Wolinsky 1980

Toward Comprehensive Health Status Measures
Author(s): Fredric D. Wolinsky and Marty E. Zusman

Source: The Sociological Quarterly, Vol. 21, No. 4 (Autumn, 1980), pp. 607-621
Published by: Wiley on behalf of the Midwest Sociological Society
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The Sociological Quarterly 21 (A utumn 1980):607-621
Toward Comprehensive Health Status Measures*

Fredric D. Wolinsky, American Medical Association
Marty E. Zusman, Indiana University Northwest
While health, itself, is the central concept in the sociology of health, little agreement
exists on what constitutes an appropriate definition of health. This paper develops two
composite health status measures (one continuous summary measure, and one set of
eight discrete health state measures) based on the World Health Organization's con-
ceptualization of the physical, social, and psychological dimensions of health. Data
from a 1978 regional survey demonstrates the continuous summary measure's reli-
ability (alpha = .70), and validity (factor analytic support for the hypothesized di-
mensions). The results also indicate that although either of the comprehensive mea-
sures significantly increase the goodness of fit of structural models of health service
utilization, the set of discrete health state measures increases more the goodness of
fit, bringing the explained variance of physician visits up from 16 percent to 30 per-
cent. The magnitude of the increments clearly demonstrates the considerable utility
of the comprehensive health status measurement approach.
The most central concept in the sociology of health is health itself. As sociologists
of health we are constantly analyzing and theorizing about the effects of social
factors on health, as well as focusing on the social nature of the health care de-
livery system. But how far have we come toward the consensus on what health
really means, a consensus which must "precede sensible discussion, investigation,
or action" (Wilson, 1970:3)? The answer, most regrettably, is not very far. Chen
(1976:33) has lamented the problem from the inside:
. . there is a diversity of opinion among authors or designers of health status indexes

at both the conceptual and methodological levels. Much of the controversy can be
attributed to the fact that health is currently an ill-defined concept, and what defini-
tions there are do not readily lend themselves to operational applications.
Rogers (1976:1) has lamented the problem from the outside, justifying the U.S.
House of Representatives' Discursive Dictionary of Health Care as a necessity,
because: ". . . interestingly enough, a comparable dictionary (or definition of
health), has not yet been prepared by the academic community, the executive
branch, or any of the interested professions." To be fair, we must point out that
some consensus exists around the basic conception of health presented by the
World Health Organization (1958), in which health is defined as: ". .. a state
of complete physical, mental, and social well-being and not merely the absence
of disease or infirmity."
But it is at this point where the consensus dissolves, for we seem to be unable
01980 by The Sociological Quarterly. All rights reserved. 0038-0253/80/ 1500-0607$00.75

*The authors thank the Eastern Carolina Health Systems Agency, the East Carolina University School
of Medicine, and the East Carolina University Department of Sociology and Anthropology for research
funds which partially supported this project. The views expressed in this paper are those of the authors and
do not necessarily represent the official position or policy of the American Medical Association. Fredric
Wolinsky's address is: Department of Statistical Analysis, Center for Health Services Research and Develop-
ment, American Medical Association. 535 N. Dearborn Street, Chicago, Illinois 60610.
608 THE SOCIOLOGICAL QUARTERLY
to agree on exactly what physical, mental, and social well-being really mean.
Moreover, camps have developed around each of the three dimensions identified
in the World Health Organization's definition of health, with their respective
partisans pursuing the measurement of that single dimension of health to the ex-
clusion of the other two. As a result, we now have physical measures (cf. Taylor
et al., 1975; Kisch et al., 1969) social measures (cf. Reynolds et al., 1974;
Stewart et al., 1977), and psychological measures (cf. Holmes and Rahe, 1967;
Beiser, 1974) of health status, although we have no comprehensive measures of
health status (the recent work of Brook et al. [1979] notwithstanding). The pur-
pose of the present paper is to move toward the development and validation of
comprehensive health status measures based on the conceptual logic of the World
Health Organization's definition of health, as elaborated in Wolinsky's (1980a)
three dimensional configuration of eight health states.
Toward a Three Dimensional Conception of Health

