of school teachers, Thus, for example, the child who was known to have a vision or hearing problem was identified, More- over, it attempted to obtain subjective ratings from the teacher as to various aspects of the child's behavior and adjustment, These could then be examined in relation to the results of various tests given in the survey, The form was given to the school principal, who was asked to have it filled out by the child's teacher or whom- ever the principal believed to be the best in- formed respondent, In those locations visited during the summer months when school was not in session, the questionnaires were mailed to the school in the early fall with a request that they be completed and returned, Mail followup rf was made when the questionnaire was not received?” 7 within a reasonable time, The overall results wefe that school questionnaires were obtained for about,” 95 percent of the sample children, ’ The final source document for ancillary data was the birth certificate of the sample child, After an examination was completed, a request was sent to the registrar of vital statistics in the State reported on the parent's questionnaire as the birthplace of a child to obtain a copy of the birth certificate, Arrangements had been made in ad- vance with the States to do this on a fee basis and consents had been obtained from the parents during the household contacts, The birth certif- icate copies were desired for several reasons. It was important, particularly in connection with the scoring of psychological tests but also in con- nection with the analysis of all the growth and development data, to have the exact and correct age for each child, It was also felt that the mother's age at the birth of the child could be obtained more accurately from this document than from reconstruction from the age reported in the household interview along with the child's age. Finally, the birth certificate provided some infor- mation related to the child at birth (birth weight, congenital conditions noted at that point, and com- plications of delivery) which could be related to some of the findings of the survey examination, 25 xX “ QUALITY CONTROL In a program like the Health Examination Survey the problems of nonsampling variability, or measurement error, loom large, The data re- corded for each sample child are inflated in the estimation process to characterize the larger universe of which the sample child is the repre- sentative, In any measurement process, here thought of as encompassing all aspects of obtaining and recording the desired data, there is inevi- tably some measurement error. Considerable at- tention was given to this problem in this program, The attack on measurement error began with a concerted effort to minimize it, Decisions as to what would be included in the examination took account of the expected feasibility of collecting reliable and valid data. The procedure for con- “ducting each part of the examination was stand- “« ardized, and written instructions spelled out in — detail how each step was to be performed. The staff was carefully selected and elaborate pro- grams of training and retraining were carried out. Some of these were formal training programs like the special 2-week period of training in audi- ometric testing given to technicians prior to their undertaking this work, Others were "in-house" retraining efforts such as those carried out on a day set aside at the beginning of each operation at a new location, Onthisday, for example, exam- ~inations were performed on nonsample persons —under the supervision of headquarters staff, Sim- ilar retraining of both Census and HES household interviewers was done at the beginning of oper- ations in each new location, The necessity for uni- formity, accuracy, legibilily, and completeness “= in the recording process was constantly stressed, To the maximum feasible extent the recording process was mechanized by the use of such devices as tape recorders, automatic printing of results, and photographic recording of scale readings (fig. 9). Such methods not only reduce recording errors but provide "hard" documents for replicate reading, Of course the use of instruments not only for recording but also for measuring intro- duces another source of possible variation, and so systematic calibration and recalibration must be carried out. This was done inthe Health Exam- ination Survey for a wide variety of instruments 26 — ra p vs ] TOLEDO PRINTWEIG! Figure 9. Automatic recording of scale readings. from audiometers to self-balancing scales and sliding calipers. Despite all precautions there is a degree of residual measurement error, Because this was recognized, an effort was made to monitor the measurement errors that could be identified as the survey was carried out. This was done in many ways and for two basic reasons; first, by becoming aware of certain kinds or causes of measurement error it was possible to further reduce it in the subsequent survey operation; second, in monitoring it, some measurement of its extent was frequently obtained, This monitoring was done sometimes by observing the process and noting deviations from the prescribed procedures, sometimes by reviewing and comparing recorded data and noting differences among technicians which suggested examiner differences, and some- times in other ways. An illustration of how this occurred and led to corrective action follows, In observing the taking of body measurements in the standing po- sition, the observer noted that the technician making the measurements was not always able to observe that the examinee had deviated from an erect vertical stance, A procedure was sub- sequently initiated whereby responsibility for observing this specific fact was placed upon the recorder who was better located to notice any deviation, Whenever the end product of a particular examination element isa "hard document" (such as the X-ray film or the electrocardiographic trac- ing), the reading and interpretation of that record can be done independently more than once, Differences, then, are brought to light and can be resolved through appropriate measures, This rep- lication of the step not only can be used to provide resolution of differences but examination of the extent of initial differences can give a measure of the measurement error that would have been involved had only the initial reading been used. By extending this same process and by rep- licating certain parts of the examination at times, it is possible to learn something about the extent of the examiner's contribution to variability in the data, To a limited extent some replication of parts of the examination was done at various times in the survey, Sometimes this was done by having repeat examinations of the same subject (a nonsample person) during the retraining ses- sions, or a part of the examination on a sample child was later repeated independently, sometimes by the same examiner and sometimes by a different one, Whenever replicate examinations of sample persons were done, the original observation was retained as the datum to be included in the survey, The second measurements were made only to use as a basis for determining (by comparison with the original measurements) something about the extent of measurement variability in the data, The findings of the survey will be published in the Vital and Health Statistics series of reports, In general, each of these reports will present the findings with respect to some one or several as- pects of the examination, In these reports attempts will be made to apprise the reader of the extent to which the data may be affected by measurement error and to call attention to this problem, In some instances the measurement process and the re- corded evidence permit computation of partic- ular measurement error; in other cases a part of the measurement error is included in the cal- culation which yields a ''standard error’ and thus is consolidated with sampling error, RESPONSE RESULTS Level of Participation Achieved The sampling plan, making use of known probabilities of selection, assured that the sample selected would be representative of the total target population. Although the design did not call for stratification by sex, separate years of age, or race, post-stratification adjustments which will be made in the estimation procedure will result in the distributions being identical in these regards (Appendix III). The sex, age, and race distributions of the total target popu- lation are shown intable 2. Even though the sample | be perfectly representative, however, the survey results might be seriously biased if a high pro-= portion of those selected in the sample were not examined, The response rate may be critical in assessing the success of a voluntary sample survey of this sort, The sample actually selected for the second cycle program consisted of 7,417 childrenat ages 6-11 years, The proportion of this sample finally examined was 96 percent (7,119), This high level of participation—only 4 percent nonresponse— A - gives striking evidence of the willingness of par———.___ ents of children inthe United States to cooperate-in- Public Health Service programs involving medical examination of children, The level of response in the first cycle, which involved adults, was consid- erably lower (86.5 percent), and that result is ’ regarded as highly successful, The high response rate is also evidence of the outstanding skill, de- votion, patience, and effort demonstrated by the field staff of the program during the 3 years re- quired to carry out the operation, The range of level of participation throughout the 40 stands at which examinations were con- ducted was fairly limited. The mean response rate (96.0 percent) represents individual stand response rates ranging only from 91 to 100 percent, There were two locations at which every one of the sample children was examined. The numbers for each individual location are shown 27 Table 2. Percent distribution of the total U.S. noninstitutionalized population between 6 and 11 years, by age, color, and sex: Health Examination Survey, 1963-65 Age in years Color and sex Total | Total 6-11 6-11 6 7 8 9 10 11 Total Percent distribution Both seXeSeeeemereacceecancann 100.0 | 100.0 17.2 17.24 16.8] 16.6 16.3! 15.9 Mal@wr =r mrmmmm_e merase reac en mn ——— 50.8 | 100.0 17.2] 17.2| 16.8] 16.7| 16.2 | 15.9 Femalee--mmrmemmncecececcncnacccanan 49,2 | 100.0 17.2 17.2] 16.7] 16.6| 16.3 | 16.0 White Both sexeSe-mmrecerccacecaanan 85.8 | 100.0 17.2 17.2] 16.7| 16.6 16.3] 16.0 WEEE mses sri. 055000 RE 43,7 | 100.0 17.2 | 17.1] 16.7 | 16.7 16.3 | 16.0 Femalew-wermmc ceca cece rcc acc mma 42,1] 100.0 17.2] 17.2] 16.7 | 16.6| 16.3 | 16.0 Nonwhite Both sexese-=cmmceceecccacan= 14.2 | 100.0 17.4%) 17.41 16.9 16.71 16.1} 15.5 Malee-memecmr cme meme mmm 7.11 100.0 17.5} 17.3) 1.7,0{ 16,7; 16.01 15.5 Femaleemrreenmmenmrmnenr ence amnnn 7.11] 100.0 17.4] 17.4] 16.9] 16,7 16.1 | 15.5 NOTE: Data are based on estimates from the Bureau of the Census. dl ———" __——-in" table 3. By way of contrast, the range of response rate for the Cycle I adult examination program was considerably wider, from 66 to 98 — pEYCENL, — Differentials in Response Among Demographic Subgroups The possibility of data from a sample survey being biased by a high rate of nonresponse is, of course, related to the possible differences between the nonrespondents and the respondents, Even a high nonresponse rate would not bias the findings if the nonrespondents were completely like the respondents with respect to all of the character - istics being studied, Conversely a low nonresponse rate might bias the findings in some respects if there were marked differentials in response among the subgroups being examined. A high level of response greatly reduces the likelihood 28 for August 1,1964, which are unpublished figures that serious bias will result, but it is still appropriate to ask whether the group of children actually examined in the survey differed from those who should have been but were not examined. This cannot be answered, of course, for the fac- tors that were obtained only by the process of examination; however, the survey did collect con- siderable demographic data on almost all the sample children, and so some comparison can be made, The findings of the Health Examination Sur- vey will be presented separately by sex and by single years of age and, frequently, by certain other demographic characteristics, notably race, geographic region, population density groups, par- ents' educational level, and family income. The response levels for the subgroups involved in each of these axes of classification show no marked differentials in response rates, It appears unlikely Table 3. Number of sample children, number and percent examined, by stand number and location: Health Examination Survey, 1963-65 Number | Examined fq Stand sample Stand location number | chile dren Num- Per~ ber cent All standS==-e-cccccmc meee mmmmm mean cee 7,417 | 7,119 96.0 Portland, Maine=-==-= === comme 1 200 198 | 99.0 Ashtabula, Ohio=== mmm come meee 2 185 175| 94.6 Poughkeepsie, New York--=-coe coco oe oem 3 193 190 | 98.4 Ottumwa, IowWa======= === meee eee 4 196 195 99.5 Boston, Massachusetts=-=====mm=mmcc como cemccceeee 5 192 174 90.6 Denver, Colorado-===-= === cme eee 6 192 189 | 98.4 Philadelphia, Pennsylvania-=-=====-ccccoomoommcmaaaaa 7 192 174 | 90.6 Lamar, Colorado-=-=-====m mmm eee eee 8 183 183 | 100.0 Charleston, South Carolina=======---cmccmmm mca 9 186 171 91.9 Los Angeles, California=-======ceccmommm mca. 10&12 285 266 | 93.0 Sarasota, Florida---====--ccccmmmo eee 11 188 185 98.4 Atlanta, Georgia-======== momo eee 13 191 187 | 97.9 San Francisco, California-=--===-c-ceccmmmmmm cacao 14 189 187 | 98.9 Baltimore, Maryland-==--==c ccm mmm 15 193 186 96.4 Mariposa, California===-=--ce comme 16 188 186 98.9 New York, New York====== cocoon eee eee 17& 19 421 390 | 92.6 Moses Lake, Washington---==-==emcem coco cmc 18 193 189( 97.9 Minneapolis, Minnesota=-======= come c momma 20 201 194 | 96.5 Grand Rapids, Michigan=-======eccomm moe 21 191 186 97.4 Neillsville, WisconsSin======= como momma 22 201 201 | 100.0 Chicago, I1linois=-===m=m moomoo emcee 23 301 283 | 94.0 Des Moines, ToWa=== == === momo oe eee eee 24 160 159 | 99.4 Barbourville, Kentucky======eceemm meee 25 196 185 | 94.4 Wichita, Kansas=-=== === mcm mmm 26 188 178 | 94.7 Marked Tree, Arkansas-=--===--cccco oom 27 186 182 | 97.8 Brownsville, Texas======== moomoo eee 28 179 175 97.8 Houston, Texas----=-==-cmc mmm eee em 29 186 181 97.3 Birmingham, Alabama--=====mc=cecom ome eee 30 149 144 1 96.6 Detroit, Michigan-=======m come emcee 31 168 162 |= 96.4 Lapeer and Marysville, Michigan----====-ccceomommaaaaoo 32 179 175| 97.8 Cleveland, Ohio====== === meme eee 33 175 166 | 94.9 West Liberty and Beattyville, Kentucky-----=-==-=----oo_ 34 172 160 93.0 Allentown, Pennsylvania=--=-====-=cc comm ocmceceea 35 173 159 91.9 Manchester and Bristol, Connecticut-=--==-==ceccecaaaaao 36 174 167 96.0 Newark, New Jersey-=======c ooo ome meee 37 177 167 WM, 4 Jersey City, New Jersey=======cm-cmcoo ome cccecceeee 38 175 163 | 93.1 Georgetown, Delaware-====== como occa 39 163 159 95.5 Columbia, South Carolina-=---===cccmmmmmmcccceemeeee 40 156 148 94.9 Icities in which trailers were located. Sample areas consisted of the PSU's which may have included several counties. NOTE: Sample ''take' for Los Angeles was deliberately somewhat low for 'two stand locations" because that area should be only slightly over 1-1/2 stands on a population basis. Chicago, on the other hand, was oversampled in comparison with other "one stand locations," since it should be represented by slightly under 1-1/2 stands. 29 ! Table 4. Number of sample children and number of children examined, by age, sex, and color: Health Examination Survey, 1963-65 Age in years Sex and color Total 6-11 6 7 8 9 10 11 Number of sample children Both sexes=--=--sccercmmnennax 7,417 || 1,161]1,293 11,281] 1,231 1,208 | 1,243 BOyS=mmmmmemmmmmcmemecmem meen —————— 3,765 596 655 649 618 594 653 Girlsececememreecc cece emma mmm 3,652 565 638 632 613 614 590 White Both sexeSee--rmcmccccccccnnnx 6,380 995 (1,112 |1,081| 1,065| 1,059 | 1,068 BOyS==rmemmmmmmcecececcecem amen ———— 3,276 508 572 565 539 526 566 GirlSemmmmececcecaccemcceram am —————— 3,104 487 540 516 526 533 502 Nonwhite Both sexes==c=-m---ccccccmcnax 1,037 166 181 200 166 149 175 BOyS=m=mmmmmmmemecaccceccemeeea————— 489 88 83 84 79 68 87 Girls-mcemcccemerecmcmmcmccccer ecm 548 78 98 116 87 81 88 Number examined Both sexes==-=--mccecmemcnnan= 7,119 1,111 | 1,241 | 1,231 | 1,184 | 1,160 | 1,192 BOyS-==m-ememeecemceee cm me mmm —————— 3,632 575 632 618 603 576 628 Girls==-eememmecccecam eee m mmm 3,487 536 609 613 581 584 564 White Both sexes=-==emmecemccmcecen= 6,100 950 | 1,063 | 1,035| 1,019 | 1,014 | 1,019 BOyS-=memmmmmmmmcememceccm meme mn 3,153 489 551 537 525 509 542 GirlS=--==--cecmcmmeemm mec mem cm —— 2,947 461 512 498 494 505 477 Nonwhite Both sexes=emcecmm--eccmmceanax 1,019 161 178 196 165 146 173 BOyS=rmrmmmmmemememcceceem meme 479 86 81 81 78 67 86 Girls=-e=smemceecemcecec ecm c mem 540 75 97 115 87 79 87 that nonresponse could bias the findings much in these respects (table 4). The differentials in response rates that did occur among the various demographic subgroups all varied within a fairly limited range. Thus the range of percentages examined for single years of age was only between 94.8 and 97.0 percent, 30 The proportion of males examined was 96,5 per- cent and the proportion of females 95.5 percent. Examinations were carried out on 95.6 percent of all white sample children and on 98.3 percent of nonwhite sample children (largely Negro). Even when age, race, and sex are considered together, the range of response was only from 93.9 percent to 100.0 percent, (Both of these extreme values happened to be for 9-year-old girls, the first white, the second nonwhité,) The other parameters named show about the same limited range of vari- ation in response, Thus the variation by region is only from 93.9 to 97.3 percent. On the basis of population-size classes the range is from 93.1 to 98.6 percent when the data are classified in fullest detail (eight groups, from 3 million and over to rural), Similarly the range of variation response rates through six groups by total family income is only from 92.4 to 97.5 percent, Finally the vari- ation in percentage cooperating was only from 94,1 to 97.1 when broad groups by education of head of family (no more than elementary school, some high school, some college) were compared, and when single years of schooling was examined, the range was from 92.1 to 100.0 percent, The differentials which were observed in the demographic or socioeconomic subgroups, though relatively small, were generally in the expected direction, Thus the response rate, though high everywhere, was even higher in the rural areas and smaller towns than in the large metropolitan centers, It was lower in the northeastern part of the United States than in other regions, The non- white group had a higher rate of participation than the white sample children, and the response rate was a little better for all boys than for all girls, All of these differences are inthe same directions as the larger differences which prevailed in the adult examination program of Cycle I, The differ - entials pertaining to income and education in Cycle II did not present an entirely consistent pattern throughout the range, The highest income group ($15,000 and over), however, had the poorest record of cooperation, and the lowest income group (under $3,000) had the highest response rate. The intermediate groups were all roughly equal. This is generally similar to the Cycle I results, When education of head of family was the variable examined, it appeared that response was highest among children whose parents had no more than elementary school education and response was poorest among persons with Syears or more of college or with 1-3 (but not 4) years of college completed. (Persons with 4 years of college had a higher level of cooperation than the foregoing two groups though lower than that for the elementary level only,) ) { } | Reasons for Sample Persons | Not Cooperating Only 298 of the 7,417 children who were se- lected in the survey sample were not examined, Even though the foregoing section has indicated that this level of nonresponse was probably not particularly biasing insofar as analysis of the data by various demographic subgroups goes, it is still of considerable interest to investigate the reason for lack of cooperation on the part of this 4 percent of the sample, The interest comes partly from needing to understand nonresponse to plan to minimize it in other surveys, An added impor- tance of understanding the character of the non- response in the children's survey is the light it may shed on possible biases in particular ele- ments of the examination collected. Thus, even though the number of noncooperating children is so small as to have negligible effect on most distributions, it might have an effect on some par- ticular item in the data collected if reasons for noncooperation were frequently related to that item, The survey operating procedures were such that if there was any opposition to participation in the examination, it usually became manifest at the time the health examination representative explained the full plan and asked for the signed consent. In a very small number of cases the Census interviewer during the earlier visit may have met with some indication of uncooperative- ness, but in any case the decision to participate in the examination was not called for until the second visit referred to above, An appointment record card, completed immediately after the visit, included comments concerning the reasons given for reluctance to participate in cases where there were any, The survey operations usually involved some further contacts with such a house- hold in an effort to explain more fully the nature of the program and gain cooperation. In each of the successive visits or other contacts (which may have involved different staff members), records were completed concerning the appointment proc- ess. These entries included not only any stated reasons for unwillingness to participate but also any relevant judgments by the staff member as to factors that might be involved. 31 Table 5. Number and percent of children not participating and reasons given: Health Examination Survey, 1963-65 Num- Reason for not Dae Pep participating chil- cent dren All reasons==========- 298 100.0 Unable to assign any reason-=--====m==-==a=--- 44 14.8 Reasons unrelated to po- tential examination findings-====-mm=m==mmu=- 145 48.6 Temporarily out of the area==-============-= 39 -—— Parent opposed to such Federal activity------- 42 -— Private medical care sufficient-===========-=- 33 -—— Schedule too filled to find time-=-=========--- 31 -——- Other reasonS-============ 109 36.6 Illness of child-------- 17 -— Child or parent fearful of doctors=-=-====-=-=-- -——— 26 --- Child generally uncoop- erative-=~====meece=e-= 27 -—— Parental concern for child's welfare--==-=---- 15 --- Illness or death of family member---------- 8 ——- Examination started but not completed--=----==- 8 -—- Religious objection to medical examination---- 8 -——— The survey records, then, on each of the 298 persons who were in the sample but were not examined should include one or more state- ments concerning the reason for nonparticipation, In over half the cases there was more than one reason listed, It is recognized that in some cases the reason given may not be the real reason, The health examination representative and the field operations manager were highly skilled, however, in the art of obtaining cooperation and this re- quired that they be able to assess correctly the factors that were involved, Their appraisals as to the reason most likely to be really involved have been taken into account in this analysis, 32 The information available for the 298 un- examined children was first classified into about a hundred separate "reason'' categories, and then these were combined by grouping essentially sim- ilar statements of reasons, (If several reasons were listed, the one which seemed to be the main obstacle was used.) The 12 categories finally arrived at are shown in table 5. These were grouped into three general classes: "Unable to assign any reason' (44), ''Reasons unrelated to potential examination findings" (145), and "Other reasons” (109). It is not implied that inclusion in the last category means that the case is necessarily typical with regard to what the exam- ination findings would have been, but only that it is possible that some of the cases in that cate- gory may have been atypical with respect to some aspect of the examination, Thus some of the cases not examined because of "illness of child" rep- resent cases of the usual acute communicable diseases of childhood which happened to occur at a time which prevented the child from being examined; some on the other hand represent children whose illness was chronic and who were therefore unlike the examined group. For about one-fourth of the cases of "Unable to assign any reason,’ the survey records failed to show a reason. In some cases this was a lost or incomplete administrative record; in others the parent simply refused to give any reason and the survey staff had no basis for inferring what was .back of the refusal, In another one-fourth of the cases the lack of cooperation was attributed to objections (unknown as to grounds) on the part of some third party-—neither the parent nor the child, Thus an individual would not cooperate because "one of his friends'' advised him not to do so. The remaining half of this unknown reason group represents cases where the record showed a variety of miscellaneous reasons which were obscure and unclassifiable in terms of the cate- gories shown above or any other clearly mean- ingful categories, The reasons which were presumed to be unrelated to any possible findings of the exam- ination (had it been made) are partially explained by the four subcategories shown in the tabulation. There were 39 instances when either the entire family or the sample child were out of the area at the time for examination, some for such reasons as vacation trips and summer camp periods. There were a number of instances where it was clear rhat the major reason for refusal was a negative attitude toward the Federal Government--either the Administration or the Federal Government's participation in suchactiv- ities as the Health Examination Survey, In some other cases where such points were raised, the health examination representative was successful in explaining the research nature of the program, the bipartisan basis for the original legislation authorizing the surveys, and the appropriateness of the activity, For 42 of the 298 nonrespondents, however, this attitude remained a barrier topar- ticipation, The "private medical care sufficient category included such cases as ones where the parent insisted that because their child received regular and complete care from a private phy- sician the examination was unnecessary, The schedule-filled group included some instances where the child was scheduled for examination but other activities resulted in a broken appoint- ment and there was insufficient time for re- scheduling, The category labeled "Other reasons' in table 5 includes 109 unexamined sample children where the basis for the refusal was one which might have some relationship to one or more of the kinds of information gathered by the survey program. Thus since the survey includes some behavioral items designed to get at the social adjustment of the child, it is important to be aware of the fact that a number of sample children were not included by reason of the apprehensiveness they or their parents had about examination by a strange doctor, In much of the information collected by the sur- vey, such a child might not be at all different from other sample children, but on the specific questions asked about behavior he might well be atypical. This needs to be taken into account in later analysis of data, In summary, then, it is believed that the de- gree of cooperation achieved in the survey was so high that the problem presented by nonresponse is minimal. At the same time it is recognized that the person on whom no data are available always presents the possibility of being unlike the others on whom data were collected and the analyst must always be aware of the possibility of bias, REFERENCES INational Center for Health Statistics: Origin, program, and operation of the U.S. National Health Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1963. National Center for Health Statistics: Plan and initial program of the Health Examination Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 4. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 3U.S. National Health Survey: A study of special purpose medical-history techniques. Health Statistics. PHS Pub. No. 584-D1. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1960. 40.8. National Health Survey: Attitudes toward coopera- tion in a health examination survey. Health Statistics. PHS Pub. No. 584-D6. Public Health Service. Washington. U.S. Government Printing Office, July 1961. 5U.S. National Health Survey: Evaluation of a single-visit cardiovascular examination. Health Statistics. PHS Pub. No. 584-D7. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1961. National Center for Health Statistics: Comparison of two vision-testing devices. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 1. Public Health Service. Washington. U.S. Government Printing Office, June 1963. "National Center for Health Statistics: The one-hour oral glucose tolerance test. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 3. Public Health Service. Washington. U.S. Government Printing Office, July 1963. 8National Center for Health Statistics: Cooperation in health examination surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 9. Public Health Service. Wash- ington. U.S. Government Printing Office, July 1965. National Center for Health Statistics: Replication, an approach to the analysis of data from complex surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 14. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1966. 10National Center for Health Statistics: Three views of hypertension and heart disease. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 22. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1967. National Center for Health Statistics: Cycle I of the Health Examination Survey, sample and response. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No.1. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1964. 2 wiional Center for Health Statistics: Glucose tolerance of adults, United States, 1960-1962. Vital and Health Statis- tics. PHS Pub. No. 1000-Series 11-No. 2. Public Health Serv- ice. Washington. U.S. Government Printing Office, May 1964. 13National Center for Health Statistics: Binocular visual acuity of adults, United States, 1960-1962. Vital and Health 33 Statistics. PHS Pub. No. 1000-Series 11-No. 3. Public Health Service. Washington. U.S. Government Printing Office, June 1964. L4National Center for Health Statistics: Blood pressure of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 4. Pub- lic Health Service. Washington. U.S. Government Printing Office, June 1964. 15National Center for Health Statistics: Blood pressure of adults by race and area, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 5. Public Health Service. Washington. U.S. Government Printing Office, July 1964. 16National Center for Health Statistics: Heart disease in adults, United States, 1900-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 6. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1964. 17National Center for Health Statistics: Selected dental findings in adults by age, race, and sex, United States, 1960- 1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 7. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1965. 18National Center for Health Statistics: Weight, height, and selected body dimensions of adults, United States, 1960- 1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 8. Public Health Service. Washington. U.S. Government Printing Office, June 1965. 19National Center for Health Statistics: Findings on the serologic test for syphilis in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 9. Public Health Service. Washington. U.S. Government Print- ing Office, June 1965. 20National Center for Health Statistics: Coronary heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 10. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1965. 2INational Center for Health Statistics: Hearing levels of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 11. Pub- lic Health Service. Washington. U.S. Government Printing Office, Oct. 1965. 22National Center for Health Statistics. Periodontal dis- ease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 12. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1965. 23National Center for Health Statistics: Hypertension and Lypertensive heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11- No. 13. Public Health Service. Washington. U.S. Government Printing Office, May 1966. 24National Center for Health Statistics: Weight by height and age of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 14. Public Health Service. Washington. U.S. Government Printing Office, May 1966. on " 5p “National Center for Heal th Statistics: Prevalence of os- teoarthritis in adults by age, sex, race, and geographic area, 000 34 United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 15. Public Health Service. Wash- ington. U.S. Government Printing Cffice, June 1966. 26National Center for Health Statistics: Oral hygiene in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 16. Public Health Service. Washington. U.S. Government Printing Office, June 1966. 2TNational Center for Health Statistics: Rheumatoid arth- ritis in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 17. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 28National Center for Health Statistics: Blood glucose levels in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 18. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 29National Center for Health Statistics: Age atmenopause, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 19. Public Health Service. Wash- ington. U.S. Government Printing Office, Oct. 1966. 30National Center for Health Statistics: Osteoarthritis in adults by selected demographic characteristics, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 20. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 31National Center for Health Statistics: Childbearing and diabetes mellitus, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 21. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 32National Center for Health Statistics: Serum cholesterol levels of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 22. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1967. 33National Center for Health Statistics: Decayed, missing, and filled teeth in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 23. Pub- lic Health Service. Washington. U.S. Government Printing Office, Feb. 1967. 34National Center for Health Statistics: Mean blood hemato- crit of adults, United States, 1960-1962. Vital and Health Sta- tistics. PHS Pub. No. 1000-Series 11-No. 24. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1967. 35National Center for Health Statistics: Binocular visual acuity of adults by region and selected demographic charac- teristics, United States, 1960-1962. Vital and Health Sta- tistics. PHS Pub. No. 1000-Series 11-No. 25, Public Health Service. Washington. U.S. Government Printing Office, June 1967. 