Medical Care

I. ETHNOMEDICINECharles C. Hughes

BIBLIOGRAPHY

II. SOCIAL ASPECTSWilliam A. Glaser

BIBLIOGRAPHY

III. ECONOMIC ASPECTSRashi Fein

BIBLIOGRAPHY

I. ETHNOMEDICINE

Judging from paleopathological evidence, diseases of one kind or another have always afflicted man. Indeed, given the nature of life and the nature of disease, it could not be otherwise; for disease is but an expression of man’s dynamic relationship with his environment. And even as there has always been sickness, accident, deformity, and anxiety to trouble man, so, too, has there been an organized, purposeful response by society to such threats. In all human groups, no matter how small or technologically primitive, there exists a body of belief about the nature of disease, its causation and cure, and its relations to other aspects of group life. There also exist therapeutic and preventive practices, many of which are empirically efficacious by standards of modern medicine, although often not for the reasons advanced by folk belief. The variability of societies and cultural systems impedes easy generalization about the nature of “primitive” or “folk” medicine (cf. Ackerknecht 1942a), but one common characteristic is its close integration with other institutions of the society. Religion, medicine, and morality are frequently found together in the behavioral act or event, and “folk medicine” becomes “social medicine” to an extent not found in industrialized societies.

The term “ethnomedicine” will be used to refer to those beliefs and practices relating to disease which are the products of indigenous cultural development and are not explicitly derived from the conceptual framework of modern medicine. In this light, most of the following discussion focuses on the non-Western, nonindustrialized societies of the world, although it is clear that in “modern” societies as well there exist beliefs and practices relating to disease and its treatment which are based on magical or religious conceptions rather than on those of scientific medicine.

Theory of disease

Man, everywhere, devises or divines causes for the significant events in his life. The afflictions which beset body and mind are explained in both naturalistic and supernaturalistic terms. A cut finger, a broken limb, a snake bite, a fever, the halting speech and wandering mind of senility—all may be regarded as sometime hazards in life. To explain such events there is always some conceptual framework founded in common-sense empiricism. But often a wound does not heal, a sickness does not respond to treatment, and the normally expected and predictable does not happen. In such cases another order of explanation is employed, one which attempts to come to terms with the more basic meaning of the event in metaphysical perspective. For most non-Western societies this transcendent explanation for the occurrence of disease tends to figure more pervasively in the total body of medical lore and practice than does the empirical framework. One reason is the greater incapacitation and mortality from disease in the underdeveloped world than in highly industrialized societies. In addition, this reality is coupled with the comparative inadequacy of ethnomedical techniques and knowledge for dealing with these common threats to the existence of the group and the person.

Widespread throughout the world are five basic categories of events or situations which, in folk etiology, are believed responsible for illness: (1) sorcery; (2) breach of taboo; (3) intrusion of a disease object; (4) intrusion of a disease-causing spirit; and (5) loss of soul (Clements 1932). Not every society recognizes all five categories; indeed, many groups are selective in the emphasis placed upon one or a combination of causes. For example, the Eskimo most frequently trace the origin of diseases to soul loss and breach of taboo, while the malevolence of sorcerers or witches is especially emphasized in many African cultures. Usually, however, these categories are more useful in analytically characterizing the etiological beliefs of a particular group than in describing the content of an entire belief system. This would be the case where a disease is believed to be caused by the intrusion of an object which contains a spirit, and it is the latter to which primary causative influence is attributed (e.g., Hallowell 1935).

The Greeks were not alone in viewing disease as a manifestation of disharmony in man’s over-all relation to the universe. “Health” is rarely, if ever, a narrowly restricted conception having its locus only in the well-being of the individual body. In discussing conceptions of illness among a west African people, Price-Williams gives a modern illustration :

In common with a great many other people, Tiv do not regard “illness” or “disease” as a completely separate category distinct from misfortunes to compound and farm, from relationship between kin, and from more complicated matters relating to the control of land. But it would be completely erroneous to say that Tiv are not able, in a cognitive sense, to recognize disease. As Bohannan has said: “The concept of a disease is not foreign to the Tiv: mumps, smallpox, . . . yaws and gonorrhoea are all common and each has a name.” What is meant is that disease is seldom viewed in isolation. (1962, p. 125)

Such a notion is widely found, as in certain American Indian groups, where bodily or mental affliction is often viewed as an indicator of moral transgression, in thought or in deed, against the norms of society. Indeed, man is frequently thought of as continuous with both the social and nonsocial aspects of his environment, and what happens in his surroundings affects his bodily well-being. Not only a person’s own actions, therefore, but also those of kinsmen or neighbors can cause sickness. Such an etiological conception has obvious implications for treatment. For example, if the curative technique includes magically based dietary restrictions, they may apply to all members of the patient’s family; a breach of the restriction by any of these people will undermine the patient’s health. Similarly, as among the Thonga of South Africa, sexual relations between any of the inhabitants of the patient’s village can aggravate his condition, and some Eskimo groups feel that the patient’s family should do no work during the period of convalescence for fear of giving offense to the spirit causing the sickness.

The belief that by his own actions a man can influence the state of his fellow’s health also has malevolent implications, as in the practice of witch-craft and sorcery. Frequently this may be an important factor deciding the success or failure of attempts at introducing new medical programs in underdeveloped societies. Cassel (1955) cites as an illustration the Zulu, who believe that only sorcerers and witches have the ability to transmit dis-ease, particularly diseases which show themselves in symptoms normally associated with pulmonary tuberculosis. Progress in one community’s acceptance of a Western-styled health program was brought to an abrupt halt when a physician tried to introduce the medical concept of contagion. He traced the course of tuberculosis through a family, showing how one person had been the original source of the disease in the group and had therefore been the agent responsible for sickness in all the others. The cautious cooperation of the family elder immediately turned into a hostile rejection, which was assuaged only after the doctor had retracted his apparent accusation that the daughter of the family was a witch.

A theory of disease implies a theory of normality. Yet the “normal” is in no way easy to define for all times and places. Aside from questions of a “statistical” versus a “functional” basis for normality, there is the cultural definition. Afflictions common enough in a group to be endemic, though they be clinical deformities, may often be accepted simply as part of man’s natural condition. Ackerknecht (1946), for example, has noted that the Thonga believe intestinal worms, with which they are pervasively affected, to be necessary for digestion; the Mano, also of Africa, feel that primary and secondary yaws are so common that they say, “That is no sickness; everybody has that.” North Amazonian Indians, among whom dyschronic spirochetosis is prevalent, accept its endemicity to such an extent that its victims are thought to be normal, and individuals who have not had the disfiguring disease are said to be looked upon as pathological and consequently unable to contract marriage. It is culture, not nature, that defines disease, although it is usually culture and nature which foster disease.

Recent behavioral science research has attempted to go beyond a “phenomenologica’ orientation in investigation of cultural theories of disease and has sought analytic categories which would relate particular emphases in a theory of disease to other aspects of social and cultural life. A striking example of this type of investigation is the work of John Whiting and Irvin Child (1953). Using a wide sample from the ethnographic “laboratory,” these investigators found high correlations between certain aspects of child-rearing practices and dominant themes in etiological beliefs related to disease, more particularly, between the hypothesized degree of anxiety generated during the socialization process—the degree of “negative fixation”—and a theory of disease which reflects these anxieties. Thus, harsh weaning is highly associated with oral explanations for onset of disease: these would include consumption of food, drink, or poison by the sick individual or oral activity on the part of others, such as incantations and spells. Societies in which independence training is characteristically fraught with emotional hazards tend also to have “dependence” explanations of illness. These include soul loss or spirit possession. “Aggression explanations” for disease are highly associated with societies in which training for handling aggressive impulses leaves a residue of unresolved anxiety, and they are expressed in theories which ascribe the cause of a disease to the patient’s disobedience or aggression toward spirits, to aggressive wishes on the part of the patient or another person, to introjection of poison other than by mouth, or to harm by magical weapons or objects.

Theory and practice of treatment

Therapeutic practices in ethnomedicine address themselves to both supernatural and empirical theories of disease causation. Ackerknecht has said that primitive medicine is “magic medicine” (1942 b); certainly much of it is, and, insofar as supernatural causes are involved, therapeutic regimes are based on countervailing supernatural powers or events. Thus, the powerful shaman or healer attempts to recover the soul lost or stolen by a human or supernatural agent. The intrusion of a disease object or disease-causing spirit is treated by extraction or exorcism, and diseases which come as punishment for breach of taboo are usually treated by divination or confession of the infraction. Forgiveness and re-establishment of harmony with the moral and supernatural order are thus important outcomes of the therapy.

In folk medicine, however, there is more to treatment than magical or religious ritualization, however effective this may be psychosocially in providing emotional catharsis and reassurance. All human groups have a pharmacopoeia and at least rudimentary medical techniques; some groups, in-deed, are exceptional in their exploitation of the environment for medicinal purposes and in the degree of their diagnostic and surgical skills (Ackerknecht 1942 b; Sigerist 1951; Laughlin 1963). The trephining done by the Inca, Masai surgery, the anatomical knowledge of the Aleut and the Eskimo, and the extensive drug repertory of west African tribes are familiar examples. In addition to trephining, numerous other types of surgery and bonesetting are found, as well as massages, bloodletting, dry cupping, bathing, inoculation, and cauterization. It has been estimated that from 25 to 50 per cent of the non-Western pharmacopoeia is empirically effective. In fact, our knowledge of the therapeutic efficacy of a large number of modern drugs is derived from the experience of primitive peoples: opium, hashish, hemp, coca, cinchona, eucalyptus, sarsaparilla, acacia, kousso, copaiba, guaiac, jalap, podophyllin, quassia, and many of the tranquilizers and psychotomimetics now used in psychiatric therapy and research.

A great part of the task of folk medicine, however, and especially of preventive medicine, is borne by cultural practices which, although oriented to different social purposes, have important functional implications for health. Thus, notable hygienic purposes are served by many religious and magical practices, such as avoidance of the house in which a death has occurred, theories of contagious “bad body humors” which necessitate daily bathing, distinctions of “hot” and “cold” food and water which require boiling or cooking, hiding of fecal and other bodily waste through fear of their use by sorcerers or witches, and numerous others.

Other cultural practices inadvertently relevant to health have a more general ecological basis. These may include customs regarding cosmetics and clothing or house styles and settlement patterns. Regardless of their value to the archeologist, the middens of ancient sedentary communities have rather baleful implications for the public health of the times. Changing economic incentives and circumstances which disrupt the adaptation of a cultural activity to its environment frequently create health hazards. May (1960) provides a striking illustration of the intersection between cultural and ecological factors in North Vietnam. Dwellers on the plains lived in low, squat houses in which they sheltered their cattle on one side and did their cooking on the other. When these rice growers moved into the hills they constructed houses according to the same general plan. In the hills, however, the incidence of malaria among them became so high as to limit further such movement, despite governmental encouragement. The people themselves ascribed the calamity to the ill will of the hill deities. In fact, however, the incidence of malaria was low among the indigenous hill people, who constructed their houses on stilts, sheltered their animals underneath, and did their cooking inside the house. Several factors were apparently instrumental in the latter case in keeping down the spread of malaria from the mosquito vector found in the hills; flight ceiling of Anopheles minimus is restricted to about ten feet above the ground, and, despite its preference for human blood, the presence of animals underneath the house and of smoke inside the house (where the cooking was done) created an unrealized protection for human inhabitants.

The study of folk medicine has important theoretical implications for the persistent question of a “magical” versus a “scientific” orientation among non-Western peoples. Erasmus (1952), utilizing data from South American Indian populations, contends that the inductive epistemological framework of folk medicine is essentially similar in structure to that of modern scientific medicine, but that the latter differs chiefly in its amenity to generalization and degree of predictive success. In folk medicine the chances of “natural” recovery are in favor of predictive successes, but, more often than in modern medicine, the theoretical propositions lying behind such predictions are merely coincidentally rather than functionally related to the phenomenon in question. Thus, the recooking, before eating, of food that has been left standing overnight is done on the basis of the need to dispel the dangerous quality of “coldness” in the food, but in fact such recooking destroys enterotoxin-producing staphylococci.

The possible implications for a sociology of knowledge are apparent: so long as any activity or set of activities produces a sufficiently high proportion of predictive successes, there will be little elaboration or alteration of the conceptual framework orienting the activity. Cognitive frameworks relating to disease are instruments in the total process of adaptation; they change, evolve, and respond when their viability and acceptability are challenged. Only when folk etiology fails too often and in too many areas to give pragmatic and especially psychodynamic satisfaction does it yield to other frameworks, autochthonous or adopted from outside.

Disease, medicine, and culture

Some knowledge of diseases, their classification and etiology, is part of all cultural systems (e.g., Lieban 1962; Rubel 1960; Price-Williams 1962). Investigators have analyzed disease categories in an attempt to understand the structure of the conceptual world of different peoples. The use of componential analysis, the investigation of semantic interrelationships of terms, has been applied to words for sicknesses (cf. Frake 1961). Aside from illustrating the extent to which concern with disease is elaborated in a folk nosology, such work also emphasizes a more general point: an effective cultural response to disease requires patterned discrimination and categorization of disease symptoms, even if treatment is based largely on methods of trial and error. Diagnostic categories, however crude, serve the purpose of directing sustained attention and reflection to the appearance of disease syndromes, thus providing empirical data for inferences about the probable effectiveness of one type of treatment or another. Undoubtedly this constitutes a kind of inadvertent experimental approach (see, e.g., Laughlin 1963; Erasmus 1952).