Building on the World Health Organization's (1958) conceptual definition of
health, Wolinsky (1980a:65-98) presented a three dimensional model of health
states. He focuses on the three dimensions along which an individual's health
may be evaluated: the physical, the social, and the psychological. Wolinsky ar-
gues that the assessment of health along these three dimensions, and therefore
their operationalization, should reflect the perspective used by the major evalua-
tor of each respective dimension. That is, physical health should be evaluated
from the physician's perspective, social health should be evaluated from society's
perspective, and psychological health should be evaluated from the individual's
perspective. Although this approach may appear quite different from a number of
extant studies of health status measurement (see for example the recent work of
Brook et al. [1979]), it is consistent with traditional medical sociology. Specifical-
ly, this approach defines physical health from the perspective of the medical
model (Williams and Wilkins, 1972), social health from the capacity for task and
role performance perspective of Parsons (1951, 1972), and psychological health
from the general happiness perspective of the individual (Gurin et al., 1960).
Moreover, it reflects the labelling effects of the evaluators along the three dimen-
sions (cf. Freidson, 1970).
Following Twaddle (1974), Wolinsky assumes that perfect health is an ideal,
and that we are actually concerned with normal health. Accordingly, health and
illness are recognized as a continuum, with a continuous range of values between
the extremes. For conceptual simplicity, however, Wolinsky dichotomizes the
continuous range of each of the three dimensions into well and ill. Again, for
conceptual simplicity, he assumes that each of the dimensions (the physical, the
psychological, and the social) are approximately equal in terms of their contribu-
tions toward defining an individual's health status. Cross-classifying the three
dichotomized dimensions of health produces eight health states. The composition
of these eight health states are found in Table 1 along with their tentative labels
(for a more detailed discussion of these health states and hypothetical examples
of individuals inhabiting them, see Wolinsky, 1980a:86-93). Wolinsky argues
that each dimension contributes its own, unique contribution toward an indi-
Health Status Measures 609
Table 1. The Composition of the Eight Health States
Psychological Physical Social

Health State Label Dimension Dimension Dimension
1 Normally well well well well

2 Pessimistic ill well well
3 Socially ill well well ill
4 Hypochondriacal ill well ill
5 Physically ill well ill well
6 Martyr ill ill well
7 Optimistic well ill ill
8 Seriously ill ill ill ill
vidual's overall health statu

occur when the individual is
Therefore, an individual's h
three dimensions are incor
either in the form of a singl
ing the eight theoretical healt
Based on Wolinsky's three
dimensions of health have
causal sense) on each other
dimension are likely to bri
other dimensions in subseq
literaturesupports this inter
to the much replicated wor
collection by Dohrenwend
of the sequential appearanc
accomplished. In the prese
among the three dimension
feedback loop wherein the h
(based on interfacing the s
relationship between socio
1980a; Wolinsky and Wol
interface).
From this three dimensional configuration and our interpretation of the inter-
relationships among the three dimensions, we assume that (1) the comprehensive
summary measure of health status may be obtained by combining reliable and
valid measures of physical, psychological, and social well-being, and, (2) the set
of discrete measures may be constructed by applying the algorithm explicit in
Table 1 to these same reliable and valid measures of the physical, psychological,
and social dimensions. The present paper is devoted to these tasks. First, we will
construct separate measures of the social, psychological, and physical dimen-
sions of health status, and assess their reliability and validity. Second, we will
combine these separate measures into both the summary and discrete compre-
hensive health status measures and assess their reliability and validity. Finally,
we will assess severally the utility of the summary and discrete comprehensive
health status measures in predicting health service utilization, comparing and
contrasting the utility of both approaches as well as their theoretical implications.
Methodology
Data on 500 respondents were gathered through personal interviews conducted