36National Center for Health Statistics: Evaluation of psy- chological measures used inthe health examination survey of children ages 6-11. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 15. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1966. APPENDIX I. APPENDIX SELECTED FORMS USED IN CYCLE II IA CONFIDENTIAL - The National Health Survey is authorized by Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey and will not be dis- closed or released to others for any other purposes (22 FR 1687). BUDGET BUREAU NO. 68-R620-54 5 APPROVAL EXPIRES JULY 31, 1965 ForM NHS-HES-2 (11-13-63) ACTING AS COLLECTING U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS AGE U.S. PUBLIC HEALTH SERVICE 1. Questionnaire NT FOR THE NATIONAL HEALTH SURVEY of Questionnaires 2. (a) Address or description of location (include city, zone, and State) 3. Identification |4. PSU e 5. 8 t 6. Serial number “number number If this questionnaire is for an ""EXTRA’’ unit in a B or NTA Segment, enter: Serial No. of 2. (b) Mailing address if not shown in 2(a) OR [| Same as shown in 2(a) If in NTA Segment, also enter for FIRST unit listed on property Item No. by which found original Sample Unit Segment List Sheet No. [ie No. 2. (c) Name of special dwelling place 7. Type of living quarters (Check one box) [_] Housing unit [7] Other unit . 49 only if “Ruel” box § es ALL segments (ask if Item 2(a) address identifies a SINGLE-UNIT structure). Ask items ; and.g anly - oo. ok = ankle 10. Are there any occupied or vacant living quarters BESIDES YOUR OWN -- i 1 (J Rum i Oia (Skin taliem --In the basement? .... [ |Yes--S___ ~~ L [J No 8. Do you own or rent this place? --on this floor? ....... []Yes--S L [I No 1 Own 2 Rent 3 Rent free --on any other floor = 9(a)) Aa pps 9(a)) of this building? .... []Yes--S L [] No 9. (a) If Own or Rent free, ask - Does this place have 10 (£2) Tabla X for such quarters NOT lated) or more acres? ALL segments (ask if Item 2(a) identifies entire floor or unn. mbered part of (b) If Rent, ask - Does the place you rent have 10 floor in a MULTI-UNIT structure). or more:cres? 11. Are there any occupied or vacant living quarters BESIDES YOUR OWN - - 1] Yes 2[ No If Item 2(a) identifies entire floor --on this floor? [7] Yes--S L [Ne If Item 2(a) identifies part of the floor, 4 specify part (Fill Table X for each quarters NOT listed.) (c) During the past 12 | (d) During the past 12 aed .. i ? months did sales of ' months did sales of ¥a the. of this Hor? crops, livestock, and | crops, livestock, and TA and NTA segments (ask at all units EXCEPT APARTMENT HOUSES). other farm products : other farm products 12 I. ) ek | | from the place smount | from the place amount . Is there any other building on this property for people to live in - either occupied | or vacant? to $50 or more? | to $250 or more? ! [7] Yes--S L [No t[]Yes 2[ JNo ! 1[]Yes 2[ No (Fill Table X for each quarters NOT listed.) - - : . r= Telephone No. ) 13. What is the telephone number here? oR [ INo telephone (INTERVIEWER): If eligible child in household enter child's name, segment, serial, and column number on Medical History Form. (READ TO RESPONDENT) In addition to the information you have already given me, | would like to leave this form to be filled out about-- . The form is self-explana- tory. A representative of the U.S. Public Health Service will come by to pick up the form in a week or so. (Ask Item 14) representative to come? ....... 14. What would be the best time of day for the Medical histories left for-- Person with whom form left-- Column No(s). Column No. and relationship 15. RECORD OF CALLS AT HOUSEHOLD Item 1 Com. 2 Com. 3 Com. 4 Com. 5 Com Date Entire household — I'ime 16. REASON FOR NON-INTERVIEW TYPE A B [+ Zz [] Refusal (Describe in footnotes) [[ | Vacant -- non-seasonal [] Demolished Interview not obtained for R [] No one at home -~ [] Vacant-- seasonal [] In sample by mistake a%Ont| ™ repeated calls (Go to |[] Usual residence elsewhere | (7) Eliminated in sub-sample | COI%: — — — — — [] Temporarily maser] 17) |] Other (Specify) [] Other (specity) : [7] Other (specity) | | | 17. TYPE A FOLLOW-UP PROCEDURE 18. Signature of interviewer 19. Code If final call results in a Type A non-interview (except Refusals)take the following steps: 1. Contact neighbors (caretakers, etc.) until you find someone who knows the family. 2. Find out the number of people in the household, their names and Sppeouimpte ages; if names of all members not known, ascertain relationships. Record this informa- tion in the regular spaces inside the questionnaire. USCOMM-DC 22318 P-63 35 36 1. (a) What is the name of the head of this household? (Enter name in first column.) (b) What are the names of all other persons who live here? (List all persons who live here.) (¢) | have listed (Read names) is there anyone else staying here now such as friends, relatives, or roomers ve = Tn Co SRA Sanne ty CaS NEAR Bal BY SERS Se Yes (List) [| No (d) Have | missed anyone who usually lives here but is now -- Temporarily in a hospital? [] Yes (List) [J No --Away on business? ...... [] Yes (Listy [_]No --On a visit or vacation?... [| Yes (List) (e) Do any of the people in this household have a home anywhere else? [J No [] Yes (Apply household membership rules, if not a household member delete) [C] No (Leave on questionnaire) Last name 1) First name ASK F N10. What were you doing most of the past 3 months — working, keeping house, or doing something else? (If ‘Doing something else,’ ask): (a) What were you doing? (Enter reply verbatim and ask 10(B)). «.u.eusueunrnssnsnesoansnnensensenseneno (If “Keeping house’ OR "‘Doing something else," ask): (b) Did you work at a job or business at any time during the past 3 months?. ............oooiiiiiiiiiiienn (If **Working'’ in 10 OR ‘Yes’ in 10(b), ask): (c) Did you work full-time or partstime?. . ........outnunnnn rn enan iran et ae tata 2 How are(is)--related to the head of the household? Relationship 3 (Enter relationship to head, for : wife, , stepson, grand her-in-law, partner, roomer’s wife, etc.) HEAD 3. Race (Mark one box for each person) tJ Yh Ole [CJ Negro 4. Sex (Mark one box for each person) [] Male [] Female Age [] Under 5. (0) How old were you on your last birthday? 1 year For each child age 5—12 listed on the questionnaire, ask: Month Day Year (b) What is the month, day, and year of--'s birth? (Check with Question 5(a) for consistency) TO INTERVIEWER: Mark “EC” box for each eligible child (age 6-11) listed on the questionnaire. If no EC, ask coverage questions on Page i [EC [] Not NOTE: Questions 6—14 must be asked only of parent(s) or guardian(s) of EC. If no parent or EC guardian is at home, arrange to call back when they will be home. Ask only for EC (children 6-11 years of age) [CJ No school 0 Name and location & 6. What is the name ond location of the school -- goes to? uw | ¥ i 3 (a) What grade is--in? Grade u.S. 7. Where were you born? = . Foreign country (Check U.S. box or write in name of country) (] Right [J Left U| 8. Are you primarily right handed, primarily left handed, or both? id you prim y rigl primarily r [7] Both uw o 2 9. What is the highest grade you attended in school? [None 2 (Circle highest grade attended or mark ‘“None.’’) Elem.... 12345678 & (If attended, ask): Na + 4k ! : ’ 3 5 . ge S| (a) Did you finish this grade (year)? RE lS XY maim o [7] Yes [] No Ol Led = Z| wl ol < 0.) [J Full-time [] Part-time 11. Are you now married, widowed, divorced, or separated? (If **Married,”” ask): (a) Have you(your husband) been married more than once? [] Married [] Divorced [] Widowed [] Separated PARENTS ONL N2. Besides (Read names of children entered in Question 1) have you and(or) your husband(wife) ever had any other children? [] Yes [No (If ‘Yes,’ ask): (a) What are their names? (b) How old i ? (If now deceased enter date of birth) (c) Where does he(she) live now? (If now deceased enter ‘'deceased’’) No parent P! D. HOUSEH Please look at this cord (Hand respondent HES-2(a) card and pencil). 13. Do any of the questions on that card apply to any members of the family? Please mark ‘‘Yes'' or ‘No’ for each question. (For each ‘‘Yes’’ marked, ask): (a) You have checked--. Who was this? (b) When was this? NOTE: If **1’’ marked, enter name of hospital or institution. Statement No. ALL FORM NHS-HES-2 (11-13-63) 4. Which of these income groups represents your total combined family income for the pes! 12 months, that is, your's, your --'s, etc? (Show Income Flash Card HES-2(b).) Include income from all sources, such os wages, salaries, rents from property, Social Security, or retirement benefits, help from relatives, etc. (Go to Question 15 on Page 4) Group Page 2 Last name @ Last name ®) Last name W Last name G) Last name O) First name [1 First name | Firstname ~~ |Firstname | Firstname © Relationship Relationship Relationship Relationship Relationship [] White [C] Negro [] White [CJ Negro |[] White [J Negro |[] White [J Negro |[] White [] Negro [] Other [] Other [C] Other [] Other [] Other [C] Male [] Female |[_] Male [] Female |[] Male [] Female |[] Male [] Female |[] Male [] Female Age [] Under Age [7] Under Age [] Under | Age [) Under | Age [] Under 1 year 1 year 1 year 1 year 1 year Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year JJEC Not EC [] Not CEC Not EC [7] Not [EC [7] Not L CJ EC EC = EC EC EC [J No school [7] No school [] No school [] No school [] No school Name and location Name and location Name and location Name and location Name and location Grade Grade Grade Grade Grade Ju.s. CJu.s. [_Ju.s. [Ju.s. [Ju.s. Foreign country Foreign country Foreign country Foreign country Foreign country [J Right [C] Left [] Right [] Left [] Right [C] Left [] Right [] Left [1 Right [] Left [1] Both [] Both [] Both [] Both ["] Both [J] None [C] None [] None [1 None ["] None Elem...123 45678 Elem... 12345678 Elem...123 45678 Elem... 12345678 Elem... 12345678 High... 123 4 High... 1 High... 123 4 High... 123 4 High... 1234 College 1 2 3 4 5+ College 1 College 1 2 3 4 5+ College 1 2 3 4 S+ College 1 2 3 4 5+ Yes TINo [Cl Yes [ CIYes [CINo ~~ [TOYes TIONe ~~~ JTOYes [TINe ~~ [[] Working [] Keeping house| [_] Working [| Keeping house|'[_] Working [_] Keeping house| |] Working _] Keeping house] [| Working [Keeping house [] Something else []) Something else [] Something else [] Something else [] Something else [1 Yes [J No [J Yes [] No [1 Yes [1 No [7] Yes [No [] Yes [CJ Ne [CC] Full-time [T] Parctime [[] Full-time [] Parctime |[] Full-time [] Part-time |] Full-time [] Part-time | [] Full-time [_] Part-time [J Married [] Divorced [[C] Married [_] Divorced |[] Married [| Divorced |[ | Married [| Divorced | [| Married [] Divorced [| Widowed |” | Separated |C] Widowed [] Separated | [] Widowed [_] Separated | [] Widowed [| Separated| [| Widowed [| Separated TJYes ~ [No CiYes ~~ [No [] Yes [No [] Yes [CI No [C] Yes [C] No Age Present whereabouts Name Relationship Year(s) Name of Institution Group Group Group Group Group Popes USCOMM-DC 22318 P-63 37 38 15. Is any language other than English spoken here in your home? [7] Yes (If **Yes,” ask): What longuage(s)? [J No Language(s) spoken (Complete front page of questionnaire) Comments: (Include here any information which might be useful to the PHS representative when she calls to pick up the Medical } distory Form.) TABLE X - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS Ate thede USE OF CHARACTERISTICS | CLASSIFICATION IF HU IN B SEGMENT, ASK Bens Sasitian) Occupied All Quarters Not a Yn why : uarters for wha S| more than one Location of unit |Do the occu- [Do these(Specify loca- Sopa Fill ey 1 Yoo (1f before July 1960) S u | group of people? re i peo ianriere Hevea: unit as (Soest dogition) 2 ‘a (Examples: location) Direct ac- | A kitchen [cada goes! Juoners What was the name of & € Yes No Basement, quarters live |cess from |or cooking |occu- and create the household head = 2 (Fill one 2nd floor, etc.) [and eat wi the outside (equipment fpan¢s interview id 1059 or 1050 of these quarters on @ line for any other or through |for exclu | to this also specily*'F EIR Seach group of a common [sive use? |quos- i first half or April 1, 19607 © |arour) people? hall? tion- oo ic HH Tas} ! a Yes | No | Yes| No | Yes| No |i’ HU es Mf 2 (3a) (3b) (4) (5a) | (5b) | (6a)](6b)] (7a) J (7TH) (8B) (9a) | (9b) (10) (11) 1 2 FORM NHS-HES-2 (11-13-63) Page 4 USCOMM-DC 22318 P-63 FORM NHS-HES-2a (3-14-82) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY Please look at the questions on this card. Mark (x) “Yes” or “'No’' for each one listed. 1. During the past ten years has anyone in the family been in a hospital, institution or any other similar place for more than a three-month comsecutive period? O Yes OJ No 2. During the past ten years has anyone in the family been confined to bed at home for more than a three-month consecutive period? O Yes Od No 3. During the past ten years has anyone in the family been unable to work or carry on his usual activities for more than a six-month period—that is, in terms of health? OJ Yes OJ No 4. During the past ten years has any relative of yours died while living in your household? J Yes | No FORM NHS-HES-2b U.S. DEPARTMENT OF COMMERCE (5-14-63) BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY Total combined family income during past 12 months Group A... Under $500 (Including loss) GroupB...$ 500-$ 999 Group C. .. $ 1,000 - $ 1,999 Group D. . . $ 2,000 - $ 2,999 Group E. .. $ 3,000 - § 3,999 Group F. .. $ 4,000 - $ 4,999 Group G. .. $ 5,000 - $ 6,999 Group H. .. $ 7,000 - $ 9,999 Group I. . . $10,000 - $14,999 Group J... $15,000 and over FOR CENSUS BUREAU USE ONLY PSU Neo. Segment No. Serial No. 39 40 APPENDIX IB CONFIDENTIAL — The National Health Survey is authorized by Public Law 652 of | FORM APPROVED the 84th Congress (70 Stat. 489; 42 U.S.C. 242¢c). All information which would 2, DGEY BUREAU NOL es permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey and will not be disclosed or released to others for any other purposes (22 FR 1687). DEPARTMENT OF HES-256 HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY CHILD'S MEDICAL HISTORY - Parent (1-8) SERIAL coL. NO. NAME OF CHILD (Last, First, Middle) SEGMENT (6-11) NOTE: Please complete this form by checking the correct boxes and/or filling in the blanks where applicable. When you have completed it, keep it until the representative of the Health Examination Survey calls on you within a few days. If there are some questions you do not understand, please complete the others and the person who comes for the form will help you with the ones that were unclear. 1. SEX 2. AGE 3. DATE OF BIRTH (Month, Day, Year) (12-14) 1 [1 Male 2 [) Female 1 2. PLACE OF BIRTH (City or Town, State) 5. WAS THIS CHILD BORN IN A HOSPITAL? “ws 1 [1 Yes 2 [J No s [) Don’t know IF YES: (Question 5) A. About how long did you (the mother) stay in the hospital after the baby was born? 1 [1 week or less 2 [J 1 to 2 weeks 3 [] Over 2 weeks 4 [] Don’t know B. Ifmother stayed over 1 week, what was the reason for staying that long? C. About how long did the baby stay in the hospital? (7) 1 [1 week or less 2 [1] 1-2 weeks 3 [] Over 2 weeks a [7] Don’t know D. If the baby stayed over 1 week, what was the reason for staying that long? 6. ABOUT HOW MANY POUNDS DID THE BABY WEIGH AT BIRTH? (18) 1 (CO) Under 5 2 [5-10 a [] Over 10 4 [) Don’t know 5. WAS THE BABY BORN ABOUT WHEN HE(SHE) WAS EXPECTED, OR EARLIER, OR LATER? 1 [7] Earlier than expected 2 [) When expected s [) Later 4 [) Don’t know If the baby was born earlier than expected, about how early? + [1] Less than 4 weeks early 2 [] 4 or more weeks early s [J] Don’t know 8. WAS THERE ANYTHING UNUSUAL OR WAS ANYTHING WRONG WITH THE BABY WHEN HE( SHE) WAS BORN? 21) 1 [O) Yes 2 [J No a [1] Don’t know IF YES: A. What was the matter? B. What did the doctor say caused this? 9. WHILE YOU (THE MOTHER) WERE PREGNANT WITH THIS CHILD DID YOU HAVE ANY MEDICAL PROBLEMS OR COMPLICATIONS? (22) + [J Yes 2 [No 3 [] Don’t know IF YES, what kind of trouble did you have? 10. HOW MANY TIMES HAD YOU (THE MOTHER) BEEN PREGNANT BEFORE, INCLUDING PREVIOUS ) 2s MISCARRIAGES AS WELL AS DELIVERIES? 11. DEFORE THIS BABY WAS BORN, WHILE YOU (THE MOTHER) WERE PREGNANT WITH THIS CHILD, DID YOU (THE MOTHER) SEE A DOCTOR? v [J Yes 2 [No 3 [] Don’t know IF YES: A. About how many months pregnant were you when you first saw a doctor? + [) Less than 3 2[]3to6 3 [CO] Over 6 4 [1] Don’t know B. About how many times altogether did you see a doctor while you (the mother) were pregnant? + [None 2()1to3 s [4 or more 4) Don’t know 12. DID YOU (THE MOTHER) HAVE ANY TROUBLE WITH THE PREGNANCY OR BIRTH OF THIS CHILD? @7n 1 [3 Yes 2 [1 No 3 [] Don’t know IF YES, what was the trouble? 13. WHEN HE(SHE) WAS A BABY, THAT IS BEFORE HE WAS A YEAR OLD, WOULD YOU SAY HE WAS IN GOOD HEALTH, IN FAIR OR POOR HEALTH? 1 [] Good health 2 [] Fair health 3 [] Poor health 4 [] Don’t know 14. WAS THERE ANYTHING WRONG WITH HIM(HER) WHEN HE(SHE) WAS A BABY? + [J Yes 2 [J No 3 [J Don’t know A. If the baby was not in good health or had anything wrong, what was the trouble? B. Did you see a doctor about it? (30) 1 [OJ Yes 2 [] No 3 [) Don’t know C. IF YES, did he say what caused the trouble? 15. WAS THE CHILD BREAST FED? (31) 1 [] Yes 2 [] No 3 [] Don’t know A. IF YES, for about how many months was he(she) breast fed? + [) Less than 1 2[)1to6 3 [Over 6 4 [) Don’t know B. When breast feeding was stopped, how easily did the baby accept the change? + [7] No problem 2 [] Some problem 3 [[] Considerable problem 16. ABOUT HOW OLD WAS THE CHILD WHEN HE(SHE) FIRST WALKED BY HIMSELF? (34) + (] Under 1 year old 2 [] Between 1 and 1) years old 3 [] Over 1% years old a [] Don’t know 17. ABOUT HOW OLD WAS THE CHILD WHEN HE(SHE) SPOKE HIS FIRST REAL WORD? 1 [] Under 1 year old 2 [) Between 1 and 1% years old 3 [) Over 1% years old 4 [) Don’t know 18. CHILDREN LEARN TO DO THINGS LIKE EATING BY THEMSELVES AND TALKING AT DIFFERENT AGES. DO YOU THINK THIS CHILD WAS ESPECIALLY FAST IN LEARNING TO DO THINGS, ABOUT AVERAGE, OR SOME- WHAT SLOWER THAN OTHER CHILDREN? (36) 1 [] Faster than other children 2 [] About the same 3 [] Slower a [] Don’t know 19. DID HE(SHE) GO TO KINDERGARTEN OR NURSERY SCHOOL BEFORE ENTERING THE FIRST GRADE? (37) + [1 Yes 2 [No 3 [] Don’t know 20. NOW TURNING TO THE PRESENT TIME. HOW WOULD YOU DESCRIBE THE CHILD'S HEALTH NOW? 1 [7] Very good 2 [] Good s [J Fair 4 [1] Poor IF FAIR or POOR, what is the trouble? 21. IS THERE ANYTHING ABOUT HIS(HER) HEALTH THAT BOTHERS YOU OR WORRIES YOU NOW? 1 J Yes 2 [J No IF YES, what is the trouble? 22. DOES THE CHILD AT PRESENT EVER SUCK HIS(HER) THUMB OR FINGERS, EITHER DURING THE DAY OR AT (40) NIGHT? 1 [) Yes 2 [J No 3 [] Don’t know IF YES, about how often? 1 [] Almost every day or night 2 [] Just once in a while 3 [] Don’t know 23. DOES THE CHILD TAKE ANY MEDICINE REGULARLY, NOT COUNTING VITAMINS? (42) 1] Yes 2 [1] No s [[] Don’t know IF YES: A. What is the medicine for? B.. What is the name of the medicine? C. Did a doctor say for him (her) to take it? (43) 1 [J Yes 2 [J No s [[) Don’t know 24. AT THE PRESENT TIME DOES THE CHILD EVER WET THE BED? 1 [J Yes 2 [1] No s [[] Don’t know IF YES, about how often does this happen? 1 [] Several times a week 2 [] Not every week but several times a month 3 [] About once a month 4 [] Less often than once a month Here are a few questions about any accidents or injuries the child may have had from the time he was a baby to today. 25. HAS HE(SHE) EVER BROKEN ANY BONES? 1 [ Yes 2 [JN 3 [] Don’t know 41 42 (47) (50) (s1) (53) (54) (63) (6a) (69) (73) 26. HAS HE(SHE) EVER BEEN KNOCKED UNCONSCIOUS? 1 [1] Yes 2 [No s [] Don’t know IF DON’T KNOW, do you have any reason to think he(she) may have been? 27. HAS HE(SHE) EVER BEEN BURNED SO BADLY THAT IT LEFT A SCAR? 1 [J Yes 2 [No s [] Don’t know 28. HAS HE(SHE) EVER HAD ANY OTHER ACCIDENT OR INJURY THAT TROUBLED HIM QUITE A BIT? 1 CJ Yes 2 [1 No 3 [7] Don’t know 29. HOW ABOUT OPERATIONS: HAS HE(SHE) HAD HIS(HER) TONSILS TAKEN OUT? 1 [1] Yes 2 [No 3 [] Don’t know 30. HAS HE(SHE) HAD ANY OTHER KIND OF OPERATION? 1 [3 Yes 2 No 3 [1] Don’t know IF YES, what was the operation and what was it for? 31. HAS HE(SHE) EVER BEEN IN THE HOSPITAL FOR ANY OTHER SICKNESS OR TROUBLE? 1 [] Yes 2 [1 No 3 [] Don’t know IF YES, what was the sickness or trouble? 32. HERE IS A LIST OF DISEASES THAT CHILDREN SOMETIMES HAVE. HAS THIS CHILD EVER HAD: If yes, about how old at the time? A. Scarlet fever? v [1] Yes 3m Age 2 () No 3 [7] Don’t know B. Rheumatic fever? 1 [1] Yes Age 2 [J] No 3 [_] Don’t know C. Polio? 1 [1] Yes» Age 2 [] No 3 [] Don’t know D. Diphtheria? 1 [1 Yes—>=— Age 2 [J No 3 [) Don’t know E. Meningitis or 1 [1] Yes—=— Age 2 [J No 3 [] Don’t know sleeping sickness? F. Tuberculosis? + [1 Yes —»=— Age 2 [J] No 3 [] Don’t know G. Diabetes or 1 [1] Yes —»=— Age 2 [J No 3 [7] Don’t know sugar diabetes? H. Epilepsy? 1 [1] Yes -»— Age 2 [1 No 3 [] Don’t know I. Chorea or 1 [1] Yes -»— Age 2 [1 No 3 [] Don’t know St. Vitus dance? J. Cerebral palsy? v [1] Yes—»=— Age 2 [J No 3 [) Don’t know K. Whooping cough? 1 [CO] Yes—>»=— Age______ 2 [1 No 3 7] Don’t know 33. HAS THIS CHILD EVER HAD MEASLES? 1 (0 Yes 2 (J No 3 [] Don’t know IF YES: A. At what age? B. Was he(she) sick longer than usual? 1 [] Yes 2 [1 No 3 [) Don’t know C. Did he(she) have to go to the hospital? ' [1 Yes 2 [J] No 3 [_] Don’t know D. Did he(she) have a high fever for more than one week? 1 [1] Yes 2] No 3 [] Don’t know E. Did he(she) seem to be unusually drowsy (sleepy) after the illness? 1 [] Yes 2 [J No 3 [) Don’t know 34. HAS THIS CHILD EVER HAD MUMPS? 1 [J Yes 2 [) No 3 [1] Don’t know IF YES: A. At what age? B. Was he(she) sick longer than usual? 1 [O) Yes 2 [1] No 3 [] Don’t know C. Did he(she) have to go to the hospital? 1» [3 Yes 2 [] No 3 [] Don’t know D. Did he(she) have a high fever for more than one week? 1 [1] Yes 2 [] No 3 [] Don’t know E. Did he(she) seem to be unusually drowsy (sleepy) after the illness? (1-5) # 1 [J Yes 2 [] No 3 [] Don’t know (79-80) END CARD 01 ta (oe) 20) (23) 29) (30) (34) (35) 35. HERE ARE SOME OTHER KINDS OF ILLNESSES OR CONDITIONS SOME CHILDREN HAVE. HAS YOUR CHILD EVER HAD: A. Asthma? 1 [O] Yes 2 [1 No 3 [_] Don’t know B. Hay fever?’ 1 [1 Yes 2 [J No 3 [] Don’t know C. Any other kinds of 1 [) Yes 2 [No 3 [) Don’t know allergies? D. Any trouble with his 1 [] Yes 2 [1 No 3 [] Don’t know (her) kidneys? E. A heart murmur? 1 [J Yes 2 [1 No 3 [] Don’t know F. Anything wrong with 1 [J] Yes 2 [J No 3 [] Don’t know his(her) heart? G. A convulsion? 1 [1] Yes 2 [J No 3 [] Don’t know H. A fit? 1 [1 Yes 2 [1 No 3 [] Don’t know 36. DOES YOUR CHILD OFTEN HAVE BAD SORE THROATS? 1 [1] Yes 2 [1] No 3 [] Don’t know 37. IN THE PAST YEAR OR SO HAS HE(SHE) HAD MORE THAN THREE COLDS A YEAR? 1 [J Yes 2 [J No 3 [[] Don’t know 38. DOES HE(SHE) OFTEN HAVE COUGHS THAT HANG ON? 1 OJ Yes 2 [J No 3 [J] Don’t know 39. HAS A DOCTOR EVER SAID THAT HE(SHE) HAS BRONCHITIS? 1 [O Yes 2 [J No 3s [J Don’t know 40. WHEN THE CHILD HAS A COUGH OR COLD DOES IT GO TO HIS(HER) CHEST? 1 [J Often 2 [] Sometimes a [] Almost never 4 [] Don’t know 41. HERE ARE SOME QUESTIONS ABOUT YOUR CHILD'S EYES. A. Has he(she) ever had crossed eyes? 1 [J Yes 2 [J No 3 [] Don’t know B. Has he(she) ever had an operation on his(her) eyes? i (J Yes 2 [J No 3 [J Don’t know IF YES, what was it for? C. Has he(she) ever had other trouble with his(her) eyes? 1 [J Yes 2 [J No 3 [] Don’t know IF YES, what kind of trouble? D. Does he(she) wear either glasses or contact lenses? 1 [J Yes 2 [J No 3 [] Don’t know 42. |F HE(SHE) DOES NOT WEAR GLASSES: A. Does he(she) ever have trouble reading or doing fine work? 1] Yes 2 [J No 3 (C] Don’t know B. Do his(her) eyes or eyelids ever swell up or get red? 1 [J Yes 2 [1 No 3 (] Don’t know C. Does he(she) ever have styes, infections, or ‘matter’ in his(her) eyes? 1 [3 Yes 2 [J No 3 [] Don’t know D. Do his(her) eyes often water? 1 [J Yes 2 [] No 3 [] Don’t know E. Are his(her) eyes often bloodshot? 1 [J Yes 2 [No 3 [[) Don’t know F. Does he(she) ever say that his(her) eyes burn or itch? 1 [0 Yes 2 [No 3 [] Don’t know G. Does bright light bother his(her) eyes? 1 [] Yes 2 [1 No 3 [] Don’t know H. Does he(she) ever see double or see things blurred? 1 [1 Yes 2 [J No 3 [] Don’t know I. Have you seen him(her) often rub his(her) eyes or blink when he(she) is reading? 1 [J Yes 2 [No 3 [] Don’t know J. Does he(she) sometimes close or cover one eye or hold his head on one side when he(she) reads or watches T.V.? 1 [1] Yes 2 [) No s [) Don’t know 43. DOES YOUR CHILD HAVE ANY TROUBLE HEARING? 1 [] Yes 2 [J] No 3s [] Don’t know 44, DOES HE(SHE) EVER HAVE EARACHES? 1 [J Yes 2 [] No 3 [J Don’t know 45. HAS YOUR CHILD EVER HAD ANY INJURY OR DAMAGE TO HIS(HER) EARS? 1 [OJ Yes 2 [J No 3 [J Don’t know IF YES, in what way was his(her) ear injured? 43 44 46. HAS HE(SHE) EVER HAD HIS(HER) EAR DRUMS OPENED OR LANCED? 1 [OJ Yes 2 No 3 [] Don’t know IF YES, how many times? 1 [] Once only 2 [] Twice only 3 [] Three times or more 47. HAS HE(SHE) EVER HAD ANY OTHER KIND OF OPERATION ON THE EARS? (38) 1 [J Yes 2 [1 No 3 [] Don’t know IF YES, what was it for? 48. HAS THIS CHILD EVER HAD A RUNNING EAR OR ANY DISCHARGE FROM HIS EARS (Not counting wax in the (39) ears)? 1 [J Yes 2 [No 3 [] Don’t know IF YES: A. How often has he(she) had this? 1 [] Once only 2 [] Twice only 3 [) Three or more times 4 [) Don’t know B. Was this his(her) left ear, right ear, or both ears? 1 [] Left 2 [] Right a [) Both 4 [7] Don’t know 49. HAS HE(SHE) EVER HAD ANY OTHER KIND OF TROUBLE WITH HIS(HER) EARS? 1 [J Yes 2 [No 3 [] Don’t know IF YES, what kind of trouble? 50. IS THERE ANY PROBLEM WITH THE WAY HE(SHE) TALKS? (43) 1 [1 Yes 2 [] No 3 [] Don’t know IF YES, what is the problem? 1+ [] Stammering or stuttering? 2 (7) Lisping? 3 [1] Hard to understand? 4 [) Something else? What is that? 51. DOES THIS CHILD HAVE A LIMP OR ANY TROUBLE WHEN HE(SHE) WALKS? 1 [Yes 2 [] No 3 [] Don’t know IF YES, how much trouble and what kind is it? 52. DOES HE(SHE) HAVE ANY PARALYSIS OR ANY WEAKNESS OR TROUBLE IN USING EITHER ARM OR LEG? (a6) 1 [1 Yes 2 [No 3 [] Don’t know IF YES, what kind of trouble? 53. HAS THE CHILD'S HEALTH EVER KEPT HIM(HER) FROM HARD EXERCISE OR PLAY? 1 [3 Yes 2 [J] No 3 [] Don’t know IF YES: A. Did a doctor say he should be kept from doing this? 1 [1] Yes 2 [1 No a [] Don’t know B. What was the condition that restricted the child? C. Is he(she) restricted this way at present? (49) + [3 Yes 2 [1] No 3 [) Don’t know 54. HOW LONG HAS IT BEEN SINCE HE(SHE) HAS BEEN TO A DOCTOR? 1+ [1 During past 12 months 2 []1to 2 years 3 [] More than 2 years 4 [] Never s [] Don’t know 55. HOW LONG HAS IT BEEN SINCE HE(SHE) HAS BEEN TO A DENTIST? 1+ []) During past 12 months 2 (]1to 2 years (51) 3 [) More than 2 years a [1] Never s [] Don’t know 56. HAS THIS CHILD EVER HAD HIS(HER) TEETH STRAIGHTENED OR HAD BANDS ON HIS(HER) TEETH? (52) 1 [Yes 2 [No 3 [] Don’t know IF NO, do you think the child's teeth need straightening? (53) 1 [Yes 2 [] No 3 [7] Don’t know Here are some questions about your child’s sleeping habits. 57. ABOUT WHAT TIME DOES HE(SHE) USUALLY GO TO BED ON NIGHTS WHEN NEXT DAY IS A SCHOOL DAY? (54-85) P.M. o1 [] No usual time 02 [] Don’t know | 58. DO YOU FEEL THAT WATCHING OR HEARING CERTAIN KINDS OF TV OR RADIO PROGRAMS OR SEEING CERTAIN KINDS OF MOVIES MAKES ANY DIF FERENCE IN HOW WELL YOUR CHILD GETS TO SLEEP OR SLEEPS? 1» [J Yes 2 [] No 3 [] Don’t know IF YES, what kinds of programs or movies? 59. DOES HE(SHE) HAVE BAD (UNPLEASANT) DREAMS OR NIGHTMARES? 1 [1 Yes, frequently 2 [J Yes, but not often 3 [] Never 4 [) Don’t know 60. DOES HE(SHE) WALK IN HIS(HER) SLEEP? + [J Yes, frequently 2 [J Yes, but not often 3 [J Never 4 [7] Don’t know (62) 3) 61. HAS HE(SHE) SLEPT OVERNIGHT AT A FRIEND'S HOUSE WITHOUT YOU OR OTHER MEMBERS OF YOUR FAMILY BEING THERE? 1 [1] Yes 2 [No 3 [] Don’t know IF YES, about how often? + [) Frequently 2 [] A few times 62. AT HOME, NOW, WHICH OF THESE DESCRIBE YOUR CHILD'S USUAL SLEEPING ARRANGEMENTS? 1 [] Sleeps alone in separate room Sleeps in separate bed in room shared with another person 2 [) With brother 3 [J With sister 4 [7] With parent 5 [] With other person Shares bed with another person 6 [] With brother 7 [] With sister s [] With parent 9 [] With other person 62. DOES YOUR CHILD SAY HE(SHE) IS AFRAID TO BE LEFT ALONE IN THE DARK? 1 [1] Yes 2 [7] No 3 [] Don’t know 64. WHAT IS THE NAME AND ADDRESS OF THE DOCTOR THIS CHILD USUALLY GOES TO? Name [1] None Address 65. WHAT IS THE NAME AND ADDRESS OF THE DENTIST HE(SHE) USUALLY GOES TO? Name [] None Address FOR GIRLS ONLY: 66. HAVE HER MONTHLY PERIODS STARTED? 1 [J Yes 2 [J No 3 [] Don’t know IF YES, how old was she when they started? Years Months 45 46 APPENDIX IC HEALTH EXAMINATION SURVEY—II AUDIOMETRY CARD 05 AUDIOMETER NO. (6-9) EXAMINER (10-11) USE THIS SECTION WHEN CARD USE THIS SECTION WHEN SAMPLE NO. IS EVEN COL. NOS. SAMPLE NO. 1S ODD CPS CPS — P telly —_— -«— ¥ ¥ - i — ee we 1] wo |e] -— feel mn 1 Jt ww | omen [| — — ¥ ¥ wm — ¥ ¥ — — wT] | ew | wT mn —> wo TT J | we | we: CONDITIONS AFFECTING TEST RESULTS: (Check) (48) J 1 None O 2 Conditions affecting test results O Cold at present 0 Ear discharge Od Equipment defective* 0 Specify... 0 Cold within past week O Earache within past week OJ Behavior* O Other* PHS—4611-2 2-64 SAMPLE NO. (1-5) AUDIO. APPENDIX ID HEALTH EXAMINATION SURVEY—! BODY MEASUREMENTS Faron wosaimirtiny OBSERVER (6-7) RECORDER CARD 06 CARD 07 coL. No. SITTING * CoL. NO. STANDING (FLOOR) * 8-10 FOOT LENGTH . 8-10 BIACROMIAL DIAM. meme meee ®e } eee een Wns BODY MEAS. 1-13 FOOT BREADTH 1-13 ACROMION TO OLECRANON 14-17 KNEE HEIGHT . 14-16 CHEST BREADTH 4TH ICS . 18-21 POPLITEAL HEIGHT . 17-19 CHEST DEPTH 4TH ICS . 22-25 THIGH CLEARANCE . 20-22 BICRISTAL DIAM. . 26-28 SEAT BREADTH . 23-25 CHEST GIRTH . 20-31 ELBOW—ELBOW BREADTH . 26-28 WAIST GIRTH . 32-35 SITTING HEIGHT—ERECT . 20-31 HIP GIRTH o 36-38 BUTTOCK-POPLIT LENGTH o 32-34 R. UPPER ARM GIRTH . 39-41 BUTTOCK-KNEE LENGTH . 35-37 R. LOWER ARM GIRTH . 2-44 ELBOW-WRIST LENGTH SKIN FOLDS 45-47 HAND LENGTH . 38-40 R. UPPER ARM (MM) . 48-50 HAND BREADTH . 41-43 R. INFRASCAPULAR (MM) . 44-46 R. LAT. CHEST STANDING (ON STEP) * WALL MB). sien .... 51-53 R. BICONDYLAR DIAM. ° 54.56 R. CALF GIRTH ° 57-60 STANDING HEIGHT . ANTHRO. NO. 47-50 WEIGHT (LBS) ° 61-62 coLs. 14-25 - - 7 79-80 END CARD 07 63-64 coLs. 32-35 79-80 END CARD 06 *Incm MEASUREMENTS NOT DONE OR SIDE VARIED—specify which and give reason ooo iain PHS-4611-3 REV. 7-64 SAMPLE NO. (1-5) 47 APPENDIX IE CONFIDENTIAL - The National Health Survey is authorized by Public Law 652 of the 84th Congress (70 Stat. 489; 42 FORM APPROVED U.S.C. 242C). All information which would permit identification of the individual will be held strictly confidential, BUDGET BUREAU NO. 68-R620-54.6 will be used only by persons engaged in and for the purposes of the survey and will not be disclosed ot released to others for any other purposes (22 FR 1687). HES-243 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE National Center for Health Statistics Health Examination Survey SUPPLEMENTAL INFORMATION FROM SCHOOL The child whose name appears below is one of the sample of children being studied in the Health Examination Survey. Please complete this form on the basis of school records and/or information the child's teacher or other school official may have. Please return it in the enclosed franked envelope. This child’s parent or guardian has given us written authorization to obtain information from the school. Name of child: (Last Name) (First Name) (Middle Name) Home address (for identification) 1. Birth date: (Month) (Day) (Year) 92. Present grade placement of this child NOTE: If this grade placement is qualified in any way, please so indicate. (e.g., “Fourth generally, but placed with third grade for (specify’)) 3. Have any grades been skipped or double promotions given? [Yes [J No 4. Have any grades been repeated for any reason? O Yes O No 5. If ““Yes’’ above, give reason: [] academic failure [] social immaturity [J excessive absenteeism [J other (specify) 6. Has this child been absent from school an unusual number of times or for an unusually long period in the most recent 6 months for which you have attendance records: OYes [No [J Don’t know [J] Not applicable 7. If “Yes” above, what is the main reason for the absence? [J lness of child [J 1llness in family [J Other (specify) [J Unknown [J Not applicable 8. 1f the tollowing special resources were available, check those you would recommend for this child: O Special provision for hard of hearing. b. Special provision for ‘‘sight saving’'. Speech therapy. Special provision for ortnopedically handicapped. Special provision for gifted children. Special provision for ‘‘slow learners’. Class for mentally retarded. Special provision for emotionally disturbed. Other (specify) None of above. 9. If you have checked any of the above items “‘a” thru “i”, are the particular resources checked available for this child? gooooogod [J Yes (If several checked, specify which available: [JNo [J Not applicable 10. If “Yes” above, are those resources being used by the child? OYes [No If “Yes’’ in item 9, but *“No’* in 10, what is the reason? 11. Which one of these statements most accurately describes this child? [J A. His adjustment is at times a concern. You think of him as a problem or future problem. [J B. Unusual in his ability to cope with normal situations. At least occasionally have thought of him as “unusually well adjusted.” [J C. You rarely think of him in terms of his behavior. He is not described by A or B. 48 15. 16. 17. 18. 19. 20. 22. 