Theories of disease generally have major relevance to the moral order, that is, to the control of man’s behavior in society. Disease is frequently seen as a warning sign, a visitation from punishing agents for a broken taboo, a hostile impulse, or an aberrant urge to depart from the approved way. In a series of classical papers, Hallowell (e.g., 1963) has analyzed the function of anxieties over sickness among the Ojibwa Indians of North America, and other investigators have looked at the same problem in different cultural settings (e.g., Lieban 1962). Sickness is often interpreted as the supernaturals’ way of indicating an act or intention of socially disruptive behavior. Especially in societies lacking strong centralized sociopolitical institutions, the occurrence and imminence of disease—with the belief that it represents punishment for aberrant, dissocial impulse or action—can be functionally important in maintaining group cohesion and restraining disruptive tendencies.

The therapeutic practices attendant upon occurrence of disease may also have socially cohesive results. Although such therapy may often be medically effective, it may serve ancillary functions in the total organization of the society. Typically, the curative session (and often the diagnostic occasion as well) involves not only the patient and the healer but also the patient’s family and neighbors. Often the therapy involves confession by the patient, and under such conditions the confession may well relieve him of diffuse as well as focused anxieties and guilt. When followed by concrete expiatory acts, it may also give him a chance to participate in his own treatment through action. (It is doubtful whether such curative rites do more than provide temporary symptom relief—but the same can be said of much modern psychotherapy.) At the same time group cohesion is often enhanced, for such confessions dramatize fundamental social values by illustrating the harm that can come from social deviance. They provide a setting in which all participants are enveloped in the aura of forgiveness and, through stress on the protection afforded by adherence to group values, assurance of good health. In short, the therapeutic context is usually explicitly a social context, and during the course of the therapy the reciprocal psychosocial involvement of the patient with his fellows is ritually underscored. As noted above, if therapeutic directives for behavior are issued, they frequently apply to the group, or selected members of the group, as well as to the patient; and if successful recovery is as dependent upon good thoughts as upon effective techniques—as frequently happens—then the assembled company must be devoid of ill wishes and hostilities toward not only the patient but also each other. The curative rite may thus serve in multiple ways as an occasion for reintegration of the group around common social values.

The practice of folk medicine is variously institutionalized. In all societies some rudimentary medical knowledge is an aspect of enculturation, but beyond this general protection there is always a specialist. Sometimes the specialist’s role is a full-time activity, but more frequently it is combined with other principal roles appropriate for the practitioner. In some societies there are more complex social arrangements than the simple dyadic relationship between healer and patient. Even as the kin and covillagers of the patient may be explicitly involved in the curative process, so too there may be a society of healers or several societies of healers devoted to diagnosis and cure of various diseases. In west Africa there are found, for example, specialized associations of healers of smallpox or snake bite; each association possesses its own rules of qualification, initiation, and procedure (Harley 1941).

Folk medicine in change

Folk medicine does not easily change under the impact of sustained contact with the industrialized world, or even as a result of deliberate attempts to introduce new conceptions of disease and hygiene. Paul (1955), Foster (1962), and others have documented the variety of factors that may impede or altogether prevent the successful introduction of a modern health program, even of so simple an innovation as the boiling of drinking water. Such factors include ecological considerations, as well as functional efficiency in domestic tasks, the social structure, the status and prestige of the innovator, and the perception of threat or advantage to the recipient. The proper role of the healer may be differently defined; in India, for example, the medical practitioner must assure the patient of recovery, and any admission of uncertainty (even couched in the form of probability) is not allowed. Rudimentary physical testing may be impossible or difficult in a non-Western context. In societies where blood, for example, is thought of as a nonregerierative substance, to take samples for testing is tantamount to inflicting deliberate harm.

It has been found to be easier to introduce behavioral changes than changes in belief about the nature of illness, its cause, and prevention. Domestic hygiene and community health may be bettered by the public health worker who influences a change in habits while not disturbing the underlying belief system. One reason for this has been mentioned above: belief systems, particularly those centered on critical areas of social value, serve more than a single cognitive function. Because they interrelate with religious and magical systems, as well as with the moral order of the society, they impart a deeper sense of resignation and acceptance of events than does an alien concept treating of a germ theory of illness. The value system of a culture provides a more satisfying answer to the question, “Why did I and not my neighbor get sick?” than does an explanation phrased in terms of communicability of a disease, thresholds of resistance, host, agent, and environment.

Yet in many instances modern medicine does get accepted; and one of the reasons is its demonstrably greater effectiveness in the treatment and prevention of many diseases. But even such acceptance is often compromised by the existence of alternative diagnostic and therapeutic frameworks: one relating to those diseases for which it is felt modern medicine is more effective, and the second relating to diseases conceived to be unamenable to modern medical treatment. The first is often applied to sicknesses introduced by the Europeans (such as tuberculosis, measles, smallpox, and others of a communicable nature), while in the second group are traditionally endemic diseases and, especially, ailments having a large component of psychological or psychophysiological involvement.

But in the extremity of fear for a patient’s life even such distinctions as these are often disregarded, and the ill person may be taken to a modern medical facility after indigenous healers have done their best—taken either to be cured or left to die. Every hospital, and not just those in non-Western, “underdeveloped” countries, will admit patients brought too late for the course of disease to be halted even by the most advanced techniques of scientific medicine. Disease being an unequivocal threat to life, adaptive responses are many and sometimes override ingrained belief, either of folk medicine on the one hand or modern medicine on the other. In this light, given the avowedly limited role of scientific medicine in society—together with the inevitability of disease—elements of folk medicine will no doubt everywhere persist, even as they do in Europe and the United States, so long as there is uncertainty of outcome or technical ineffectiveness in alleviating pain, prolonging life, and guaranteeing cure.

Charles C. Hughes

[See alsoHealthand Illness. Directly related are the entriesanthropology, article on APPLIED ANTHROPOLOGY; Magic; Pollution; Religion.]

BIBLIOGRAPHY

Ackerknecht, Erwin H. 1942 a Primitive Medicine and Culture Pattern. Bulletin of the History of Medicine 12:545–574.

Ackerknecht, Erwin H. 1942b Problems of Primitive Medicine. Bulletin of the History of Medicine 11:503–521.

Ackerknecht, Erwin H. 1946 Natural Diseases and Rational Treatment in Primitive Medicine. Bulletin of the History of Medicine 19:457–497.

Ackerknecht, Erwin H. 1965 History and Geography of the Most Important Diseases. New York: Hafner.

Cassel, John 1955 A Comprehensive Health Program Among the South African Zulus. Pages 15–41 in Benjamin D. Paul (editor), Health, Culture, and Community. New York: Russell Sage Foundation.

Clements, Forrest E. 1932 Primitive Concepts of Disease. California, University of, Publications in American Archaeology and Ethnology 32, no. 2:185–252.

Dubos, RenÉ (1959) 1961 Mirage of Health, Utopias, Progress, and Biological Change. New York: Harper.

Dubos, RenÉ 1965 Man Adapting. New Haven: Yale Univ. Press.

Erasmus, Charles J. 1952 Changing Folk Beliefs and the Relativity of Empirical Knowledge. Southwestern Journal of Anthropology 8:411–428.

Foster, George M. 1962 Traditional Cultures, and the Impact of Technological Change. New York: Harper.

Frake, Charles O. 1961 The Diagnosis of Disease

Among the Subanun of Mindanao. American Anthropologist New Series 63:113–132.

Hallowell, A. Irving 1935 Primitive Concepts of Disease. American Anthropologist New Series 37:365–368.

Hallowell, A. Irving 1963 Ojibwa World View and Disease. Pages 258–315 in lago Galdston (editor), Man’s Image in Medicine and Anthropology, New York Academy of Medicine, Institute of Social and Historical Medicine, Monograph No. 4. New York: International Universities Press.

Harley, George W. 1941 Native African Medicine: With Special Reference to Its Practice in the Mano Tribe of Liberia. Cambridge, Mass.: Harvard Univ. Press.

Hughes, Charles C. 1963 Public Health in Non-literate Societies. Pages 157–233 in lago Galdston (editor), Man’s Image in Medicine and Anthropology. New York Academy of Medicine, Institute of Social and Historical Medicine; Monograph No. 4. New York: International Universities Press.

Kuhn, Thomas S. 1962 The Structure of Scientific Revolutions. Univ. of Chicago Press.

Laughlin, William S. 1963 Primitive Theory of Medicine: Empirical Knowledge. Pages 116–140 in lago Galdston (editor), Man’s Image in Medicine and Anthropology. New York Academy of Medicine, Institute of Social and Historical Medicine, Monograph No. 4. New York: International Universities Press.

Lieban, Richard W. 1962 The Dangerous Ingkantos: Illness and Social Control in a Philippine Community. American Anthropologist New Series 64:306–312.

May, Jacques M. 1960 The Ecology of Human Disease. New York Academy of Sciences, Annals 84:789–794. → A paper delivered at a conference on culture, society, and health held and sponsored by the New York Academy of Sciences and the Research Institute for the Study of Man.

Paul, Benjamin D. (editor) 1955 Health, Culture, and Community: Case Studies of Public Reaction to Health Programs. New York: Russell Sage Foundation.

Price-Williams, D. R. 1962 A Case Study of Ideas Concerning Disease Among the Tiv. Africa 32:123–131.

Rubel, Arthur J. 1960 Concepts of Disease in Mexican-American Culture. American Anthropologist New Series 62:795–814.

Sigerist, Henry E. 1951 A History of Medicine. Volume 1: Primitive and Archaic Medicine. New York: Oxford Univ. Press.

Whiting, John W. M.; and Child, Irvin L. 1953 Child Training and Personality: A Cross-cultural Study. New Haven: Yale Univ. Press. → A paperback edition was published in 1962.

II. SOCIAL ASPECTS

Medical care is the application of scientific knowledge and technique to solving the physical and emotional problems of man. To a physician, medical care denotes the body of diagnostic and therapeutic theory and procedure developed to understand, cure, and prevent diseases. A social scientist, however, defines medical care as a system of social institutions in a larger social structure. Since medical care is given by specialized personnel, it presents to the social scientist several problems in the sociology of professions. Since much medical care is given in organized settings, it can also be studied from the viewpoint of the sociology of formal organizations.

The demand for medical care

Medical institutions cannot originate without a market. Anthropological evidence suggests that recognition of physical and emotional problems by potential patients is universal among the world’s populations: whether he is a Western city dweller or a peasant in an underdeveloped country, the human being is aware of discomfort and an inability to perform his normal social roles. However, the decision to take practical action and the choice of remedies vary widely according to the social system and according to the individual’s statuses in each social system.

Religion and science

The meaning of illness and the practical action deemed appropriate in a society derive from the prevailing bodies of religious and scientific thought. In many underdeveloped countries, widespread beliefs attribute injuries and illness to alienation from divine forces or from social obligations. For remedies appropriate to the imputed causes, large numbers of people may rely on personal rituals or on the guidance of priests and folk practitioners. Where Western medical institutions have been imported into such societies by governments or missionaries, they may be used by only the small minority that is urban and Westernized (Williams & Scharff 1960, p. 18).

Extensive public use of medical care depends on widespread acceptance of certain doctrines about God and man: human life on earth should be pre-served; the alleviation of physical discomfort does not contradict divine intent but may even serve God’s will; practical action to save life is not inconsistent with divine purpose or church obligations. These doctrines have been prominent in Christianity, classical Islam, and Judaism. For these rea-sons, public utilization of therapeutic and preventive medicine has been widespread in the ancient Middle East and in the modern West. As Western religions spread in Asia, Africa, and Latin America, or as contrary traditional religions are redefined to tolerate or encourage the alleviation of discomfort by practical secular action, public utilization of scientific medical institutions increases.

In many societies, the prevailing religious and scientific beliefs define illnesses differently and, thus, teach a range of responses. For example, externally visible injuries and infections may be at- tributed to mundane events, while internal physical and mental malfunctions are believed to originate supernaturally. Since direct physical remedies are considered appropriate for the former and magical or propitiatory methods are alone believed efficacious for the latter, the population may bring its surgical and infectious problems to the Western-style doctor and hospital, while retaining clergymen and folk practitioners for internal and mental illnesses.

The referral of particular categories of people is often a function of religious belief. For example, folk religion in some Arab and Asian countries assumes that the evil eye and divine wrath fall particularly heavily upon babies and children. therefore, pediatric illnesses may be thought irremediable; few children are brought for medical care; and pediatrics remains an undeveloped specialty in medicine (Cameron 1960; Williams & Scharff 1960, pp. 18,32,34).

Other social determinants

The demand for medical care varies with other broad characteristics of society, such as the general levels of urbanization, literacy, prosperity, and industrialization. Poverty breeds disease and neglect, and consequently the world’s numerous underdeveloped countries have potentially huge numbers of patients (Brockington 1958, part 2). Illiteracy prevents many citizens from learning, where to find medical care, and services are often inaccessible in the rural areas, where much of the population lives. However, as information spreads about the availability and efficacy of medical installations, public use increases. As urbanization rises, so does the number of patients; in the cities of underdeveloped countries, vast throngs of ill persons tax the outpatient clinics and inpatient wards of public hospitals (McGibony 1961, pp. 51-52; Mazen 1961, pp. 40, 72, 273-275).

Within each country, social class and literacy appear to correlate with the use of medical care. The lower and poorer social classes may have the greatest number of physical and mental problems. But the higher classes make greater use of medical services because of their greater understanding of medical services, their social sophistication, and their ability to pay (Kadushin 1964). The problem varies by social class: for example, in the developed countries, coronary disease and ulcers are found more often among the upper class, infections and tuberculosis more often among the lower class (Freeman et. al. 1963, chapter 14 passim; Susser & Watson 1962, chapter 3).