during the Spring of 1978 in a rural North Carolina county. The design employed
a multi-stage area-probability sample into which thirty-two of the county's eighty-
nine census enumeration districts were selected. Sex, age, and race quotas based
on 1975 Census data were imposed at the final stage, with interviewers assigned
randomly selected households as starting points. From there, interviewers pro-
ceeded in a randomly predetermined fashion to identify the first households
which contained the appropriate individuals necessary to fill their quotas. An
intensive series of call-backs was used, resulting in a 100 percent completion rate.
Accordingly, the sample is representative of the noninstitutionalized, nonstudent
population aged twenty-one years or more.
Measuring Physical Health. Although the most accurate measure of the physi-
cal dimension of health status would be a physician's examination, both the fiscal
constraints of this project and other logistical problems prohibited the use of such
techniques. Therefore, the Kisch et al. (1969) Health Status Proxy was em-
ployed, as modified by Carlton and Miller (1971). Kisch et al. (1969) have
shown the Health Status Proxy measure to be both reliable and valid when com-
pared to the criterion of subsequent physician examinations. The Health Status
Proxy measure is based on four questions, two tapping acute conditions and two
tapping chronic conditions. The acute side of the physical health dimension is
determined by the number of nonobstetrical hospitalized days during the past
twelve months, as well as the respondent's answers to a severity-stratified check-
list of acute conditions. The chronic side is determined by the dosage-stratified
number of pharmaceuticals (except "the pill" or vitamins) taken continuously
for one month or more during the past year, as well as the respondent's answers
to a severity-stratified checklist of chronic conditions. According to Kisch et al.
(1969) individuals are in perfect physical health if their score is zero, with high
scores indicating poorer physical health.
Measuring Social Health. Based on Parsons' (1951) original conception of

health as the optimum capacity to perform social roles and tasks, Fanshel and
Bush (1970) identified eleven states along a continuum of the ability to function
socially. In subsequent works, Bush and his associates (Patrick et al., 1973;
Kaplan et al., 1976) focused on role activity, mobility, and body movement,
which Reynolds et al. (1974) have refined into the well-validated Function Status
Index. The present paper uses the two short-form measures of the Reynolds et al.
(1974) activity and mobility scales commonly employed in the Health Interview
Surveys (HISs) of the National Center for Health Statistics (NCHS). These
short forms assess the extent to which the respondent's major role activity and
normal mobility are limited as a result of health conditions.
Measuring Psychological Health. The psychological dimension of health has

been measured in two ways, both of which are based on what has come to b
known as the "global happiness" question (Gurin et al., 1960). The first measur
is the standard subjective measure of health status used in the NCHS-HISs, a
well as in most health care surveys. This measure asks respondents to rate thei
health by means of four categories: excellent, good, fair, and poor. The secon
measure is an experimental feeling-thermometer with which respondents ar
asked to place themselves along a health scale on which 100 percent represent
perfect health, and 0 percent represents very poor health.
Reliability and Validity for Each Dimension

The means and standard deviations of all of the variables employed in the d
mensional analyses may be found in Table 2. To enhance the clarity of th
presentation, the variables are positioned beneath the theoretical constructs fo
which they are operational indicators, along with their specific coding algorithms.
Physical Health Scale. As previously mentioned, a modified version of the

Kisch et al. (1969) Health Status Proxy measure was used as the operational in
dex of physical health. The Proxy score taps both acute and chronic condition
The chronic conditions are measured by chronic drug use and the response to
severity-stratified chronic conditions checklist. The acute conditions are mea-
sured by nonobstetrical hospitalized days and the response to a severity-stratified
checklist of acute conditions. Table 3 shows the correlation matrix for the four
indicators. As can be seen, the intercorrelations involving the hospitalization
measure are rather low. Nonetheless, the overall reliability of the physical health
scale using Cronbach's alpha (as calculated from Nunnally's [1967:193] equation
6-18) is .55. While this may seem low, we hasten to point out that it has been
attenuated artificially in the process of merging the 112 questions from the check-
list into the two checklist totals (i.e., by reducing "k" in Nunnally's equation 6-18
from 114 items to 4 items, the denominator of coefficient alpha is increased, re-
sulting in a significant decrease in the value of coefficient alpha).
The validity of the physical health scale has been established by Kisch et al.
(1969) and by Carlton and Miller (1971). These authors have demonstrated
that the physical health scale correlates well with the criterion measure of a physi-
cian examination. In addition to this criterion validation, the physical health
scale also meets the requirements for content validity, in terms of both face and
sampling requirements. The construct validity of the physical health scale has
also been established by its empirical correspondence to existing theoretical
models of health service utilization.
Social Health Scale. In this study, social health is measured using the short
forms of the limited activity and mobility scales. The correlation coefficient be-
tween these two measures is .39, indicating that Cronbach's alpha is .56 (in the
special case of a two item scale, Nunnally's [1967: 193] equation 6-18 for Cron-
bach's alpha reduces to rkk X, where r, is the correlation between the two
bachs apha edues t rk --1 + -r~~
Table 2. Means, Standard Deviations, and Coding of the Variables
Standard
Variable Response Coding Mean Deviation
Physical Health
Non-Obstetrical Number of days plus 4 (if any) 1.7260 6.8531
Hospitalization
days during the
past year
Chronic drug use 10 points each for daily use; 5.8595 12.3582
during the past 5 points each for occasional
year use
Acute conditions 2, 5, or 10 points for each 14.8195 29.7606