23. As you know, the ability to pay attention to a task and to sustain attention (concentrate) changes with age, although children of the same age differ. Check the item which best describes the child in the classroom situation. [J A. Pays attention as well as most children his age. [J B. Characteristically is more attentive than others his age. gc. Characteristically is less attentive than others his age. [J] D. No basis for judging which of above fits this child. In the classroom situation which one of these statements most nearly describes this child? [J A. Almost constantly moving, inappropriately talks out loud, drops things, leaves his seat when he should not, finds reasons to be ‘‘on-the-move™. ’ P 2 : [J B. Slightly more restless than most children his age. But usually is not a problem in the classroom. [J C. Shows average amount of restlessness if fatigued, bored, etc. Motor activity level is as expected for his age. [J D. Remains quiet long after the average child has become restless. Sometimes seems too controlled for his age. [J E. No basis for judging which of above fits this child. Below are a list of statements which may or may not describe this child. If the statement is descriptive of him/her, place a check mark (V) in front of the statement. If it does not describe this child, leave the space blank. (You may check several items). [J A. Other children frequently accuse him of fighting. [J B. “‘Accidentally’’ trips, shoves or hits other children. Is too ‘‘rough’’ with other children. [1 C. Frequently comes to your attention because he has been injured. [J D. Aggressive behavior frequently makes disciplinary action necessary. [J E. Children frequently complain that he uses bad words. [J F. Parents of other children call to complain about his behavior. [J G. No method of discipline seems to work with him. [J H. No basis for judging about this child in these areas. [J I. None of above statements describe this child. How frequently is any specific disciplinary action required for this child? [J A. Frequently []B. Occasionally [JC. Never []]D. No basis for judging which of above fits this child. When children ‘‘choose sides” is this child usually [J A. Among the first few to be chosen. [J B. Neither among the first nor the last ones chosen. [J C. Almost always among the last ones chosen. [1D. Relationship to group so changeable you can‘t predict order in which he would likely be chosen. CJE. No basis for judging which of above fits this child. When a leader is chosen by the group, is this child [J A. Chosen more frequently than the average child. [J B. Chosen about as often as the majority of the children. [J C. Almost never chosen. [J D. No basis for judging which of above fits this child. With respect to intellectual ability, would you judge this child to be: [J A. About average for his age (neither in the top - about one-fourth, nor the bottom - about one-fourth). [J B. Clearly above average for his/her age (In about the top fourth). [J C. Clearly below average for his/her age (In about the bottom fourth). [J D. No basis for judging this child. With respect to academic performance, would you judge this child to be: [J A. About average for his/her age (neither in the top - about one-fourth, not the bottom - about one-fourth). [J B. Clearly above average for his/her age (In about the top fourth). [J C. Clearly below average for his/her age (In about the bottom fourth). [] D. No basis for judging this child. How long have you (the person providing the above information) known this child? [J] Less than one month. [] More than one but less than six months. [] More than six months but less than one year. [) More than one year. In what capacity have you known this child? [J Teacher in classroom. [ Teacher in special area (specify) [J School principal or assistant [J Other (specify) Name of respondent providing information on this child (School) Date completed——————————————————— 3 APPENDIX IF CONFIDENTIAL - The National Health Survey is authorized by Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 242c). All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey and will not be disclosed or released to others for any other purposes (22 FR 1687). HES - 257 DEPARTMENT OF (1-5) HEALTH, EDUCATION, AND WELFARE Public Health Survey Mational Health Survey Child’s Medical History - Interviewer NAME OF CHILD (Last, First, Middle) SEGMENT SERIAL COL. NO. (6-11) 1. Were there any questions on the Health History Questionnaire that you could not answer, or questions where you were not sure what was wanted? [JYes [JNo (If Yes) a. Which questions? b. What was the trouble? 50 | Be sure to check over the self-administered questionnaire for completeness and for inadequately answered ‘‘open’’ questions | One of the things we want to find out is something about what children of this age eat since that is related to health. 2. Will you please try to remember as well as you can just what ate yesterday and let me note it down? 3. How was this different from most days, or was it about the same? 4. How many definite meals were there yesterday where the child sat down with others for a period of eating, and which meals were they? 5. Which one of the statements in each of these sets best describes ee AT, a. (1) [J Eats too much (2) [JUsually eats enough (3) [JDoesn’t eat enough b. (1) [J Eats nearly all kinds of food (2) [J Eats most kinds of foods, dislikes a few kinds (3) [J Somewhat fussy about kinds of food he (she) eats (4) [J Very fussy about food; won’t eat many things c. (1) [J On most days, eats two or more meals with others in the family (2) [J On most days, eats one meal with others in the family (3) [J] On most days, doesn’t eat any of his (her) meals with other members of the family 6. Marriage history (Parents’): (Enter present status from items 12 and 12a on HES-2. Complete only as indicated in instructions.) Wife Husband (if data different) Present status: Year first married?: Year ended?: How ended?: Married again, etc: 7. Age agreement between HES-2 and Child’s Medical History - Parent. OYes [J No a. If no, which is correct? 10. Twin status as indicated by HES-2. Is this child a twin? [] Yes [J No a. If yes, is the child an identical twin? [Yes [J No Does have certain tasks as jobs he (she) is supposed to do regularly just as part of the family? Yes [No a. If yes, list them (up to 3 tasks). Does he (she) have a pet? [OJYes [J No a. If yes, does he (she) take care of it? [J Usually [J Sometimes but not often [J Not usually but often [J Not at all I would like to ask a few questions about —________’s friends and playmates. 11, 12. 13. 15. 17. 20. 21. 22. Does he (she) have [Ja. Only a few [Jb. A good number [J ec. Very many other children who are good friends? Are his (her) friends mostly [Ja. Older [Jb. About the same age as he is? Je. Younger How many of his (her) close friends do you know by sight and by first and last name? Da. All (Jb. Most all [Je. Quite a number (Jd. Only a few When it comes to meeting new children and making new friends is [Ja. Somewhat shy [Jb. About average willingness [Jec. Very outgoing - makes friends easily How well would you say he gets along with other children? (Ja. No difficulty; is well liked [Ob. As well as most children [Je. Has difficulty with many children Has ever “‘run away from home’’-- that is, disappeared at a time when you thought this is what he (she) might be doing and stayed away so long that you had to have people start searching or looking for him (her)? [Jes [J No a. If yes, how often has this happened? b. If yes, what was the reason? Has anything ever happened that seemed to seriously upset or disturb your child? [JYes [J No a. If yes-- Tell me about it. b. How old was he (she) at the time? With respect to how relaxed or how tense or nervous your child is, would you rate him (her) a. [J Rather high strung, tense and nervous. b. [J] Moderately tense. c. [J Moderately relaxed. d. [] Unusually calm and relaxed. With respect to your child’s temper or his (her) getting angry, would you rate him (her) . [J Has a very strong temper, loses it easily. [J Occasionally shows a fairly strong temper. . [J Gets angry once in a while but does not have a particularly strong temper. a oo oT» . [J Hardly ever gets angry or shows any temper. Aside from regular classes in school, does take any special lessons or classes (e.g., music, dance, athletics)? Yes No [J Don’t know IF YES: What are they? Does belong to any clubs or group activities such as Cub Scouts, Brownies, ete. ? [J Yes [J No [J Don’t know IF YES: What ones? About how much time does your child spend on the usual day away from home when you do not know definitely where he (she) is? a. [J None at all b. [J Some but less than 2 hours 51 c. [J Between 2 and 4 hours d. [J More than 4 hours 23. About how much time would you guess your child spends on the usual day doing each of the following: (Enter number of hours or fraction of hours or zero as appropriate) a. Watching television? Listening to radio? Reading newspapers, comics, magazines? Reading books (except comic books)? Playing with friends? mo a0 Playing by himself? g. Working (doing chores, etc.)? 24. Have you ever had, over a considerable period of time, a good bit of trouble in getting your child to a. Go to bed when you thought it was bedtime O Yes J No b. Get to sleep after he (she) had gone to bed O Yes OO No c. Take a nap when he (she) was little J Yes OO No 25. What would you say were ’s best (strongest) points and worst (weakest) points? a. Best b. Worst INSTRUCTIONS FOR COMPLETING THE INTERVIEWERS’ QUESTIONNAIRE CHECKING THE CHILD’S MEDICAL HISTORY - Parent Ask Question 1 on the Interviewer Questionnaire to ascertain whether or not the respondent had any difficulty with any questions. If the respond- ent reports any difficulties record the number of the question or questions and the nature of the problem. Explain the questions and obtain and record the proper answers. Next check over the entire questionnaire to see that all relevant items are answered. If you find blanks ask the question and record the re- sponse. Please record all of your comments and responses in red pencil. At the same time, review and ask required probes for the open questions. Throughcut the self-administered questionnaire you will find several open questions, such as 5b and d, 8a and b, 9a, etc. The respondents may give inadequate answers to these open questions and the inter- viewer will need to review each one carefully. When to probe for more information must be left to the interviewer's judgment. Remember that the main purpose of these questions is to provide information to the doctor who will examine the child. The doctor cannot question the mother because she will not be present during the examination. He cannot question the child because the child will not have the necessary informa- tion in most cases. Therefore, the interviewer must be sure that the responses are sufficiently clear and complete to provide the doctor with all the information he needs. The interviewer will, of course, not understand the medical significance of much of the information. She can, however, decide when there is enough information to give her a clear picture of the situation. Record responses directly on the self-administered ques- tionnaire. Examples: Question 21a, mother reports ‘‘heart condition’’. We would like to have more details about the condition. Question 26, either a “Don’t Know” or a ‘‘Yes’’ answer calls for some checking. Here, as elsewhere, if ‘Don’t Know’ merely indicates lack of information, there is nothing to add. Whenever there is a history which the mother thinks may apply, that should be described. Question 30a, the response is ‘‘stomach operation’’. Again, a more detailed report is needed. To probe for more information use general “‘non-directive’’ probes. Non-directive probes are questions which ask for more information but do not suggest any particular response patterns. Examples of such probes are: ‘‘Tell me more about that’, “Can you give me some more informa- tion about that’’, etc. One such probe is “I notice you said. . . . .”” “Can you tell me something more about that?’’ It should be used to followup all open ques- tions which are not entirely clear. Write the responses in the spaces following the question, or on the back of the page. Verbatim reporting is important. Review Question 32, and for questions a through k ask the additional questions below, recording the item number and answers on the reverse side of that page of the ‘‘Child’s Medical History - Parent’’. Probes for use with ““Yes’’ answers to Question 32: a. Was he (she) sick in bed at home? How long? b. Was he (she) sick in bed at a hospital? How long? Where? c. Did he (she) completely recover so that he (she) was no different from the way he (she) was before the illness? If not, describe how he (she) was different afterwards. 52 ASKING ADDITIONAL INTER VIEWER’S QUESTIONS Next, ask the series of questions about eating habits of the child. Be sure to record the diet consumed on‘‘yesterday’’ -- the day imme diately preceding your visit -- even if the parent says that was not the usual diet. It is important that we ask about a specific day decided in advance. Record the items in whatever way the parent can describe them. Thus it might be for a particular child the mother could say, ‘he had one egg and toast and a glass of milk in the morning; then he ate whatever the lunch was at school; then he had a peanut butter sandwich and a cake when he came home . . . .etc.” It is not necessary for you to record the incidental wording of the mother’s statement for this: simply list all the items named - both what they were and how much was eaten. Refer to Question 12 on the Census Questionnaire (NHS-HES-2) and note the answer as to ‘‘present marital status’ and, if relevant, “married more than once’. Then ask the following questions, first with respect to the respondent and then separately with respect to the spouse if a spouse is currently a member of the household. a. In what year were you first married? If Question 12 was checked ‘““Married’’ and 12a was answered ‘“No’’, then omit the rest of the question. Otherwise, continue: b. What year did that marriage end? c. How did that marriage end - death of your husband (wife), divorce, or separation? If Question 12 was checked ‘‘Married’’ and 12a was ‘‘Yes’’, then ask: d. In what year were you next married again? e. Was that your present marriage? If e above is answered ‘Yes’ then omit following questions: If e is answered ‘*“No’’ go back to b above and record answers to questions b, c, d and e for each successive marriage until e is answered “‘Yes’’. If Question 12 was checked ‘“‘Widowed’’, “Divorced”, or ‘‘Separated’’, ask questions b and c¢ above. Then ask: f. Were you married again? If answer to f is “No’’ then omit the following questions. If f is answered *‘Yes”’ then ask: g. In what year were you next married again? Then repeat b, c¢, f and g until f is answered ‘“No’’. Compare the age recorded on the Census Questionnaire with the age on Page 1 of the Child’s Medical History - Parent. Be sure any disagree- ment is correctly resolved. Also examine the ages shown for other siblings on HES-2 to determine whether this child may be a twin. If so, get the parent’s statement as to whether the twins are “‘identical twins’ as distinct from ‘‘fraternal twins’ The remainder of the questions are of interest *o the physicians and the psychologists in connection with evaluating the stage of mental and social development the child has reached and in obtaining information relevant to mental health. 000 53 APPENDIX AUDIOMETRY TESTING PROCEDURES General, — At the beginning of each day, turn onthe audiometer at least 10 minutes before performing the daily field check on the audiometer. Leave the audiometer turned on until the comple- tion of testing in a day. Do second field check upon completion of testing. Make sure that both doors of the audiometry room are closed when testing. Another member of the staff may have to close the outer door after you are in the room, Recording. —Use left hand section of form when sample number is even; and use right hand section of the form when sample number is odd. When the sample children shows signs of fatigue, do not test the last 2 frequencies (8,000 and 3,000); place X in these boxes and check "behavior," specify "fatigue," For any other part of the test that cannot be com- pleted enter X in the appropriate box and indicate the reason under "Conditions Affecting Test Results," Instructions to the examinee. —After entering the beginning time and TechnicianNo., on the control record the technician will proceed with the following steps: 1. Detailed instructions should be given children to stress the following points: a, Earphones will be placed by the technician and must not be touched by the child. . Sounds will be heard in one ear at a time. Sounds will get progressively fainter. . Child should show when the sound is heard by raising his right or left hand depending on the ear in which the sound is heard. e. Child should keep his hand up until the sound is no longer heard. f. Child should raise his hand to the sound even though it sounds very faint. g. During the test eyeglasses, earrings, and chewing gum should be removed. 00 oO 2. Examples of detailed instructions (particularly for younger children): "You are going to listen to some sounds from earphones inside this quiet room, Sometimes the sounds will be like whis- tles, sometimes like horns. They might be easy to hear, or they might sound tiny or soft. If you 54 hear the sounds in the right ear (point to the ear), put up your right hand (point to or touch the child's right hand). Now, if you hear the sounds in the left ear (point to left ear), put up your left hand (point to or touch the child's left hand). You will have to listen very carefully to hear the sounds." Conduct of the Hearing Test 1. w Take the child into the test room and seat him with his back to the window. Close the test room doors. Repeat the instructions briefly. Make sure that the ears are not obstructed with cotton before placing the earphones. Place the earphones on the child making sure that the earphone opening is over the ear canal and that the earphone has a good seal against the child's ear. Red earphone is placed on the right ear, grey on the left. Girls should pull hair back off the ear before earphone is placed. Make sure the audiometer is ready for the test by checking thatitis setin the following manner: a. Power on for at least 10 minutes prior to start of test. b. Interrupter switch in the Off position; output switch at the word "right." Frequency dial set at 4000 cycles. Intensity dial set at 60 decibels. 30-db switch on the "in'' position. Earphone indicator on the 30-db switch box is turned to the ear being tested first as prescribed by the test form; when the ex- aminee number is odd, use the right-hand column and follow the sequence indicated— the right ear is first; when the examinee number is even, use the left-hand column and follow the sequence indicated there—the left ear is first. The 4000-cycle tone is introduced to the first ear to be tested at a level of 60 decibels for about 3 seconds. This should be well within the range of audibility for most children and will serve as listening practice. m0 a0 10. 11. 12. 13. 14. 15. 16. 17. 18. When the child responds, set the intensity dial 10 decibels below the previous stimulus intensity (50 db) and present the tone for about 5 seconds. The procedure of dropping the level of the tone in 10 decibel steps with at least one presentation at each level should be continued until no re- sponse is obtained, Then raise the intensity dial 5 decibels. If a response is obtained at this level, the in- tensity is reduced 10 decibels. If there is no response, raise the intensity Sdecibels. Always descend 10 decibels and count the number of re- sponses at the threshold while ascending in in- tensity in 5 decibel steps. The threshold recorded is the lowest dial read- ing at which 50 percent or more responses are obtained, that is 2 out of 3 or 3 cut of 5 trials. Below this level less than 50-percent response is obtained and above this a 100-percent re- sponse is approached. Make the proper two-digit entry on the test form. Repeat the procedure presenting the 4000-cycle tone to the second ear to be tested and then shift to the next frequency as indicated on the test form, until the test has been completed for all frequencies and for both ears. Remove the earphones and immediately com- plete the questions pertaining to the reliability of the test. Apply disinfectant lightly to the headband and earphones with a wad of cotton while the child is watching. Escort the child from the test room. Fill in all information asked for on the form. Procedure Necessary for Threshold Accuracy : Nou oe 10. il, Avoid rhythmic presentation of signals to the child. The child may respond to the rhythm rather than to the sound. This is especially true of younger children. Avoid a long, drawn-out search for a threshold which tends to lessen the interest and coopera- tion of the person being tested and to produce fatigue. If necessary, shift to another frequency and test, then return to the problem frequency later. Note at the bottom of the form any change in the order of the test on the test form. Avoid giving visual or auditory cues when the tone is presented; for example, looking at the person each time a tone is presented, or making a click with the interrupter switch, or clicking the intensity dial. Double check the dial reading. Check whether the switch was on "in'' position. Avoid activity which will distract the child. Check the response of the child occasionally by leaving the tone off for several seconds and then presenting the tone to see if the child is respond- ing consistently. Avoid presentation of the test tone for longer than 5 second. This may lead to a false response. Count only the ascending responses in determin- ing the threshold. Avoid being influenced by the threshold obtained for the first cycle tone when obtaining the thresh- old for the second presentation of this tone. Make sure all forms are complete, Record the time the test is finished and Technician number on the control record. When the testis not done or incomplete, record reason. OOO 55 APPENDIX lI ESTIMATION PROCEDURE An examination finding for a sample child is in- cluded in tabulations as a weighted frequency, the weight being a product of the reciprocal of the proba- bility of selecting the child, an adjustment for non- response cases, and a poststratified ratio adjustment which increases precision by bringing survey results into closer alignment with known U.S. population fig- ures by color and sex within single years of age 6 through 11. In the second cycle of the Health Examination Sur- vey the sample of slightly more than7,400 children was the result of three stages of selection, the probability of selecting an individual sample boy or girl being the product of the probabilities of selection at each stage. Briefly the three stages of probability selection are of: 1. A single PSU from each stratum of PSU's. 2. Twenty segments from each sample PSU. 3. Sample children from among eligible chil- dren found in the segments. Since the strata are roughly equal in population size and a nearly equal number of sample children were examined in each of the sample PSU's, the sample de- sign is essentially self-weighting with respect to the target population, that is, each child 6 to 11 years old has about the same probability of being drawn into the sample. The adjustment for nonresponse is intended to mini- mize the impact of nonresponse on final estimates by imputing to nonrespondents the characteristics of "'simi- lar" respondents, relating nonrespondents to respond- ents by ancillary data known for both. In the second cycle the usual household nonresponse due to refusals to be interviewed and ''mot at homes'' was virtually zero, so the only nonresponse category requiring some adjustment was the "failure to be examined" nonre- sponses, which amounted to 4.0 percent of the 7,417 sample children, "Similar" respondents were judged to be children in a sample PSU having the same age (in years) and sex as the children not examined in the sample PSU, The weights of all respondents in a PSU having the same age and sex were adjusted upward to give representation to the nonrespondents in the PSU having that age and sex. The poststratified ratio adjustment used in the second cycle achieved most of the gains in precision which would have been attained if the sample had been drawn from a population stratified by age, color, and sex and makes the final sample estimates of population agree exactly with independent controls prepared by the Bureau of the Census for the U.S. noninstitutional population as of August 1, 1964 (approximate mid-survey point) by color and sex for each single year of age 6 through 11. The weights of every responding sample child in each of the 24 age, color, and sex classes is adjusted upwards or downwards so that the weighted total within the class equals the independent population control. —_—0 0 56 Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 20. Series 21. Series 22. OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS Public Health Service Publication No. 1000 Programs and collection procedures.— Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data evaluation and methods research.—Studies of new statistical methodology including: experi- mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Analytical studies.—Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and committee reports.— Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Lata from the Health Interview Survey.— Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey. Data from the Health Examination Survey.—Data from direct examination, testing, and measure- ment of national samples of the population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutional Population Surveys.— Statistics relating to the health characteristics of persons in institutions, and on medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients. Data from the Hospital Discharge Survey.— Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals. Data on mortality.—Various statistics on mortality other than as included in annual or monthly reports—special analyses by cause of death, age, and other demographic variables, also geographic and time series analyses. Data on natality, marriage, and divorce. — Various statistics on natality, marriage, and divorce other than as included in annual or monthly reports—special analyses by demographic variables, also geographic and time series analyses, studies of fertility. Data from the National Natality and Mortality Surveys. —Statistics on characteristics of births and deaths not available from the vital records, based on sample surveys stemming from these records, including such topics as mortality by socioeconomic class, medical experience in the last year of life, characteristics of pregnancy, etc. For a listoftitles of reports published in these series, write to: Office of Information National Center for Health Statistics U.S. Public Health Service Washington, D.C. 20201 PUBLIC HEALTH SERVICE PUBLICATION NO. 1000-SERIES 1-NO. 5 NATIONAL”, . CENTER NI For HEALTH Number 6 STATISTICS The Agency Reporting System for Maintaining the National Inventory of Hospitals and Institutions U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Public Health Service Publication No. 1000-Series 1-No. 6 For sale by the Superintendent of Documents, U.S. Government Printing Oflice, Washington, D.C., 20402 - Price 25 cents NATIONAL CENTER| Series 1 For HEALTH STATISTICS | Number 6 VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES The Agency Reporting System for Maintaining the National Inventory of Hospitals and Institutions A study of the development, composition, implementation, and evaluation of the Agency Reporting System. This sys- tem was used to reconstruct and keep current the Master Facility Inventory. Washington, D.C. April 1968 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service John W. Gardner William H. Stewart Secretary Surgeon General NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, PH.D., Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development ALICE M. WATERHOUSE, M.D., Medical Consultant JAMES E. KELLY, D.D.S., Dental Advisor LOUIS R. STOLCIS, M.A., Executive Officer DONALD GREEN, [nformation Officer DIVISION OF HEALTH RESOURCES STATISTICS SIEGFRIED A. HOERMANN, Director JOHN MONROE, M.S., Assistant Director JACQUELINE GLEASON, M.A., Chief, Health Manpower Statistics Branch PETER L. HURLEY, Chief, Health Facilities Statistics Branch JOHN MONROE, M.S., Acting Chief, Hospital Discharge Survey Branch Public Health Service Publication No. 1000-Series 1-No. 6 Library of Congress Catalog Card Number 67-62376 PREFACE The National Center for Health Statistics (NCHS) collects and publishes data on health and health-related topics. Data are collected on both the institutional population and the noninstitutional population. Comprehensive statistics onthe health of the institutional population are provided by utilizing probability sample surveys. These sur- veys are most efficient when the samples can be drawn from an up-to-date list of places in the universe, properly classified, and accompanied by such critical attributes as the numbers of employees and beds. The Master Facility Inven- tory (MFI) comprises this list. It is imperative that the MFI be kept as cur- rent as possible if it is to serve as an efficient sampling frame. Tc aid in accomplishing this purpose, extensive time and preparation have been devoted to the development of a system of agencies, known as the Agency Reporting System (ARS), which will provide information on new institutions at regular intervals to be incorporated into the MFI. The origin and development of this system were the result of the extensive collaboration of the Surveys and Research Corporation, the Bureau of the Census, and NCHS. The Surveys and Research Corporation can- vassed prospective sources of facility listings, suggested agencies for inclusion in the ARS, and recommended steps to be taken in launching the ARS. The Bureau of the Census conducted visits to agencies maintaining the largest lists of facil- ities and/or agencies having a large turnover of facilities. Also most of the processing involved in assembling the updated MFI was handled by the Bureau of the Census. NCHS coordinated the pro- jects undertaken by the Bureau of the Census and the Surveys and Research Corporation. In addition, NCHS conducted a survey by mail of all agencies included in the ARS that were not visited by the Bureau of the Census, and several members of the NCHS staff contributed in other ways to the research leading up to the establishment of the system. This report was prepared by Darrel Eklund. eee ni CONTENTS Page Preface -----=mmm-mmmmmmm mmm mmm em m mmm mmm mmo mmm iii INtroduCtion ==-== === === co mmm momo mm meee memo m moomoo —-o-o oo 1 Background --====-== mmm me mm me mm 1 Development of the First Master Facility Inventory-------------------- 1 Evaluation of Coverage of the Master Facility Inventory-----------~---- 2 Maintaining the Master Facility Inventory----------==-=--------------- 2 Development of the Agency Reporting System------=--======-c----------- 3 Survey CHIONOLOZY BN PROCITE mm mrs mimi mmm mimi mim on st 0.100 0 5 ho wk 3 Composition of the Agency Reporting System=--------===-----------o-mmno- 5 State Administrative Agencies------=-==----ocommmmmmmm memo moe 6 State Regulatory Agencies--------==-=------comomoomoooooo momo moo 7 Secondary SOUFCES--=-=========-=--==---m—mem—eo—ooomo-oo—--oooooo- 9 Implementation of the Agency Reporting System----=-=-------=-=-==------ 10 OAINING AGENCY COOPETRUION www es mo sri 5 550 05 i 1 10 Reconstructing the MFl--~---crecccmmcr mmm cee eee mmm mm mmm mm em 11 The Agency Reporting System Information Files------------=--c------- 11 Basic Information File-----=-eccocmmmom mmm meee m mmm meme m 12 REPOFUING TOTOTTNALION FTL www rs mm im sim om ry io 00 tw a 12 Evaluation of the Agency Reporting System-----==---=------c-mc----n--m- 13 Investigation of Coverage Gaps-------==-===========meme————————————— 13 Homes for the Aged--=---==-==--o-cmmmmmmommmmmemmmm mmm mmm mmm 13 Homes for Dependent Children-------=-----=-=--------o-omoomomoonoo- 14 Future Maintenance of the ARS and MFI-------ceouoococnmmmomonnom 17 Appendix 1. Survey Letter Announcing Visits Conducted by the Bureau of the CensuS--=-m==m-=- o-oo eee meme meme mememmooo—-——- 18 Appendix II, Annual Report Card Used in the Reporting Information F ile--- 19 vi CONTENTS—Con., Table 1, 10. Number of survey schedules mailed and response, by type of schedule-- Number of State administrative and regulatory agencies, by type------- Number of State and Federal administrative and regulatory agencies in the survey, by type--=-- === mmo. Number of State agencies administering facilities, by type------------- Number of State agencies regulating facilities, by type------=-=------ Percent distribution of facilities in files reported by regulatory agencies, by type-- mmm mm mee ee Percent distribution of 1964 additions to files of regulatory agencies, by type of establishment------=-nocmmmmmm oo ___ Percent distribution of 1964 additions to files of regulatory agencies, by type of agency---- === comm. State estimates of the number of facilities not included in the Agency Reporting System and specific area of undercoverage----------=---- Percentage of facilities missed in the Master Facility Inventory at the national level according to State agency estimates-------=--=ooco- Page on 15 SYMBOLS Data not available--===emmcemmcccceee ee Category not applicable-======cccececauao Quantity ZerO=======mm-mmommmc meee Quantity more than 0 but less than 0,05---- Figure does not meet standards of reliability or precision------=-----cuu-- 0.0 vii viii IN THIS REPORT the Agency Reporting System (ARS) is described. The ARS was chiefly conceived of as a means of updating the Master Facil- ity Inventory. This system of agencies was developed by canvassing State and Federal agencies, national ovganizations, and commercial publishers believed to maintain files containing the names and addvesses of in-scope facilities, such as hospitals and nursing homes. The implementation of the ARS was initiated by visiting the agencies maintaining the lavgest lists of facilities and/ov having the lavgest turn- over of facilities. The remaining agencies in the ARS weve contacted by mail. In this initial contact, the agencies’ cooperation was enlisted in reporting new facilities at that time and at vegulav intevvals in the fu- ture. An evaluation was made of the undevcovevage in the Master Facility In- ventory to determine the adequacy of the ARS as a means of providing a complete and curvent list of in-patient facilities. The evaluation ve- vealed that the undevcovervage in the Master Facility Inventory was quite small, THE AGENCY REPORTING SYSTEM FOR MAINTAINING THE NATIONAL INVENTORY OF HOSPITALS AND INSTITUTIONS INTRODUCTION Background The National Center for Health Statistics (NCHS) maintains a system for collecting data on health and health-related topics. In addition to compiling national figures from State and local registration of vital events such as births, deaths, marriages, and divorces, NCHS conducts a variety of continuing and ad hoc sample surveys to collect information on the general health of all persons living in the United States. The Health Interview Survey and the Health Examination Survey collect information on the noninstitutional population. The Institutional Pop- ulation Survey provides health statistics on the institutional population and represents the most efficient medium for the collection of statistics on utilization of long-stay hospitals, resident institutions, and other types of health facilities. In addition, NCHS collects information about persons discharged from short-term hospitals. This information is collected in the Hospital Discharge Survey. In the latter two surveys infor - mation is obtained from the facility providing service and a major part of the data collected is based on existing records. The universe or sampling frame for the Institutional Population Survey and the Hospital Discharge Survey is the Master Facility Inventory (MFI). This inventory includes all types of in- patient facilities, such as hospitals, nursing homes, homes for the mentally retarded, and homes for dependent children. The program of the MFI includes the development and maintenance of a list of nomes and addresses of all facilities or establishments within its scope and the col- lection of information from these places which describe them with respect to their size, type, and current status of business. The information not only provides a basis for stratifying the MFI into homogeneous groups for the purpose of sampling, but also provides important national statistics about the availability of such facilities in the Nation.1 Development of the First Master Facility Inventory There were three basic operations in the development of the original MFI. First, an in- vestigation was made to determine what files on facility names and addresses were available inthe United States, and which of the files should be merged to produce the most complete list of facilities. Second, the selected files were matched to eliminate duplicate names. And third, a ques- tionnaire was mailed to each address on the list to determine if the place was still in operation and to collect information for classifying the facilities by type of business, ownership, and size. The mailing list was essentially the product of collating the files of four Federal agencies, IN ational Center for Health Statistics: Development and maintenance of a national inventory of hospitals and institu- tions. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 3. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1965. each containing between 20,000 and 30,000 names and addresses of facilities. Additional facilities were added to the list by matching places named in directories maintained by national associations and organizations and by State licensure files for nursing homes and related facilities. The matching procedure was a simple one, primarily because little information was avail- able on which to make comparisons. The principal factors were name and address, but, when avail- able, the number of beds, type of ownership, and type of business were used to aid inthe matching. The criteria for matching were not strict. If there was any doubt concerning the match, the case was considered a 'monmatch' and included in the mailing list. This procedure insured maxi- mum coverage among establishments in the lists being collated, but it also resulted in duplication, an undesirable trait of a sampling frame. Evaluation of Coverage of the Master Facility Inventory The importance of knowing the completeness of the frame when conducting sample surveys cannot be overemphasized. Whether or not the survey results produce relatively precise na- tional estimates is largely dependent upon the MFI's including all facilities in the Nation. There was some confidence that the newly developed MFI did indeed include all but a negligible num- ber of hospitals and institutions in the United States. The confidence, however, reflected only subjective evaluations based primarily on the fact that the inventory was developed by merging several very large files and, consequently, was the most complete file of its kind. Such subjective evaluations unfortunately did not permit definitive statements about the MFI's completeness. It was apparent that some objective method of evaluation was needed. The comprehensiveness and completeness of the MFI were evaluated with the aid of a multi- frame method. The method involved the overlap between the MFI and a complete listing of in- scope facilities in an area sample of the United States, Each facility in the area sample was matched against the facilities in the MFI. The measure of undercoverage in the MFI was based on the subsample of places which did not match. The results of the study, referred to as the Complement Survey, indicated that the first attempt at developing a national inventory of hos- pitals and institutions had been relatively success- ful, It was found that at the time of its development, the MFI was about 90 percent complete in terms of facilities and about 95 percent complete in terms of number of beds. Although the sample was small, it provided some idea about coverage by type of establishment. The most complete coverage seemed to be for hospitals as all hos- pitals in the area sample were listed in the MFI. Nursing and personal-care-type homes were less complete (about 90 percent); for other types of institutions, the coverage was estimated to be about 80 percent complete. ? Maintaining the Master Facility Inventory The MFI is composed of many types of facil- ities that are in an almost continuous state of change. Many new facilities are being built and additions are being made to existing structures. Some facilities are going out of business per- manently while others only change ownership or management. Since the MFI is to be the sampling frame for surveys of hospitals and institutions, it must be kept current. Maintaining the MFI involves adding new facilities which go into business each year, deleting those which go out of business, and obtaining certain information from those currently in business. It was planned to survey all new facilities each year to obtain the data needed for classification purposes and to survey the entire MFI every 2 years to bring it upto date.! Before the plan for surveying the MFI was implemented, a decision was made to reconstruct the MFI. The decision was prompted largely be- cause of the lack of adequate means for adding new facilities to the MFI. Supplementary de- ficiencies such as duplication of facilities and difficulty in identifying specific areas of under- coverage were also considered. Thus, in the re- construction of the MFI a system of agencies Senyant, E. E., and DeLozier, J. E.: Methodology for De- veloping, Maintaining, and Evaluating a Sampling Frame of Hospitals and Institutions. Paper presented atthe 94th Annual Meeting of the American Public Health Association, San Fran- cisco, Calif., Oct. 31-Nov. 4, 1966. was desired that would provide a reliable input system for the addition of new facilities, minimize the amount of duplication in the MFI, and enable NCHS to identify and eliminate undercoverage in the MFI. There were a large number of possible sources of facility information, many of which overlap but none of which were sufficient alone. These sources included State licensure agencies, certain departments of the Federal Government, and private agencies and organizations which maintain or publish facility lists. The development and maintenance of this system of agencies, known as the Agency Reporting System, are discussed in detail in this report. DEVELOPMENT OF THE AGENCY REPORTING SYSTEM The development of the Agency Reporting System (ARS) was initiated by the contract awarded to the Surveys and Research Corporation by NCHS on October 26, 1964. The objectives of the contract were to survey and identify agencies maintaining lists of hospitals and institutions providing long-term medical, nursing, personal, domiciliary, or custodial care; to obtain infor- mation on the scope and character of their name and address files; and to make recommendations to NCHS concerning the agencies to be included in the ARS. It was agreed that the goal would be pursued via the following steps: 1. To canvass all State and Federal agencies, national organizations, and commercial publishers believed to maintain files be- cause they a. License, approve, register, certify, supervise, or otherwise regulate hos- pitals or institutions, b. Operate one or more hospitals or insti- tutions, c. Administer Federal grant programs affecting hospitals or institutions, d. Conduct programs whose administra- tion yields as a byproduct listings of facilities which include hospitals or institutions. 2. To solicit from them, via a mail schedule (or interview in the case of Federal agen- cies), information on the scope and char- acter of their files, methods used to up- date the files, publication practices, and related information. 3. To ascertain the extent to which these files account for all hospitals and insti- tutions deemed to be within the scope of the MFI, particularly with respect to fa- cility "births." 4. To make recommendations concerning the agencies and organizations which would be invited to participate in the ARS and the operational characteristics of the ARS. 5. To prepare a report embodying survey findings and recommendations. Survey Chronology and Procedures The early months of the Surveys and Re- search Corporation's work were devoted to the development of schedules and instructions in close collaboration with NCHS staff. Field visits to test the schedules were made in the District of Columbia and Pennsylvania in December 1964, Successive redrafts of the schedules led toapre- test conducted during March and April 1965 in California, Illinois, Louisiana, New York, and Wyoming, Two schedules and three procedures were used in the pretest. One schedule was addressed to State regulatory agencies, the second to all other types of respondents. The three procedures rep- resented three different approaches to the problem of how to best identify and obtain the participation of all potential respondents in the States. In the first procedure the director of the de- partment was contacted and asked to distribute schedules to the persons named in his department. In the second procedure the schedules were mailed directly to the persons concerned along with a letter mailed to the director identifying persons contacted in his department. In the third pro- cedure the director was requested to identify appropriate persons in his department who had lists of facilities. The persons identified were then sent schedules by the Surveys and Research Corporation. Field visits were subsequently made to all respondents, who were interviewed as a basis for assessing the relative merits of the procedures used. Pretest results indicated that a direct ap- proach to the person who had the lists of facilities, Table 1. Number of survey schedules mailed and response, by type of schedule Schedule response Type of schedule Total A B C Total schedules mailed-==c-c-eccceccea-- Schedules returned----ce-eccccccccacannax With sufficient information to be punched 560 151 | 142 | 267 —————————————— 496 || 145 | 137| 214 334 135 | 113 86 Insufficient information, not punched-----eccecacccccccncan- 162 10 24 | 128 Schedules not returnede=e=eeseececcecceccceccceeeccecenana== 64 6 5 53 Requested information supplied via letter or phone-=----=----- 43 4 2 37 No response, information obtained from other sources-=------- 21 2 3 16 usually proved productive. Thus the final pro- cedures incorporated this feature of the second procedure along with some minor characteristics of the other two procedures. In November 1965 a second pretest, which was a trial run of the final schedules and pro- cedures, was conducted in the States of Michigan, New Jersey, and South Carolina. This proved sufficiently successful to encourage NCHS and the Surveys and Research Corporation to plan for a general mail-out in January 1966. The general mail-out (excluding the pretest States) took place, as scheduled, in January 1966. It was preceded by telephone calls to the principal respondents in all States (except Alaska and Hawaii) to verify the correctness and complete- ness of the mailing list and to establish personal contacts useful in promoting survey cooperation. The mailing list required few substantive changes as a result of the telephone calls. Three schedules were used in the general mail-out: A. addressed to State regulatory agencies and designed to obtain information not only on the number and types of establishments in their files but also on their regulatory coverage and practices and the availability of facility names and addresses in reproduced form; B. addressed to State agencies administering facilities within survey scope, requesting data on the number and types of such facilities, and a listing by name and address; C. addressed to other State agencies believed to have lists of facilities, to national voluntary agencies, and to commercial publishers; re- questing data on the number and types of facilities in their files, and their practices with respect to listing requirements, infor- mation gathering methods, and publication. Altogether, 560 schedules were mailed (in- cluding the schedules used in the two pretests), of which 496, or 89 percent, were returned. The response rate was actually better than the per- centage of returns would indicate, since 43 of the 64 respondents with no schedules supplied the essential information requested, via correspond- ence or telephone. The effective response rate on the survey may therefore be put at 96 percent. Of the remaining 21 in the nonresponse group, only 2 were State regulatory agencies, Three were State administrative agencies, 3 were other State agencies, and the remaining 13 were national voluntary agencies. The basic information that was requested via schedule from the nonresponse regulatory and administrative agencies was ob- tained from other agencies in the State or from national directories. Table 1 summarizes the re- sponse obtained from the survey schedules which were mailed. Not all of the 496 returned schedules Table 2. Number of State administrative and regulatory agencies, by type Type of agency Number Total, unduplicated=--===--= 323 Administrative agencies-ee-=-- 269 Administrative only-e--eccececcaa- 211 Administrative and regulatory---- 58 Regulatory agencies=-e----ce-- 912 Regulatory only-=---e--- cameccaa- 54 Regulatory and administrative---- 58 with sufficient information to warrant transfer to punchcards, One-third of the respondents had checked as a response the statement 'No estab- lishment files maintained’ or had made a written declaration to that effect. Falling within the scope of the survey and supplying sufficient information to be edited, coded, and punched were 334 sched- ules, or 60 percent of the total mailed. The 334 schedules with information sufficient for coding and punching came from 234 agencies. In striving for comprehensive coverage a substantial number of State agencies were identified, but were not mailed schedules, either because they were one- facility agencies or for other valid reasons. Between 500 and 600 State agencies were viewed as potential respondents in the course of the survey. The survey process (involving sched- ule entries, correspondence, telephone calls, and field visits) resulted in the identification of 269 State agencies? which administer one or more facilities falling within the scope of the survey, and 112 agencies with statutory authority to regu- Bas the term is used here, ‘‘State agency’’ refers to the most inclusive structure of State government responsible for the operation of the facility shortof the Governoror the legis- lature. This is usually a department, but can be the board of trustees for a State school for the blind if the board is not under any department and reports directly to the Governor in the State legislature. A youth division of a corrections de- partment is not considered a State agency, but anindependent youth division or youth authority is. late facilities, The survey also identified 49 agencies, including a number with regulatory responsibilities, which have occasion to maintain files based on neither administrative nor regu- latory responsibilities. A summary of number and types of agencies responding is given in table 2. COMPOSITION OF THE AGENCY REPORTING SYSTEM A total of 323 State agencies were identified as producers of primary data on establishments and therefore as potential respondents for the ARS. They are referred to here as producers of Table 3. Number of State and Federal administrative and regulatory agencies in the survey, by type Type of agency Number Totale-eccemeccacccnamccana 327 State agencies, unduplicated=- 323 Health department-e--cmmecccecccccca 44 Mental health departmente=me-- ——— 23 Welfare department--e-eecceccmcmcn 45 Health and welfare departmente=-=- 5 Education departmenteme-ececemeccan 26 Corrections departmente===mecececa= 32 Mental health and corrections department-eeeececceccceccccacan L Department of institutionse—eeee-- 12 Youth authority-e--eece-- cemmeen—— 7 Tuberculosis board or commission- 5 State board of regentS-=-eew-- -—— 4 Board of State training schools-- 4 State university or medical college=ccmcccccccrarcmmnccaaan 30 Long-stay State hospital facility=ececcmcemmcmmccncccanas 9 Short-stay State hospital facility=eeemeecccccamrcmcccamcanaa 2 State veterans' home=e-eceaamcaaaa 14 State training schooleeemmmcccaa- 13 State school for the deafewe-a--- 8 State school for the blinde=m====- 2 State school for the deaf and the blind-ecemmcmccmcmmccccnnaas 6 All other--eceeccmmmmc cece 31 Federal agencies operating civilian hospitals or insti- primary data because name and address informa- tion originates in these agencies by reason of their administrative or regulatory functions. Some are responsible for lists containing more than 1,000 names. Others, by contrast, are one-facility agencies and can report only for themselves. To those State agencies which produced pri- mary data should be added four Federal agencies operating within-scope facilities (Public Health Service's Division of Indian Health, the Depart- ment of the Army, the Veterans Administration, and the Bureau of Prisons in the Department of Justice), The list provided by the Department of the Army includes the facilities of all the uni- formed services, The number of State and Federal administrative and regulatory agencies in the sur- vey are given by type in table 3. State Administrative Agencies States administer a wide range of medical- care and resident-care facilities. They include examples of every type of in-scope facility, with the exception of homes for unwed mothers. Twen- Table 4, Number of State agencies administering facilities, by type Type of agency Number Health department=----==---ccccmcccmmccm ccm ccc ccc cece m ec ccc cmc emcee mma Mental health department---=-=====-cec-cmeeemccccccecccec cnc c cnc ccc cen ————— Public welfare department=--==-=--=ccccccmmcccmcmcec emcee cc ccc mmcc mm cmae ooo Combined department of health and public welfare----=---=--c--coccccccncaacaaxa- Education department=-=-----seecmcccc cmc r ecm mem m emcee mc cc cees meme Corrections department-----=-es-m-meeemceccccccccc cee cece e esc cccce mmm ———— Combined department of mental health and corrections------=----=ccceccccaa—c=- Institutions department=-===-===---cceccmmcccccccece emcee em ecco cm cece Combined department of welfare and institutiong---------cc-c-cccccccccccccnnaa- Rehabilitation department==-===--==-cececeecccccccmmee cece cc cece ccc cm aa Hospital department--======--eecmmceccecccee ccc ccc cece er cc cece e meee —e———— Youth authority----====receccomenmnrrcer meee eer c creer rnc n cere nse crc ——— Tuberculosis board or commission-=-----=----ceccecccccc ccc cccccccceccccccennan- State board of regents-=-=-e---e-me-ccecccecccceccccccce cece ec nc ccc ceca cee —- Board of trustees for State training schools--===------eccccccccecccccccnnnaa- Department of veterans' affairs--------cc-cecceccmccccccc ecco Board of trustees, State schools for deaf and blind----===----cccccccoco—oaoo- State juvenile court systemr-=====--=m-rresssescsecsssccccce ccs sss ec ec ————— Crippled children's board-----==--c-ececcmcmccncccnccnan—a" memmmmmeccmneee een State eleemosynary board===---e=em-eccccccccccccccc nec cc cr cmcc cece cman Military affairs department-=-=-=----=eereereeccececc;c esse ees. ee.eceeec_ee————- Board of control, State homes for the aged---====----ccemccccccccmccencccccna=- State university (operating general hospital)=---=-=---cccccecccccncccacacca—- One-facility independent agency: State training school--==-==weemccrrrnmrcr cer er creer ccc; c eee ccc _ cc — State home for veterans-----=-=====m-eremesecccceccacecsccccnecccsncccccenan- Long~stay hospital facility--=========mmemesrercermccc cece rcnccsne ce cceaeee= State school for deaf-----=--=-eeccrcccmcemcmrcccc ccc ccc cde e ccc cece ———- State school for deaf and blind--------e-emereccreccc nme c ccc cere cece cee ne- State facility for mentally retarded-------=====--em=mecceeccn eee ecceeen=-" State penal facility--~-=e-e--eecercccrmcccceecc ccc cc rece cece ce ————— State home for the aged---==-==-cecccmccccccccmccccmrcc ccc ccc cree c ccc cc ene State school for blind----==-----e-cceccmcrcccrcccccrm cere c ccc eee c ec ——— State general hospital----==-----ecccccemcccccccccccc ccc cc ccc emcee neem Short-stay hospital facility----------cecccccemcccccccccrc cc ccccnccccccccene=- State facility for alcoholic§----==---c-ceccccccccccncccr ccc rece ccc cece nee State home for dependent children--====---eecceccccec ccc cccecncccccccnnaa" State facility for crippled children---=-=-===-cccccmccccccccceccccncncena=- 269 HH Ww RH WN ENN FRHENNNMNNWROOORW OHKFRFRHENHFWAPUNKHFRERENNNUULOWN ty-two health departments, 23 mental health de- partments, 18 welfare departments, and 32 cor- rections departments are numbered among the 269 agencies reporting the operation of one or more facilities. Fully one-third of the agencies are one-facility organizations. For example, 30 State universities operate general hospitals in connection with the medical school; the hospitals are independent of operating controls other than those imposed by the university. The complete list of State agencies administering facilities is given in table 4. All 50 States and the District of Columbia are represented among the 269 agencies. The range in number of agencies by State is from 2 in such States as Alaska, Iowa, Maine, and Montana to 13 in Connecticut. For the country as a whole, the average of administrative agencies is five per State. The survey identified, inall, 1,244 State facil- ities in operation in the spring of 1966. The largest group was composed of 284 penal and correctional facilities for adults. State hospitals for the men- tally ill constituted the second largest group, and training schools for juvenile offenders the third. Substantial numbers were also contributed by homes for the mentally retarded and long-stay hospitals other than for psychiatric care. Differences in the number of facilities by type reflect in large measure the traditional responsibility of State governments for the care of major offenders, the mentally ill, the mentally retarded, and selected types of chronic illness. The lesser importance in the State institutional pattern of short-stay hospitals, childrens homes, and nursing and personal care homes for the aged, infirm, and chronically ill persons may be attributed to the major role of voluntary agencies, local governments, and commercial enterprises in the development of facilities in these areas. The range in the number of facilities by State was from 5 in Nevada to 85 in New York. Differ- ences in this respect among States correspond roughly to differences in population. Departments of correction accounted for the largest numbers of facilities (213) administered by the States. This represents about one-sixth of the total. The second largest group was made up of departments of mental health, and the third largest by welfare departments. A substantial number was also accounted for by the ''depart- ments of institutions'' which exist in 12 States. Health, education, and youth authority agencies contributed smaller numbers. These differences among departments reflect in part the major responsibility, historically assumed by State governments, for providing care for selected types of patients, prisoners, and handicapped individ- uals, and the tendency of States to concentrate such facilities in a few departments, i.e., corrections, mental health, and welfare. One of the questions asked in the survey con- cerned facilities added in 1964, The extent of the facility turnover in the Nation was of course a key consideration in the design of the survey because of its obvious implications for the maintenance by NCHS of an up-to-date inventory of institutions. But it was not expected that State-operated facilities would show a high turnover rate, The relative stability of the patient and resident popu- lation was verified by survey results which indi- cated that the annual changes in the number and composition of State-operated facilities were quite small, Among 112 agencies responding to this question, only 15, or 1in8, reportedany facilities added in 1964. One agency listed four facilities opened, a second agency opened two facilities, and the remaining 13 opened one each. The 19 facilities added comprised 2 percent of the total number reported by the 112 agencies in operation at the time of the survey. State Regulatory Agencies The survey identified 112 State agencies with regulatory responsibilities for one or more types of facilities within the scope of the survey. These responsibilities assume different forms indiffer- ent States and include such functions as approval, inspection, licensing, and certification. Licensing is the most common form of regulation. A byprod- uct of regulation in all States is the accumulation of names and addresses of facilities, These gen- erally appear in the form of annual lists or directories and sometimes contain supplementary information such as bed capacity, types of care offered, type of control, and license number. Health departments and welfare departments accounted for 75 percent of the 112 agencies re- porting regulatory functions. A summary of State Table 5. Number of State agencies regu- lating facilities, by type Type of agency Number Totaleecemecencmcamcccancnn 112 Health departmente-eececececaa cmmemaa 43 Mental health department=eeme=- -—— 11 Public welfare departmente~eeecaa 40 Department of health and public welfaremeeeas cenccanmenen— “ema 5 Education departmente=e=«- meeea— 3 Department of institutionse-ecece= 2 Department of mental health and correctionsS=ececcuccacacnccmccan 1 Department of welfare and insti=- tutionS-ceecccacmccacanana ——————— 1 Hospital departmenteeeeece-a ——e——— 1 State medical care commissioneee= 1 Commission on hospital care~eee=- 1 Commission for the blind-ecceceaua 1 Youth authority-eeeececececcacaa —————— i Department of licenses and inspectiongeeeccccaacaa cnn e———— 1 agencies which regulate facilities is given in table 5. The number of regulatory agencies varies by State from one to four. In Alaska, Kansas, Maine, Missouri, Nevada, New Hampshire, New Mexico, New Jersey, Pennsylvania, and Utah all regulatory functions for facilities are located in one depart- ment, At the other extreme are States such as California, Massachusetts, Michigan, New York, and North Carolina, each with four regulatory agencies—health, mental health, public welfare, and one other, which varies among the five States, The most common pattern is represented by the State with two regulatory agencies—health and public welfare, Regulatory agencies participating in the sur- vey reported approximately 30,000 facilities in their files, This figure does not represent the true number of facilities regulated in the country, since this number may actually be larger or smaller. Some agencies failed to report all their facilities. Others, on the contrary, included in the number they reported facilities which are not regulated by the respondent or are regulated by another agency. Respondents were asked to report the number of establishments in their files. They were not asked to report the number regulated. While the files are largely limited to regulated facilities, some contain, in addition, the names and addresses of facilities of the same type operated by the State or Federal Government that are not subject to regulation and some that are regulated by another agency. The extent of duplication in the regulated group and the size of the group not regulated but listed in the files are not known and could be determined only, per- haps, on the basis of a name and address match. The number of facilities reported by State varied from fewer than 100 in Alaska, Delaware, Nevada, and Wyoming to close to 2,500 in Cali- fornia, Eight States reported more than 1,000. Nursing and convalescent homes comprised about one-half of the establishments reported, short-stay hospitals almost one-fourth, and homes for the aged other than nursing homes, one-sixth, These were the three biggest blocks and accounted for 86 percent of the total. Another 5 percent was Table 6, Percent distribution of facil- ities in files reported by regulatory agencies, by type Percent distri- bution Type of agency 3 Q Iu o — ' i ' ' 1 I ! t 1 1 1 ' 1 ' 1 ' 1 1 1 1 1 - o Q o | No Ww Short-stay hospitals--=-ececaaas Peachustale hospitals====cccacaa Other long-stay hospitals--«-=-- Diagnostic and treatment centerg==e=cccccccnmnccncaaaaaa Facilities for the mentally re- tarded=-=-=ecccccmmmmcaiaaaa Other facilities, mental illnessec=-ccccccmmmmcccaaaaa Other medical facilities~======= Nursing and convalescent homes-- Other homes for the aged--=--==-- Homes for crippled children=----- Other personal care homes=-===== Homes for the blind=---=ccacacaa Homes for the deaf-=---ccacaaaa- Homes for dependent children---- Homes for unwed mothers==--==«-- Training schools for juvenile delinquents=-==cccecmcccacacaan Detention homes==--==cccacacaaan Other establishments--=--=-e---- © eo eo Ho = NUOO = = © © © 0c ee © © © ® © © ° wun UF FUFWOYWN Ea nN OOO oOpOOCOO Table 7. Percent distribution of 1964 additions to files of regulatory agen- cies, by type of establishment Percent Type of establishment distri- bution Total==---e-memmececcacaa" 100.0 Nursing homes-=-=-==--eccccceoa= 61.7 Other homes for the aged-==---=--- 23.7 Short-stay hospitals-~~-------=- 7.0 All others-===-e-ccccccccnccaaax 7.6 contributed by homes for dependent and neglected children. All other types of facilities aggregated less than 10 percent of the total. The distribution of facilities by type is shown in table 6. The paramount role of the State health depart- ment in the field of regulation clearly emerges when facilities are grouped by type of regulatory agency. Health departments accounted for 70 per- cent of the facilities reported in the files of regu- latory agencies. Welfare departments supplied 17 percent and combined health and welfare another 5 percent. This concentration is consist- ent with the dominance of hospitals, nursing homes, and homes for the aged among the facil- ities reported, and with the usual role of the health department in the regulation of such facil- ities. With 112 regulatory agencies reporting some 30,000 names and addresses in their files, the average number per file was about 268 establish- ments. By and large, however, files on particular types of facilities tended to contain fewer than 100 names. This was true of all psychiatric and other long-stay hospital files, of files on facilities for dependent children (with two exceptions), and on facilities for unwed mothers. Respondents were requested to report the number of facilities added to their files in 1964, but about 40 percent left the item blank. Some undoubtedly meant this as a zero entry; others either overlooked the item or did not attempt an answer. From the 60 percent with an entry, a total of a little more than 1,200 facilities was added to the files in 1964; or about 4 percent of the 30,000 names and addresses in the files of all 112 agencies. It is reasonable to assume that, with more agencies reporting, the number of facilities added in 1964 could have been as high as 5 or 6 percent of the total in the files. In general, the larger the file, the larger the number added. California, Illinois, and Texas each added more than 100. In some of the smaller States, facilities added in 1964 numbered fewer than 10. For the same reason, the additions were concentrated in the nursing home files and, among agencies, in the health department as illustrated in tables 7 and 8. Related to the question of currency of the name and address of the facility regulated is agency practice with respect to frequency of contact. Ninety-three percent reported that facilities are required to renew their license or permit annually or to be inspected or approved annually. Nearly all regulatory agencies issue a printed or mimeographed list of the facilities they regu- late. Publication is usually annual, but about one agency in five issues lists ona quarterly or semi- annual basis, and about 3 percent on a biennial basis, another 28 percent use an entirely different approach such as issuing revised sheets as needed containing new names or changes in address or ownership. Secondary Sources The 323 State agencies and 4 Federal agencies compose both the vast majority and the most important respondents in the ARS. State agencies which neither administer nor regulate facilities are being evaluated and may be included in the Table 8. Percent distribution of 1964 additions to files of regulatory agen- cies, by type of agency Percent Type of agency distri- bution Total-===ccccccccncmcanaa= 100.0 Health department=-=----=-==-cc-= 76.7 Welfare department---=--=-=-=--- 11.9 Combined health and welfare department==---=-=ce-emecaoo=a= 2,4 All others--==-===ceccceccanaaa= 9,0 ARS if additional facilities can be picked up from them. National voluntary agencies, mostly under denominational auspices, which issue lists or directories of hospitals and institutions operated by member organizations may also be considered, in a sense, primary data producers. Since all or nearly all of their establishments are included in the lists put out by State regulatory agencies, and since the latter agencies possess legal authority to collect the information thus endowing the State lists with an "official" status, it is best perhaps to restrict the term ''primary data producers" to State and Federal agencies. There were 34 such national organizations to be included in the ARS that were identified in the survey, all of which furnished lists for examination and analysis. With the inclusion of four commercial direc- tories of hospitals and/or other facilities, 365 agencies and organizations have been identified which produce lists of in-patient facilities. These 365 agencies and organizations compose the ARS,’ IMPLEMENTATION OF THE AGENCY REPORTING SYSTEM Obtaining Agency Cooperation The Surveys and Research Corporation (SRC) submitted the final report and recommendations for launching the ARS on October 31, 1966. It was decided that NCHS would initiate correspondence during January and February 1967 with all agen- cies that were recommended for inclusion in the ARS. An extensive review of the agencies recom- mended for inclusion in the ARS was niade. Per- sonal visits were recommended for all agencies maintaining a large number of facilities in their files and having a relatively high turnover of facilities, The remaining agencies were to be canvassed by a mail survey. There were approxi- mately 80 State agencies located in 50 departments that were selected to be visited. These agencies were located in 40 States scattered throughout the country. An agreement was made with the Bureau of the Census to conduct the visits to the State Surveys and Research Corporation: Updating the National Inventory of Hospitals and Institutions, Vol. 1. Washington, D.C. Oct. 1966. 