Family structure. The demand for medical care is affected in several ways by family structure. In the Muslim countries and in some others, religion and custom decree that women are to work and live solely within the family circle. Therefore, women hesitate to visit the hospital and particularly to become inpatients, since this would involve immodest contact with male strangers. More men than women use medical services in the Muslim countries, but the opposite is true elsewhere, particularly in the West (compare Mazen 1961, pp. 213-214 and Fehler 1961, p. 397). Medical special-ties involving female modesty, particularly obstetrics and gynecology, are developed far more in the West than in the countries with sheltered women.

In preindustrial societies, the breadwinner is indispensable to provide current income, and the mother cannot easily be spared from her family duties. Thus, young adults may postpone medical care, particularly if inpatient hospitalization is likely, and medical services are used predominantly by children, the elderly, and severely ill young adults. However, in some underdeveloped countries, babies and young children occupy such a sub-ordinate position in the family that they are brought for medical care much less often than adults (Stever 1961, p. 335). In general, the utilization of medical services is higher in the industrial countries, not only because family nursing is deemed less efficacious than expert hospital or clinic treatment, but also because employers expect efficient performance and because urban living conditions make home care difficult. The modernization of underdeveloped countries includes the establishment of Western-style medical institutions and the propagation of Western health norms, and consequently the foregoing cross-national differentials in the utilization of medical care will diminish.

Medical practice

Since every society has the functional problems of explaining illness to the sick and their families and of guiding practical action, each society develops a body of medical theory from its basic ideas about the universe, life, and man. These theories vary in their empirical utility and in their implications for remedial treatment. Some of the principal civilizations—notably, European, Islamic, Indian, and Chinese—derived considerable and still influential systems of medical theory from their religions and ontologies (Castiglioni 1927).

Each of the principal medical traditions became institutionalized in the form of a theoretical literature, recognized practitioners, and educational techniques for transmitting knowledge and remedial skill from one generation of practitioners to the next. Much of the training has been didactic, but some—particularly in the Greek-Islamic-Western tradition—has made the neophyte an apprentice or observer of a practitioner at work.

Western medicine

Transmitted to Europe by certain medieval Italian universities, Greek-Islamic medicine ultimately proved the most productive in empirical knowledge and in therapeutic success. Several characteristics of European thought and society seem to have been crucial conditions for its growth. First, much of Western scientific thought has been inductive and empiricist, and some of this thinking contributed to medicine. Thus, although deductive and metaphysical theory was not absent from Western medicine, and although the speculative system builders vigorously fought new trends, simultaneously there developed a medical tradition of observation, experimentation, and critical verification of facts and therapies. Western medical knowledge and remedies—particularly in recent centuries—have been under continuous re-vision in the light of new evidence, to a degree found in no other medical tradition. Furthermore, the empiricist spirit of Western medicine has resulted in a tradition of medical education in hospital wards and experimental laboratories, to a degree found nowhere else (Shryock [1936] 1947, especially chapters 1-11).

Second, religions in much of the world insist on preserving the complete body of the deceased person, usually as a condition for his heavenly salvation. But Christianity distinguishes more clearly between soul and body, and it pictures the salvation of the soul while the body rots. Therefore, Christianity has been able to tolerate the widespread use of autopsies, while most other religions discourage them, and much of the physiological and therapeutic knowledge of Western medicine has resulted from post-mortem examinations. Potentially productive medical traditions in other societies, such as Islam, have been stunted because the dominant religions forbade autopsies.

A third reason for the greater success of the Western medical tradition has been the West’s technical inventiveness. This approach industrialized the West’s economy. But even before the industrial revolution, the West’s gadget-consciousness introduced into its medical research and practice extremely fruitful diagnostic and therapeutic devices, such as the microscope and thermometer. During the nineteenth and twentieth centuries, the indus-trial revolution has enabled Western medicine to employ even more complex devices, such as the X ray or the anesthetic equipment essential for thoracic surgery, which could not be invented by the world’s numerous preindustrial societies.

Finally, the West has had a long tradition of bureaucratic organization. In this respect, of course, the West has not been unique; but its distinctive achievement was to apply such methods to the financing, staffing, and dissemination of medical care. Nationwide systems of public health regulation, hospitals, medical education, and health insurance evolved under the auspices of churches, governments, and voluntary associations. All the foregoing variables—cumulative scientific knowledge, technology, and extensive formal organization—have combined in recent centuries to produce a highly developed system of medical care in the West and, increasingly, through cultural diffusion, in other societies.

Doctor and patient

The individual doctor renders medical care to the individual patient in a variety of settings: the patient’s home, the doctor’s office, hospitals, or polyclinics. The relationship between doctor and patient in the West is thought of by social scientists as a special case in the sociology of professional-client relationships.

American sociologists’ thinking about the doctor’patient confrontation has been greatly influenced by a theoretical model suggested by Talcott Parsons (Parsons 1958; Parsons & Fox 1952). The sick person, according to this model, is temporarily exempt from his normal social roles but is expected to perform certain well-defined patient roles. The doctor specializes in diagnosing and solving the patient’s problems in accordance with the social norms of his profession, and he has the social responsibility of controlling the patient for the good of society and of the patient himself. The patient is expected to obey the doctor and strive for recovery in accordance with the expectations of each stage of his treatment. Gradually the dependence of patient upon doctor diminishes, and the patient resumes his normal family and economic roles.

Parsons’ analysis pictures an intelligent and ambitious patient and presupposes the achievement-oriented social system of the West. Research needs to be done in order to determine its applicability in non-Western societies with different values and with large proletariats possessing less ambition and more pessimistic medical prognoses. [SeeProfessions.]

Occasionally social scientists have observed the relationships between doctor and patient in hospitals and private offices, and they have attempted to trace the clinical consequences of the social structures governing this two-person interaction. For example, the class differences between doctor and patient have been found to affect the success of their clinical relationship: since the less educated patient is less able to communicate with the doctor in the latter’s own vocabulary, he is asked to give fewer reports, and he receives fewer explanations and fewer instructions for home care than do patients of higher social classes (Freeman et al. 1963, chapter 11 passim). Another example of research on the social conditions governing relations between doctor and patient is Burling’s finding that the patient’s confidence in the doctor increases if the patient is not socially isolated but enjoys close personal relations with family members and with other patients (Burling et al. 1956, chapter 3).

Many of the clinical decisions of the doctor have been found to depend on his own social relations within the medical profession and within the larger, lay community. For example, the doctor’s ethnicity, family origins, and prior educational career—as well as his professional skill—affect the types of colleague networks and hospitals that he will join, and these contacts will determine the quality of his facilities, the skill of his consultants, and the affluence of his practice (Hall 1946). Adoption of new drugs—and possibly other innovations—by the individual doctor occurs earlier and more often if the doctor is closely related to a network of colleagues, and the adoption pattern for the net-work is led by certain doctors with a proclivity for adopting new things generally (Coleman et al. 1959).

The hospital

In many societies, all patients are treated in their homes by family members, with occasional visits by the priest or medicine man or with occasional visits by the patient to the medicine man. Among a few preindustrial peoples—such as the early He-brews and some contemporary African tribes—the medicine man maintains beds where he can watch and treat patients in proximity to his own medical supplies or religious shrines. However, only a few civilizations have produced hospitals in large number and as important centers of medical care.

Certain conditions in the social structure seem essential for the existence of an extensive and important hospital system. The society must have skill in creating and running organizations. The religious and other social beliefs must legitimize the diversion of substantial resources for the treatment and maintenance of sick strangers. Sick people and their families must accept the idea of living away from home under the control of strangers. Finally, the society must produce and train enough people qualified to work in hospitals and must motivate them to care for sick strangers.

Extensive hospital programs occurred in the past under the ancient Hebrews, in ancient India during a period of synthesis between Buddhism and Hinduism, and in medieval Islam. Religion was a powerful motive in all three societies, since it taught that human life should be saved, that illness was a remediable blight upon life, and that scientific knowledge could properly be applied in combating disease. Resources were readily available for hospitals, and the Hebrew and Muslim religions preached that private charity for the poor and sick were necessary conditions for salvation. Islam and India were ruled by governments which recognized that large cities could not be run efficiently without therapeutic and custodial centers. Furthermore, both Islam and India, during the periods of their hospital programs, had experience in creating net-works of formal organizations—in Islam as a result of ecclesiastic work and in both countries as a result of powerful and active governments.

However, the hospital programs soon declined in all three societies because the necessary social conditions were incomplete. Hospitals require dedicated staffs, and none of these religions preached the duty or desirability of lifetime careers of caring for sick strangers. In fact, the caste taboos of Brahmanical Hinduism discouraged a large number of employees from working in the same place and from giving all necessary care to the general public. None of these countries had monastic traditions, and thus, the church could not run hospitals when the state was conquered by foreigners—in the Hebrew and Muslim cases—or when the state lost interest in running hospitals—as in India and the unconquered parts of Islam.

The role of Christianity

Christianity has been far more conducive to the development of hospitals than other world religions. Like the others that encouraged limited hospital programs, Christianity preached the value of human life and the desirability of preserving it through applied science. But above all, Christianity provided the doctrinal and organizational basis for hospital staffs. Humble and charitable care of the sick and poor was com-mended as one of the principal paths to salvation. Instead of sheltering women and thus discouraging nursing careers—as did Islam—Christianity encouraged unmarried women to do charitable work among the public and even to live away from home if necessary. Not only did Christianity legitimize hospital employment by lay women; the Catholic church organized brotherhoods of monks and orders of nuns who nursed hospital inpatients as their apostolic mission. Employing bureaucratic procedures learned in large part from the government of the Roman Empire, the church organized hospitals, financed them through its extensive fund-raising machinery, and maintained them. Thus, Christianity’s ecclesiastic structure produced a continuity in hospital affairs regardless of the fluctuations in state policy.

For many centuries, European hospitals were run by the church or by associations of laymen affiliated with the church, and they were staffed by nuns. For much of their history they were custodial institutions, where sick and dying people were maintained and given religious guidance. Greek-Islamic therapy was introduced when some of the medieval nursing monks attended southern Italian medical schools. Thereafter, hospital systems created and maintained by the church also became the workshops of doctors and centers of medical education. European hospitals became secularized as the function of religion changed in Western social structure, as medical science became more successful and influential, and as lay governments became more powerful and more responsive to their citizens’ demands for social wel-fare. In the late Middle Ages the church forbade monks to practice surgery and restricted their other medical work; lay physicians were welcomed into the hospitals and soon commanded all their medical practices (Rosen 1963).

Secularization of hospitals

Between the Reformation and the present day, many church-affiliated hospitals have been taken over by governments, and many new hospitals have been created by governments or by secular owners. Even after these transfers to government, Catholic nuns and Protestant deaconesses continued to work in hospitals; however, a new occupation of trained lay nursing arose in the late nineteenth century, and these nurses have been taking over the numerous jobs that cannot be filled by the now contracting religious orders. Church-affiliated hospitals staffed by nuns can still be found in countries where the church must seek new converts and retain the loyalty of its own communicants, such as in non-Christian societies and in the Western countries with mixed religions (for example, Germany, Hol-land, Switzerland, and the United States).

As Western medical care spreads throughout the world, so does the Western hospital in its present secularized form. However, a serious obstacle is the recruitment of enough lay graduate nurses in non-Christian societies. Christian values seem to be an important recruitment motivation for lay nurses, just as they have been for nursing nuns.

It is evident from unpublished research by the present author that underdeveloped countries without large Christian minorities have great difficulty in staffing their hospitals.

The rise of scientific medicine

Since the hospital is organized to protect and treat sick people, its goals, structure, and functions depend on the current state of medical science. As a result of the great medical advances of recent centuries, the Western hospital has been transformed. Previously, the hospital was a charitable establishment to care for the helpless and protect society from the infected. In order to perform such work, only a small staff of supervisors and unskilled attendants was needed; only a few doctors visited, to give quick treatments or to perform occasional clinical experiments. Since these were custodial institutions for the poor and since the wealthy could afford home visits by doctors, the higher classes were treated and housed in their homes. Because infection and pain were common in hospitals, much of the public avoided surgery and feared hospitalization.

Modern medicine learned to classify diseases and distinguish among the treatments for each; the hospital needed to separate patients according to disease for distinctive treatment by category, and therefore, modern hospitals became departmentalized. The understanding of sterile technique and the introduction of antiseptics reduced cross-infections, made surgery and obstetrics safe, and increased therapeutic success and public confidence. Surgery also became more successful and popular because of the introduction of anesthetics. Surgical facilities grew in hospitals, and surgeons gained prestige and wealth. The wards became places for continuing treatment and were recognized as places of potential but preventable cross-infections. Scientific nursing education was introduced, closer controls were instituted over lower nursing ranks, and nursing staffs were greatly increased in size. The introduction of laboratories, operating theaters, and many ancillary services increased the size of para-medical staffs and raised the cost of hospitals. Since medical specialists needed to treat their patients by means of these facilities, members of higher social classes were hospitalized. The physical appearance of existing hospitals was improved, and private hospitals originated. Since specialty training required acquaintance with the advanced techniques found in hospitals, large and disciplined medical staffs were created, and many hospitals added educational and research goals to their mission of patient care. To administer such large and complex organizations, there developed new occupations specializing in hospital management; to supply the hospitals there arose new and immensely profitable pharmaceutical and equipment industries.