(a 58 item condition checked, based on
checklist) the condition's severity
Chronic condi- 2 or 4 points for each 10.6852 12.5808
tions (a 54 item condition checked, based on
checklist) the condition's severity
Social Health
Limited Activity 0. cannot perform usual 2.5631 0.9192
activities
1. can perform usual
activities, but limited
in kind and amount
2. can perform usual
activities, but limited
in outside activities
3. not limited
Limited Mobility 0. confined to bed 4.7889 0.8346

1. confined to house
2. need help of another
person in getting around
3. need help of a special
aid in getting around
4. have trouble in getting
around alone
5. not limited
Psychological Health
Subjective Health 1. poor 3.0060 0.8715
(How would you rate 2. fair
your health?) 3. good
4. excellent
Feeling Thermometer 0 percent (very 76.9080 23.0347

(Where would you place poor health)
yourself on this through 100 percent
health scale?) (perfect health)
Table 3. Correlation Matrix for the Physical Health Scale
Drug Hospitali- Acute Chronic

Use zation Conditions Conditions
Drug Use 1.00

Hospitalization .20 1.00
Acute Conditions .10 .06 1.00
Chronic Conditions .34 .09 .21 1.00
items). While this is lower than desirable,

reliability coefficient has been attenuated
(single summary questions) have been de
shown to be reliable (Reynolds et al., 19
The criterion and construct validity of
onstrated in the work of Reynolds et al
dated scales of Fanshel and Bush (19
Kaplan et al., 1976). These authors have
(from which the present short form soc
able and valid measures of Parsons' (195
health.
Psychological Health Scale. To measu

standard subjective health status measure (
fair, good, or excellent), and a new fee
with responses ranging from 0 percent
the two measures is .73, indicating Cron
level of reliability for an exploratory two-
Although the reliability of the psychol
establish, there has been very little effort
In fact, the validation of psychological h
gressed beyond content validity (cf. Br
however, the psychological health scale c
physical health scales, providing tentative
absence of an acceptable criterion measur
lishing the criterion validity of the psycho
Constructing the Single Summary Measu
After standardizing all of the items and su

sions, and then multiplying the physica
-1 (so that all high [positive] scale score
tive] scale scores indicate illness), the d
ponents factor analysis with oblique rotati
tation we expected to identify three rela
rotation), one for each health status dim
(1979) suggestion that a general health
in addition to the WHO's three specified
to allow for the identification of up to four principal factors. Table 4 contains

the resulting factor pattern.
As Table 4 indicates, the emergent factor pattern is generally consistent with
our theoretical expectations. The italicized factor loadings highlight the substan-
tively significant clusters of items for each of the four factors. Based on these
factor loadings we have labelled factor one as psychological health, factor two as
social health, factor three as self-reported physical health conditions, and factor
four as legitimized physical health conditions. Labelling the factors is a rather
direct process, although we had not expected self-reported physical health con-
ditions and legitimized physical health conditions (both items loading on the lat-
ter factor reflect physician validation of the sick role) to emerge as separate
factors. This is, however, consistent with Brook et al.'s (1979) findings. Overall,
then, the factor analysis generally verifies the expected factor pattern among the
items, suggesting construct validation for the three dimensional approach in
general.
To construct the single summary measure of health status, scale scores were
constructed for the physical, social, and psychological dimensions, these scale
scores were standardized, and then the standardized scale scores were summed.
The resulting inter- and corrected item-total correlations are shown in Table 5.
As Table 5 indicates, the lowest inter-item correlation (.32) is between the
Table 4. Factor Pattern of the Health Items
Factor
1 2 3 4
Self-reported Legitimized
Health Psychological Social physical physical
Item health health conditions conditions
Chronic drug use -.02 .19 .01 .66

