The MOS social support survey

This paper describes the development and evaluation of a brief, multidimensional, self- administered, social support survey that was developed for patients in the Medical Outcomes Study (MOS), a two-year study of patients with chronic conditions. This survey was designed to be comprehensive in terms of recent thinking about the various dimensions of social support. In addition, it was designed to be distinct from other related measures. We present a summary of the major conceptual issues considered when choosing items for the social support battery, describe the items, and present findings based on data from 2987 patients (ages 18 and older). Multitrait scaling analyses supported the dimensionality of four functional support scales (emotional/informational, tangible, affectionate, and positive social interaction) and the construction of an overall functional social support index. These support measures are distinct from structural measures of social support and from related health measures. They are reliable (all Alphas >0.91), and are fairly stable over time. Selected construct validity hypotheses were supported.social support reliability and validity

The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection

A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form

Effects of cost sharing on seeking care for serious and minor symptoms. Results of a randomized controlled trial

To estimate the effect of cost sharing on seeking care for serious and minor symptoms, we analyzed data for 3539 persons aged 17 to 61 from the Rand Health Insurance Experiment. Participants were randomly assigned to a free-care group or to insurance plans requiring them to pay part of the costs (cost-sharing group). Annual surveys were administered to determine if participants had serious and minor symptoms during the preceding month and whether they saw a physician. Serious symptoms were judged by a panel of physicians to warrant care in most instances; minor symptoms were judged neither to be severe nor to warrant care in most instances. The cost-sharing group was nearly one third less likely than the free-care group to see a physician when they had minor symptoms (6.3% compared with 9.0%; p less than 0.04). The free-care and cost-sharing groups did not differ significantly in seeking care for serious symptoms (22.3% compared with 17.9%; p = 0.095). However, for participants with low socioeconomic status who began the study in poor health, the prevalence of serious symptoms was higher in the cost-sharing than the free-care group (29.1% compared with 23.8%, p less than 0.004)

The Fracture of Relational Space in Depression: Predicaments in Primary Care Help Seeking.

Primary care clinicians treat the majority of cases of depression in the United States. The primary care clinic is also a site for enactment of a disease-oriented concept of depression that locates disorder within an individual body. Drawing on theories of the self and stigma, this article highlights problematics of primary care depression treatment by examining the lived experience of depression. The data come from individuals who screened positive for depressive symptoms in primary care settings and were followed over ten years. After iterative mixed-methodological exploration of a large dataset, we analyzed interviews from a purposive sample of 46 individuals using grounded and phenomenological approaches. We describe two major results. First, we note that depression is experienced as located within and inextricable from relational space and that the self is experienced as relational, rather than autonomous, in depression. Second, we describe the ways in which the experience of depression contradicts a disease-oriented concept such that help-seeking intensifies rather than alleviates the relational problem of depression. We conclude by highlighting that an understanding of illness experience may be essential to improving primary care depression treatment and by questioning the bracketing of relational concerns in depression within the construct of stigma

The Fracture of Relational Space in Depression: Predicaments in Primary Care Help Seeking

Primary care clinicians treat the majority of cases of depression in the United States. The primary care clinic is also a site for enactment of a disease-oriented concept of depression that locates disorder within an individual body. Drawing on theories of the self and stigma, this article highlights problematics of primary care depression treatment by examining the lived experience of depression. The data come from individuals who screened positive for depressive symptoms in primary care settings and were followed over ten years. After iterative mixed-methodological exploration of a large dataset, we analyzed interviews from a purposive sample of 46 individuals using grounded and phenomenological approaches. We describe two major results. First, we note that depression is experienced as located within and inextricable from relational space and that the self is experienced as relational, rather than autonomous, in depression. Second, we describe the ways in which the experience of depression contradicts a disease-oriented concept such that help-seeking intensifies rather than alleviates the relational problem of depression. We conclude by highlighting that an understanding of illness experience may be essential to improving primary care depression treatment and by questioning the bracketing of relational concerns in depression within the construct of stigma

Social support and stressful life events: age differences in their effects on health-related quality of life among the chronically ill