Hospital organization

Within individual countries—and particularly in the United States—social scientists have studied interpersonal processes within hospitals, using the same concepts that they ap ply to any other organizations. For example, American sociologists have long been interested in latent social processes and in the entire set of functions and dysfunctions resulting from certain institutional arrangements. Thus, American medical sociologists have not only studied the manifest hospital structure and its successes but have pointed out the presence of latent processes with paradoxical outcomes. The hospital, they say, is manifestly dedicated to the provision of means for treating patients successfully. However, every organization requires an administrative structure to arrange its resources economically and to control deviant behavior. Thus, therapeutic and administrative structures exist simultaneously in the hospital, each with its own priorities and personnel. Emphasizing one set of goals (such as administrative order) is dysfunctional for maximization of the other structure’s goals (such as patient care), and conflicts occur between the two lines of authority (such as the lay administrators and the doctors). Several studies of mental hospitals note the dilemma of combining organizational imperatives and therapy: the custodial structure necessary to control patients and maintain order is dysfunctional for mental care. [SeeOrganizations, article on Organizational Goals; see also Freeman et al. 1963, chapter 10, and Reader 1959.]

A specialist in administrative medicine might primarily study the formal organization of hospitals, but sociologists—whether observing factories, schools, or hospitals—search for the informal social structures that may substantially deviate from the formal chain of command and that may powerfully influence the system in action. Some American medical sociologists have been participant-observers in hospital wards. They have described the informal social system among patients, and they have identified how this informal ward society alternately raises and lowers the morale of individual patients and alternately supports and disturbs each patient’s relationships with the hospital staff (e.g., Fox 1959). From such research in mental hospitals has come the advice that the individual patient’s recovery depends not only on treatment received during the hours reserved for formal therapy but also on harmonious relationships involving all patients and staff members throughout the day. The successful “therapeutic communities” are said to have democratic decision making, full communication of ideas and grievances, stable and rewarding careers among staff members, a proper balance between freedom and control, and an ideal combination of self-reliance and group support (Stanton 1954).

Quality of medical care

From the viepoint of the social sciences, medical care is a strategic area for studying the institutionalization of social values and of applied scientific technique. However, from the viewpoint of the public and of an increasing number of medical practitioners, the proper task of the social sciences is to evaluate and improve the quality of care. Therefore, many medical organizations have retained social scientists to gather information and give advice. Some of the resultant studies deal with the training of doctors and nurses: the formal and informal organization of the curriculum, of the student community, and of the hospital are found to promote student learning in some ways and to inhibit it in others; and this information has been used by curriculum planners and administrators in the improvement of their instruction.

Determinants of good care

Several studies have attempted to locate elements in the social organization of medical care that affect the quality of treatment. Usually this research involves collab-oration by physicians and social scientists: the former identify the actions constituting “good medical care,” while the social scientists contribute knowledge about research techniques and ideas about the possible determinants of good care. For example, O. L. Peterson and his associates (1956) observed the work of general practitioners and concluded that class standing in medical school, length of preparatory education, exposure to refresher courses, and other experiences are strongly related to several indicators of good care. Contrary to common beliefs, involvement in medical society affairs, prestigious hospital appointments, hours of work, and certain other variables were found to have little relationship to good care in this sample.

In an ambitious study of ten hospitals, Basil S. Georgopoulos and Floyd C. Mann (1962, chapters 5 and 8) discovered that certain social attributes of the hospital correlated more strongly with quality of care than did other commonly credited determinants, such as the volume of material facilities, size of budget, number of beds, and ratio of personnel to beds. The organizational characteristics associated with good care were: high coordination throughout the hospitals, harmonious relations among departments and between doctors and nurses, lower absenteeism among graduate nurses, and efficient but congenial management. In another organizational study of hospitals, Melvin Seeman and John W. Evans (1961) found that the informal social organization of the ward affects the clinical performance of interns and nurses: where power inequalities and other forms of social distance are greater, efficiency and skill are lower.

Some social research methods have been used to gather expert opinions about the nature and sources of good care. For example, Milton C. Maloney and his associates (1960) used survey techniques to get a sample of expert opinion about the quality of care: they asked doctors about the care the doctors obtained for themselves and for their families. These expert judges preferred treatment by full-time specialists in metropolitan medical centers.

Doubtless applied social research will become an increasingly recognized fact of medical care in all countries. Modern medicine is devoting more attention to the “stress diseases” and other medical conditions that seem related to social roles. The organizational problems of medical care are rising because of increased costs, scarcities of personnel and of services, and because of the demands by social planners for greater efficiency and economy in medical administration. Teamwork among clinicians, administrators, and social scientists may consequently become commonly accepted as the means to a common goal of better quality care.

[Directly related are the entries Health; Medical Personnel; Public Health.Other relevant material may be found in Mental Disorders, Treatment of; Mental Health; Psychiatry.]

William A. Glaser

BIBLIOGRAPHY

Interest in social determinants of medical care first entered the literature of the field through the writings of several leading medical historians (e.g., Sigerist 1960; Shryock 1936)and through research in epidemiology and public health (see the bibliographies for the articles on these two topics).

Sociologists, social psychologists, and other social scientists began to write about medical care only in recent decades. Much of their work has been designed to provide practical information for psychiatric hospitals, the curriculum committees of medical and nursing schools, epidemiologists, and other medical practitioners with practical problems requiring knowledge of the facts. However, some research has been designed by social scientists to test hypotheses derived from their own disciplines. The voluminous American literature is summarized in Freeman et al. 1963, and some of the principal studies are reprinted in Jaco 1958. Research by social scientists is also well advanced in Great Britain, where a group of specialists in “social administration” provide facts and advice about all aspects of social policy, including health (Susser & Watson 1962). Similar work is beginning elsewhere: for example, Konig & Tonnesmann 1958 summarizes the research in Germany. Bibliographies of the American and European literature are provided by Freidson 1961/1962 and Pears all 1963. Much of the social research on the quality of care is summarized by Anderson & Altman 1962.

Several writers on public health and administrative medicine have summarized the health problems and forms of medical organization in the world (e.g., Brockington 1958). As yet, no social scientist has written a general survey of the variations in the social organization of medical care throughout the world.

As social scientists have written more about medical care, their ideas have become more widely accepted in the writings of clinicians, and particularly by psychiatrists. An increasing number of writings by physicians, nurses, and medical administrators about the proper management of medical organizations and about the proper treatment of patients incorporate concepts and generalizations about the effects of the patient’s family settings, the community’s culture, the social relationships between patient and clinician, the personality traits of persons experiencing stress and social isolation, and so on (e.g., Balint 1957).

Anderson, Alice J.; and Altman, Isidore 1962 Methodology in Evaluating the Quality of Medical Care: An Annotated Selected Bibliography, 1955-1961. Univ. of Pittsburgh Press.

Balint, Michael 1957 The Doctor, His Patient and the Illness. London: Pitman Medical Publishers.

Brockington, C. Fraser 1958 World Health. Harmondsworth (England): Penguin. → Includes an ac-count of the first ten years of the World Health Organization.

Burling, Temple; Lentz, Edith M.; and Wilson, Robert N. 1956 The Give and Take in Hospitals: A Study of Human Organization in Hospitals. New York: Putnam.

Cameron, Alick 1960 Folk-lore as a Medical Problem Among Arab Refugees. Practitioner 185:347-353.

Castiglioni, Arturo (1927) 1958 A History of Medicine. 2d ed. New York: Knopf. → First published as Storia delta medicina.

Coleman, James; Menzel, Herbert; and Katz, Elihu 1959 Social Processes in Physicians’ Adoption of a New Drug. Journal of Chronic Diseases 9:1-19.

Fehler, J. 1961 Verweildauer im allgemeinen Krankenhaus. Krankenhaus (Stuttgart, Germany) 53:397-403.

Fox, RenÉe C. 1959 Experiment Perilous. Glencoe, III.: Free Press.

Freeman, Howard E.; Levine, Sol; and Reeder, LEO G. (editors) 1963 Handbook of Medical Sociology. Englewood Cliffs, N.J.: Prentice-Hall.

Freidson, Eliot 1961/1962 The Sociology of Medicine: A Trend Report and Bibliography. Current Sociology 10/11:123-192.

Georgopoulos, Basil S.; and Mann, Floyd C. 1962 The Community General Hospital. New York: Mac-mill an.

Hall, Oswald 1946 The Informal Organization of the Medical Profession. Canadian Journal of Economics and Political Science 12:30-44.

Jaco, E. Gartly (editor) 1958 Patients, Physicians and Illness: Sourcebook in Behavioral Science and Medicine. Glencoe, III.: Free Press.

Kadushin, Charles 1964 Social Class and the Experience of 111 Health. Sociological Inquiry 34, no. 1: 67-80.

König, RenÉe and Tõnnesmann, Margaret (editors) 1958 Probleme der Medizin-Soziologie. Cologne (Germany): Westdeutscher Verlag.

Mcgibony, John R. 1961 Health Care in India: Its Patterns and Problems. Hospitals 35, no. 10:40-44; no. 11:47-52.

Maloney, Milton C.; Trussell, Ray E.; and Elinson, Jack 1960 Physicians Choose Medical Care: A Sociometric Approach to Quality Appraisal. American Journal of Public Health 50:1678-1686.

Mazen, Ahmed Kamel 1961 Development of the Medical Care Program of the Egyptian Region of the United Arab Republic. Ph.D. dissertation, Stanford Univ.

Parsons, Talcott 1958 Definitions of Health and Illness in the Light of American Values and Social Structure. Pages 165-187 in E. Gartly Jaco (editor), Patients, Physicians and Illness: Sourcebook in Behavioral Science and Medicine. Glencoe, III.: Free Press.

Parsons, Talcott; and Fox, RenÉe (1952) 1958 Illness, Therapy, and the Modern Urban Family. Pages 234-245 in E. Gartly Jaco (editor) Patients, Physicians and Illness: Sourcebook in Behavioral Science and Medicine. Glencoe, III.: Free Press. → First published in Volume 8 of the Journal of Social Issues.

Pearsall, Marion 1963 Medical Behavioral Science: A Selected Bibliography of Cultural Anthropology, Social Psychology, and Sociology in Medicine. Lexington: Univ. of Kentucky Press.

Peterson, Osler L. et al. 1956 An Analytical Study of North Carolina General Practice: 1953-1954. Journal of Medical Education 31, no. 12, part 2.

Reader, George G. 1959 Medical Sociology With Particular Reference to the Study of Hospitals. Volume 2, pages 139-152 in World Congress of Sociology, Fourth, Transactions. London: International Sociological Association.

Rosen, GEORGE 1963 The Hospital: Historical Sociology of a Community Institution. Pages 1-36 in Eliot Freidson (editor), The Hospital in Modern Society. New York: Free Press.

Seeman, Melvin; and Evans, John w. 1961 Stratification and Hospital Care. American Sociological Review 26:67-80, 193-204.

Shryock, Richard H. (1936) 1947 The Development of Modern Medicine. New York: Knopf.

Sigerist, Henry E. 1960 On the Sociology of Medicine. New York: MD Publications.

Stanton, Alfred H. 1954 The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. New York: Basic Books.

Stern, Bernhard J. 1941 Society and Medical Progress. Princeton Univ. Press.

Stever, Robert C. 1961 Medical Impressions From India and Nepal. Journal of Medical Education 36: 330-337.

Susser, Mervyn W.; and Watson, William 1962 Sociology in Medicine. Oxford Univ. Press.

Williams, Cicely D.; and SCHARFF, J. W. 1960 An Experiment in Health Work in Trengganu, Malaya. Beirut: American Univ., School of Public Health.

III. ECONOMIC ASPECTS

The economic aspects of medical care encompass a broad and diverse area. It can include discussion of medical care utilization by various income groups, licensing arrangements, incomes of practitioners, fee structures, and so forth. This discussion will be limited to three topics: (1) some of the special characteristics that distinguish medical care from other goods and services; (2) the various alternative mechanisms for financing medical care services utilized at the present time; (3) general economic problems related to alternative patterns of financing.

Special characteristics

Medical care, although generally viewed as a consumption commodity, has come to have a special status among the wide variety of such goods and services. This status affects its organization, the amount of resources it commands, and the patterns used in its financing.

Social-psychological factors

The view that medical care is somehow “different” is mainly an out-growth of what may be called social-psychological factors. Medical care is felt to be (and obviously often is) intimately related to health and to life itself. The public associates medical care with dramatic lifesaving procedures, with the treatment of potentially fatal illness, and with the alleviation of suffering and pain. Since life is not considered a luxury commodity, those things which are believed to be associated with its preservation, e.g., medical care, have come to be considered a “human right.” As a consequence, it is felt that the amount of medical care received—that the right to life or the prevention of pain—should not depend on the individual’s income and purchasing power. Actual practice, of course, is often at wide variance with beliefs and declarations in this area.

Unpredictability of need

A number of significant economic distinctions between medical care and most other goods also impel the public to the view that the financing and organization of medical care should be treated differently from the financing of other goods and services. Perhaps of primary importance is the fact that illness, and consequently the need for care, is unpredictable for the individual, although it is predictable for the group. The individual, therefore, finds it impossible to anticipate the frequency of medical care, the amount he will need, and the costs that will be associated with such care. Furthermore, the economic burden imposed may be extreme—the illness may be severe and the economic consequences catastrophic. Not knowing the costs, he cannot save the appropriate amount in advance of an illness of unknown severity that may occur at some unknown time and with unknown frequency. This matter assumes increased significance, since real limitations exist on the possibility of postponing medical care purchases.