Hospitalization days .04 -.09 .01 .33
Acute conditions -.01 .02 .53 --.01
Chronic conditions .29 .01 .23 .19
Limited activity .17 .46 -.06 .29
Limited mobility .06 .59 .07 -.06
Subjective health .82 .01 .07 .00
Feeling thermometer .88 .09 --.10 -.03
Table 5. Inter- and Corrected Item-Total Correlat
Physical Social Psychological Corrected

Health Health Health Item - Total
Scale Scale Scale Correlation
Physical Health Scale 1.00 .46

Social Health Scale .32 1.00 .50
Psychological Health Scale .47 .53 1.00 .61
physical and social dimensions of health, while the highest inter-item correlation
(.53) is between the psychological and social dimensions. Among the item-total
correlations the pattern is similar with the psychological dimension having the
highest (.61) correlation, while the physical dimension has the lowest (.46).
Turning to the reliability of the summary measure, we find it to be quite re-
liable for a newly developed scale, having a Cronbach's alpha of .70. As with the
reliabilities of the measures of the three dimensions, the reliability of the sum-
mary item is attenuated artificially because only the three dimensional scale
scores are added together, not the numerous individual questions which compose
them. Accordingly, achieving an alpha of .70 with a three item scale demon-
strates substantial reliability.
For the most part, the validity of the summary measure has already been
demonstrated. To the extent that one accepts the content validity of the dimen-
sional measures of physical, social, and psychological health presented above, the
summary measure's content validity is also accepted. To some extent, criterion
validity has been demonstrated in that one dimension of the summary measure
(physical health) correlates quite well with the only known dimensional criterion
measure: physician examinations. Because the other two dimensions of the sum-
mary measure correlate rather well with but do not load on the physical dimen-
sion, they too must be related to that criterion measure. The construct validity of
the summary measure has, in part, already been supported by the principal com-
ponents factor analysis. It will be examined further in a subsequent section of
this paper where the summary measure and the set of dummy variables measur-
ing the eight theoretical health states are severally used to predict health service
utilization.
Constructing the Discrete Comprehensive Measures
Using the standardized scores for the physical, social, and psychological health
scales, the set of discrete comprehensive measures was constructed according to
the algorithm explicit in Table 1. If an individual's standardized score on any of
the three health dimension's scales was greater than or equal to zero, he or she
was considered to have a well evaluation on that dimension. If individuals' stan-
dardized scores on any of the three health dimension's scales were less than zero,
they were considered to have an ill evaluation on that dimension. Computer
routines were used to compile individuals' health status (well or ill) along all
three health dimensions, to identify the overall discrete comprehensive health
state to which they belonged, and finally to construct the set of dummy variables
for the eight theoretical health states. Table 6 shows the frequency distributions
that result for each of the eight health states.
As the data in Table 6 indicate, nearly half (48.3 percent) of all the indi-
viduals were classified as normally well (having well evaluations on all three
dimensions). Only 13.2 percent were classified as seriously ill (having ill evalua-
tions on all three dimensions). With the exception of the pessimistic (11 per-
cent) and the physically ill (11.5 percent), no other health state was occupied
by more than 8 percent of the sample. These data indicate that 61.5 percent of
the sample (the normally well and the seriously ill) had consistent evaluations
on all three dimensions, while 24.7 percent have two well evaluations (the pessi-
Table 6. Frequency Distributions of the Discrete Health States
Adjusted
Health State Label Frequency Percentage*
1 normally well 172 48.3
2 pessimistic 39 11.0
3 socially ill 8 2.2
4 hypochondriacal 14 3.9
5 physically ill 41 11.5
6 martyr 27 7.6
7 optimistic 8 2.2
8 seriously ill 47 13.2
Totals 356* 100%
*144 cases had missing data on one or more
mistic, socially ill, and physically