10 agencies. The agencies were to be visited for the dual purpose of securing their cooperation in the ARS and to plan acceptable arrangements for submitting lists of all new facilities to the Center. There were two arrangements that needed to be worked out with each agency contacted. One was to update the list sent by the agency to SRC, that is, to arrange for the agency to submit the names and addresses of all the new facilities® starting business between the publication date of the list received by SRC and December 31, 1966. The other was to arrange a continuing reporting system on either an annual basis or a more fre- quent interval, starting on January 1, 1967, In preparation for these visits a pretest was held in November 1966 inthe District of Columbia, Maryland, New Jersey, and Virginia. The pretest visits were conducted jointly by personnel from the Bureau of the Census and NCHS. Each visit was preceded by a letter explaining the ARS to the agency and announcing the forthcoming visit, the date and time of which would be arranged by telephone. The pretest showed that the agencies were quite willing to join the ARS on a continuing and regular reporting basis. If they did not periodically publish lists of new facilities as part of their regular duties, the agencies were some- what reluctant to take the time to identify them in their files. Some agencies had no system of keeping track of new facilities and consequently were unable to identify them. Thus, arrangements were made for several agencies to send only a current list of facilities. The new lists sent by the State agencies have to be matched each time against the most current lists on file in NCHS to identify new facilities. Personal visits were begun on a full-scale basis in the latter part of January 1967 and were completed in the latter part of February 1967. For a few of the visits, the Bureau of the Census interviewers were accompanied by members of the NCHS staff, so that a first-hand report might be Bon facilities include: (1) additions to buildings, if this new component has a function different from the function of the original building (nursing home added to a general hos- pital); (2) facilities that change their function from a non- health or custodial care facility into a health-oriented facility (hotels converting into homes for the aged); (3) facilities added due to a change in agency requirements; and (4) newly con- structed facilities. obtained concerning agencies maintaining some of the largest files. These visits were to agencies located in California, Illinois, New York, and Ohio. The visits were usually the first ones scheduled in their region and served to aid the interviewers in understanding the more intricate mechanisms of the ARS. Each visit was again preceded by a letter explaining the ARS to the agency and an- nouncing the future visit, for which the date and time would be arranged by telephone. The letter is reproduced in Appendix I of this report. The results of the visits indicate that all agencies were willing to provide lists of facilities which they have available in their files. Many agencies publish monthly or quarterly lists of new facil- ities and were willing to furnish these. There were a number of agencies that do not identify new facilities and would agree only to provide a current list of facilities on a regular basis. Thus, as described above, the new lists sent by the State agencies have to be matched each time against the most current lists on file in NCHS to identify new facilities, The agencies that were not visited maintained small files of in-scope facilities or had relatively little turnover of facilities. In early February 1967 a letter was sent to each of these agencies, explaining the ARS to the agency and asking it to cooperate with the Center. Each agency was asked to update the list sent by the agency to SRC and to participate ina continuing reporting system on an annual basis. Almost 70 percent of the agencies had responded by the middle of March. At this time a followup letter was sent to the agencies which had not responded. Within the next month the response climbed to 85 percent and in mid-April the remaining agencies were contacted by means of a telephone followup. By July 1967 participation was virtually 100 per- cent with only one list not received. Reconstructing the MFI The new MFI was assembled in three basic stages. In the spring of 1966, SRC supplied to the Center the State lists that were collected in its survey of State agencies. These lists were dupli- cated to maintain a file at NCHS and out-of-scope places were deleted from the lists. The lists, from State agencies that were slated to participate in the ARS, were then sent to the Bureau of the Census. The Bureau of the Census standardized the names and addresses of the facilities; elim- inated duplicates by matching; punched names, addresses, and some supplementary information such as number of beds and telephone numbers on cards; put the information on tape; and printed comprehensive lists containing all the in-scope facilities that were found in the lists obtained by SRC. Thus, the first stage of the updated MFI was completed. The second stage involved lists supplied by national voluntary organizations, Federal agen- cies, State agencies that were not scheduled to participate in the ARS, and the list of facilities in the old MFI, Facilities appearing in these lists were matched against each other and matched against the listing obtained in the first-stage compilation of the updated MFI. All names and addresses of facilities that were on these lists and noton the "stage one'' list were standardized, punched on cards, and added to the ''stage one" listing of facilities along with additional informa- tion such as telephone number, number of beds, etc. The third and final stage dealt primarily with adding to the list new facilities reported by the ARS and a separate group of homes for the aged in California. Homes for the aged maintaining fewer than 16 beds were not included in the report from California because they are county regu- lated. Since there were a large number of these facilities (over 3,000), each county was asked to send lists of these facilities to NCHS. The same procedure was then followed in this stage as in "stage two." The completion of this stage re- sulted in the printing of the updated MFI. The Agency Reporting System Information Files The Agency Reporting System is subdivided into two information files. A Basic Information File is maintained to record information about each type of facility within each State and a Re- porting Information File is maintained to assist in mailing letters and recording responses from each of the agencies in the Agency Reporting System. 11 Basic Information File The Basic Information File provides infor- mation from each State and the District of Columbia concerning each type of facility listed in the Master Facility Inventory and also about the lists from which each type of facility is enu- merated, The information recorded for each type of facility includes control (State, local, voluntary, or proprietary), type of regulation (licensure, administrative, etc.), and coverage by number of beds. The information recorded concerning the list for each type of facility includes source of list (name and address), title, and/or description of the list; date of the list; frequency of publica- tion; number of facilities on the list; and number of facilities added in 1964. The file may be used to determine if a list of facilities from a source not in the Agency Reporting System is superior to the list which is being used, provided that sufficient information can be obtained about the new proposed list, The Basic Information File is set up in the following manner: The States are listed alpha- betically; then the types of facilities within each State are listed in order on separate index cards containing the desired information about each type of facility and its list or lists. The system de- scribed above is available for a quick reference in contrast to the situation which might exist if the information were stored on computer tape. Thus if new information is found for some type of facility the appropriate card may be pulled from the file and changed. Reporting Information File A Reporting Information File is needed to insure that NCHS can promptly and efficiently contact and record the responses of all agencies or organizations participating in the Agency Re- porting System, The information needed about each agency is recorded on individual index cards. Three opera- tional systems are used, Allthree systems record the State and department in which the agency is located, the name of the list, the source code (a 3-digit code that identifies a specific list), and the name and address of the contact person in the agency, The first system is used for recording infor- mation about agencies that have chosen to report annually. Two types of information are collected: (1) information necessary to provide a record of agency contacts, such as the date of the mail re- quest for listings, the first mail followup, the second mail followup, the telephone followup, and the date of response from the agency (recorded each year); (2) information concerning the list which the agency returns, such as publication date of the returned list and number of new facilities added since the last report, This card is repro- duced in Appendix II, The second system is used for recording information about agencies thathavechosentore- port quarterly or semiannually, It differs from the first system in having only one mail follow- up and having a check list onthe back of the cards for recording the number of new facilities, the date the list is received, and the reporting interval of the agency. The third system is used for recording infor - mation about agencies that have chosen to report every month, The information collected with this system is the number of new facilities added dur- ing the year. Also on the back ofthe cards in this system is a check list for recording the number of new facilities, the date the list is received, and the reporting interval of the agency. The first card in this file contains the sug- gested dates for requesting annual listings and suggested dates for all followup correspondence, The date that the mail request for listings is sent and the dates of any followup correspondence deemed necessary will be recorded as well as the individual agency's date of response. These cards are placed in alphabetical order by State and by department within State, For those agencies reporting annually the date of response will be recorded and the corre- sponding card will be pulled and placed in the back of the file, Before each followup correspond= ence it is necessary to look at the front of the file to see which agencies have not responded and hence must be sent a followup. Thus the cards will be alternated from front to back on a year- to-year basis, so that agencies which have not responded may be readily identified, All agencies that choose to report more than once during the year will have a card made out and placed in alphabetical order by State and by department within the State, On the back of each card is a check list to record the date of response and the number of new facilities. After each agency responds, the information requested on the check list is transcribed and once a year (preferably during January or February) the number of new facilities added during the previous year is totaled on the check list and transcribed on the front of the card. Periodic review of the check lists will indicate if the agencies are responding as ex- pected. If they are not, followup correspondence will be initiated if necessary. After the appropriate information has been recorded on the cards, all lists of new facilities are placed in envelopes labeled by State to await their addition to the Master Facility Inventory. EVALUATION OF THE AGENCY REPORTING SYSTEM Investigation of Coverage Gaps The success of the ARS depends largely on the extent to which a coverage gap of facilities can be minimized, both now and in the future. The question arises, how complete is the cover- age of institutions throughout the Nation in the updated MFI? To evaluate the coverage, the questionnaires collected in the ARS survey of State agencies and the report submitted by the Surveys and Research Corporation were reviewed. The coverage was analyzed along two problem dimensions: (1) in- adequate coverage due to larger bed-size mini- mums established by the various State licensing agencies than specified by the MFI, and (2) insuffi- cient information because of no regulation of the type of facility in question. Coverage gaps with regard to bed-size mini- mums were established using the requirements for inclusion in the MFI—that is, one or more beds for all hospitals and three or more beds for nursing homes and other institutions included in the MFI, The problem arising from the minimum requirements for licensure based on the number of beds was approached through a one-to-one match of the national lists with the lists of existing facil- ities supplied by the individual States. In the questionnaire used by SRC, the State agencies were asked to report the number of those facilities in the State which were not regulated by the Department and not included in their files. Not all State agencies responded but for those that did, the estimate was used as a baseline in estimating the total number of facilities contrib- uting to the coverage gap due to lack of regulation, Once the possible problem areas were iden- tified it was necessary to determine if the type of facility was, in fact, a coverage gap and if so, approximately how many facilities were missed in compiling the MFI, The initial screening was intended to identify all possible problem areas, Many of the areas first identified as having coverage gaps later proved to have complete, or nearly complete, coverage. The result of the investigation was the indica- tion that only two types of facilities contribute sufficient undercoverage to warrant examination in this report. These types are homes for the aged and homes for dependent children, which will be discussed next, Homes for the Aged The major problem in the ARS lies in the area of homes for the aged providing personal care. This area is difficult to evaluate since the State licensure requirements vary considerably when differentiating between homes providing some kind of nursing skill and other facilities considered to be "boarding homes.' The definition of an institution as used in the MFI requires that the facility provide something more than just room and board, This discrepancy between the national and State definitions leaves several facilities ina borderline area, To insure that the coverage of the MFI is complete, these borderline cases have been included, at least until they are provedto be out of scope through the MFI questionnaire. Idaho, South Carolina, and West Virginia do not license personal care homes and have no regulatory program for those facilities defined as less than ''skilled" nursing homes, With the exception of Idaho which lists seven so-called boarding homes in their files, these States ex- clude those facilities which provide personal and/or custodial care from their lists. The cover- 13 age gap in this type of facility is estimated as quite large. West Virginia estimates the number of such facilities in the State at approximately 500 to 600. This estimate may be too large, how- ever, since it may include boarding homes pro- viding nothing more than room and board. South Carolina and Idaho (with the exception of the seven facilities listed on their schedules) did not provide estimates of the number of facilities which may be in the State. The literature of the national voluntary organ- izations in the area of homes for the aged is limited in that most of the lists are published by various denominations and include only facilities which are under those particular religious aus- pices. If the required information about homes for the aged in these three problem States is to be obtained from these sources, a time-consuming search of these numerous publications would be involved. Even if this were done, the list would not be complete because many proprietary facil- ities would be missed since facilities under religious auspices are usually nonprofit. The national listing used to evaluate the undercoverage of homes for the aged was the ''Di- rectory of Nonprofit Homes for the Aged, 1962." This source is not complete in listing facilities of this type. An example of the undercoverage can be seen in West Virginia. The schedule received from this State reports an estimate of 500 to 600 personal care homes. Excluding those facilities classified as nursing homes, the directory re- ports only two nonprofit homes for the aged in West Virginia, This discrepancy between the State estimate and the directory is large enough to throw doubt on both the estimate and the completeness of the directory. Likewise, the di- rectory reports three establishments each for Idaho and South Carolina. It seems unreasonable that States of this size could have as few as three facilities providing personal care for the aged, even considering that the directory lists only non- profit homes. Included in the report submitted by SRC is the recommendation that a one-time census in these States be made to identify the personal care homes. Because of the large cost of such an undertaking, it could be justified only if there were a large number of facilities in these States. However, West Virginia is the only State providing an esti- 14 mate of facilities. Since there is no complete national listing it is impossible to give a meaning- ful estimate of the number of facilities in Idaho and South Carolina, Therefore action on this recommendation has been deferred until more information is available, California posed a unique problem with re- gard to homes for the aged. The licensure pro- gram at the State level includes only those facil- ities of 16 beds or more, The control of all smaller facilities is relegated to the counties. A special survey letter was sent to each county requesting a listing of homes for the aged with fewer than 16 beds. The survey resulted in the addition of more than 3,000 facilities to the MFI and the elimination of this particular coverage gap in California. Three additional States posed problems of a lesser nature. Kansas does not license either church-owned nursing homes or personal care homes. The State estimates that approximately 17 facilities of this type exist in the State. When the "Directory of Nonprofit Homes for the Aged" was checked, no facilities falling into this category were identified. To discover these 17 facilities it may be necessary to check the many listings of religious organizations. However, these facilities might also be found in the State Board of Health files and a followup inquiry to the State could be fruitful. Nebraska reported that its licensing program excludes fraternal homes and estimates that two facilities fall into this gap. Connecticut does not license municipal homes for the aged. Neither the two facilities estimated by Nebraska nor the three municipal facilities estimated by Connecti- cut were identified in the directory. For total estimations in this area it will be necessary to accept those made by the States. Homes for Dependent Children At first glance this segment of the MFI seemed to be the greatest problem area, since 14 States were found to have either large bed-size minimums or no licensure requirements of such facilities. However, the number of facilities re- sulting in this coverage gap provedto be less than the homes for the aged. Table 9. State estimates of the number of facilities not included in the Agency Reporting System and specific area of undercoverage Type of facility State Specific area of undercoverage Estimate TOTAL em mm me ee mm mm mm tr mm mm me tm eee, —————————————— 610 Eee Psychiatric hospitaleeeeceee-- | Massachusetts--- | Private hospitals, voluntary admissione--- 4 Homes for mentally retarded.- | Alabamoeeececece-- Voluntary and proprietaryeeceececececeeea i 2 Connecticutemee- Private home S-eaemmmmmmmnnnmeme ome i 2 Homes for the agedemecececea- Connecticut emwn- Municipal HONE Sememmmmmnmmmmmmneme mann —— 3 IAali0 ens wnwmnnce All personal care NOMES-meeeeemmmmeecemen- (1) KansaSemmememeen Church-owned home Semmeemcccccccmmean —-—— 17 Nebraskeeemmemea Fraternal homeSeeemmmmmmmm neem meee enn—— 2 South Carolina=- | All homes fOr 8geAmmmmmmmmmmmmece——————— +) West Virginia--- | All personal care hOMESemmmmmemmmmeemem-—— 500 Homes for dependent children. | Californigeeee-- Facilities under 16 bedSeeeermmemcmecmmen= (Y) Louisiane mmmmmn Facilities under 10 bedSemmccmemecman ———— {(*) MissOurieeeeeea= Religious facilitieSemmmmmccmcrcncann ——— 40 Nevadtm mee m— ~=-= | Proprietary faciliti€Seecmcemeccccnccnnanen 8 New Jerseyeeemm= Facilities not receiving public fundse-e-- 27 South Carolina-- | No specific arefeececceccccccccccccnenen -— 5 [11-1 «TO — No informatioNeeeemmememececcmem meee ceeneen (*) The State made no estimate. With regard to the minimum bed-size stand- ards, there are only two States which remain as problems. California licenses only those facilities with 16 beds or more. There is no record of smaller facilities, except perhaps at the local level. Louisiana is the second State where bed-size requirements for licensure may omit several facilities. In Louisiana, only facilities with 10 or more beds are regulated. The only national list- ings available in this area are inadequate in their coverage. The ''Directory of Member Agencies" of the Child Welfare League lists governing agen- cies rather than individual facilities. "Child Wel- fare Statistics, 1965," published by the Children's Bureau of the U.S. Welfare Administration, re- ports fewer facilities for all States thanhave been reported by the States themselves. Because some States failed to report all facilities to the Child- ren's Bureau this source is not adequate for use in a match of State and national lists. This source, in addition, includes some of the special children's units of mental hospitals and hence the figures are incorrect for the area of homes for dependent children because these larger hospitals are tabu- lated separately in the MFI. Louisiana also has no regulation for those homes not receiving public funds. However, there are only three such facil- ities in Louisiana and these are known to the State. The problems resulting from no licensure of facilities are unresolved since there is no adequate national list against which a check can be made. Problems of this nature exist in Mis- souri, New Jersey, South Carolina, and Utah, A complete listing of undercoverage by type of facility and by State is given in table 9. Table 10 shows the estimated amount of undercoverage for all the types of facilities included in the MFI on the national level. Both the overall undercover - age and the undercoverage by type of facility are given. These estimates have been determined through one-to-one matches of State lists with available national lists of the facilities in question. When a nonmatch occurred, the facility was added as an estimate of the amount of undercoverage. When no national lists were available for a particular type of facility, the number of facilities 15 Table 10. Percentage of facilities missed in the Master Facility Inventory at the na- tional level according to State agency estimates Per- cent- Over=- Esti- , age ot all ia Number eac per- Type of facility Total ARS Federal Dorey missed | type of | cent- facil- age ity missed missed Totale-memcmccmcccccaaa 35,179 34,654 525 | 35,789 610 ves 1.7 Short-stay hospitals==----- 7,418 7,030 1388 | 7,418 - = - Psychiatric hospitals=----- 580 536 RA 584 4 0.7 0.0 Long-stay hospitals-—=-m===== 559 538 21 559 - - - Diagnostic~-treatment Centereemmmmmcmcccaccceaan 44 - 44 - - - Homes for mentally retardede-eccececcccccanana 608 608 - 612 4 0.7 0.0 Other facilities for mentally illececcccceccanan 119 119 - 119 - - - Other medical facilities--- 18 - 18 - - - Nursing homes--ee-cececacan 14,043 14,043 - | 14,043 - ir i, = Homes for the aged-=ee=ca-- 8,765 8,738 227 9,287 522 5.6 X35 Homes for crippled children-eceececcccceccaaaaan 57 - 57 - - - Other resident facilities-- 103 103 - 103 - * - Homes for blind--eceeceececa- 55 - 55 - - - Homes for deaf---cecceececacaa 65 - 65 - - - Homes for dependent 5 & children«smensmusmnn nsw 1,397 1,397 -| 1,477 80 "5.4 20,2 Homes for unwed mothers=---- 223 223 - 223 - - - Training schools=eeemcececaca 281 281 - 281 - - - Detention homeS-=-eececececam 320 320 - 320 - - - Penal institutions=e---e--- 350 305 345 350 - - - Other-eecececccccccccccccacaa 174 174 - 174 - - - lAmerican Hospital Association: Hospitals, Guide Issue. 2Master Facility Inventory. 31960 U.S. Census. 4No estimates for South Carolina and Idaho. reported, No estimates for California, Louisiana, and Utah. than reported, reported by the State as falling outside the scope of their licensure laws was the estimate used. In some States there was no way to estimate the number of facilities affected and these are noted in table 10. The total amount of undercoverage for the new MFI as found from the tables is approximately 2 percent, Although the tables do not indicate other prob- lem areas, it should be noted that two other areas 16 Percentage missed will be greater than Percentage missed will be greater might result in undercoverage in the ARS. These are homes for unwed mothers and detention homes. Although information is available on these two types of facilities, it is obtained, for the most part, from lists supplied by the national voluntary organizations rather than from the files of the State agencies. The accuracy of the lists, there- fore, is dependent on the completeness of these organizational listings. A discrepancy in the number of reported State penal institutions should also be noted. The number of prisons reported by the States under the ARS totals a little over 300. However, in 1960, the Bureau of the Census enumerated 1,027 State prisons. The reason for this discrepancy cannot be readily seen. All States report at least one State prison on their lists. It might be necessary to check closely the reported penal institutions for each State and prove worthwhile to use the Census data to identify missing facil- ities. Future Maintenance of the ARS and MFI The ARS consists primarily of State agencies, Federal agencies, and national voluntary organi- zations. During the three stages of compilation of the updated MFI a detailed count was made of the contribution which each individual list made to the updated MFI. From this information future composition of the ARS may be determined. For instance, suppose a list from a State agency that is not slated to participate in the ARS is examined. If this list makes a meaningful contribution, then the agency submitting the list will be included in the ARS for future reporting. The MFI is now being updated, with three major goals. First, to identify in-scope facilities, second, to classify the facilities by type, and, finally, to weed out facilities that have gone out of business. A number of facilities were listed on the old MFI that were not on any of the lists supplied from the ARS. It is thought that these facilities will be found to be out of business when the survey of the updated MFI is completed. If these facilities are still functioning, steps will have to be taken to seek sources for the names of the missing facil- ities. These sources, of course, would then be included in the ARS for future reporting. Other methods of evaluating coverage in the MFI will be used. The Complement Survey, dis- cussed earlier, will be conducted each time the entire MFI is surveyed. However, if it turns out that the ARS provides adequate coverage, the Complement Survey can be conducted at less fre- quent intervals. Tentative plans also call for using professional journals and lists for spot checking to see if all new facilities are being picked up by the ARS. After the ARS is established, it is planned to survey the entire MFI biennially. The biennial surveys will provide not only current information needed for sample design and estimation purposes, but also national statistics on the number and types of hospitals and institutions in the country and changes that occur between survey dates. 000 17 APPENDIX | SURVEY LETTER ANNOUNCING VISITS CONDUCTED BY THE BUREAU OF THE CENSUS DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE WASHINGTON, D.C. 20201 NATIONAL CENTER FOR HEALTH STATISTICS REFER TO: Dear .ir: The National Center for Health Statistics (NCHS) of the U.S. Public Health Service conducted a survey several months ago in which information was obtained from all State agencies which have files or lists of hospitals and institutions. The Public Health Service wishes to thank you and your Department for its cooperation during that survey. As you may recall, the purpose of the survey was to gather information needed to arrange a system for keeping up-to-date a national inventory of hospitals and institutions. Through the survey, a minimum set of State agencies was identified which, when taken together, can provide the names of nearly all new hospitals and institutions in the country, thus enabling NCHS to keep the Master Facility Inventory current. This national inventory is needed as a sampling frame to be used by the Center in carrying out its mandate from Congress to collect, on a con- tinuing basis, information about the health conditions of persons in the United States. Your office is among those included in the minimum set of agencies needed for a successful updating system. Tne NCHS would like to make arrangements with your office to provide, on a periodic basis, the names and addresses of all new hospitals and institutions added to your files. In the near future, an employee of the Bureau of the Census, representing the National Center for Health Statistics, will be contacting you to make arrangements to meet with you. The purpose of his visit will be to arrange for the reporting of new facilities in such a way as to place a minimum of burden on your staff. In the meantime, should you have any questions or desire any additional information, please place a collect telephone call to Mr. Peter Hurley who has principal responsibility for this project. His telephone number is Area Code 202, 962-1915. Your continued cooperation in this important program is greatly appreciated. Sincerely yours, Theodore D. Woolsey Acting Director 000 APPENDIX II ANNUAL REPORT CARD USED IN THE REPORTING INFORMATION FILE Annual Report Card State Name of Contact Ferson Department Address of Contact Person Name of list Source code Mail request for listing 1966 1967 1968 1969 1970 First mail follow-up Second mail follow-up Telephone follow-up Date of response Pub. date of returned list No. of new facilities added since last year 19 Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 20. Series 21. Series 22. OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS Public Health Service Publication No. 1000 Programs and collection procedures.— Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data evaluation and methods research.—Studies of new statistical methodology including: experi- mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory. Analytical studies.—Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and committee reports.—Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Data from the Health Interview Survey.— Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey. Data from the Health Examination Survey.—Data from direct examination, testing, and measure- ment of national samples of the population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutional Population Surveys.— Statistics relating to the health characteristics of persons in institutions, and on medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients. Data from the Hospital Discharge Survey.— Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals. Data on mortality.—Various statistics on mortality other than as included in annual or monthly reports—special analyses by cause of death, age, and other demographic variables, also geographic and time series analyses. Data on natality, marriage, and divorce. — Various statistics on natality, marriage, and divorce other than as included in annual or monthly reports—special analyses by demographic variables, also geographic and time series analyses, studies of fertility. Data from the National Natality and Mortality Surveys. — Statistics on characteristics of births and deaths not available from the vital records, based on sample surveys stemming from these records, including such topics as mortality by socioeconomic class, medical experience in the last year of life, characteristics of pregnancy, etc. For a listoftitles of reports published in these series, write to: Office of Information National Center for Health Statistics U.S. Public Health Service Washington, D.C. 20201 PUBLIC HEALTH SERVICE PUBLICATION NO. 1000-SERIES 1 -NO. é VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES NATIONAL " fo Series 1 For HEALTH Number 7 STATISTICS | ET ET RL OT Tg for a National Survey of Nursing Homes " 0 U. S: DEPARTMENT OF [/ === \* HEALTH, EDUCATION, AND WELFARE \:\ (iL{ 1) Js [+2 ay Public Health Service QR y Public Health Service Publication No. 1000-Series 1-No. 7 For sale by the Superintendent of Documents. U.S. Government Printing Office Washington, D.C., 20402 - Price 50 cents NATIONAL CENTER| Series 1 For HEALTH STATISTICS | Number 7 VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES Design and Methodology for a National Survey of Nursing Homes A description of the sample design and survey procedure used by the National Center for Health Statistics for obtaining statistics about nursing homes in the United States, their patients, and their employees. Washington, D. C. September 1968 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Wilbur J. Cohen William H. Stewart Secretary Surgeon General NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, PH.D., Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development ALICE M. WATERHOUSE, M.D., Medical Consultant JAMES E. KELLY, D.D.S., Dental Advisor MARGERY R. CUNNINGHAM, Information Officer OFFICE OF STATISTICAL METHODS MONROE G. SIRKEN, Ph.D., Director E. EARL BRYANT, M.A. Deputy Director Public Health Service Publication No. 1000-Series 1-No. 7 Library of Congress Catalog Card Number 68-62231 PREFACE A growing concern of public health administrators and others who have a responsibility for providing health facilities and services is the health and personal-care requirements of senior citizens. In response to this concern, the National Center for Health Statistics (NCHS) began a program in 1963 to collect statistics from long-stay hospitals and resident care institutions such as nursing and convalescent homes. The data from these surveys provide an objective basis for evaluating the health status of residents and patients and whether or not the available facilities and staff are sufficient to meet the patients’ needs. This report presents a detailed description of the design and methodology being used by the NCHS for a series of ad hoc surveys of nursing and personal care homes. It serves to provide technical support for the publications in Vital and Health Statistics, Series 12, which present the substantive findings of the surveys. However, an equally important objective of the report is to provide a tested and standard methodology that can be used by State and local agencies. The development of methodology and conduct of the survey was a group effort, involving the staff of the U.S. Bureau of the Census, the National Center for Health Statistics, and of the many nursing homes which cooperated in the survey. George F. Kearns and Edward F. Knowles had primary responsibility in the U.S. Bureau of the Census for preparing instruction and interviewer training manuals and for providing liaison with the field staff of the Bureau of the Census who conducted the survey. The sample was designed by Walt R. Simmons, who also served as consultant on all phases of the survey. The survey was developed and conducted under the supervision of Earl Bryant with the assistance of Carl Taube and Gooloo Wunderlich of the NCHS staff. Mr. Bryant also prepared this report. The success of the survey was made possible through the cooper- ation of many individuals, including Bureau of the Census interviewers and field supervisors and employees of nursing homes who completed questionnaires. Their assistance is gratefully acknowledged. SYMBOLS Data not available-=-==-mmemcc emcee em Category not applicable---=em-ceeeaaaaaa- Quantity zZero=======-m-cmemccmmcmmeeeee Quantity more than 0 but less than 0,05---- Figure does not meet standards of reliability or precision----=-==---ocoo-- CONTENTS Page Preface === coc mmm em iii Introduction =-=--=cm mmm erm — 1 Survey Methodology ==--====--- ccm m mmm mee meee 2 Development of Questionnaires and Procedures------=cemomomcmamaaoano 2 Procedures Used in the National Survey---------ecoecmomomoomcmaaaoo 3 Design and Selection of the Sample--====mm mmm mmm eee 6 The Sampling Frame and Stratification Procedure------=---cccemcaoao- 8 Selection of Sample Establishments ----==c-cccoommmmom meee 8 Selection of Sample EMPlOyees === m= nna mm mmm 8 Selection of Sample Residents ----==-==ccmmmcmmcm mre 12 Evaluation of Measurement Err0rS---=-ceececmm mmm emcee meme 12 Evaluation of Errors in Selecting Sample of Employees-----=--=---=---- 13 NONYESPONSE === === mmm mm eee eee eee meme 14 References —-=--c mmm m mm mmm eee eee meme 16 Appendix I. Estimation and Sampling Variance Equations-----=-------- 17 Estimator for Resident-Type StatistiCS-----=---mmcmmmmm mmm emcees 17 Estimator for Employee-Type StatistiCS-=-===-=-mmmmmmcmm mcm mmeeeee 17 Estimator for Establishment StatisticS---=-=--cccccmmmmmm cece 18 Procedure for Computing Sampling Errors-----------cceeoccmmeacoaa-- 18 Appendix II. Definitions of Terms Used in the Survey------------co---- 20 Terms Used on the Establishment Questionnaire (HRS-3a)------=--ccu-- 20 Terms Used on the Staff Information and Control Record (HRS-3b) ------- 21 Terms Used on the Staff Questionnaire (HRS-3d) ----------cnccemccooo- 21 Terms Used on the Resident Questionnaire (HRS-3¢)-==---=cccceemoaomm- 21 Appendix III. Classification of Homes by Type of Service---------------- 23 Appendix IV, Forms and Questionnaires-----=---m-m-cmomcoccmoomaoooo- 24 vi THIS REPORT gives a detailed description of the survey design used in 1964 by the National Center for Health Statistics (NCHS) for collecting statistics on the Nation's nursing homes, theiv patients and employees. The report also provides information on the magnitude of certain types of measurement evvors, including evvors in selecting the sample of employees, and of nonresponse. The sample design was a stratified, two-stage probability design. The first stage was a systematic sample of homes from a list frame (the Master Facility Inventory) within each of 12 bed-size, type-of-sevvice strata. A sample of patients and a sample of employees was selected from each of the sample nursing homes, The second stage sample was selected by the interviewer at the time of her visit to the home accovd- ing to instructions provided by NCHS, The survey was complex since information was collected about three different sampling units (homes, patients, and employees) and a number of different respondents and data sources weve used, The veport gives a sequential account of how the survey was conducted in a home, DESIGN AND METHODOLOGY FOR A NATIONAL SURVEY OF NURSING HOMES INTRODUCTION An integral part of the program of the National Center for Health Statistics (NCHS) is a series of ad hoc national surveys of the institutional popu- lation. These, combined with surveys of the non- institutional population conducted by NCHS provide comprehensive statistical information about the health of the American people.!3 The universe for the institutional population surveys includes both long-term medical and resident care facilities. Resident care facilities are those in which unrelated individuals reside, usually for relatively long periods of time (30 days or more), and those which provide special care of or take into custody residents, patients, or in- mates. They may be classified into two major groups: (1) nursing and personal care homes and (2) custodial care homes, resident schools and penal institutions. A long-term medical facility is defined as any hospital with an average patient stay of 30 days or more. The surveys are being conducted on an adhoc basis, primarily because of the great heter- ogeneity of the institutional population and associ- ated problems of measurement. They are not necessarily conducted in a sequence to gradually cover all types of institutions, nor to cover all types of institutions ina single survey. Rather, the type of survey to be conducted depends on current needs for data on specific segments of the popu- lation. The first institutional population survey was of resident places providing nursing and personal care to the aged and chronically ill. Since this was the first national survey of its kind in the United States and because of the increased empha- sis on the health and welfare of aged citizens, a large volume of data were needed—more than could be collected in a single survey. Conse- quently, it was decided to conduct the survey in two phases. The first phase of the survey, referred to as Resident Places Survey-1 (RPS-1), was con- ducted in 1963 and was limited to the types of data that could be readily and reliably obtained by mail. This included information about the establishments (such as their admission policies and size) and certain personal and health charac- teristics of the residents or patients. Health characteristics that were easily discerned, such as patient's degree of ambulation, continence, mental awareness of surroundings, or his ability to see and hear, were reported by a nurse or other employee respondent. In addition to nurs- ing and personal care homes, RPS-1 included long-term chronic disease units of general hos- pitals, as well as geriatric, chronic disease, and mental hospitals. The second phase of the survey (RPS-2) was conducted in 1964 by personal visits to the estab- lishments. Detailed information was collected on the characteristics of residents, including data on chronic conditions and impairments; on the characteristics of employees, such as their work experience, special training to care for the aged and chronically ill, and wages; and on certain characteristics of the establishments themselves. The scope of the survey was not as broad as RPS-1 in that it excluded all types of hospitals, except those specializing in the care of geriatric patients. A number of reports have been published on the findings of both phases of the survey.t 13 This report describes the design and method- ology used for RPS-2, Itillustrates the procedures to be used in similar future surveys and provides technical background information for the substan- tive reports published in Series 12 of Vital and Health Statistics. The methodology is presented in detail so that others in State or local govern- ments who may be planning similar surveys can have the benefit of this experience. SURVEY METHODOLOGY Development of Questionnaires and Procedures The questionnaires -and procedures were developed in a pilot study conducted in Washington, D.C., during the fall of 1963 and were refined in a pretest in Baltimore, Maryland, during the winter of 1964. In each instance, as well as in the national survey, the staff of the U.S. Bureau of the Census had the primary responsibility for training interviewers and collecting data. Con- tent of the questionnaires and specifications and design of the survey were the responsibility of the National Center for Health Statistics. A pilot study was necessary to obtain insight into a number of problems. Information was needed on the availability of data, how to phrase and order questions, the availability of lists of residents and employees which could serve as sampling frames, the most efficient and effective procedure for conducting the survey, the best time to arrange for interviews, and how to obtain completed questionnaires for employees not pres- ent or available at the time of interview, Three interviewers were used in the pilot study. Two of them were regularly employed as interviewers for the Health Interview Survey, one of the major statistical activities of NCHS.2 They were, therefore, familiar with much of the subject matter to be covered in RPS-2, especially about chronic conditions, impairments, use of special aids, and other data that they ordinarily collect in the household interviews. The other interviewer, regularly employed in another large survey—Current Population Survey (CPS) *—con- ducted by the Bureau of the Census, had experi- ence in establishment surveys but lacked the knowledge and experience of the other two in health surveys. The pilot study, as well as the pretest, provided an opportunity to determine the feasibility of using CPS interviewers in the national survey. If the CPS interviewers could be satisfactorily trained in the time allowed, more flexibility in the field staff could be at- tained. At the close of a 1-day training session held at the Bureau of the Census, each interviewer was given five assignments. Administrators of the selected nursing homes were contacted by tele- phone to make appointments for conducting the survey. To aid the interviewers and tohelp insure cooperation, NCHS mailed a letter to each admin- istrator. The letter told the purpose of the survey, solicited cooperation, and stated that a repre- sentative of the Bureau of the Census would call in a few days to determine a convenient time for visiting in the home. For each appointment, the interviewer was accompanied by a statistician who was familiar with survey objectives. The statistician's primary role was to observe the interview and answer questions which might arise that the interviewer could not answer, Alternative approaches were tried during the series of interviews, and notes were made on problems that arose as well as on suggested solutions to the problems. After all interviews were completed, ameet- ing was held with all the people participating in the pilot study to discuss individual experiences and to decide on procedures and questionnaires that were most likely to be successful. Following this discussion, the questionnaires were revised and definite procedures were formulated for the national survey. A formal pretest was conducted during Febru- ary 1964 in 19 nursing homes in Baltimore. The procedures developed in the pilot study seemed to function smoothly. Therefore, with minor adjust- ments, questionnaires and methodology were made ready for the national survey. The questionnaires, letters, and other forms developed and used inthe national survey are reproduced in appendix IV. Definitions of terms are given in appendix II. Procedures Used in the National Survey Training of field supervisors and intev- viewers, —For the national survey, training of personnel was conducted in two stages. First, the people who were to supervise the field oper- ations in the various regions of the country were instructed in all phases of survey operations, including training of interviewers, obtaining es- tablishment cooperation, interviewing proce- dures, nonresponse followup, editing, and quality control. This instruction was given through the use of study manuals, training guides, and so forth, and in a formal 1-day training session attended by all regional supervisors for the Health Inter- view Survey program. After the supervisors had become familiar with survey procedures and objectives, they were given the task of training interviewers in their respective regions. Interviewer training was divided into two parts: a home-training assignment and on-the- job training by the supervisor on first interview assignments. At least 1 week before an inter- viewer was to complete her first interview assignment, she was sent a package of training materials, supplies, and instructions for con- tacting and obtaining the cooperation of estab- lishments. Home training consisted of studying the interviewer instruction manual, answering questions about the questionnaires and proce- dures, and working through a practice narrative, i.e., a mock interview, Questionnaires were completed with the answers provided inthe narra- tive. The material was presented in the same sequence as the procedure to be followed in con- ducting the survey in an establishment. The inter - viewer was told to read, in order, the appro- priate sections of the training guide and instruction manual and to answer the questions that appeared at the end of each section. She was to compare her answers with those on a key and to review the troublesome areas before proceeding to the next section of the training materials. The interviewer was to make notes on anything not understood and to get them clari- fied by her supervisor before her firstinterview. On-the-job training involved a meeting of the interviewer and supervisor immediately prior to the interviewer's first assignment, allowing 1 to 2 hours to discuss survey procedures and to answer any questions that the interviewer might have. Then the supervisor accompanied the in- terviewer on her first assignment to observe the interview. Afterwards they met again to discuss problems encountered in the interview. As a quality control measure, statisticians from the Bureau of the Census and NCHS made visits to a number of the regional offices about 2 to 3 weeks after the survey began to be sure that the supervisors understood and were prop- erly carrying out survey specifications. They also made spot checks on interviewer perform- ance by visiting several establishments with the interviewers. A total of 141 interviewers were employed in the survey, of which about half were regular interviewers for the Health Interview Survey. The remaining interviewers were employed in other continuing surveys conducted by the Bureau of the Census, most of whom were interviewers on the Current Population Survey. Obtaining establishment coopevation.— The initial contact with the sample establishments was made by mail (Form HRS-3f in appendix IV) about a week prior to the time of the inter- viewer's visit to the establishment. The letter, signed by the Director of the Bureau of the Census, told the administrator about the survey, requested his cooperation, and indicated that a representa- tive would call to make an appointment for con- ducting the survey. The interviewer's telephone call followed within 3 to 4 days. In the conver- sation, she suggested a date that fitted into her overall interviewing schedule, but to the extent possible, the administrator was given a choice. The interviewer tried to schedule the interview for about 9:30 a.m. so as not to interfere with the early morning duties at the home. Beginning this early, many of the interviews could be completed before noon. Those that could not be completed before noon were discontinued about 11:30 and resumed around 2:00 p.m. Since the length of an interview was uncertain, the inter- viewer was instructed not to make more than one appointment a day. Visit to the establishment to conduct the survey.—After introducing herself to the admin- istrator, the interviewer began the interview by describing briefly the three elements of infor- mation covered by the survey (establishment, staff, and patient information) and by specifying the order in which the interview was to proceed. The following is an example of the recommended approach: "Mr. Green, this first form (referring to the Establishment Questionnaire) is for obtaining information about the number of beds, number of employees, number of patients discharged last year and so on. As you can see, this will probably take five or ten minutes. "Next I want to get a list of all your em- ployees. For some of them, I want to ask a few questions and have those who are avail- able complete a very brief questionnaire, "Finally, I need to get some information about some of the patients or residents. Since this pertains primarily to health, I would probably need to get this information from the person in the immediate charge of their care." This example was modified as necessary to fit the situation. To illustrate, in some homes the design called for collecting information on all staff and patients rather than on a sample. The interviewer emphasized that the data would be held strictly confidential by the Bureau of the Census and the National Center for Health Sta- tistics and would be used for statistical purposes only. Ordinarily, with this assurance, the ad- ministrator did not hesitate to cooperate fully in the survey. However, if he was reluctant to identify the names of individuals, they were identified on the questionnaire by numbers only. Thus, to obtain information about such persons, the interviewer would pose questions like, '"Now I want to ask about the third patient in the file; the eighth patient in the file," and so on. Completion of the Establishment Question- naive (HRS-3a).—The respondent, usually the administrator, was handed a copy of the form to make it easier for him to follow questions as they were asked by the interviewer. The respondent usually knew the answer to most of the ques- tions. However, when he was not sure of the answers, he was requested to refer to records or possibly to another employee in the home. The procedure varied somewhat, depending on the sit- uation, and it was left tothe interviewer to choose the procedure that seemed most efficient and practicable. For example, she might point out to the administrator before the interview began that certain information would likely have to come from the records. The administrator could then assign another person to compile the necessary information while the interviewer proceeded with other parts of the survey. In general, records were used to obtain the number of residents in the home, number and types of discharges, and number of employees. The number of residents receiving nursing care during the week prior to the survey may have been based on the personal knowledge of the nurse providing care or on the records; the larger the home, the more likely that records would be available and used. In answering the question about residents receiving nursing care, the respondent had access to Card A, "List of Nursing Services" (appendix IV). Completion of the Staff Information and Con- trol Record (Form HRS-3b).— After completing the Establishment Questionnaire, the name (in- cluding the title of Mr., Mrs., Miss, or Dr.) of each employee working in the establishment 15 hours or more per week was listed on the Staff Information and Control Record, indicating in the appropriate column of the form the pro- fession or type of work performed. As the respondent called out the name of each employee, he was asked, '"What is his job here?" Reference was made to Card B, "List of Selected Job Cate- gories," to determine the code number to enter on the form. (Card B is reproduced in appendix IV.) If the employee's job was in the group numbered 1-10 on Card B, he was considered "professional," and the code for his job was written in column 1 of the form. For an "admin- istrator,'" it was determined if he performed any of the other jobs shown on Card B. If so, the code number(s) for the other job was entered inparen- thesis beside the code numbers designating '"ad- ministrator." If the employee's job was classified as Code 11 (other nursing personnel), he was con- sidered ''semiprofessional' and an "11" was written in column 2 of the form. Other employees (numbers 12-15 on Card B) were considered as "monprofessional.'” For each such person em- ployed 15 hours or more per week, the appropri- ate code was written in column 3 of the form. If a person's job title was not listed on Card B, the interviewer used her judgment as to which group it belonged. After the names of all employees were listed, the number listed was compared with the number recorded on the Establishment Questionnaire as usually working 15 hours or more per week in the establishment. If the numbers were different, they were reconciled and changes were made accord- ingly. Next, a systematic sample of the employees listed on the Staff Information and Control Record was selected. The interviewer had specific in- structions about how to select the sample, which are discussed in the next section on Design and Selection of the Sample. The remainder of the form was then completed for each sample person in the order listed. In general, the question about the sample person's sex was asked only if it was not obvious from the person's name and title. The interviewer was instructed to make an entry for each item on the form for every sample person. If the informa- tion, which ordinarily came from payroll records, was not available, an entry of unknown was made. Completion of the supplemental Staff Ques- tionnaire (HRS-3d) and selectinga sample of resi- dents.— Upon completion of the Staff Information and Control Record, the interviewer initiated a Staff Questionnaire for each ''professional’ and "semiprofessional" employee in the sample by entering an identification number, the employee's name, and the type of job he had in the establish- ment. For those on duty at the time of interview, questionnaires were distributed to be completed, if possible, before the interviewer left the estab- lishment. The administrator was requested to distribute questionnaires to the remaining sample employees as they came to work. These em- ployees, as well as those on duty at the time of the interview who were unable to complete the questionnaire right away, were asked to complete the form and mail it to the Bureau of the Census. Precaution was taken to guard the confidentiality of information provided by the staff present at the time of the survey through the provision of envelopes in which a person could seal his com- pleted form, if desired. Completed questionnaires were returned to the interviewer, who reviewed each form for com- pleteness before she left the establishment. The interviewer also made an entry on the Staff Infor - mation and Control Record for each sample ''pro- fessional" and "semiprofessional' employee as to whether the supplemental Staff Questionnaire was completed at the time of her visit or whether a form was left to be completed later. Collecting forms before leaving the home was an important part of the survey methodology in that it minimized the need for expensive followups in case of non- responses or incompleted responses, and it maxi- mized the quality of completed questionnaires since the interviewer had a chance to review them for completeness. Completion of the Resident Questionnaire (HRS-3c).— After completing the Staff Informa- tion and Control Record for each sample employee, the interviewer told the respondentthat she needed to obtain certain information about a sample of the residents or patients in the home and asked if a list containing the names of all residents was available from which a sample could be selected. If not, a listing was made. In either case, however, the interviewer had to make sure that the list contained the names of all people who were on the register of the establishment, exclusive of discharges, and that the number registered was consistent with the number recorded on the Estab- lishment Questionnaire. While the respondent was distributing the Staff Questionnaire to employees in the home, the interviewer selected a sample of residents and entered each of their names on the Resident Questionnaire. The respondent, who was often the adminis- trator at this point in the survey, was shown a copy of the questionnaire to indicate the specific types of information needed about the residents. He was asked if part or all of the information could be provided from records or if it would be necessary to obtain part of it, especially that per - taining to health, from a person directly responsi- ble for care of the patients. Usually another person such as the nurse in charge of nursing care was designated as the respondent. Records were assembled for each sample person and then the interview began, completing the Resident Questionnaire shown in appendix IV for each resident. Maximum use was made of the records for each question. However itis believed that the respondent's personal knowledge was the primary source of veteran status, frequency of visits by relatives, limitation of mobility, use of special aids, use of dentures, and the primary type of care received by the resident at the time of his admission to the home. In answering questions 9 (use of special aids), 13 (prevalence of chronic conditions), 14 (preva- lence of impairments), and 17 (provision of nurs- ing and personal care), special cards (Cards C-F) were used which listed possible answers (appendix Iv). Although the chronic conditions listed on Card D were in lay terms, an attempt was made to obtain the exact medical name of each condition reported. Thus, if the respondent said a patient's "heart trouble" was a myocardial infarction, the latter term was recorded in table 1 of the Resi- dent Questionnaire. Ordinarily, by the time the interview about residents was over, the Staff Questionnaires had been returned to the interviewer. These were reviewed for omissions and completed as neces- sary before the interviewer left the home. The interviewer was also required to com- plete a special form called the "Interviewer Check List" (appendix IV) before leaving the establish- ment, This was instituted when the survey was about half finished to guard against the types of errors that seemed to be predominant, especially those relating: to sample selection, After completing the survey in an establish- ment, the questionnaires were mailed toa census regional office for certain processing before being sent to headquarters in Washington, D.C. Regional office processing and followup. —As the questionnaires were received in the census regional offices, they were reviewed for complete- ness and for problem areas that may be apparent in the survey procedures. Editing consisted pri- marily of an inventory of forms to be sure that (1) a questionnaire was present for each sample person and each sample establishment, (2) each form was properly identified with a predetermined establishment number, (3) an entry appeared in certain crucial items of the questionnaires, (4) the sampling procedure was carried out properly, and (5) a control was kept on the receipt of Staff Questionnaires mailed in by respondents who did not complete questionnaires at the time of the interviewer's visit in the establishment. Mail or telephone followups were made as necessary to complete questionnaires or correct errors. As Staff Questionnaires were received in the mail, they too were edited for completeness, and entries were made on the Staff Information and Control Record to show the date the form was received in the regional office. Nonresponse followup involved two stages of solicitation. The first was by mail 1 week after the interviewer's visit inthe home (Form HRS-3g, appendix IV), and the second was 2 weeks later by telephone. In both instances the sample em- ployee was contacted. Results of the nonresponse followup are discussed inthe section on Evaluation of Measurement Errors. When Staff Questionnaires had been received from all sample employees and when errors or omissions had been corrected, the questionnaires were forwarded to Washington for final proc- essing. In Washington, spot checks were made of completed questionnaires throughout the survey to detect any errors consistently being made. As such errors were detected, they were brought to the attention of all regional office directors. In fact, these spot checks ultimately led to in- stituting a routine procedure (the Interview Check List shown in appendix IV) for the interviewers to use to minimize errors. DESIGN AND SELECTION OF THE SAMPLE The RPS-2 was based on a stratified, two- stage probability design. The first stage was a systematic sample of establishments. With these establishments serving as primary sampling units, systematic samples of residents and em- ployees were selected. The design was to be approximately optimum to produce statistics with a specified precision at a minimum cost. The ability to produce such a design was conditioned by the fact that no single factor could determine uniquely the design. This was a multipurpose survey; therefore the design had to be balanced to satisfy a number of objectives. Also the design would need to be based on less than precise information about population variances and unit costs, which were determined from pretest data and other national surveys. In planning the RPS-2, some of the leading considerations were as follows: 1. The survey should provide separate esti- mates for each of 12 bed-size, type-of- service strata. 2. Estimates were required for specified characteristics of establishments, resi- Table A. Number of establishments, beds, and employees in the RPS-2 sampling frame, by primary strata (type of service and size of establishment) Number of establishments Number | Number of Type of service and size of establishment of beds | employees 1 Group I Group I Group I Group II Total=-=---ccmmmm mmm m mmm meme eee 16,748 2,772 | 587,300 256,200 Nursing care All sizes--==c--mmemmmmme meee 8,155 2,772 | 336,800 172,400 Under 30 beds-=---------mmmmmm mmm mmm 4,400 2,578 79,000 42,500 30-99 beds----=----mmmmmece meme 3,247 185 | 158,300 80,900 100-299 beds=-=-==--=---mmmmmm mmm meme mmm oo 448 6 66,000 32,500 300 beds and over------------c-cmmmmmmmnann 60 3 33,500 16,500 Personal care with nursing All sizeS------cc-mmmmmmm mmm ee mmm 4,972 - | 189,400 66,600 Under 30 beds--=-=----c-cmmmmmm emcee meme 3,168 -| 47,900 18,700 30-99 beds-==-==---mm-mmmmmmmm mmm 1,423 - 71,800 26,200 100-299 beds-=-----c--cmmcmmmm mmm meme mmo 345 - 52,400 16,700 300 beds and over-------------e-mccmoomemno 36 - 17,300 5,000 Personal care All sizes-=-=------mmmmmm meme 3,621 - 61,100 17,200 Under 30 beds-=---c---mcommmm mmm enema emo 3,187 - 37,200 10,500 30-99 beds=----=---mmmmmm mmm emo 402 - 18,500 5,100 100-299 beds------ccmmmm meme meee eee 29 - 4,300 1,300 300 beds and over=--=--------ccmmccommcoooano 3 - 1,100 300 !The establishments in Group II are classified on the basis of old information ob- tained from source lists used in assembling the MFI, They are shown under nursing care in this table for convenience. dents, and employees. Certain parameters to be estimated may prevail in no more than 1 percent of the population. 3. The estimated statistics should be within 20 percent of its true value at least 95 percent of the time. 4. Estimates should be derived from a ratio estimation technique insofar as possible, utilizing census-type data collected in a previous survey. 5. The type of detail needed from the survey demanded that the survey be conducted by personal visits to sample establishments. 6. The sample size for residents or staff within an establishment should have an upper limit of 10 to 15 persons. This was necessary since one person often would respond for all sample persons. The Sampling Frame and Stratification Procedure Conceptually, the sampling frame for the survey was composed of all establishments inthe United States that provided long-term nursing and personal care to the aged and chronically ill. This included such places as geriatric hospitals, nursing and convalescent homes, and homes for the aged. The principal frame was the Master Facility Inventory (MFI), which is a listing of the names, addresses, and descriptive data for the vast majority of institutions and hospitals in the United States. The MFI was supplemented by a probability sample of establishments not in the MFT list, which is commonly referred to as the Complement Survey. A detailed description of the MFI and the Complement Survey has been pub- lished.!?16 The establishments in the MFI were divided into two groups on the basis of whether or not current information was available about the es- tablishment. Group I was composed of establish- ments which returned a questionnaire in a pre- vious survey of the MFI. Group II contained places which were possibly within the scope of RPS-2 but were not confirmed in the MFI survey, i.e., nonresponse, questionnaires not delivered by the Post Office because of insufficient ad- dresses, and newly listed establishments which had not been sent a questionnaire. Group I was sorted into 12 type-of-service, bed-size groups. Further stratification within each of these pri- mary strata was accomplished by sorting on type of ownership and then on State and county within each service-size-ownership group. Group II was considered a separate stratum and was substratified in a similar manner except that the specific type of establishment was not known. Only information from source lists used in assembling the MFI was available for Group II places. The distribution of establishments, beds, and employees in the sampling frame by primary strata (type of service and size of establishment) is shown in table A. The procedure for classifying establishments by type of service is shown in appendix III. Selection of Sample Establishments The sampling of establishments from the MFI was systematic after a random start within each of the primary strata, The first-stage sam- pling fractions varied depending on the size and type of establishment, ranging from unity for establishments with 300 beds and over to 1 in 50 for personal care homes with less than 30 beds. Table B shows for each stratum the sampling fractions used, number of establishments selected in the sample, and the number of establishments in scope and in business atthe time ofthe survey. It should be noted that the majority of the establishments in Group II were either out of business or out of scope of the survey. Of the 73 places selected in the original sample, only 19 were found to be in business and within the scope of RPS-2, Selection of Sample Employees The sample of employees was selected by Bureau of the Census interviewers, using a sys- tematic sampling technique after a random start within each of three job category strata. The random ''start with" number and sampling inter- Table B. Sampling fractions for selecting establishments for RPS-2, and distribution of the sample by primary strata (type of service and size of establishment) Total Number Type of service and size of establishment CW 2 ir 35% Sample | business Group I ; Pr Lins sss stim mss sem reste we a rn ma me -| 11,128 | '1,066 Nursing care All sizeS=-------smmmmmmmeeeeeeeeeemeeee———m——e— - 634 597 Under 30 beds==-=--=-==cmmmmmmmm meme eee eee 1/25 179 158 30-99 bed§=========-mmmemmmmeeemeeeemeeeesseeeeemeeee—eae 2/25 260 249 100-299 beds======m==mmmmmmm meee memesseeeeeeeemmeen 3/10 135 132 300 beds and OVer=-=======-----mmmmeieseeeeeemeeemeeeee 1/1 60 58 Personal care with nursing All sizeS=---=----ememememmeemeeeeeeeee meme - 381 369 Under 30 beds----------emmccmmmm mee ceccccmcmce meme 1/25 128 118 30-99 beds---=-=-----mmmmmm meee eeemsmeeneee eee 2/25 114 113 100-299 beds----===--eemmmemmem mee ceesmeeee eee meme 3/10 103 102 300 beds and OVer==-====-mmmmmceeoscemeoottme meme 1/1 36 36 Personal care All sizeS=-------msm-mmemmmmcemmeeeeememmemm memo - 113 100 Under 30 beds=----------emecmmcc cece mem meee 1/50 64 53 30-99 beds-=------=-mmmmemeeem meme eee emeeeeeeemm monn m mm 2/25 32 32 100-299 beds=---===----mmemmmememeememmmeemeeeeee——m—— mm 1/2 14 12 300 beds and OVer======mm---cmccccommmmccmnmcmm nme 1/1 3 3 Group II Total=---=---semcmrmemm meme cmmmme meme m emma - 73 19 Under 25 beds=---===---mmcmmmmmmmmmeemmeeee meme men 1/50 52 15 25-99 beds==-=-==-m-mmmmmecememmeememmemeeeeeemeee——eo—oao 2/25 15 3 100-299 beds=---====-mmmemmmm emcee mmm mmeeee—eeee—— eee 1/2 3 - 300 beds and OvVer===--==-e---m-ommmmemeeeeeeneee meee 1/1 3 1 IThe sample includes 4 establishments from the Complement Survey; see text for ex- planation. val ("take every" number) were specified by the Washington office and were entered on the Staff Information and Control Record for each estab- For Professional Staff lishment in the sample, These figures were deter- mined by using the following tables: Strata code 11 12 [13 | 14 21 22 123 124 31 32 133, 34 81 82 | 83 | 84 Start with 1 1 4 Vv 1 1 2 Vv 1 1 2 Vv 1 1 3 Vv Take every all [all | 4&4 9 lall (all | 4 all | all | 4 9 |all| all | 4 9 ¥Denotes variable "start with" numbers ranging from 1-9 (see text). Semiprofessional Staff Strata code 11 112 |13 | 14 21 {22 123} 24 3132 [33] 34 81 | 82 |83| 84 Start with 1 | vv 5117 1 yy 6 |12 1 | vy 1 1 1 vy 612 Take every all 2 8 | 18 jall 2 8 118 |all 2 8 | 18 {all 2 818 ¥¥Denotes a variable "start with" number of either 1 or 2. Other Staff Strata code 11 112 | 13] 14 21 | 22123 | 24 3113233 34 81 | 82 | 83 | 84 Start with Liw | 517) vw! 612] tlw] 1] 1| 1lww]| 6] 12 Take every all 2 8118 |all 2 818 |all 2 8 | 18 | all 2 8] 18 ¥¥Denotes a variable The establishment stratum code, which was determined from the name and address label on the Resident Questionnaire for each sample estab- lishment, identified the appropriate "start with" and "take every'' numbers for each of the job cate- gories. For example, if the stratum code for the establishment was 33, the "start with'' number for professional staff was 2 and the sampling inter- val was 4; for both semiprofessional and other staff the "start with" number was 1 and the sam- pling interval was 8. In certain instances, variable "start with" numbers were used. For professional staff em- ployed in establishments with 300 beds and over (denoted by ¥ in the table for professional staff), a "start with" number of 1-9 was assigned in 10 "start with" number of either 1 or 2. numerical order to the first nine establishments listed in each of strata 14, 24, 34, and 84. The process was repeated until the starting number had been assigned for each of the establishments in these strata. For semiprofessional and other staff employed in establishments with 30-99 beds (denoted by ¥¥ in the above tables) a number ''1" or "2" was assigned alternately to each estab- lishment in the affected strata (strata 12, 22, 32, and 82). Part of the procedure that an interviewer followed in conducting the survey in an estab- lishment was to make a list of all employees working in the establishment 15 hours or more per week and to select a sample of employees. The procedure used for establishing this sampling Table C. Number of employees in sample establishments, number of employees in the sample who responded, and number of employees in (type of service and size of establishment) the sample per sample establishment, by job category and primary strata Number of employees in sample Number of employees in the Puvbey of saplayses establishments sample who responded 1 ihe sanple per sample establishment Type of service and size of establishment Prge Semi. Pro- Soke PEO Semi - Total fes- Pro. Other | Total fes- Don Other | fes- Pro« Other sional sional sional elondl sional shonal All types-- | 49,993 9,341 | 17,841 | 22,811] 11,832 3,710 | 4,277] 3,845 3.4 3.9 3.5 GROUP I Nursing care Under 30 beds-- 1,812 495 842 475 1,661 495 777 389 3.1 4.9 2.5 30-99 beds===== 6,371 1,369 2,918 | 2,084 3,833 1,358 1,459 | 1,036 53 5. 