Although postpayment over a period of time would be a possible remedy for part of the problem, difficulties with that device are many: (1) illness may affect both short-run and long-run earning power and thus make such postpayment difficult, perhaps impossible; (2) the service rendered cannot be repossessed if there is a failure to meet payments; (3) the individual may feel that he has little or nothing to show for the medical care received, i.e., he is no better off than before he became ill and is simply back to the pre-illness state, to which he feels he might have returned even without the care; (4) treatment may involve discomfiture and pain, neither of which is certain to make one feel well disposed to those who rendered the treatment and thus to meeting periodic payments to the provider of care; (5) the individual does not consider that he is continuing to derive benefits from the service rendered in the past—as contrasted with the continuing pleasures derived from the purchase of consumer durables and other goods.

Externalities

A second characteristic of medical care services not shared by most other commodities involves externalities. These are present when benefits (or costs) accrue to others because the individual takes a particular action. The purchase of some types of medical services clearly involves such externalities. This is most evident in the case of communicable disease. All of us derive benefits from the immunization of others and from the prevention and treatment of the communicable diseases that affect them. The benefits to society, therefore, exceed the individual consumer’s benefits. Conversely, there are costs to individuals when disease is not controlled in some other part of the population. The matter of externalities can be viewed even more broadly if we include satisfaction as well as dollar benefits in our consideration. If others are crippled, sick, or disabled, and if we are made uncomfortable by knowing about or seeing these conditions, then the benefits to society of rehabilitation or cure exceed the benefits accruing to the individual who is rehabilitated or cured. The increase in social satisfaction should, therefore, also be included in the calculus.

Economic theory has shown that where positive externalities (external benefits) exist, the individual underinvests in the commodity, from society’s standpoint. Thus the private sector underinvests, insofar as there is insufficient philanthropy or absence of compulsion. This characteristic becomes one of the bases for public intervention in the health sector and is one of the reasons that government is often the major financing agent for certain types of health expenditures. [SeeExternal ECONOMIES AND DISECONOMIES; Welfare ECONOMICS.]

Investment

Yet another special feature of medical care is implied by the use, in the preceding paragraph, of the term “invest.” Medical care is in part a consumption commodity, but also in part an investment good. The purchase of medical care today increases the level of health and thus raises productivity in the future. Such sacrifice of current consumption in order to raise future output is the essence of all investments. Thus, the term “investment” need not be applied solely to expenditures on material capital. Accordingly, the analysis of public policy toward medical care can be cast in an investment framework.

Quality assessment problems

An additional significant distinction between medical care and other services is the consumer’s relative inability to judge the quality of the product he is purchasing. This matter has even greater importance when it is recognized that sins of omission or commission on the part of the physician or persons working under his direction may have serious and non-reversible consequences. Even ex post evaluation of quality by the consumer is difficult, and the satisfaction or dissatisfaction with the medical care provided may, therefore, be based on various extraneous factors. Since medical care may involve more serious matters than are involved in the purchase of other consumer goods, and since the search to find quality care is more difficult than with other goods, some measure of protection is afforded the consumer by licensing arrangements. In this manner authorities “guarantee” some presumed minimum level of competence. The economic issues in such licensing arrangements are many, since, depending on the standards set and the responsibility of those who provide licenses, supply may be artificially and unnecessarily restricted, with consequent increase in prices for services and in incomes of practitioners not sufficiently compensated for by increase in quality of care. [SeeLicensing, OCCUPATIONAL.]

Alternative financing mechanisms

The special characteristics of medical care have played a role in inducing governments to participate actively in the medical care sector. The form that such participation has taken has differed greatly and is a product of institutional and ideological constraints. Nevertheless, the role of government in the health sector and in financing health care is acknowledged in all countries. This role often takes the form of government participation in funding or distributing medical care for specific categories in the population. These categories of persons may be defined by specified health characteristics (e.g., the blind, the disabled), by age characteristics (e.g., the aged, children), by economic status (e.g., the indigent, the medically indigent), or by other special characteristics that define a particular population group (e.g., veterans, mi-grant workers). On occasion, combinations of these characteristics are utilized to determine eligibility, and individuals must then meet more than one criterion. Government participation and support, of course, need not be confined to categories of persons and in some countries covers the total resident population.

Voluntary insurance (United States)

Voluntary health insurance has developed as one method of financing designed to meet the problem of unpredictability of illness and the need for medical care. The insurance principle lends itself to application in the health area, although it is relatively difficult to apply to certain health expenses and to certain population groups. This type of financing is most highly developed in the United States, where hospital insurance and surgical-medical insurance are provided both by nonprofit plans and by commercial insurance companies.

The expansion of private voluntary health insurance in the United States began in the 1930s with the development of Blue Cross plans for hospital coverage (with backing by the American Hospital Association) and Blue Shield plans for surgical-medical insurance (with backing by the organized medical profession). These plans are nonprofit and serve local areas (usually entire states), although national coordination is provided.

Commercial insurance companies entered the field in the late 1930s, largely through group coverage and utilizing arrangements for reimbursement of charges up to specified amounts rather than for provision of specified services (as in the nonprofit hospitalization plans). Commercial carriers competed successfully with the Blue Cross and Blue Shield plans. In part this was because the “Blues” used community rating: the rates charged for each of the various contracts offered were the same for all groups in a community. Commercial carriers used experience rating, wherein the rates charged any single group varied with the experience of that group. As a consequence, low-risk groups and individuals often found it advantageous to deal with a commercial carrier where premiums reflected their own experience and utilization of services rather than the average experience, including that of the high risks, in a community. The greater the number of low risks who left the “Blues,” the higher the insurance rates rose for those remaining. Thus those who previously found themselves on “the margin” now found it advantageous to shift to commercial carriers. This mechanism could, in theory, continue indefinitely. It is one of the important considerations in the social insurance area and is often used to argue for a compulsory element in social insurance. As a result of the force of this process, experience rating is now widely used even by those plans which originally rejected it on philosophic grounds. With experience rating, high-risk groups (e.g., the aged) find that the rates charged are higher than would be the case under community rating and that it becomes more difficult to participate in the plan.

This problem, as well as a number of other conditions, led the United States to institute, effective in 1966, a public system of health insurance, as part of its social insurance system, providing for limited financing of some medical care for persons 65 years of age and older. The pressure for such a system of insurance was also heightened by the fact that the aged often are not members of groups eligible for group insurance coverage. Insurance rates for individuals are significantly higher than group rates (and not only because the employer frequently pays a portion of the premium under group coverage). The high medical expenses of the aged and their relatively low financial resources compound the problems of finance. [SeeAging, article on ECONOMIC ASPECTS.]

It is estimated that in 1965 about 80 per cent of the civilian population in the United States had some insurance protection against the costs of basic hospital care, about 75 per cent had some surgical expense protection, and almost 60 per cent were eligible for some additional coverage for in-hospital physician visits. Although the benefits met about 70 per cent of the total cost of hospital care, only about one-third of total consumer expenditures for personal health care were met by insurance. In the United States, health expenditures are financed largely by the private sector: of the $37,000 million of national health expenditures in 1964 (5.8 per cent of the gross national product), 74 per cent came from the private sector and only 26 per cent from the government—equally divided between the federal government on the one hand and state and local governments on the other. About 50 per cent of all personal health service expenditures were paid for by the recipient of the services (or his family), while third parties (government, insurers, etc.) paid for the remainder.

The problem of high-risk groups under experience rating in a voluntary insurance plan can be solved by a compulsory insurance program or direct government provision or financing of services. however, the traditional arguments that are used by those who favor approaches involving more government participation go beyond the solution of the difficulties that some groups and individuals face under experience rating. They include matters such as ease and economic efficiency of administration, comprehensiveness of care, coverage of the total population (including those groups that voluntary insurance finds it difficult or inefficient to reach or whose economic status is so low as to inhibit purchase of insurance), more ready control of inflation in medical care costs, increased equity in financing of care, and more possibility of increasing emphasis on certain aspects of medical services, e.g., preventive care. The success with which any of these objectives would be met would depend upon the particular characteristics of the health insurance or financing plan. The social security characteristic of a plan does not in itself guarantee comprehensiveness of coverage, quality of service, control of inflation in medical care prices, equity in financing, and so forth. Just as the voluntary private health insurance system can take many different forms and thus meet different problems, raise different issues, and resolve basic questions in different ways and with varying degrees of success, so too can each alternative basic system for financing or providing care.

National Health Service (United Kingdom)

One type of approach to the financing and provision of medical care services is that employed in the United Kingdom under the National Health Service. Medical care services (rather than reimbursements) are provided all residents. The major costs of the program are financed out of general revenues, although small weekly contributions are paid by workers and employers. Some cost sharing by the patient for medicines and selected other items is also provided for. All residents are eligible for such services as general and specialized care, dental care, and hospitalization. The services are provided by doctors and druggists who are under contract to the National Health Service and by public hospitals owned by the central government. The physician receives a payment for each person on his rolls. This capitation method of payment of physicians encourages patients to have a continuing relationship with a particular general practitioner. The capitation method of payment, as contrasted with a payment for services rendered, is considered not only to be a good financial arrangement but also to represent a basic philosophical approach to medicine which is believed to have advantages that go beyond ease of administration.

The United Kingdom thus has a pattern of financing and organizing medical care substantially different from that of the United States, or from that which the latter will employ for those 65 years of age and over. Perhaps 85 per cent of all health expenditures in the United Kingdom are paid for by third parties, a much larger percentage than in the United States. The amount of resources allocated to health services in the United Kingdom (4.2 per cent of a lower GNP) also differs from that in the United States (as indicated previously, 5.8 per cent of GNP). It is not clear, however, what part of these, and other, intercountry differences is attributable to differences in relative price level (i.e., the relative costs of health services as compared with other goods and services in each country), differences in efficiency in the health sector, differences in levels of health and “needs,” differences in quality of care, and differences in real resources devoted to health care. But it is clear that there do exist wide differences in the percentage of GNP devoted to health services in various countries. The significance and implications of these differences have yet to be thoroughly examined, but they do not seem to be related to the prevailing patterns or sources of finance or to the significance of the government sector in the health area.

Basic alternatives

The three main patterns of nonmarket provision of medical benefits in the various countries are (1) provision of direct services through facilities owned and operated by the government or by a social insurance fund; (2) services provided to patients, with the provider of services being paid directly by the government or fund; (3) reimbursement of fees paid directly by patients to providers of the services. As will be discussed below, the need for rationing of services still remains under the various arrangements, and patients are, therefore, often called upon to share the costs of the services rendered.

While a number of countries provide comprehensive medical services to all residents (although patients may pay part of the cost of the service provided), and an additional number of countries provide various selected therapeutic services, the particular benefits available and the mechanisms by which care is financed, provided, and organized differ greatly. In some countries medical services are provided to parts of the population under social insurance arrangements; in others, benefits are provided through membership in sickness funds to which employees, government, and (in some countries) employers contribute and in which member-ship is compulsory for certain categories of persons. Particular financing mechanisms are not necessarily tied to particular organizational arrangements, and thus many different combinations exist.

Economic problems

Need for rationing

Whatever the organizational pattern for distributing and financing medical care, the absence of a perfectly operating market for medical care presents certain difficulties. Although medical care is often viewed as a basic human right, few scientific standards exist to define the amount of care that an individual “needs” or should utilize (i.e., the health benefits associated with given amounts of care). However great the public dissatisfaction with the medical care received, it is a fact that some individuals tend to utilize more services than they require or are believed to require. Furthermore, changes in the price of medical care services do tend to change levels of utilization. Declines in price are associated with increases in usage. Although an increase in utilization is often one of the purposes of government in creating systems that reduce price or provide insured health benefits, allocation problems remain. If society were to allocate sufficient resources to medical care so that no choice need be made between care for the individual who is dying but can be saved and the hypochondriac who wants reassurance (that is, if we were prepared to meet all increases in, and levels of, utilization), then rationing of medical resources would not be required. But such a situation is neither conceivable nor, given competing demands on resources, desirable. Thus rationing becomes imperative, and since society is willing to make some interpersonal utility comparisons regarding who needs care, the rationing scheme must incorporate the public’s judgments.

Nevertheless, since there is little scientific agreement on desirable utilization rates (or on the relationship between utilization rates and levels of health), it is difficult to agree upon, set, and control such rates and to develop medically “optimal” rationing devices. In the absence of control of usage, budgetary, physical, and personnel shortages often appear, particularly because consumers often demand more care than the authorities have estimated would be the case. Attempts to balance resource limitations (including budgetary considerations) against the private decisions to visit physicians, to enter hospitals, and to utilize medical care in quantities determined by the individual (the balancing of “scarcity” and “human right”) have always been necessary and have seldom been easy to achieve.

Were the health sector treated as most other services are generally treated, this particular problem would not exist. If consumers, out of their own budgets and without public or private subsidization, chose to “overutilize” services (judged by some scientific standard), this would be fully acceptable. The price mechanism would serve as a rationing device and, however “foolish” some might feel these expenditures to be, the consumer would be sovereign.

Since government plays a role in the health field, even if in many cases it is limited to support for construction of physical resources (e.g., hospitals), or to training of personnel (e.g., supporting education), or to financing of certain types of care (e.g., for needy or aged persons), the government must be involved in the development of rationing devices to replace market forces. The same need exists, of course, when private physicians offer charity care.