(the hypochondriacal, martyrs, a
the sample are well on at least two
Assessing the Utility of the Co
To assess the utility of the compre

were used to predict six differen
(1) the volume of physician visit
(3) contact, (4) volume measur
dentist utilization, and (6) the in
model, health service utilization
bling characteristics of the indiv
were age, race, sex, occupation, edu
dren in the family. The enabling
veteran's status (as an insurance c
the home (permitting telephone c
and Blue Shield coverage. (The co
and illness-morbidity characteristi
specified by Andersen and his c
algorithms for the utilization meas
cause of space limitations.) In the
dicted by the same predisposing
plus four traditionally coded indica
vidual, including: limited mobilit
the weighted index of chronic con
utilization from the same predispo
mary comprehensive measure of h
utilization is predicted by the same
the set of dummy variables meas
Table 7 indicates the utility (R2) o
of the six types of health service
troduced into the analyses as a result of using hospitalization experience a

of the four subscales comprising physical health, the coefficients reported in T
bles 7 and 8 were recalculated using an algorithm excluding the hospitaliza
experience subscale. Comparing the recalculated coefficients with those rep
in Tables 7 and 8 reveals no substantive differences. Accordingly we are confid
that the coefficients reported in Tables 7 and 8 are accurate estimates of
underlying structural parameters.
The upper panel of Table 7 contains the explained variances (R2) obtained
each model with each utilization measure, and the lower panel contains th
sults obtained from testing three hypotheses concerning the utility of the
models in predicting the six types of health service utilization. The first hypot
sis was that the utility of model 3 would be greater than the utility of mo
Table 7. The Utility (R2) of Models With Different Health Status Measur
In Predicting Different Types of Health Service Utilization
Utilization
Model* Physician Hospital Dentist
Interval' Volume2 Contact:, Volum

Model 1:
P + E .041 .044 .023 .032 .096 .175
Model 2:
P + E + IM .126 .164 .034 .054 .110 .177
Model 3:
P + E + He .135 .200 .065 .156 .099 .176

Model 4:
P + E + Hs .232 .302 .081 .103 .111 .218

..................................................................................
Hypothesis 1:
R2 > R2, Yes Yes'** Yes** Yes** No** No
Hypothesis 2:
R2. > R2, Yes** Yes** Yes** Yes** Yes Yes**
Hypothesis 3:
R2'4 > R23 Yes** Yes** Yes** No** Yes** Yes**
* Legend
P = Predisposing characteristics
E = Enabling characteristics
IM = Traditional illness-morbidity (health status) measures
H, = Continuously coded comprehensive health status measure
H8 = Set of dummy variable health state measures
Yes = Hypothesized effects observed
** = Significant at the .05 level
1 Interval since the last visit to a physician
2 Number of visits to a physician in the past 12 months.
': Was the respondent hospitalized in the past 12 months.
4 Number of hospitalized days in the past 12 months.
. Number of visits to a dentist in the past 12 months.
6 Interval since the last visit to a dentist.
Table 8. Partialled Metric Regression Coefficients of the Discrete Health Status

Measures on the Different Types of Health Service Utilization
Utilization
Discrete Physician Hospital Dentist

Health
States Intervalt Volume2 Contact3 Volume4 Volume. Interval6
(1) Normally Well - -
(2) Pessimistic - .26 .81 .10 -.12 .14 .50
(3) Socially Ill - 1.07 1.07 .03 .18 1.33 - 1.31
(4) Hypochondriacal -1.08 2.39 -.03 .31 -.20 .02
(5) Medically Ill - 1.14 2.24 .13 .75 .28 - .04
(6) Martyr - 1.09 3.04 .45 4.64 .05 - .05
(7) Optimistic - .84 1.82 .20 3.58 -.24 .78
(8) Seriously Ill - 1.40 3.63 .19 4.24 .43 - .14
1 Interval since the last visit to a physician.