There is substantial evidence of individual variation in health-related quality of life measures that is not accounted for by age or disease condition. An understanding of factors that determine good health is necessary for maintained function and improved quality of life. This study examines the extent to which social support and stressful life events were more or less beneficial for the long-term physical functioning and emotional well-being of 1,402 chronically ill patients. Analyses, conducted separately in three age groups, showed that social support was beneficial for health over time regardless of age. In addition, low levels of support were particularly damaging for the physical functioning of older patients. Stressful life events impacted differentially on health-related quality of life; relationship events had an immediate effect on well-being which diminished with time; financial events had an immediate negative effect on functioning and well-being which persisted over time for middle-aged patients; bereavement had a delayed impact on quality of life, with the youngest patients especially vulnerable to its negative effects; work-related events had both negative and positive effects, depending on age group. Results reinforce the importance of identifying and dealing with psychosocial problems among patients with chronic disease

The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups

The widespread use of standardized health surveys is predicated on the largely untested assumption that scales constructed from those surveys will satisfy minimum psychometric requirements across diverse population groups. Data from the Medical Outcomes Study (MOS) were used to evaluate data completeness and quality, test scaling assumptions, and estimate internal-consistency reliability for the eight scales constructed from the MOS SF-36 Health Survey. Analyses were conducted among 3,445 patients and were replicated across 24 subgroups differing in sociodemographic characteristics, diagnosis, and disease severity. For each scale, item-completion rates were high across all groups (88% to 95%), but tended to be somewhat lower among the elderly, those with less than a high school education, and those in poverty. On average, surveys were complete enough to compute scales scores for more than 96% of the sample. Across patient groups, all scales passed tests for item-internal consistency (97% passed) and item-discriminant validity (92% passed). Reliability coefficients ranged from a low of 0.65 to a high of 0.94 across scales (median = 0.85) and varied somewhat across patient subgroups. Floor effects were negligible except for the two role disability scales. Noteworthy ceiling effects were observed for both role disability scales and the social functioning scale. These findings support the use of the SF-36 survey across the diverse populations studied and identify population groups in which use of standardized health status measures may or may not be problematic

Do depressed patients in different treatment settings have different levels of well-being and functioning

Differences in the functioning and well-being of adult patients with current or past depressive disorder who visited clinicians of different specialties in health maintenance organizations, solo practices, or large multispecialty group practices were examined. For patients in different systems, there were no significant differences in functioning and well-being across 12 domains tested. Patients of mental health specialists had worse mental health and more limitations in social activities, whereas patients of medical clinicians had worse physical functioning, more pain, more physical/psychophysiologic symptoms, and worse health perceptions. Thus, each system of care had depressed patients with a similar functioning and well-being burden but specialty sectors had patients with slightly different functioning and well-being profiles, probably reflecting patient selection of type of provider

Increasing Immunization Rates Among Inner-City, African American Children: A Randomized Trial of Case Management

CONTEXT.— Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested. OBJECTIVE.— To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families. DESIGN.— Randomized controlled trial with follow-up through 1 year of life. SETTING.— Low-income areas of inner-city Los Angeles, Calif. PATIENTS.— A representative sample of 419 African American infants and their families. INTERVENTIONS.— In-depth assessment by case managers before infants were 6 weeks of age, with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed. MAIN OUTCOME MEASURES.— Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention. RESULTS.— A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. CONCLUSIONS.— A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed

Comparison of health outcomes at a health maintenance organisation with those of fee-for-service care

To determine whether health outcomes in a health maintenance organisation (HMO) differed from those in the fee-for-service (FFS) system, 1673 individuals ages 14 to 61 were randomly assigned to one HMO or to an FFS insurance plan in Seattle, Washington for 3 or 5 years. For non-poor individuals assigned to the HMO who were initially in good health there were no adverse effects. Health outcomes in the two systems of care differed for high and low income individuals who began the experiment with health problems. For the high income initially sick group, the HMO produced significant improvements in cholesterol levels and in general health ratings by comparison with free FFS care. The low income initially sick group assigned to the HMO reported significantly more bed-days per year due to poor health and more serious symptoms than those assigned free FFS care, and a greater risk of dying by comparison with pay FFS plans