Controlling utilization

The problem of “over-utilization” (which can be viewed as the problem of scarcity) arises in all medical care financing mechanisms. The mechanisms of control when there is governmental involvement or control by a voluntary insurance carrier may, of course, differ. It is true that for many services waiting time, in-convenience, and even loss of income serve as deterrents to use. Even so, the use of “free” (but not costless) services may exceed the necessary, or “need,” level. Therefore, additional monetary deter-rents are often used, in the attempt to control overutilization. In particular, they are used to influence the consumer’s choice between different types of care, e.g., office calls rather than house calls, home care rather than hospital care. Payment of some percentage of the costs (e.g., of hospital care) or in the form of some fixed charge (e.g., for a house call) is often instituted in order to induce the consumer to ration the care he seeks and in order to lead him toward those types of care which utilize less of society’s economic resources. Such charges are also often made for prescription drugs. Since the use of such drugs is governed largely by the physician rather than by the patient, these charges may be instituted primarily as a device to cut the costs financed by the program rather than in order to change consumer behavior (although they do this as well).

The difficulty, sometimes unrecognized, with these procedures is that the money deterrent has a differential impact on individuals, depending greatly upon their “taste” and need for medical care, the accessibility of medical care, their total income, and the prices of other goods and services. What may be a small deterrent for some (perhaps the “optimal” deterrent from the point of view of the third party that finances the service or from the point of view of society) may represent a great deterrent for others and a trivial deterrent for still others. Income and price considerations thus reenter the medical market place, although with less impact than would be the case in the absence of third-party payments. Furthermore, it is clear that the conflict recurs between encouragement to use services in the “correct” quantities and rationing of care. No single level of fixed charges applying to all members of the population and designed to deter unnecessary use, but not to inhibit necessary use, can be the correct level for each individual. The operational consequences of the fixed charge will vary with a number of institutional considerations. It cannot be presumed that the consequences are necessarily severe (if maintaining accessibility is the primary goal) or are necessarily minor (if cutting utilization is the primary goal). The fixed charge in third-party payments does illustrate the fact that it is difficult to define that part of medical care which society considers a luxury and that part which is considered a need. With scarce resources a trade-off between goals is required—and difficult to determine.

Future developments in the provision and financing of medical care will be related to developments in medicine itself and to the acquisition of additional knowledge concerning the relationship between medical care and health and between health and. productivity. The growing ability of medicine to prevent illness and to care for and rehabilitate the sick will bring increased pressures on the health sector. In most nations the role of government in health is likely to increase. In part this will take the form of intervention in the financing of services via social insurance or other arrangements. The financial responsibility, as well as the special characteristics, of medical care out-lined earlier will result in government’s assuming an increasing responsibility in the determination of the total amount of manpower and resources devoted to health and medical care and to the allocation of resources within the health sector itself.

The meeting of this responsibility will involve an increased reliance on new evaluative techniques. In recent years, partly as a result of the pressures for health expenditures and for planning of medical care in the less developed countries, and partly as a result of the refinement of benefit-cost analysis, the analysis of medical care has acquired an increasingly analytic economic content. In this approach, health and medical care are viewed in an economic context, and medical care programs are evaluated in relation to their cost and their potential impact on productivity through lower levels of morbidity and mortality. The economic value of man as a producer lies at the heart of the analysis, and the costs of various diseases are calculated in terms of the direct costs of treatment and medical care and the indirect costs to the economy of loss of productive power.

Decisions concerning the allocation of resources to the health sector will, of course, not be based solely on the measurement of pecuniary costs and benefits. Nevertheless, such measurements are of assistance. It can, therefore, be anticipated that as understanding of the methodology of benefit—cost analysis grows, it will be increasingly used in governmental evaluation, planning, and budgeting processes.

Rashi Fein

BIBLIOGRAPHY

The World Health Organization (Geneva) periodically issues publications on the level of health and on the financing and organization of health services in particular countries.

Klarman, Herbert E. 1965 The Economics of Health. New York: Columbia Univ. Press.

Social Security Bulletin. → Published since 1938. Regularly contains articles on the economic aspects of medical care.

U.S. Department of Health, Education, AND Welfare 1964 Social Security Programs Throughout the World: 1964. Washington: Government Printing Office.

Winslow, Charles E. A. 1951 The Cost of Sickness and the Price of Health. Geneva: World Health Organization.

HEALTH SERVICES

SCHOOL
Kerry Redican
Charles Baffi

COLLEGES AND UNIVERSITIES
Molly Black Duesterhaus

SCHOOL

Provision of public school health services in the United States has been sporadic, reflecting the tenor of the times, and influenced by pressure groups, vested interests, and resistance to change by those in administrative positions.

The initial justification for provision of school-based health services was primarily to control communicable diseases in order to cut down on school absenteeism. At the turn of the twentieth century, physicians were appointed as public school health officers. The first school nurse was employed by the New York City Board of Education in 1902, for the express purpose of controlling communicable diseases, particularly infectious skin diseases. Even though the number of physicians who were employed by schools outnumbered the number of nurses employed by schools by approximately three to one, school nurses were the main providers of school health services. Because of prevailing social mores, hygiene instruction in the late 1800s and early 1900s centered on a physiological and anatomical study of the negative effects of alcohol, tea, coffee, and tobacco.

Administrative responsibility for health services was often assigned to a specifically established department within the school, which was often under the direction of a local physician who was accountable to a school superintendent. In other instances, the responsibility for this service was assumed by a community health agency under the direction of a local health officer. These remained accepted practices even into the twenty-first century.

As new scientific knowledge emerged, new movements for improved personal and community health became popular. Addressing health problems of children and youth required a multidimensional approach. School health services only focused on medical related services, not environment or education. It became clear that the school needed to be concerned about not only school health services but also about the school environment and health education. Further, school health services, provision of a healthful school environment, and health education needed to function in a coordinated context in order to be effective. This set the foundation for the development of the school health program.

The original school health program model consisted of school health services, healthful school living, and health education. The goal of the school health program was to provide opportunities for every child to reach their full potential as a student as well as a contributing member of society. The major objective of the school health program was the promotion of physical, mental, social, and emotional well being. This model prevailed for years.

School health services as a part of the overall school health program provided health and medical services to students. These services tended to be one of three types: basic, expanded, or comprehensive. Basic health services include such things as immunizations, hearing and vision screenings, scoliosis screening, sports physicals, health counseling, and nutritional screenings. Expanded health services included health promotion/disease prevention, mental health counseling, substance abuse counseling, family life/sex education, and care of special needs children. Finally, comprehensive health included reproductive health care, primary care, chronic illness management, and prenatal care.

CDC Model

The services, environment, instruction focused model of the school health program worked well but still was not inclusive or comprehensive enough to meet the needs and interests of students. A more comprehensive model was needed. The concept of the Centers for Disease Control and Prevention (CDC) comprehensive school health programs model was first proposed in a landmark work published by Diane Allensworth and Lloyd Kolbe in 1987. The model employed the use of eight components. These include the following:

1. Health education: classroom instruction addressing physical, mental, and social dimensions of health; developing health knowledge, attitudes, and skills; and tailored to each age level. Designed to motivate and assist students in maintaining and improving their health, prevent disease, and reduce the number of health-related problem behaviors they exhibit.
2. Physical education: planned, sequential instruction that promotes lifelong physical activity. Designed to develop basic movement skills, sports skills, and physical fitness as well as to enhance mental, social, and emotional abilities.
3. School health services: preventive services, education, emergency care, referral, and management of acute and chronic health conditions. Designed to promote the health of students, identify and prevent health problems and injuries, and ensure care for students.
4. School nutrition services: integration of nutritious, affordable, and appealing meals; nutrition education; and an environment that promotes healthy eating behaviors for all children. Designed to maximize each child's education and health potential for a lifetime.
5. School counseling, psychological, and social services: activities that focus on cognitive, emotional, behavioral, and social needs of individuals, groups, and families. Designed to prevent and address problems, facilitate positive learning and healthy behavior, and enhance healthy development.
6. Healthy school environment: the physical, social, and emotional climate of the school. Designed to provide a safe physical plant, as well as a healthy and supportive environment that fosters learning.
7. School-site health promotion for staff: assessment, education, and fitness activities for school faculty and staff. Designed to maintain and improve the health and well-being of school staff, who serve as role models for students.
8. Family and community involvement in school health: partnerships among schools, families, community groups, and individuals. Designed to share and maximize resources and expertise in addressing the healthy development of children, youth, and their families.

Components to School Health Services

Every current comprehensive approach to school health includes at least the eight components of the CDC model. The School Health Services component is generally structured around preventive services, education, referral, emergency care, and management of acute and chronic conditions.

Preventive services. Activities typically included in preventive services are educating teachers on the signs and symptoms of health problems of students and health screenings. Teachers are in a unique position to observe health problems among students. They have an advantage in that they can compare students and notice differences that might indicate a potential health problem. Even parents do not have this strategic advantage. It requires that teachers be trained to identify health related issues that may be noticeable during their daily observations of students. This training is often included in a pre-professional course or through in-service instruction offered by the school or school district. The goal of teacher observation is not diagnosis but referral.

Preventive services also include health screenings of students. The most common health screenings conducted in schools include vision, hearing, growth and development, blood pressure, cholesterol, and dental health screenings. Often the school will establish a partnership with a local public health department. The health department's professional staff is responsible for conducting the screenings. The purpose of screening is not to diagnose but to identify a potential health problem and refer the student for a more complete evaluation.

Referral and follow-up represent the culmination of teacher observation and screening. The referral process is initiated in one of two ways: First, a teacher makes an observation that indicates a student might have a health problem, and refers the student to the school nurse or the person in the school responsible for health concerns. Second, if a student does not pass a particular health screening, the student is referred again to the school nurse or the person in the school responsible for health concerns. What follows is a series of conferences, such as teacher/nurse, nurse/parent, and student/nurse.

Emergency care. Unintentional injuries are the leading cause of death in children and youth ages one through twenty-one; for every childhood death caused by injury, there are approximately 34 hospitalizations, 1,000 emergency room visits, and many more visits to private physicians. Because of the magnitude of injuries to children and youth, and because many injuries occur in the school, it is important that schools as a part of health services address safety and emergency care.

Safety and emergency care is normally addressed in two ways: written policies including legal aspects and preparations for handling emergencies. All schools should have written policies, which reflect a sound philosophy of safety and emergency care and specific procedures for school personnel to follow in both prevention of accidents and the protocol in dealing with accidents and emergencies.

Management of acute and chronic conditions.

School health services are concerned with both acute and chronic health conditions of students. Acute conditions are normally communicable diseases and chronic conditions are such things as diabetes, asthma, and juvenile arthritis.

It is extremely difficult if not impossible to prevent the spread of common communicable diseases in school settings. Such illnesses as colds and influenza will run their epidemiologic course. School health services must include policies on how to handle communicable diseases; in other words, when to allow students back in school or sending students home who are sick. Further, schools health services must have documentation that students are up-to-date on immunizations. Schools will typically partner with local public health departments to receive guidance in how to handle communicable disease in the school setting.

Education and universal precautions are two important pieces in the management of acute conditions. Spread of communicable disease can be prevented through sound health practices, even as simple as washing hands. Schools must educate both personnel and students on the importance of sound health practices.

At times, a student will have an injury, perhaps resulting in their bleeding or vomiting. Both blood and vomit, as well as other body fluids, can contain pathogens and disease can be transmitted. Blood can contain HIV and the viruses responsible for viral hepatitis. Following universal precautions will limit the likelihood of transmission of disease through exposure to body fluids. Universal precautions are those activities designed to deal with body fluids and include use of gloves, masks, and proper receptacles for placing materials used to clean up body fluids. School are required to have an exposure control plan and have materials readily available for use when dealing with body fluids.

Issues and Trends

Numerous health problems that were once largely family and community problems now impact the school. Violence, drug use, teen pregnancy, sexually transmitted diseases, and poverty all have tremendous implications for school health services, yet because of the political and economic environment, there is, in general, less funding for programs to deal with these issues. Further, the complexity of the health problems and issues makes citizens question what the exact role of the school is in trying to solve or manage problems that are a result of powerful cultural influences. There seem to be two major perspectives, both with political implications. One is that the role of the school is to teach basic skills, such as reading, writing, math, and history, and health-related issues are a family problem or at best a community problem. The opposite perspective is that the government and by extension the school should play a major role with regard to student health problems and work closely with students in any way possible.

Perhaps the most controversial trend is the implementation of school-based health centers or clinics located in the school. School-based health centers were first established in the early 1970s. They were implemented as a response to health problems such as sexually transmitted diseases, unplanned teenage pregnancy, and substance abuse.

Funded by the federal government and private foundations, school-based health centers are located in forty-five states and the District of Columbia. As of 2000, approximately one-half of the health centers are located in high schools, one-quarter are located in elementary schools, and the remainder are located in other settings. The majority of the centers are located in poor urban and rural areas where coordinated medical and social services are lacking or where there are many uninsured children/parents, making access to services difficult.

Services provided by school-based health centers include but are not limited to primary care (diagnosis and treatment of simple illness), primary prevention (health education programs, vaccinations), and secondary prevention (early detection). These services range from diagnosing such maladies as colds, flu, and sexually transmitted diseases to substance abuse counseling. Services offered vary among communities and from community to community.

School-based health centers face an uncertain future primarily because they rely so heavily on external funding. As the nation grapples with the issue of providing access to health care for all Americans, school-based health centers need to be well positioned to meet the care and prevention needs of children and youth.