9 4,2 100-299 beds=--=- | 10,538 1,817 | 4,411 | 4,310 1,474 395 548 531 3.0 4.2 4.0 300+ beds=-===- 16,441 3,309 5,141 7,991 1,047 368 266 413 6.3 4.6 72.1 Personal care with nursing Under 30 beds-- 765 207 334 224 765 207 334 224 1.8 2:3 1.9 30-99 beds=-==== 2,211 375 903 933 1,286 371 455 460 3.3 3.9 4.1 100-299 beds=-= 5,128 769 1,463 2,896 717 212 165 340 2+ 1.6 3.3 300+ beds====== 5,130 693 1,379 3,058 309 78 69 162 2.2 1.9 4.5 Personal care Under 30 beds=-- 202 76 42 84 190 73 41 76 1.4 0.8 1.4 30-99 beds=-=-==-- 425 87 127 211 250 87 61 102 2.7 1.9 3.2 100-299 beds=--- 510 65 100 345 85 20 17 48 1:7 1.4 4.0 300+ beds==-=== 259 36 86 137 20 4 7 9 1.3 2.3 3.0 GROUP II Under 25 beds-- 143 32 63 48 143 32 63 48 2.1 4,2 3.2 25-99 beds====- 52 2 30 13 31 9 15 7 3.0 5.0 2.3 100-299 beds--- - - - - - - - - - - - 300+ beds====== 6 2 2 2 1 1 - - 1.0 - - frame is described on page 4. The sample of employees was selected by applying the ''start with" and "take every' numbers that appeared in the heading of the Staff Information and Control Record for an establishment. Table C shows by primary strata the distribution of total employees in the sample establishments, employees in the sample who responded, and the number of em- ployees selected in the sample per sample estab- lishment. There was no particular order for listing em- ployees inthe sampling frame. For the most part, payroll records were used to identify employees for the listing. Sometimes, especially for small places, the list was made up on the basis of the respondent's memory. The order was alphabetical by employee name for some places, in numerical order according to procedures used innumbering records in other places, and still in other places the names were ordered according to the em- ployee's type of work. Consequently, there is no apparent reason to believe that the order of the listing resulted in an appreciable systematic bias in the sample estimates. 11 Selection of Sample Residents In general, the procedure for selecting a sample of residents from an establishment was similar to that for sampling employees. A major difference was that residents were not stratified within a place while employees were. Thus, for residents, stratification was done only in the first- stage sample of establishments. The overall sampling fraction was 1 in 50 for each stratum. That is, within each stratum, the product of the fraction for selecting establishments and the fraction for selecting residents was 1 in 50; therefore, the sample was theoretically self- weighting. A random ''start with" number and ''take every'' number were entered on page 3 of the Resident Questionnaire for each sample estab- lishment prior to interview assignment. The numbers were determined from the following table by knowing the establishment strata code which was part of the name and address label. For nursing care homes and personal-care- with-nursing homes with less than 30 beds (strata codes 11 and 21), "start with" numbers "1" and "2" were assigned alternately to each establish- ment in the two strata. In addition to entering the ''start with" and "take every' numbers on the Resident Question- naire, the first three sample designation numbers were written on page 2 of the questionnaire (a listing sheet for sample designation numbers and for sample persons). This provided an example for the interviewer to follow in determining the remaining sample designation numbers for the establishment. Specific instructions of how to determine the sample designation numbers and how to select a sample of residents were written on page 3 of the questionnaire. The sampling frame of residents, i.e., a list of persons who were registered as patients or residents in the home at the time of the survey, was usually readily available in one form or another. If not, the interviewer created a list. The order of the lists varied for different estab- lishments-—some were in alphabetical order, some were inorder by serial numbers, and others were in order according to date of admission. Possibly the most common sequence was alpha- betical. In determining an appropriate sampling frame, the interviewer was instructed to make sure that the list did not contain the names of anyone who was no longer a resident. As a check on the accuracy of the sampling frame, the number of persons listed was compared with the number reported earlier inthe interview by the respondent in answer to the question "How many residents (patients) are currently on your register as formal admissions who have not been discharged? Do not include employees or proprietors." (See Estab- lishment Questionnaire in appendix IV.) When there was a difference in the twonumbers, recon- ciliation and necessary corrections were made. Table D shows the distribution of the number of residents in the sample establishments and the number of residents selected in the sample by strata, EVALUATION OF MEASUREMENT ERRORS The data collected in RPS-2 are subject to two types of errors: errors of measurement and sampling errors. Measurement errors include response errors; nonresponse errors; and errors made in sample selection, data processing, or other deviations from the specified sample design. Strata code 111213 | 1421 (222324 313233] 34] 81| 8283] 84 Start with=-==~==e=-- vl 1| 946 |W | 2| 3157 1] 2| 5149) 1| 4] 16] 20 Take every------=--=-- 2| 4115|50| 2] 4|15|50fall | 4 |25|50fall| 4&4 | 25] 50 ¥¥Denotes a variable ''start with' number of either 1 or 2. Table D. Number of residents in sample establishments and number of residents selected in the sample, by primary strata (type of service and size of establishment) Total number of residents Type of service and size of establishments In sample In the stab- 1 lishments | SaMP1€ All types! All sizes===--=-- 100,129 | 10,342 Under 30 beds==-=-==-==~ 5,034 2,669 30-99 beds=======-==== 17,918 | 4,593 100-299 beds====-===== 33,960 2,252 300 beds and over=--=-- 43,217 828 Nursing care All sizes======~ 61,171 6,106 Under 30 beds===-====- 2,955 1,395 30-99 beds=====-====== 11,430 2,948 100-299 beds=-=====-== 18,520 | 1,223 300 beds and over---=-=- 28,266 540 Personal care with nursing All sizes-====== 35,206 | 3,358 Under 30 beds=--=====-=-- 1,565 760 30-99 beds=====w-=e==-- 55332 1,358 100-299 beds========== 13,827 960 300 beds and over=-=---- 14,462 280 Personal care All sizeS====-=- 3,752 878 Under 30 beds===--==-- 514 514 30-99 beds=======v-w=- 1,136 287 100-299 beds=-===-====-- 1,613 69 300 beds and over-=--- 489 8 lThese figures exclude residents of Group II sample establishments. Sampling error, on the other hand, is primarily a measure of variability in estimates that occurs by chance because only a sample of the population is surveyed. The methodology for computing sampling errors, as well as for making estimates based on RPS-2 data, is given in appendix I. As calculated for RPS-2 data, the sampling error also reflects part of the variation which arises in the measurement process. However, systematic accumulative biases are not part of the sampling error. Objective evaluation of such biases usually require special studies, carried out under a controlled procedure, which were not done for RPS-2. As pointed out in other parts of the report, however, an attempt was made to keep systematic bias to a minimum by certain built-in controls. Evaluation of Errors in Selecting Sample of Employees Since the names of every sample employee working 15 hours or more per week were listed on the Staff Information and Control Record, it was possible to detect deviations from the speci- fied sampling procedure. The types of errors that could occur included (1) the number of employees listed in the sampling frame that did not agree with the number reported by the respondent to be working 15 hours or more per week (question 10 on the Establishment Question- naire), (2) errors in the listing of employees who usually worked less than 15 hours per week, (3) entering a code for a job category in the wrong column of the Staff Information and Control Rec- ord and thus in the wrong strata, (4) failure to enter a job category code for a listed employee, and (5) misapplying the ''start with" and "take every'' numbers. In all 142 such errors were made —about one error per interviewer for all of her assignments, which included, on the average, about eight establishments. About half of the in- terviewers carried out the sampling procedures without a detected error. Also, the errors were concentrated in only a few of the homes. Of the 1,073 places for which Staff Questionnaires were completed, deviations from specified sampling procedures occurred in 123 (11 percent) of the homes. Thus, except for a few instances, there was only one error per home. As part of the field editing procedures, the interviewer's work relating to sampling was reviewed. Any errors found were referred to the Washington Office for a decision as to whether the errors were serious enough to resample employees in an establish- ment. The errors discussed in this section were Table E. Number and percent distribution of the sample of professional and semipro- fessional employees, by job category and response status Response status Total employees in sample Questionnaire Questionnaire Job category returned not returned Number | Percent Number | Percent | Number | Percent Total==---=-ccommcmcmeee em 7,99 100.0 7,337 94.3 457 5.7 Administrators-------------------- 969 100.0 948 97.8 21 2.2 Registered nurses=----------------- 1,207 100.0 1,148 95.1 59 4.9 Licensed practical nurses--------- 1,266 100.0 1,180 93.2 86 6.8 Nurse's aideS-=-==cmccmmcmmaoaoono 4,278 100.0 3,999 93.5 279 6.5 Other professionals==-------------- 274 100.0 262 95.6 12 4.4 considered too minor to warrant the expense of revisiting the establishments involved. Nonresponse Several types of nonresponse were possible, such as (1) an establishment refused to cooperate, (2) an establishment cooperated by providing in- formation on only certain parts of the survey, (3) Staff Questionnaires left at the establish- ment to be completed by the sample employee were not mailed to the census regional office, or (4) certain items on the questionnaire were not completed. The only types of nonresponse of any consequence were types (3) and (4). Only 12 of the 1,085 sample places refused to cooperate. Seven of these were quite small, maintaining fewer than 30 beds; four had 30-99 beds; and one had 100-299 beds. The overall nonresponse rate for profes- sional and nonprofessional personnel was 5.7 per- cent. The rate ranged from a low of 2.2 percent for administrators to 6.8 percent for LPN's as indicated in table E. The low nonresponse rate for administrators was because most of their responses (71 percent) were obtained by the inter - viewers. The major reason for nonresponse was the inability to contact the employee. Of the 5.7 percent total nonresponse, 1 percentage point had changed their place of employment and their addresses or telephone numbers were not avail- able and 2.5 percentage points could not be con- tacted for other reasons. Only 0.2 percentage points were attributed to refusals. Failure to obtain answers to items on the questionnaires was generally not a problem as indicated in tables F, G, and H. Table F shows the percent of items on the Establishment Questionnaire not completed. The on the Estab- not completed, Percent of items Questionnaire Table F. lishment by item Percent not completed Item Number of residents receiving nursing care----------=cema==- Who is in charge of nursing CAre======-mcmmemmmmm meme Full time or part time-------- 24-hour nursing care---------- Physician arrangement=--------- Dentist arrangement----------- Deaths during 1963------------ Discharges other than deaths during 1963-----------ocooon- a NOOR PW © S Roo oO=®® © proportion was less than 5 percent for all items except live discharges. The nonresponse rate for sample residents ranged from almost zero for sex to a high of 21 percent for veteran's status (table G). During the developmental stage of the survey, there was an indication that many respondents (i.e., adminis- trators, nurses, etc.) would not know whether a patient was a veteran. Therefore, in the national survey the interviewers were instructed to obtain the information from the patient himself if it was not available elsewhere. Apparently, the question was confusing to some of the interviewers since it was not answered for such a high proportion of residents. Table H shows the percent of nonresponse for specified items on the Staff Information and Con- trol Record and the Staff Questionnaire. The non- response rate was so high for some items that the Table G. Percent of items on the Resident Questionnaire not completed, by item Percent Item not completed Age: Month and years=-----=-----=-- Month only=--====c-c-cecco-nn — OOO No OF OXMOWO wo NH OWLO OOO Veteran status=-=-------=-----=--= Marital status-----=----=-==-=- Date admitted: Month and year-------=----=- Month only----=-=------cocom== Residence prior to admission-- How often visited------------- Special aid-------=-----c-un--n Date last saw doctor: Month only=-------c-ceceuenna- Month and year-------------- Date last saw dentist: Lost all teeth-------------- Full dentures---------=-===-== Initial care------==mmmmm————- Charges =m wm mmm mom mmm mmm miei Primary source--------=--c-=-= Secondary source--------=-==-- Nursing services received----- Mobility status=----=-===--===-= ce RFONFOOW RN RFNWHEH HH = > INot ascertained. Table H. Percent of items on the Staff Information and Control Record and the Staff Questionnaire not completed, by item Percent Item not completed Job category«=-=-mmmmmmmmm———— 0.4 Pay period, wages, and hours worked per week: Total sample-----====meme==- Administrators-------=-=-=---- Other professional---------- Semiprofessional-===-===-=---- Nonprofessional-=-=-=-======--- SeX----=-smmemmmmm mm mm mmm mmm Room and board--------=-====---- Month last started work in this establishment----------- Year last started work in this establishment---------=-===-=- Age----mmmmmmmm eee mmm ———— Work experience in this estab- lishment=----=---cccceoncauan- Education: Level and grade------------- Grade only-----==--==-==c-u-- Special courses--------=======- DEBT CRE mi mmr we tm ok os a mio am No N= UNS oO OunWwN P— ow ~ WO WNNDOO Woo OH aN wn ~ ~~ estimates were meaningless. Items of nonre- sponse for each job category included pay period, wages, and hours worked per week—of which 28.6 percent of the administrators left one or more of the items blank. The percent of nonresponse was reported for the three items combined for each job category because of the way nonresponse for these items were imputed. Rather thanimpute for each item separately, it was considered best to impute for all three if any one of them was left blank. When possible, the procedure was to assign the wages, hours worked, and pay period of a person in a similar job working inthe same estab- lishment to those persons who did not respond. The nonresponse rate was also high for item 4 on the Staff Questionnaire, which concerns the degree, diploma, or license that an employee may have had. Nevertheless, information from the 86 percent who answered the question was valuable since the primary use of the data was to evaluate 15 the validity of the person's classification by job category. The question concerning special courses in the care of the aged and chronically ill was also often left blank. Of the total sample em- ployees, information was obtained from only 85.7 percent. The nonresponse rate of 14.3 percent included 5.8 percent of employees who did not send in a questionnaire plus 8.5 percent who did not answer the question. Although the nonresponse rate for the ques- tion on education was low, the data have serious limitations for another reason. College education was not adequately defined in the survey, espe- cially as it pertained to nursing education. Some registered nurses, for example, indicated that they had 3 years of college as a result of their training to become a nurse, when the nursing school they attended was not affiliated with a college or university; others with the same train- ing said they had only a high school education. REFERENCES National Center for Health Statistics: Origin, program, and operation of the U.S. National Health Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1963. ZN ational Center for Health Statistics: Health survey procedure, concepts, questionnaire development, and defini- tions in the Health Interview Survey. Vital and Health Statis- tics. PHS Pub. No. 1000-Series 1-No. 2. Public Health Serv- ice. Washington. U.S. Government Printing Office, May 1964. Sationsl Center for Health Statistics: Plan and initial program of the Health Examination Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 4. Public Health Service. Washington. U.S. Government Printing Office, July 1965. E. E., Nelson, A. B., and Taube, C. A.: Health characteristics of patients in nursing and personal care homes. Proceedings of the Social Statistics Section, 1965, American Statistical Association, Washington, D.C., 1965. pp. 168-176. SN ational Center for Health Statistics: Institutions for the aged and chronically ill, United States, April-June 1963. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 1. Public Health Service, Washington. U.S. Government Print- ing Office, July 1965. 000 SNational Center for Health Statistics: Characteristics of residents in institutions for the aged and chronically ill, United States, April-June 1963. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 2. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1965. TNetiondl Center for Health Statistics: Characteristics of patients in mental hospitals, United States, April-June 1963. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 3. Public Health Service. Washington. U.S. Government Print- ing Office, Dec. 1965. 8National Center for Health Statistics: Utilization of insti- tutions for the aged and chronically ill, United States, April- June 1963. Vital and Health Statistics. PHS Pub. No. 1000- Series 12-No. 4. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1966. Stional Center for Health Statistics: Employees in nursing and personal care homes, United States, May-June 1964. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 5. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 10x ational Center for Health Statistics: Employees in nursing and personal care homes: number, work experience, special training, and wages, United States, May-June 1964. Vital and Health Statistics. PHS Pub. No. 1000-Series 12- No. 6. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1967. UN ational Center for Health Statistics: Chronic illness among residents of nursing and personal care homes, United States, May-June 1964. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 7. Public Health Service. Washington. U.S. Government Printing Office, May. 1967. 12x ational Center for Health Statistics: Prevalence of chronic conditions and impairments among residents of nurs- ing and personal care homes, United States, May-June 1964. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 8. Public Health Service. Washington. U.S. Government Print- ing Office, July 1967. 13x ational Center for Health Statistics: Charges for care in institutions for the aged and chronically ill, United States, May-June 1964. Vital and Health Statistics. PHS Pub. No. 1000-Series 12-No. 9. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1967. ys Bureau of the Census: The Current Population Sur- vey—A Report on Methodology. Technical Faper No. 7. Wash- ington. U.S. Government Printing Office, 1963. I5National Center for Health Statistics: Development and maintenance of a national inventory of hospitals and institu- tions. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 3. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1965. 168,vant, E. E., and DeLozier, J. E.: Developing, main- taining, and evaluating a sampling frame of institutions. Pub. Health Rep. 83(2):161-166, Feb. 1968. APPENDIX | ESTIMATION AND SAMPLING VARIANCE EQUATIONS Three basic types of statistics were collected in RPS-2: X-characteristics of residents, Y-characteris- tics of employees, and Z-characteristics of establish- ments. The principal type of estimate derived from these data was a total such as the number of residents aged 65-74 with arthritis, the number of RN's with 5 years or more of experience, or the number of beds in nursing care homes. The formulas for obtaining estimates relating to residents, employees, and estab- lishments are shown below. Estimator for Resident-Type Statistics The estimated total number of residents with an X-characteristic is denoted by where AA A A X=X +X,+X;, A L m np: Xz BM JN 1 i=1 A m i=1 nn k=1 ijk’ B, i ii A L222 my ™ NN, Bj Xyme 3 ob EZ J Xx» and i=1 m, Ii=1 pa, k=1 ) A g X, = weighted sum of residents with the X-charac- teristic selected from the Complement Uni- verse, i.e., from places not listed in the MFI. The terms involved in the equations are defined as follows: X... = X-characteristic of kth resident in the jth establishment in the ith service-size stratum. ijk B, = total number of beds maintained by estab- lishments in the jth service-size stratum of the MFI, based on data collected in the MFI survey and adjusted to exclude beds in estab- lishments no longer in business or out of scope of RPS-2. A m, . B=_1 = B;; = estimated number of beds main- [=k ! tained by responding in-scope es- m. | 1 tablishments in the ith service- size stratum of the MFI based on data collected in the MFI survey. M; = total establishments in the ith stratum ofthe universe. m; = number of sample establishments selected from the ith stratum. rm; = number of responding in-scope sample estab- lishments in the ith stratum. 2 I = total number of residents on the register of the jth sample establishment inthe sth stra- tum. A; = number of sample residents in the ;thestab- lishment in the sth stratum for whom questionnaires were completed. L, = number of primary strata from which estab- lishments were selected with probability less than 1. L, =number of primary strata from which estab- lishments were selected with probability of unity, plus the Group II stratum. The estimator for x, includes correction for non- response of both establishments and residents, in that ng refers only to responding residents and B,is an estimate based only on responding establishments. B, is the actual number of beds in the ith stratum of the MFI, including beds maintained by establishments not responding in RPS-2. The estimator for X, differs from that for £2 primarily because it does not contain the ratio adjustment; it is an estimate of an X-character- istic among residents in establishments with 300 beds or more and in establishments in Group Il of the sam- pling frame. Estimator for Employee-Type Statistics This estimator is similar to that for residents, except that it takes into consideration the stratification of employees within establishments and contains a ratio adjustment by strata to correct for underrepresentation 17 or overrepresentation of specific job categories in the particular samples selected within the establishments. . A — Sox ed The estimate Y of an employee statistic Y is given by the equation: A A A A ¥=¥+¥+% . The subscripts refer to the same subgroups as ex- plained above for residents. 7, is represented by a similar expression, except that it does not include the first-stage ratio adjustment B,/B., but has instead a nonresponse adjustment factor m;/. mn. Y; is the weighted sum of employees with a y- characteristic who were selected from establishments in the Complement Survey universe. The terms used in the equations are defined as follows: T;;, = total employees in the rth employee stra- tum in the jth establishment in the sth service-size stratum. tir = total responding sample employees in the rth employee stratum inthe jth establish- ment in the sth service-size stratum. T, ,, = total employees in the Sth job category in the rth employee stratum in the sth service-size stratum. m A Tj. . Tins™ ~ tis Where = Lie t.. . = total responding sample employees in the ijrs Sth job category in the rth employee stratum in the jth establishment in the ith service-size stratum. Other terms in the formula are defined as part of the X-statistic estimator. Estimator for Establishment Statistics The estimator for statistics such as number of establishments, number of beds, or other statistics which may be considered as characteristics of estab- lishments is represented by the following equation: A 2 A A Z= 1H Z,+ 2, where A 1 s 2-7 5% 3% 2, i= A j=1 MY B, m; L i. A 2 z,= 2 ¥ 3 Zz, , and Ye = ti. ) i=1 rm i=1 A Z, is a weighted sum of Z-characteristics among establishments in the Complement Survey. Each term of the equations has been defined previously in the report. Procedure for Computing Sampling Errors The formulation of sampling variance is different, depending on the estimation technique employed in a strata—whether a ratio estimate or a simple inflation estimate is used and whether the estimate involves single-stage or two-stage sampling. For simple infla- tion estimates involving two-stage sampling, the follow- ing formula was used 10 obtain the sampling variance of an estimated total, 2, for the rth stratum, 2 . 2 m 2 af JOM a) gr (Mh Ne Re X; M, m, i mm; (m;i=1 N, 2 ij A A . where S? and S2 are estimatorsof SZ 1X; 2X 1X and si ij i respectively, and are represented by the formulas: : A A 2 . n.. ¥ 12 22 2 XX; XxX) ~ m; N; (N=) z Xi — Xi) X= m—1 j=l N, 7, k=1 m (a, —1 . A 2 n.. v Az 2 Xi =X)? wm, = 2 For estimates based on the first stage of sampling (e.g., an establishment-type statistic such as the num- ber of beds), the last term of the variance formula vanishes. In strata where ratio estimates were used, the variance formulation is more complex and may be represented by the general variance equation 2 . 62 = MM - mp 4, + R? 5 _2R § ] = 1X; 1B, i 1X; B; 2 M, mh, i i m 2 . . M [+ FNM 82 ] J] m, Lm i=1 Nn ii 0.8 m; 2 2 where S z 8-5) bist om mo, AA ! (X.—-X.XB.—B) - — hr and 5, 8, z i i i i=1 m; —1 In the above formulas, the following terms need defining: s2 and similar terms represent the variation between i establishments in the sth stratum; +. is a measure of 1 variation within the jth establishment in the sth stra- tum, A . Xi; = estimated total number of units in the jth establishment in the ith stratum with the X -characteristic. A X,= average estimated total number of units per establishment in the jth stratum with the X -characteristic. A X; = estimated average number of persons in the jth establishments in the sth stratum with the X-characteristic. A AA R =X /8 In RPS-2 a variety of estimates were made, such as the number of residents by sex, age, health condition, service received, and so forth. Each of those estimates has a sampling variance, and, in general, the variance of one statistic is different from that of another. Since it was not feasible to compute variances for all of the statistics derived from the survey, an approximate method was used which in essence involved fitting a curve to a number of point estimates, computed by the exact formulas shown above. The curve-fitting operation is an iterative process on a computer, using the general equation Yj; = a+ Li . Y, is the relvari- Xi ance of the jth statistic (X) from the sth curve, The constants ''a'" and '"b'" are functions of the estimates and the computed point estimates of relvariances. (The relvariance is the ratio of the variance to the square of the estimate. For example, the relvariance of X, is ” J Xp?) 19 APPENDIX II DEFINITIONS OF TERMS USED IN THE SURVEY Four numbered forms were used in the survey and are reproduced in Appendix IV. Form HRS-3a, the Establishment Questionnaire, and Form HRS-3b, the Staff Information and Control Record, were combined into a booklet of forms, one of which was used for each establishment in the sample. Form HRS-3c, the Resi- dent Questionnaire, was also in booklet form, con- taining a listing sheet on which the name of each sam- ple resident was recorded, instructions for selecting a .sample of residents, and 14 individual resident questionnaires. Ordinarily, only about 10 residents in a home were in the sample; therefore, except in rare instances, one booklet was sufficient for a home. Form HRS-3d was a loose-leaf, single-page question- naire for collecting supplemental information about the professional and semiprofessional employees in the sample. It was the only questionnaire of the four to be completed by the sample person himself. Terms Used on the Establishment Questionnaire (HRS-3a) Beds: A bed is one set up and regularly maintained for use by a resident or patient, whether or not it is in use at the present time. This excludes beds used by the staff and those used exclusively for emergency services. Resident or patient: The terms ''resident' and 'patient' are used synonymously. A resident is any person who has been formally admitted to a home but not dis- charged. This includes a resident who is tempo- rarily away in a hospital, visiting with friends or relatives, on vacation, or some other place, but whose bed is maintained for him in the home. Nursing care: Nursing care is defined as provision of any one of the services listed on Card A, List of Nurs- ing Services, shown in Appendix IV. For the pur- poses of RPS-2, a person was receiving nursing care if he received at least one of the listed serv- ices during the 7 days prior to the interview in the home. 20 Supervisory nurse: The person who supervises nursing care is the person in charge of the daily nursing activities provided in the home, such as the head nurse, This is not the person who employs the nursing staff (i.e., the owner or administrator), unless he also supervises the daily nursing activities of the nurses. On duty 24 hours a day: This means that nursing service is routinely pro- vided at all hours of the day or night by either a nurse or nurse's aide. A person is not "on duty" if she is available to provide care only upon call or in emergencies. For example, a nurse who re- sides in a nursing home is not onduty while asleep even though she is available to provide nursing care, Full-time staff physician: This is defined as a physician (i.e., a doctor of medicine or a doctor of osteopathy) who is em- ployed by the home for the care of the residents and who works in the establishment at least 40 hours per week. A dentist on the premises full time: This is defined as a dentist who is employed by the establishment and who works in the establishment at least 40 hours a week or more. Arrangement with a physician (ov dentist): This refers to an agreement, either written or oral, between the home and a doctor relating to the care of residents of the home. This excludes any arrangements that a resident might have with his private physician or dentist. Regular intervals: This is defined as "once a week," "once a month," "every Friday for half a day," or any other specified periodic interval of time. Discharge: This term is defined as formal removal of a resi- dent's name from the register of an establishment. A discharged person no longer occupies a bed in the establishment, and a bed is not held for his possible return to the establishment. Employee: This refers to any person who works in the estab- lishment, other than voluntary workers. Although employees are usually paid, "unpaid workers" (such as nuns) in certain types of establishments are considered employees. Fifteen hours ov move per week: This refers to the number of hours that a person usually works in an establishment. New employees were included even though they had not worked as many as 15 hours in the establishment at the time of the interview, provided they were expected to work at least 15 hours per week. Employees on vacation, sick leave, or temporarily away for other reasons, were also included if they usually worked 15 hours or more per week. Terms Used on the Staff Information and Control Record (HRS-3b) Terms identifying the three job categories and other terms used on the Staff Information and Control Record are given below. Professional: This category includes administrators, physicians dentists, occupational and physical therapists, dietitians or nutritionists, social workers, regis- tered professional or graduate nurses and li- censed practical nurses. Semiprofessional: In this category are other nursing personnel such as nurse's aides, practical nurses, student nurses, and other supporting nursing staff. Nonprofessional: This refers to clerical and other office staff and food service personnel such as cooks and house- keeping personnel, No attempt was made to define specific job cate- gories, e.g., a ''registered professional nurse’ or a "dietitian." Instead, an item was added to the Staff Questionnaire (item 4 on HRS-3d) for the purpose of screening certain job categories that might tend to be ill-defined, For example, an entry in the box '"Mem- ber-—American Dietetic Association provides a means of evaluating the level of skill possessed by a person employed as a dietitian, Hours usually worked per week in this establish- ment was defined by giving examples: (1) If the employee's standard work week is 60 hours and he usually works 60 hours per week, enter 60 hours, (2) If the employee worked 60 hours last week but he usually works 50 hours per week, enter 50 hours. (3) If the employee's standard work week is 40 hours, but he usually works 20 hours overtime, enter 60 hours. Cash wages refers to aperson's gross wages or salary, i.e., before any deductions