Given the political, cultural, and economic climate of the United States two future scenarios emerge. First, with the increasing emphasis on providing access to health care to all Americans it is possible that there will be a greater role for the school in providing health services to students, especially in medically underserved areas. Second, with the increasing shift to managed care it may prove more cost-effective for third-party payers to underwrite health services delivered in a school setting rather than in a community private sector setting.

See also: Family and Consumer Sciences Education; Full-Service Schools; Guidance and Counseling, School; Health Education, School; Physical Education; School-Linked Services, subentry on Types of Services and Organizational Forms; Sex Education.

bibliography

Allensworth, Diane. 1994. "School Health Services: Issues and Challenges." In The Comprehensive School Health Challenge, ed. Peter Cortese and Kathleen Middleton. Santa Cruz, CA: ETR Associates.

Allensworth, Diane, and Kolbe, Lloyd. 1987. "The Comprehensive School Health Program: Exploring an Expanded Concept." Journal of School Health 57 (10):409–412.

Newton, Jerry; Adams, Richard; and Marcontel, Marilyn. 1997. The New School Health Handbook, 3rd edition. Paramus: Prentice-Hall.

Schlitt, J. J. 1991. Bring Health in School: Policy Implications for Southern States. Washington, DC: Southern Center on Adolescent Pregnancy Prevention.

U.S. Department of Health and Human Services. 1999. School Health Programs: An Investment in Our Nation's Future. Atlanta, GA: Centers for Disease Control and Prevention.

U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services.

internet resources

Hurwitz, Nina, and Hurwitz, Sol. 2000. "The Case for School-Based Health Centers." American School Board Journal. National School Boards Association website. <www.nsba.org>.

Porter, Michael, and Kramer, Mark. 2000. "Determining a Policy Agenda to Sustain School-Based Health Centers." National Assembly on School-Based Health Care website. <www.nasbhc.org>.

Kerry Redican

Charles Baffi

COLLEGES AND UNIVERSITIES

College health-service programs provide low-cost, primary medical care for students on college campuses. Kevin Patrick estimated in 1988 that 80 percent of America's more than fourteen million college students received primary health care from campus health programs. Just as modern medicine has changed, so too has the scope of services college health centers provide. Medical developments allow for most injuries and illnesses to be treated by ambulatory clinics, and this same trend is seen in most college health centers. These centers often provide care for acute illnesses and injuries on an outpatient basis, while also meeting the needs of students with continued and chronic illnesses and providing wellness education to the campus community.

In addition to meeting the basic and most common needs of the students they serve, campus health-service programs also act as referral agents for students to connect with medical providers, as needed, in the local community. College health services are continually evolving and changing in order to best provide treatment and education for the campuses they serve.

Staffing

College health-service staffs vary widely in the range and level of services they provide. Once directed mainly by full-time medical doctors, most college health centers are now lead by Licensed Nurse Practitioners (LPNs), Registered Nurses (RNs) or Physician Assistants (PAs). Some health centers continue to have full-time physicians on staff (particularly at larger universities and institutions with medical centers), while others maintain part-time relationships with local doctors to staff particular hours each week. Health centers with less comprehensive services (usually at smaller, private colleges) often act as a link to services in the immediate community.

Services

College health-service programs tend to have three primary areas of responsibility: physical, mental, and educational. Medical services range from basic care in the form of treatment for colds, viruses, and minor injuries at less comprehensive centers to thorough lab tests, X rays, specialists, and pharmacies at the most comprehensive centers. Many college health programs also provide counseling services. Some counseling services are limited to basic intervention and referral for long-term care, while others provide extensive and long-term psychotherapy.

The most common, and a primary focus of college health-service programs, is that of intervention and health, or wellness, education. Although all student health centers concern themselves with the immediate healing of ill students, most will also work to educate students about approaches to healthier lifestyles in order to prevent future illness or injury. Wellness themes exhibited on many college campuses are health and nutrition, stress management, eating disorder awareness, smoking cessation and prevention, time management, alcohol abuse prevention, strategies to avoid depression, and issues around sexually transmitted diseases and their prevention. Some colleges maintain twenty-four-hour care for students; however, most colleges maintain regular weekly hours during the academic year with a system for emergency assistance when needed.

Payment

Many college health centers are funded through fees students pay to the college or university and subsidized with institutional resources. Sometimes these fees are included within the tuition charges of a college or university, while other institutions may charge a separate student health fee in addition to the college tuition. Prepayment for student health services ensures that students have access to the treatment and services needed while at school. At many colleges, basic and most common services are offered to full-time students at little or no charge. Many college health centers will provide, as needed, over the counter medications free of charge; however, they will charge for, or send students to a pharmacy for, prescription medications. Students will usually incur charges for lab work, other diagnostic tests, and services provided by referrals made to outside physicians and specialists. Most colleges and universities require students to have and maintain health insurance. Although many students may continue on their parent's health insurance plans, other students may need to purchase individual health insurance, and can usually do so through programs offered at their college or university.

Requirements

Most, if not all, colleges and universities require that undergraduate students complete health history forms prior to their arrival on campus. This information assists health center staff to prepare for any special needs identified on the form and to have a recorded history in case information is needed to properly treat a student. In addition to the form, all students are required to have current immunizations per state law and institution policy. Documentation of these immunizations must be provided in order to attend the institution.

Confidentiality

Services provided by college health centers are deemed confidential. Health center staff work in partnership with students to get well, make good choices, and develop healthy living habits. The responsibility of informing parents falls to the student in most cases. Only when a condition warrants notification will health services staff break the confidence of the relationship, usually with the permission of the student unless there is concern about harm to self or others.

See also: Drug and Alcohol Abuse, subentry on College; Personal and Psychological Counseling at Colleges and Universities; Personal and Psychological Problems of College Students.

bibliography

Patrick, Kevin. 1988. "Student Health: Medical Care within Institutions of Higher Education." Journal of the American Medical Association 260:3301–3305.

internet resource

American College Health Association. 2002. <www.acha.org>.

Molly Black Duesterhaus

LONG-TERM CARE, QUALITY OF

Quality in long-term care requires three steps: (1) defining quality of care ; (2) assessing care and services to determine whether quality standards are being met; and (3) correcting quality problems when they are identified. Quality questions in long-term care go beyond the traditional safety and protection issues that have historically dominated the field of tong-term care; policy-makers and regulators are concerned with determining if public monies are paying for effective services that result in better health or improved functioning for the consumer.

Nursing homes

Concerns about the quality of nursing home care and ineffective government regulation of facilities dates back to at least 1970. (Medicare and Medicaid were enacted in 1965 and soon after, there was an expansion of nursing homes and increasing concerns about quality.) A 1987 law known as the Omnibus Budget Reconciliation Act (OBRA 1987) raised quality-of-care standards for nursing homes participating in Medicare and Medicaid and strengthened federal and state oversight. Following the law's implementation, several studies found evidence of improvements in nursing home care, including a decline in the use of physical and chemical restraints, reduced prevalence of dehydration and pressure ulcers, and less frequent use of catheters. Pressure ulcers are a standard measure of nursing home quality, simply because avoiding these skin wounds requires coordinated care efforts to turn and take care of bedridden residents.

Despite these improvements, studies indicate that many nursing homes continue to provide inadequate care. The U.S. General Accounting Office (GAO) in 1999 found that one-fourth of nursing facilities have serious deficiencies that have caused actual harm to residents or placed their health and safety at risk (see Scalon 2001). According to the Institute of Medicine, many of these homes have had repeated serious deficiencies, and even when problems have been identified, state and federal enforcement policies are often effective in ensuring that they are corrected and remain corrected.

There is a growing awareness among nursing-home administrators, state and federal regulators, consumer advocates, and others that staff shortages and insufficient staff training are part of the problem. High turnover in nursing-home staff (currently at 40 to 75 percent nationally, and as high as 500 percent in certain facilities) makes it difficult to recruit and retain a high quality workforce. Staff turnover among certified nursing assistants (CNAs), who are at the front lines of nursing-home care, is particularly detrimental to overall quality of care. Instability in the CNA workforce means that residents are constantly receiving care from new people who often lack experience and a knowledge of individual residents. In such an environment, continuity of care is compromised. In addition, the cost of training new staff drains resources from resident care.

Improvements in the basic elements of nursing-home care, such as fire safety, inappropriate use of physical or chemical restraints, and a lack of available social programs, have been recorded. Nursing-home quality now needs to broaden its focus to address both issues of quality of care and quality of life. The emphasis on health and safety, which has been dominant in the U.S. regulatory system, needs to be expanded to emphasize the critical aspects of life, such as choice and control of the services received, if nursing homes are to be quality settings.

Assisted living

Assisted living is usually defined as a residential-care setting for persons who can no longer live independently and who require some supervision or help with activities of daily living (ADLs), but who may not need the level of skilled care provided in a nursing home. National definitions and regulations of assisted living do not exist, thus assisted living varies considerably from state to state. Most definitions specify that assisted living provide personal care and supportive services twenty-four hours a day; including some health care, meals, and housing in a congregate residential setting serving primarily an older population. The intensity of services, the range of disabilities for which services are provided, the type of living arrangements, and many other aspects of assisted living vary a great deal, often within, as well as between, states.

The ability of residents to age in place as their health declines or their needs change is determined largely by admission and discharge criteria. There is considerable variation across the states in these criteria, some of which comes from state regulations, some from the facilities' choice of whom to serve, and some from the particular services an assisted-living facility chooses to provide or make available.

Frequently identified quality problems in assisted living include facilities providing inadequate or insufficient care to residents; insufficient, unqualified, and untrained staff; and not providing residents appropriate medications—or storing medications improperly. In addition, state regulations on assisted living generally focus on three main areas: requirements for the living unit, admission and retention criteria, and the types and levels of services that may be provided.

Regulations that ensure the safety and quality of care in assisted living are limited. Regulations in most states set the parameters for assisted living, but owners and operators define the practice. A 1999 GAO report also found that assisted-living facilities have quality problems related to incorrect, incomplete, and misleading information provision; inadequate care; insufficient staffing; and medication errors.

In 1996, several organizations representing consumers and providers formed the Assisted Living Quality Coalition (ALQC) to address issues of quality improvement in assisted living. The goal was to develop an assisted-living quality framework by promoting the highest possible quality of life for older adults and those with disabilities by advocating for an assisted-living philosophy of independence, privacy, dignity, and autonomy.

During its deliberations, the ALQC sought the counsel and advice of numerous individuals and organizations representing consumers, providers, state regulators, ombudsmen, third-party payers, and investors. The coalition also examined a variety of approaches to promoting quality, including traditional state regulation, accreditation, contracts, and quality indicators. The coalition's report, published in 1998, includes guidelines for states developing standards. As of 2001, however, there had been no federal action on the coalition recommendations.

Home care

There are two major categories of home care. Home health care is skilled care that is provided to individuals and families in their place of residence for the purpose of promoting, maintaining, or restoring health, or for maximizing the level of independence while minimizing the effects of disabilities and illness. This care is primarily funded through the Medicare program and to a lesser extent, by Medicaid. Home and community-based services (HCBS) include a range of services that help with the tasks of daily living, such as personal care, homemaking, cooking, and laundry. These services are typically provided under the Medicaid program through HCBS waivers or the personal care option, through the Older Americans Act. or through the Social Service Block Grant. All fifty states and the District of Columbia now provide HCBS waivers for long-term care services, including personal-care services, care management, adult day care, home-delivered meals, emergency response systems, transportation programs, respite programs, caregiver support programs, and home modification programs.

Quality home-care services involve the provision of appropriate and competent medical and personal-care services, incorporating those values of significance to consumers: independence, choice, control, dignity, and privacy. A 1997 GAO report found that very poor care was provided by a number of home health agencies. Several examples were cited showing quality problems in home care, including agency administrators with no health care experience and agencies serving ineligible patients and falsifying records and staff credentials. Moreover, the report stated that only 3 percent of all certified home health agencies have been cited by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) for being out of compliance with one or more conditions.

Regulation and research help guide the process of assuring the quality of home care. The research on home health care points to a mixed experience in developing good strategies for ensuring the quality of care. The majority of the research in home care has examined structural and process measures, rather than outcomes of care. Medicare-funded home health care generally appears to be of adequate quality in terms of the transactions between caregivers and consumers. However, the program has suffered from problems of overuse and inappropriate use, leading to new constraints on payments that may adversely affect the quality of services for those consumers with the most severe needs. Access to home and community-based services, especially personal attendant services for people with disabilities, is not uniformly available across states and the need for these services appears to be largely unmet. Research shows that access to services and choice of appropriate services are essential to the quality of home care.

More research is needed towards developing an appropriate array of community-based long-term care services to meet the needs of consumers and assess the quality of the services and outcomes. Furthermore, consumers should ultimately define quality of care. As Kane, Kane, and Ladd point out, "Only the person receiving the care and help can judge how it enhances or interferes with their happiness, productivity, and social lives" (p. 193). Home-care programs are beginning to develop approaches to assessing consumer satisfaction with services and outcomes of importance.

An additional mechanism for assuring quality in the nursing home and home care settings is through the nursing home ombudsman program. Funded through the Older Americans Act legislation, this program establishes an advocacy and complaint system in each state. Typically administered by the state unit and regional area agency on aging, the ombudsman function involves the investigation of complaints received by consumers, advocates, or employees surrounding the quality of care received. Complaints can be received via a 1-800 hot line or through the mail. Ombudsman can either report problems to the legal or inspection system or negotiate a resolution to the problem with the provider and consumer. Although originally designed for nursing homes, the ombudsman function has been expanded to other long-term care settings in recent years.