are made for income tax, bonds, health insurance, social se- curity, and so forth. For owners or proprietors, cash wages refers to adjusted gross income—i.e., after operating expenses have been deducted but before any deductions for taxes, bonds, and so forth. Terms Used on the Staff Questionnaire (HRS-3d) This questionnaire was designed to be as self- explanatory as possible since generally it was to be completed by the respondent without assistance from an interviewer. The job that the sample staff member held in the establishment was written on the form by the interviewer in the space provided for question 2, "How many years have you worked asa " (i.e., registered professional nurse, nurse's aide, etc.). Thus, the length of time employed does not necessarily refer to the person's total work experience in nursing homes and hospitals but to her experience in the type of work she was doing at the time of the survey. Terms Used on the Resident Questionnaire (HRS-3c) Date of admission: This refers to the date the resident was last ad- mitted to the home. If he had more than one epi- sode of stay in the home, the reference is to the date of his most recent admission. In bed all or most of the day: This means that the person stays in bed most of the time because he is unable to get up (health reasons) or because he prefers to stay in bed even though he is physically able to get up (psychological reasons). A resident who is unable to getup by him- self but who is routinely put in a wheelchair and is up and about most of the day is not considered as "in bed all or most of the day." If a person is con- fined to bed with an acute condition, such as a se- vere cold, but will be up and aboutin a few days, he was not considered as 'in bed all or most of the day." However, a person recently confined to bed with a chronic condition who is likely to continue to be confined to bed for a long period of time is considered "in bed all or most of the day." In own voom all ov most of the day: This means that a person is restricted tohis room for health reasons or because he prefers to stay 21 in his room even though he is able to move about (psychological reasons). Going off the premises: This means leaving the home either alone, with relatives or friends, or with a staff member to go shopping, walking, visiting with friends or rela- tives, and so forth. This excludes going off the premises to see a doctor or dentist. Special aids: Reference is made to those listed on Card C shown in Appendix IV. For a special aid to be counted in the survey, it was necessary for the sample resi- dent to be actually using the aid. Last time vesident saw doctor: This refers to the patient's present stay in the home for treatment, medication, or examination by a medical doctor. Seeing a doctor involves either a visit by the doctor to the home or a visit by the resident to the doctor's office for medical advice, treatment, medication, or an examination. The visit by the doctor to the establishment need not be a special visit to see the patient, but to be counted, the doctor must provide either treatment, medication, or examination. A doctor merely going over the charts or making rounds and saying, "How are you, Mrs. Jones?' does not constitute a visit. Medication: This includes any medicine prescribed by the doctor even though it may be a nonprescription medicine such as aspirin. Seen by the dentist: This refers to a visit by the dentist to the estab- lishment to provide dental care to the patient, or a visit by the patient to the dentist's office to receive dental care, including routine dental exami- nations. Also included is dental care provided by a dentist employee of the establishment. Chronic condition: 22 A condition is considered to be chronic if (1) it is described by the respondent as one of those listed on Card D, "List of Chronic Conditions," or Card E, "List of Selected Conditions," or (2) it is not on Card D or Care E but is recorded in the patient's medical record and reported as chronic by the respondent. (Cards D and E are reproduced in Appendix IV.) Primarily nursing cave: This term is used in the survey in two ways. One relates to the primary type of service provided by an establishment to the majority of its resi- dents. The classification criteria are given in Appendix III. "Primarily nursing care," as used on the Resident Questionnaire refers to primary type of care actually provided to the sample per- son when admitted to the establishment. "Nursing care" is defined as any one of the items 7-19 on Card F, "List of Services." (Card F is reproduced in Appendix IV.) Primarily personal cave: This term is also used in two ways, similar to those for 'primarily nursing care." ''Personal care," when referring to individual patients, is the provision of any one of items 1-5 on Card F. "Primarily personal care' means that personal care was the predominant type of service pro- vided, although minimal nursing care may alsohave been provided. Room and board only: This means that neither nursing nor personal care was provided to the resident when he was first admitted to the establishment. Total chavge for resident's cave: This term refers to the charge made "last month" by the establishment for the services that are pro- vided to a resident. These services usually include lodging, meals, nursing care, and personal care. The charge made by the establishment includes charges for special services if such services are provided by establishment employees or by outside employees if their services are contracted for by the establishment. Excluded are charges for serv- ices that are not part of the establishment's bill, such as those provided by a patient's private physician. APPENDIX CLASSIFICATION OF HOMES BY TYPE OF SERVICE For purposes of stratification of the universe prior to selection of the sample, the homes on the MFI were classified as nursing care, personal-care-with-nursing, personal care, or domiciliary care homes. The latter two classes were combined to produce the three types of service classes shown in table A. Details of the classification procedure in the MFI have been pub- lished. 15 Due to the 2-year interval between the MFI survey and the RPS-2 survey, it was felt that, for producing statistics by type of service from the RPS-2 survey, the homes should be reclassified on the basis of the current data collected in the survey. This classifica- tion procedure is essentially the same as the MFI scheme. The three types of service classes delineated for RPS-2 are defined as follows: 1. A nursing cave home is defined as one in which 50 percent or more of the residents received 000 nursing care (see definition, Appendix II) dur- ing the week prior to the survey in the home, with an RN or LPN employed 15 hours or more per week. In this report geriatric hospitals are included with nursing care homes. A personal-care-with-nursing home is defined as one in which either (a) over 50 percent of the residents received nursing care during the week prior to the survey, but there were no RN's or LPN's on the staff; or (b) some, but less than 50 percent, of the residents received nursing care during the week prior to the sur- vey regardless of the presence of RN's or LPN's on the staff, A personal care home is defined as onein which residents routinely received personal care, but no residents received nursing care during the week prior to the survey. 23 24 APPENDIX IV FORMS AND QUESTIONNAIRES U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS WASHINGTON, D.C. 20233 Dear Administrator: The Bureau of the Census, acting as the collecting agent for the United States Public Health Service, is conducting a nationwide survey of nursing homes, homes for the aged, and other establishments providing nursing, personal, and domiciliary care to the aged and infirm. The purpose of this survey is to collect much needed statistical information on the health of residents and on the types of employees in these homes. This survey is part of the National Health Survey program authorized by Congress because of the urgent need for up-to-date statistics on the health of our people. The purpose of this letter is to request your cooperation and to inform you that a representative of the Bureau of the Census will visit your establishment within the next week or so, to conduct the survey. Prior to his visit, the Census representative will call you to arrange for a convenient appointment time. All the information given to the Census representative will be. kept strictly confidential by the Public Health Service and the Bureau of the Census, and will be used for statistical purposes only. Your cooperation in this important survey will be very much appreciated. Sincerely yours, Scasssirs Richard M. Scammon Director Bureau of the Census OFFICE OF THE DIRECTOR U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS’ Dear About a week ago the Bureau of the Census conducted a survey in the establishment in which you are employed to obtain information on the work experience and education of certain professional and semi-professional employees of the home. At that time we left a questionnaire for you to complete and return to us. According to our records, the questionnaire has not been received. Another copy of the questionnaire is enclosed for your use if the other copy has been lost or misplaced. Please complete the questionnaire and mail it to the Bureau of the Census within 5 days. For your convenience, a self-addressed envelope which requires no postage is enclosed. If you have already returned the original questionnaire, please disregard this reminder. Thank you for your cooperation. Sincerely yours, Richard M. Scammon Director Bureau of the Census Enclosures Please send completed form to: FORM HRS-3g (4-2-64) USCOMM-DC 24447 P-64 Budget Bureau No. 68-R620.R2; Approval Expires December 31, 1964 CONFIDENTIAL - This information is collected for the U.S. Public Health Service under authority of Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All information which would permit identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for any other purposes (22 FR 1687). ForM HRS-3a (Verify name and address and make any necessary corrections) (4-1-64) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. NATIONAL HEALTH SURVEY ESTABLISHMENT QUESTIONNAIRE Number 1. How many beds are regularly maintained for residents (patients)? (Include any beds set up for use whether or not they are in use at the present time. Exclude beds used by staff or any beds used exclusively for emergency services) Number 2. How many residents (patients) are currently on your register as formal admissions who have not been discharged? (Do not include employees or proprietors) Number | 3. During the past 7 days how inary of these — — residents | OR [] None (patients) received nursing care? By nursing care we mean | (Go t 7) any of the services listed on this card. (Show card A) | 9 tog. Regi d Li d 4. Is the person who supervises NURSING CARE [J professional 2) Peay s Someone a registered professional nurse, a lizcased nurse nurse else practical nurse, or someone else? 5. Does she work full-time or part-time? 1 [C1 Full-time 2 [J Part-time By full-time we mean 40 or more hours a week. 1[] Yes 2] No 6. Is there a nurse or nurse's aide ON DUTY 24 hours a day? 7a. Does this home employ a full-time staff physician 1 Yes . 2] No for the care of the residents (patients)? (Go to question 8) b. Does this home have an arrangement with a physician to come to the home at regular intervals for the care a. oo to question 8) 20 Ne of the residents (patients)? Y N c. Does this home have an arrangement with a physician to come J (Go to question 8) 20] No to the home when needed, but not at regular intervals? d. Does this home have an arrangement with a physician to give 107] Yes 2] No medical care to the residents (patients) IN HIS OFFICE? 1 Y N 8a. Does this home employ a dentist on the premises full a (Go to question 9) 203 Ne time to give dental care to the residents (patients)? b. Does this home have an arrangement with a dentist 1] Yes 2] No to come to the home at regular intervals to give (Go to question 9) dental care to the residents (patients)? 3 i i Yes 2[] No c. Does this home have an arrangement with a dentist to come OJ ; to the home when needed but not at regular intervals? (Go to question 9) 1] Yes 2] No d. Does this home have an arrangement with a dentist to give dental care to the residents (patients) IN HIS OF FICE? Page 1 USCOMM-DC 24497-P64 9. We want to know the total number of residents (patients) who were discharged during 1963 - both those who were discharged to their home or some other place and those who died. First, | wont to ask about those who died. a. How many persons died during 1963 while residents (patients) in your establishment? Include Nuribar those who died while ON Your REGISTER even though they were temporarily away in a hospital or some other place. b. Excluding deaths, how many other discharges did you have in 1963? ........ PHOT I MER Of these — (q. 9b) — discharges, other than deaths, how many were discharged to the following places: (1) Resident's (patient's) home or family? . . . . ................. FEWER (2) Another nursing home, home for the aged, or similar establishment? . ............. + + (3) Mental hospital? ......ovvvvnnnnn WERE AE BR RE KE RE vam Cee (4) Nonmental hospital? .............. pA RRA EAE Ee Pee nee ae (3) Other ploces? cis iswswimsrnivipwsvanesmens BUH ER HE BW EEE (6) Place unknown? .........c0vvtvnnnnnnn ve we we ee we 0 YE Te EE Se Number 10a. How many persons work in this establishment? (Include owners who work in the establishment as well as all paid employees and members of religious orders) b. How many of these — (q. 10a) — persons usually work LESS than 15 hours a week in this establishment? (Subtract the answer to question 10b from the answer to question 10a and insert the difference in item 10c below) c. Now | need to list thenames of the employees who usually work 15 hours or more per week in this establishment. Name of respondent(s) Telephone number and ext. Title or position Date completed Census Interviewer’s name EN——— Comments FORM HRS-3a (4-1-64) Page 2 USCOMM-DC 24496-P64 27 8¢ ForRM HRS-3b (4-1.64) STAFF INFORMATION AND CONTROL RECORD U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS (Ask only for sample employees) Establishment number What is his job here? (Enter How often is )Whot are i sadiion to number from Card B) he paid? his cash is: €0Sh woges When INTERVIEWER H wages or [°F salary per did he « . IT Sex il (Enter code) [salary pay perioc, Goes: 1 yigey) “Pprofes- | Semi- Non- many he routinely get | _ Employees who work 15 sional” |profes- | profes- (Enter hours 1s Weekl pat Poy ither room or ou or more hours a week (N w ber sional’ | sional’’ v €" ldoes he y Pete board? ering Fill buff Staff Questionnaire in this establishment 1-10) S [(Number | (Numbers fo USUAL-|2 — Every 2 any de- I “Yas, ask et sh. form (Form HRS-3d) for each = ) 11) 12-15) mele Y } weeks So frone hat does he getd ment? sample employee in columns ey (Enter Mr., Mrs., Miss, SW Sw SW and work perf _ yooh] h b Enter code) (b) and (¢) only 2 or Dr., first initial sii week in ) y de for 1 — Room and (Enter E and last name) TE this es- | 4 — Annually mace tor e 5 TE TE for blish income board month (Check box for each s (Circle ; 3 female) [ToPUiSh- I's _ Other tax, in- 2 — Room only and eck onc box lor ea v (Circle (Circle ment? : ’ « Bozrd sample employee eligible g sample \ 1 (Specify [surance [3 oard only year) To ett bod 2 persons) jSompie [927s period) |ete.? 4 — None of or statf form persons) | persons) the se (a) (b) (c) (d) (e) (g) (8) (h) (i) (J) (k) Month [] Completed at time of visit [C] Form left to be mailed in [Year | Date received in R. 0. | 1 Month [] Completed at time of visit [] Form left to be mailed in Year | Date received in R. O. | 2 Month [] Completed at time of visit [] Form left to be mailed in Year | Date received in R. 0. | 3 Month [] Completed at time of visit [C] Form left to be mailed in [Year |” Date received in R. O. | 4 Month [] Completed at time of visit [C] Form left to be mailed in Year ~~ |” Date received in R. 0. | 5 Month [] Completed at time of visit [C] Form left to be mailed in Year | Date received in R. 0. | 6 Month [] Completed at time of visit [] Form left to be mailed in Year Date received in R. O. 1] 7 Page 3 RESIDENTS OR PATIENTS IN SAMPLE (a) (b) (a) (b) 1 21 2 22 3 23 4 24 5 25 6 26 2 27 8 28 9 29 10 30 11 31 Z 32 13 33 14 34 15 35 16 36 17 37 18 38 19 39 20 40 FORM HRS-3C (3-23-64) Page 2 29 30 Establishment number SAMPLING INSTRUCTIONS FOR RESIDENTS (PATIENTS) The sampling instructions for the residents (patients) of this establishment are: Start with Take every The first three sample designation numbers have been entered in column(a) of the worksheet on page 2. Continue to add the ‘‘Take every’’ number for each succeeding line until the sum exceeds the total number of patients now on the register as shown by the entry in question 2 of the Establishment Questionnaire Form HRS-3a. ’ Enter the name of the sample resident (patient) in column (b) on the line opposite the sample designation number which matches the resident’s position on the register. Example: The “‘Start with’’ is 1 and the “‘Take every’’ is 2. The numbers in column (a) on the worksheet are 1, 3, 5, 7, 9, etc. When sampling the register, you take the first patient, the third patient, the fifth patient, etc., and enter their names in column (b) on the appropriate line. For each sample resident (patient) listed in column (b), complete a Resident (Patient) Questionnaire, Form HRS-3c, contained in booklet form: Page 3 USCOMMeDC 24499-P64 | Budget Bureau No. 68-R620.R2; Approval Expires December 31, 1964 Establishment number Resident's (patient's) line No. (Record in Table 1 each chronic condition mentioned) Month | Year 1. What is the month and year of this resident's (patient's) birth? | 2. Sex 1 [] Male (Ask question 3) 2 [|] Female (Go to question 4) 30. Hos he served in 3c. NOTE TO IN TERVIEWER: the Armed Forces of Source of veteran status the United States? 1 [C] Yes (Ask Q. 3b) 2[] No (Go to Q. 4) 3] Unknown information b. Didihe serve in 1] Record 2[ | Sample person World Wer 17 1[] Yes 2[]No 3[] Unknown 3] Respondent 4. |s this resident (patient) married, y Mariied 3 Di ced 1 Nev ied widowed, divorced, separated, or OJ ih CJ ivoree 5/1 Never mastle never married? 2] Widowed 4] Separated Month Tyear 5. In what month and year was he (last) admitted to this home? y 6. With whom did he live at 1 [_] Spouse only 7] In another nursing home or the time of his admission? 2[ 7] Children only related facility (Check the FIRST : 8 [| In mental hospital por that applies) 3[_] Spouse and children — : ‘ } kev be al a[ | Relatives other than spouse or 9 [J In a long-term specialty hospita — children (except mental) 5] Lived in apartment or own home — 10 ]In a general or short-stay hospital alone or with unrelated persons 11[ | Other place (Specify) 6 [| In boarding home 7. Howetten do friend or 1 [| At least once a week 3[ | Less than once a month (Check the FIRST 2[ |] Less often than once a week but at a] Never box that applies) least once a month 8a. Does he stay in bed all or most of the day? 1 [] Yes (Go to question 9) 2[ | No (Ask mastion 8b) b. Does he stay in his own room all or most of the day? 1[ | Yes 2] No (Ask question 8c) c. Does he go off the premises just to walk, shop, or visit with friends or relatives and so forth? 1] Yes 2] No 9. Which of these special aids (Check all that appl i T i pply) does this resident (patient) se? (Show card C wii . . v ( ) 1{__] Hearing aid a[_] Braces 7 [] Eye glasses 2] Walker 5s [_] Wheel chair OR 3] Crutches 6 [| Artificial limb(s) 8 [| None of these aids used 10. During his stay here when did he last see a Month year d doctor for treatment, medication, or for an | [I Nee: saw octor examination by the doctor? | while here 11a. During his stay here, has he seen a dentist? 1] Yes (Ask question 11b) 2[ | No (Go to question 12) Month year b. When was the last time he saw a dentist? | 120. Has he lost ALL of his teeth? 1[] Yes (Ask question 12b) 2 [| No (Go to question 13) b. Does he wear full upper and lower dentures? 3] Yes a[ | No 13. Does this resident (patient) have any of these conditions? (Show card D. Record in Table 1 each condition which the patient has) 1] Yes 2] No 14. Does he have any of these conditions? Co oo (Show card E. Record in Table 1 each condition which the patient has) 1] Yes 2[] No 15a. Does he have any other CHRONIC conditions listed in his record that you have not told me about? 1] Yes 2] No If “Yes,’’ ask: b. What are they? FORM HRS-3C (3-23-64) 3 32 Table 1 Enter conditions from questions 13, 14 or 15 For the following conditions ask these questions ILL EFFECTS OF STROKE. .... What are the present ill effects? SPEECH DEFECT 5 5 6454 3% » aus What caused the speech defect? Do PARALYSIS, PERMANENT fier Enter the words used by the respondent to STIFFNESS .uiuinsnnainsnrnn What part of the body is affected? | write describe the condition. TUMOR, CYST, OR GROWTH . . . . What part of the body is affected? | in Is it malignant or benign? this DEAFNESS, HEARING TROUBLE, column OR ANY EYE CONDITION. ..... Is one or both ears (eyes) (Include glaucoma and cataracts) affected? (a) (b) (c) 1. 2. 3. 4. 5. 6. 7. 8. 16. If any eye conditions have been recorded in Table 1, ask: [CJ No eye condition reported (Go to question 17) You told me about this resident's (patient's) eye condition. Can he see well enough to read ordinary newspaper print with glasses? 1[] Yes 2[]No 17. During the past 1 [] Help with dressing, shaving, 8] Temperature—pulse— 17 [_] Intravenous injection 7 days which of or care of hair respiration 1 I far inject these services ; 8 [| Intramuscular injection did this resident 2] Help with tub bath 9 [] Full-bed bath 19 [] Nasal feeding (patient) receive? or'shower 10] Enema 3[] Help with eating . 11 [| Catheterization OR (Show card F and (feeding the resident (patient)) 12 [] Bowel and bladder check each one 4] Rub and massage retraining ON __ mentioned) s [|] Administration of 1 Blood 20 oneof the above * medications or treatment . ~ oo Er eanre services received 6 [] Special diet £ Sg . 15] Oxygen therapy 7 [] Application of sterile 161] Hypaderie Inject] dressings or bandages yROgeImic; injection 18. At the time this resident (patient) was admitted to 1 [] Primarily 2 [| Primarily 3 [] Room and this home, what kind of care did he receive—primarily nursing personal * 2rd only nursing care, primarily personal care, or room and care care board only? (Check one box only) Amount 19. What was the TOTAL charge for this resident's (patient's) care last month? $ koa. What is the PRIMARY source of payment for his care? | 20b. Are there any additional sources of payment? (Check ONE box only) 1 [] Own income or family support (Include private plans, retirement funds, social security, etc.) 2 [] Church support 3[] Veterans benefits a] Public assistance or welfare (Check ALL boxes that apply) 1 [] Own income or family support (Include private plans, retirement funds, social security, etc.) 2 [] Church support 3[] Veterans benefits 4[] Public assistance or welfare s [| Initial payment — life care 6 [|] Other (Please describe) s [| Initial payment — life care 6 [| Other (Please describe) OR 7 [] No additional sources USCOMM=DC 24499-P64 Budget Bureau No. 68-R620.R2; Approval Expires December 31, 1964 FORM HRS-3d (3-31-64) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE CONFIDENTIAL — This information is collected for the U.S. Public Health Service under authority of Public Law 652 of the 84th Congress (70 Stat. 489; 42 U.S.C. 305). All infor- mation which would permit identification of the individual will be held strictly confiden- tial, will be used only by persons engaged in and for the purposes of the survey, and will not be disclosed or released to others for mny other purposes (22 FR 1687). a. Establishment U.S. NATIONAL HEALTH SURVEY number b. Line number STAFF QUESTIONNAIRE c. Name of person who should fill this form The U.S.. National Health Survey of the Public Health Service is conducting a nationwide survey in nursing homes, homes for the aged, and other related types of establishments. The purpose of the survey is to obtain certain information about the staff employed in these establishments as well as about the health of patients or residents in the establishments. Please answer the questions on this questionnaire. When you have completed it, mail it to the Bureau of the Census in the postage-free, self-addressed envelope provided. Since it takes only a few minutes to complete the ques- tionnaire, we would very much Bpiseniae it if you will complete and mail the form within the next 5 days. Your answers will be given confidential treatment by the U.S. National Health Survey and the Bureau of the Census. The information will be used for statistical purposes only, and will be presented in such a manner that no individual person or establishment can be identified. Thank you for your cooperation. Age 1. How old were you on your last birthday?. . . ........ CERI TRIAGE FRI VY ERIE PIR FER mw Number of — 2. How many years have you workedas a -- a — — in this establishment? . . . . . ......... LL. Years and months b — — in other nursing homes, homes for the aged, or related facilities? Years and ‘months c——inhospitals?. . ........LL Years and months (If your present job is in a hospital, do not include the experience shown in question 2a.) NOTE TO NURSES: Do not include special duty or/priv ate duty nursing. 3. What is the highest grade you COMPLETED in school? + Elementary school... 1 2 3 4 5 6 7 8 (Grade school) (Circle the highest grade completed) 2 High school. «vous. 1 2 3 4 3 College ev vv vv ann 1 2 3 4 5+ 4. Which, if any, of the following degrees, diplomas, or licenses do you have? 2] Licensed practical nurse (L.P.N.) (Check all boxes that apply) 3 [_] Degree in home economics 4] Member — American Dietetic Association 5 [_] Registered occupational therapist 6 [_] Registered physical therapist 1 [_] Registered professional nurse (R.N.) 7 [] Doctor of Dental Surgery or Dental Medicine (D.D.S. or D.M.D.) 8 [_] Physician (M.D. or D.O.) 9 [] Master of Social Welfare (M.S. W.) 10 [_] Other (Please specity) OR 11 [_] None of the above Continue on reverse side USCOMM-DC 24510-P64 33 34 5. Have you taken any of the courses listed below? [J Yes [J No For each course that you have taken, please indicate by checking the appropriate column, whether the course was ‘accredited under college or university sponsorship’ or whether it was a "'short course, institute, or workshop.’ Accredited course Short course, Line Types of courses under college or institute or No. university sponsorship workshop (a) (b) (c) 1 Nursing home administration 2 Nursing care of the aged or chronically ill 3 Medical or dental care of the aged or chronically ill 4 Mental or social problems of the aged or chronically ill 5 Physical therapy or rehabilitation 6 Occupational therapy 7 Nutrition or food services Comments FORM HRS-3d (3-31-64) USCOMM-DC 24510-P64 LIST OF NURSING SERVICES Temperature—pulse—respiration Full bed bath Application of sterile dressings or bandages Catheterization Bowel and bladder retraining Blood pressure Hypodermic injection Intravenous injection Intramuscular injection Nasal feeding Irrigation Oxygen therapy Enema Card A WHICH OF THE FOLLOWING JOB CATEGORIES BEST FITS THE JOB WHICH THIS EMPLOYEE DOES IN THIS ESTABLISHMENT? L. 12. 13. 14. 15. 16. Card B] LIST OF SELECTED JOB CATEGORIES Administrator Physician (M.D. or D.O.) Dentist Occupational Therapist Physical Therapist Dietitian or Nutritionist Social Worker Registered Professional Nurse Graduate Nurse, but not registered Licensed Practical Nurse Other nursing personnel (include, (a) practical nurse, (b) nurse's aide, (c) student nurse, and (d) other sup- porting nursing staff) Orderly Clerical, bookkeeping, or other office staff Food service personnel (cook, kitchen help, etc.) Housekeeping personnel (maid, mainte- nance man, etc.) Job other than those listed above (Please describe employee's duties) N oO nw Ny . Eyeglasses Card C SPECIAL AIDS Hearing aid Walker Crutches Braces Wheel chair Artificial limb 35 Card D LIST OF CHRONIC CONDITIONS Does this resident have any of these conditions ? 1. Asthma 2. CHRONIC bronchitis 3. REPEATED attacks of sinus trouble 4. Hardening of the arteries 5. High blood pressure 6. Heart trouble 7. 111 effects of a stroke 8. TROUBLE with varicose veins 9. Hemorrhoids or piles 10. Tumor, cyst or growth 11. CHRONIC gall bladder or liver trouble 12. Stomach ulcer 13. Any other CHRONIC stomach trouble 14. Bowel or lower intestinal disorders 15. Kidney stones or CHRONIC kidney trouble 16. Mental illness 17. CHRONIC nervous trouble 18. Mental retardation 19. Arthritis or rheumatism 20. Diabetes 21. Thyroid trouble or goiter 22. Epilepsy 23. Hernia or rupture 24. Prostate trouble 25. ADVANCED senility Does this resident have any of these conditions? Card E LIST OF SELECTED CONDITIONS 36 1. Deafness or SERIOUS trouble hearing with one or both ears 2. SERIOUS trouble seeing with one or both eyes even when wearing glasses 3. Any speech defect 4. Missing fingers, hand, or arm--toes, foot, or leg 5. Palsy 6. Paralysis of any kind 7. Any CHRONIC trouble with back or spine 8. PERMANENT stiffness or any deformity of the foot, leg, fingers, arm, or back Card LIST OF SERVICES 1. Help with dressing, shaving, or care of hair 2. Help with tub bath or shower 3. Help with eating (feeding the patient) 4. Rub and massage 5. Administration of medications or treatment 6. Special diet 7. Application of sterile dressings or bandages 8. Temperature—pulse—respiration 9. Full bed bath 10. Enema 11. Catheterization 12. Bowel and bladder retraining 13. Blood pressure 14. Irrigation 15. Oxygen therapy 16. Hypodermic injection 17. Intravenous injection 18. Intramuscular injection 19. Nasal feeding RESIDENT PLACES SURVEY - 2 INTERVIEWER CHECK LIST Make the following checks on the appropriate RPS-2 questionnaires for each establishment before you leave the establishment. Place a check mark [M in the box to the right of each check item after making the specified check and determining that the item is correct. If the item is not correct, make any necessary corrections by talking to the administrator, resampling, or any other procedure which the item requires. After correcting the item, make a check mark in the box after the item. A completed check list is required for each establishment. Establishment Number Form HRS-3a 8. Column (k)-A Staff Questionnaire has been ‘completed at the time of visit’ or “‘left to be mailed in’’ for each OJ sample employee in columns (b) and (c) only. Ul 1. Question 9=The sum of the entries in questions 9b (1)-9h(6) is equal to the entry in question 9b. 2. Question 10—The entry in question Form HRS-3c 10c is the difference between the 9. The number of sample residents (patients) number in question 10b subtracted is correct using this procedure: from the number in question 10a. a Eutor the number of residents X 4 J B 9 (The number in question 10c cannot ) . ; Example be larger than the entry in 10a.) 0] (patients) shown in question 2 8 of the HRS-3a. 202 Form HRS-3b b. Subtract the ‘‘Start with’ 3. The number of employees listed on number w= Form HRS-3b is the same as the c. Divide the difference by the number entered in question 10c of “Take every’ number (whole 12 Form HRS-3a. J numbers only) 15) 193 4. Columns (b), (¢), and (d)—~A job d. Add‘‘1” to the quotient 12+1=13 category number is entered in one of obtained above. This is the columns (b), (c), or (d) for each number of sample patients which 13 sample employee listed. 4 should be entered in page 2. residents 5. Column (c)-Each employee with an Example: In the example above (patients) entry of “11’” in column (c) has a the number of residents (patients) should be letter suffix, e.g. (11A). If the in q. 2 of the HRS-3ais 202. The listed. entry is 11D, the job description is ‘Start with’’ is 9 and the ‘‘Take given in a footnote. 0 every’ is 15. fill 6. The sample selection in columns (b), Form HRS-3d {¢), and (d) is eorrect. (Look at the 10. Each Staff Questionnaire ‘‘completed at “Start with’’ and ‘Take every’’ numbers on page 3 for each column and review your selection.) the time of visit’ has been reviewed for omissions (age, job experience, etc. and the back of the questionnaire). J O 7. Columns (e) through (j) are completed for each sample employee in columns (b) - (d). 11. Each Staff Questionnaire has only one job category description in question 2. [J] OJ 77 U. S. GOVERNMENT PRINTING OFFICE: 1968—342041/6 37 Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 20. Series 21. Series 22. OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS Public Health Service Publication No. 1000 Programs and collection procedures.—Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions, data collection methods used, definitions, and other material necessary for understanding the data. Data evaluation and methods research.—Studies of new statistical methodology including: experi- mental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, contributions to statistical theory.’ Analytical studies.—Reports presenting analytical or interpretive studies based on vital and health statistics, carrying the analysis further than the expository types of reports in the other series. Documents and committee reports.— Final reports of major committees concerned with vital and health statistics, and documents such as recommended model vital registration laws and revised birth and death certificates. Data from the Health Interview Survey.— Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other health-related topics, based on data collected in a continuing national household interview survey. Data from the Health Examination Survey.—Data from direct examination, testing, and measure- ment of national samples of the population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological characteristics; and (2) analysis of relationships among the various measurements without reference to an explicit finite universe of persons. Data from the Institutional Population Surveys.— Statistics relating to the health characteristics of persons in institutions, and on medical, nursing, and personal care received, based on national samples of establishments providing these services and samples of the residents or patients. Data from the Hospital Discharge Survey.—Statistics relating to discharged patients in short-stay hospitals, based on a sample of patient records in a national sample of hospitals. Data on mortality.— Various statistics on mortality other than as included in annual or monthly reports—special analyses by cause of death, age, and other demographic variables, also geographic and time series analyses. Data on natality, marriage, and divorce. — Various statistics onnatality, marriage, and divorce other than as included in annual or monthly reports—special analyses by demographic variables, also geographic and time series analyses, studies of fertility. Data from the National Natality and Mortality Surveys. — Statistics on characteristics of births and deaths not available from the vital records, based on sample surveys stemming from these records, including such topics as mortality by socioeconomic class, medical experience in the last year of life, characteristics of pregnancy, etc. For a listof titles of reports published in these series, write to: - Office of Information National Center for Health Statistics U.S. Public Health Service Washington, D.C. 20201 PUBLIC HEALTH SERVICE PUBLICATION NO. 1000-SERIES 1 -NO. 7 U.C. BERKELEY LIBRARIES WRI (021205890