Assuring the quality of long-term care is a complex undertaking. For instance, although researchers have developed or identified a variety of approaches for determining the quality of home-care services, no method has yet been judged entirely adequate. Problems with the quality of care being provided across all types of long-term care settings remain, and better mechanisms are needed to adequately assess quality in these settings. More attention should be given to issues such as consumer choice, safety, and broadening consumer participation in decision making.

Traditionally, long-term care has focused heavily on structure and process strategies to ensure quality of care. Recent experiences indicate that consumers can provide important input into the quality assessment process. Efforts to educate consumers directly, inform them of their rights, and inform them of reasonable costs for services all are elements of a strategy to promote quality.

Future approaches

Total quality management (TQM) represents a major new approach to managing long-term care. TQM is the integration of a customer-focused, continuous-improvement philosophy, analytical skills, people skills, and a structure and organization within an internal and external culture (organizational or corporate culture which represents the values and beliefs of the organization) driven by leadership. The uniqueness and power of TQM is the integration and balance of the different components, not in the use of its individual parts. Moreover, TQM is grounded in a philosophy of meeting and exceeding customer-defined requirements and working for continuous improvement.

Recent work on quality has identified five principles that are applicable to quality efforts in long-term care:

1. Providers must know their customers. Quality improvement suggests that organizations have a range of customers. It is essential for agencies to recognize the many different customer groups that they serve. In long-term care, important customer groups such as home-health or nursing-home aides are often ignored.
2. Providers must listen to consumers. Quality improvement indicates knowing what consumers want and how they feel about the long-term care service delivered is an essential ingredient in achieving quality.
3. Information is essential for good decision making. For many agencies, basic information about the service recipients, costs, and outcomes of care are simply not available. Quality improvement suggests that agencies must be able to use systematic information to make decisions.
4. The group is smarter than the individual. This principle states that, in the problem solving and improvement process, a group, in this case, a group of individuals involved in the delivery of service, will make better decisions than an individual, and therefore must be involved in changing the way care is delivered.
5. Suboptimization is a key challenge facing organizations. Suboptimization occurs when one unit maximizes its efficiency at the expense of other units within the organization. Rather than having individual department or unit goals, agencies need to have a common goal—quality long-term care service.

Implementing total quality principles requires a clear commitment to continuously improving the quality of services delivered. Such programs are not easy to develop, but without a solid approach to involving consumers in the quality process, it is difficult to achieve the quality goals desired by providers and consumers.

Shawn Davis Robert A. Applebaum

See also Aging in Place; Assisted Living; Home Care and Home Services; Long-Term Care; Nursing Homes.

BIBLIOGRAPHY

Applebaum, R., and Davis, S. "Long-Term Care Off to the Races: But Does Anyone Know Where the Finish Line Is?" The Gerontologist 40 (2000): 377–379.

Applebaum, R.; Straker, J.; and Geron, S. Assessing Satisfaction in Health and Long-Term Care; Practical Approaches to Hearing the Voices of Consumers. New York: Springer, 2000.

Assisted Living Quality Coalition. Assisted Living Quality Initiative: Building a Structure that Promotes Quality. Washington, D.C.: ALQC, 1998.

Cramer, B.; Harmuth, S.; and Gamble, E. Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers. Raleigh, N.C.: North Carolina Division of Facility Services, 1999.

Eustis, N.; Kane, R.; and Fischer, L. "Home Care Quality and Home Care Workers: Beyond Quality Assurance as Usual." The Gerontologist 33 (1993): 47–54.

Harrington, C.; Carrillo, S.; Thollaug, P.; and Summers, R. "Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1991 through 1997." Washington, D.C.: Health Care Financing Administration. www.hcfa.gov/medicaid

Hawes, C.; Rose, M.; and Phillips, C. A National Study on Assisted Living for the Frail Elderly: Results of a National Survey of Facilities. Beachwood, Ohio: Myers Research Institute, Menorah Park Center on Aging, 1999.]

Institute on Medicine. Best at Home: Assuring Quality Long-Term Care in Home and Community-Based Settings. Washington, D.C.: National Academy Press, 1996.

Institute on Medicine, Committee on Improving Quality in Long-Term Care. Improving the Quality of Long-Term Care. Washington, D.C.: National Academy Press, 2001.

Institute on Medicine, Committee on Nursing Home Regulation. Improving the Quality of Care in Nursing Homes. Washington, D.C.: National Academy Press, 1986.

Kane, R.; Kane, R.; and Ladd, R. The Heart of Long-Term Care. New York: Oxford University Press, 1998.

Mollica, R., and Snow, K. State Assisted Living Policy: 1996. Portland, Maine: National Academy for State Health Policy, 1996.

Phillips, C. "Measuring and Assuring Quality Care in Nursing Homes." In Linking Quality of Long-Term Care and Quality of Life. Edited by L. Noekler and Z. Harel. New York: Springer, 2001.

Phillips, C.; Morris, J.; Hawes, C.; Fries, B.; Mor, V.; Nennstiel, M.; and Iannacchione, V. "Association of the Resident Assessment Instrument (RAI) with Changes in Function, Cognition, and Psychosocial Status." Journal of the American Geriatrics Society 45, no. 8 (1997): 986–993.

Scanlon, William. Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern. GAO-01-750T. Washington, D.C.: United States Governmental Printing Office, 2001.

U.S. General Accounting Office. Assisted Living: Quality of Care and Consumer Protection Issues in Four States. Washington, D.C.: U.S. Governmental Printing Office, 1999.

U.S. General Accounting Office. Medicare Home Health Agencies: Certification Process Ineffective in Excluding Problem Agencies. Washington, D.C.: U.S. Governmental Printing Office, 1997.

U.S. General Accounting Office. Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Standards. Washington, D.C.: U.S. Governmental Printing Office, 1999.

NURSING HOMES: CONSUMER INFORMATION

Every year over 1.5 million people (of all ages) in the United States spend some time in a nursing home (McKnight's; Kassner and Bectel). Although many return home after a brief stay, others spend their last years as nursing home residents. Whether one plans to stay for a few weeks or a few years, choosing a nursing home is a difficult decision. Nursing homes vary in services provided, amenities available, type of staff, types of residents, and quality of care. Fortunately a great deal of information is available to assist prospective nursing home residents and their families in choosing the nursing home that best meets their needs. This information is largely of two types—general advice about how to choose a nursing home and what to look for when one visits, and specific information that allows consumers to compare individual nursing homes. This entry will discuss these two broad categories of information, explain how the information is gathered, and provide suggestions about how to use the information to make an informed decision.

General advice

Before focusing on nursing homes specifically, a good starting point is to understand the array of options called long-term care.

The federal Administration on Aging (AoA) has one of the most comprehensive Web sites for issues relating to older people, their families, and the general public. Covering everything from Alzheimer's disease to federal aging policy and government programs, the AoA Web site (www.aoa.gov) provides numerous links for consumers seeking information about older adults, long-term care in general, and nursing homes in particular.

Since nearly half of all the people who turned sixty-five in 1990 will spend some time in a nursing home (Kemper and Murtaugh, 1991), choosing a nursing home before one is actually needed is a valuable activity. Available advice includes how to discuss nursing home choices with family members, financial planning, how to purchase long-term care insurance, and guides for visiting nursing homes, with questions to ask and things to observe. Organizational and governmental sites such as AARP (www.aarp.org), the Centers for Medicare and Medicaid Services (www.medicare.gov), the American Association of Homes and Services for the Aging (www.aahsa.org), and the American Health Care Association (www.ahca.org) have publications that can be downloaded. Similar information is also available on commercial sites such as www.agenet.com, www.seniorsite.com, and www.elderweb.com. Many state and local departments on aging have similar materials with a special focus on local or state long-term care services. Because of the wide availability of these kinds of guides, no one should begin the nursing home search without one. Checklists can be printed from Web sites and completed for each facility one visits. After four or five facilities have been visited, the completed checklists provide important comparative information with which to make the choice that best meets the needs of the prospective resident.

Nursing home information

Specific information about individual nursing facilities has become widely available on the Internet. The federal government (at www.medicare.gov), state nursing home associations, state government departments, and newspapers have all gotten into the business of comparing nursing homes. More states are adding Web sites each year. Some Web sites use a report card grading system; others use stars, akin to restaurant and hotel rating systems. While these provide quick comparative information, not everyone's needs are the same. The things about a facility that are most important to one person may not be the things that those who developed the ranking system had in mind.

Facility deficiencies. One component included in almost all national- and state-level sites is information from the annual inspection survey. Every nursing facility that is certified to receive Medicaid or Medicare payments is visited at least once a year. At the annual visit the survey team collects information about the staff and residents, conducts interviews with a sample of residents; reviews a sample of resident records, inspects the physical aspects of the facility, and observes the provision of care. Over 150 different aspects of care are observed during each survey. In each area that the nursing home fails to meet the regulated standard, a deficiency is recorded. Deficiencies are classified according to their severity (the amount of potential harm that could come to residents), and their scope (whether the potential harm was isolated, affecting only one resident, or widespread, affecting many). In 2001 the national average number of deficiencies cited is six. Some Web sites post the proportion of compliance, which can be misleading. For example, Ohio surveys for 192 deficiencies, and the poorest performing facility was in 80 percent compliance, a B- in most grade books. Deficiency information is most useful when comparing one facility with another, and when the reasons for the deficiency can be explored.

The most comprehensive source of deficiency information is medicare.gov, the Medicare Web site; their Nursing Home Compare provides survey information for all Medicare and Medicaid facilities in the United States. Knowing whether a home has a history of harming residents, providing poor care, or otherwise jeopardizing those in its care is an important factor in the decision-making process.

However, this information has some limitations. First, surveys are conducted at approximately one-year intervals, so the information may be out of date. The nursing home may be quite different today than it was when the deficiencies were found. Historical survey data can help in interpreting the latest survey because they show whether a facility is improving or declining. No matter what is shown on the Internet, a visit to the facility should be part of the selection process.

Another limitation of survey data is that they may not be reliable. Different surveyors may produce very different lists of deficiencies for the same nursing home. It is not uncommon for nursing homes to find that a practice that has not caused a deficiency for years has suddenly become unacceptable when a new team of surveyors is sent in.

The deficiency language (which most Web sites use) is broad and general, so it is not clear what actually caused the deficiency. The Pennsylvania Department of Health posts the deficiencies, and the explanation of what caused each deficiency. This is helpful because it provides examples of the kinds of things that result in particular deficiencies. The department of health Web site in one's state should be checked to see if this information is available.

Despite the limitations mentioned above, comparative survey information is one important component of the nursing home choice. Knowing how one facility compares with the average in the state or with the facility down the street can certainly help in narrowing a search. It also provides guidance about what kinds of questions should be asked during a visit to a particular facility. Many high-quality facilities receive survey deficiencies; the things surveyors cite may not affect a resident's satisfaction with the facility at all. Some Web sites post results from resident and family satisfaction surveys—these results are important to consider in conjunction with the results collected during the annual survey.

Residents. Several Web sites (Medicare, Texas Department of Health) provide information about the characteristics of residents who live in each facility. Knowing more about the residents living in a facility can be useful in matching the needs of the prospective resident with the residents already being served. For example, if a facility has a much higher than average proportion of residents with behavioral symptoms (one of the resident classifications), it may specialize in dementia residents. On the other hand, there may be a higher proportion of residents with behavioral symptoms because the staff is poorly trained in behavioral management. Resident information can be useful in deciding whether the prospective resident is likely to fit in, and whether the facility has experience caring for others with similar needs. Quality indicators, taken from assessments of resident conditions, appear on some Web sites. They suggest areas where a facility has potential problems in providing care for certain kinds of residents. If quality indicators for the facilities in one's state cannot be located, one should ask to see the facility's quality indicator report.

Staff. Information about the number and type of staff is collected when each facility has its annual survey. The Nursing Home Compare Web site posts this information as nursing staff per resident. If one is choosing a nursing home for someone with complex medical conditions, then the number of registered nurses in the facility is likely to be more important than for someone who needs only basic assistance with bathing or dressing. A 2000 report to Congress recommended an optimal staffing measure of 2.9 hours of certified nurse aide staffing, per resident, per day (Health Care Financing Administration). However, if this standard is not met in the facilities being considered, it may be because the facility serves a diverse group of residents, some of whom require much more or much less care than the average.

Using information wisely

A search for Nursing Home Survey, or Choose a Nursing Home, or a visit to any of the Web sites mentioned in this entry will provide plenty of information about long-term care and making nursing home comparisons. Internet information is highly useful for developing an understanding of long-term care and long-term care planning in general, locating facilities in the area one is interested in, learning more about those specific facilities, and preparing for nursing home visits. One can download a checklist for a visit and prepare specific questions about a facility's survey history, residents, care specialties, and staffing. One can easily make comparisons to narrow the search to the facilities most likely to meet the prospective resident's needs. However, gathering consumer information from the Internet is no substitute for the sights and sounds of a nursing home visit.

Jane Karnes Straker

See also Long-term Care; Long-term Care, Quality of.

BIBLIOGRAPHY

Health Care Financing Administration. "Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes." World Wide Web document, www.hcfa.gov

Kassner, E., and Bectel, R. W. Midlife and Older Americans with Disabilities: Who Gets Help? Washington, D.C.: AARP Public Policy Institute, 1998.

Kemper, P., and Murtaugh, C. "Lifetime Use of Nursing Home Care." New England Journal of Medicine 324, no. 9 (February 28, 1991). McKnight's Online. "Frequently Asked Questions about Long-Term Care." World Wide Web document, www.mcknightsonline.com