2 Number of visits to a physician in the past 12 months.
3 Was the respondent hospitalized in the past 12 months.
4 Number of hospitalized days in the past 12 months.
5 Number of visits to a dentist in the past 12 months.
6 Interval since the last visit to a dentist.
The second hypothesis was that the utility of model 4 would be greater than the
utility of model 2. Hypotheses 1 and 2 reflect the assumption that either of the
comprehensive measures of health status (summary or discrete) will provide a
better measure of health status than traditional measures, resulting in a better pre-
diction of health service utilization. Hypothesis 3 assesses whether or not the sim-
ple additivity and equality assumptions of the summary measure are correct, or
whether each of the eight theoretical health states represents a unique (discrete)
health status. If the eight health states are unique, then the utility of model 4 will
exceed the utility of model 3.
As the data in Table 7 indicate, hypothesis I is supported in more cases than
it is rejected (the utility of models 2 and 3 are approximately the same for the
dentist interval measure). Hypothesis 2 is accepted for all six tests of the model.
Hypothesis 3 is also accepted for all tests of the model, except for the hospitali-
zation volume measure. Taken together, these data demonstrate (1) that the
comprehensive measures of health status are better measures (in that they have
greater utility in predicting health service utilization) than the more traditional
and unidimensional measures, and (2) that the discrete comprehensive measures
have greater utility than the summary comprehensive measure. Moreover, exam-
ining the magnitude of the explained variances reveals that especially for the dis-
crete comprehensive health status measures the increments to R2 are considerable.
This is especially true for the physician utilization measures, where the R2 is in-
creased from .126 for the interval measure and .164 for the volume measure
(which is quite consistent with the utility of generic access models applied to
national data, as reported by Wolinsky, 1978), to .232 and .302, respectively. In
fact, the 30 percent explained variance for the physician volume measure is one
of the largest ever reported in an application of the generic access model. That
the largest increments to R2 occur for physician utilization measures is consistent

with the fact that physician utilization is much more likely to be patient-initiated,
and thus much more likely to be affected by the individual's comprehensive health
status than is hospital utilization. Further, because even comprehensive health
status is not likely to be very closely related to dentist utilization, the increments
to R2 for dentist utilization should also be small, and they are. These findings are
further evidence of the construct validity of the comprehensive measures.
Because of the considerable amount of support demonstrated for Hypothesis 3,
a further analysis of the simple additivity and equality assumptions inherent in
the summary comprehensive measure is warranted. To assess these assumptions
at the same time (i.e., that each dimension contributes equally and that the three
dimensions contribute additively to the individual's overall health status), we
need only to compare the partialled metric regression coefficients of the discrete
health status measures on health service utilization. Under the simple additivity
and equality assumptions we expect (1) the effects of any health states with any
one ill evaluation and any two well evaluations will be the same, (2) the effects
of any health states with any two ill evaluations and any one well evaluation will
be the same, (3) the effects of any health states with any two ill evaluations will
be equal to the effects of any two health states with any one ill evaluation each,
and (4) the effect of health state 8 (with three ill evaluations) will be equal to
the effects of any combination of health states having three ill evaluations. As-
suming that the partialled metric regression coefficient for health state 1 is b,
(and b2 through b8 for health states 2 through 8), these expectations may
be expressed as: (1) b2 = b3 = b,; (2) b, = b- = b7; (3) b4 = b6 = b7 = 2(b2
or b, or bs) =b2 + b3 = b3 + b5 b2 -+ bs; and (4) b8 = 3(b2 or b3 orbs) =
1.5(b, or b6 or b,). Table 8 contains the partialled metric regression coefficients
necessary to assess these expectations. A visual inspection of the coefficients in
Table 8 indicates that the simple additivity and equality assumptions do not hold.
(A statistical analysis of the partialled metric regression coefficients using chi-
squared tests yields similar results but is not presented here because of space limi-
tations.) For example, in column one (the interval measure of physician utilization
b2= = b3 although b3 = b, b8 =/ 3(b2 or b3 or b,), and (b, or b6 or b,) -= 2(b2 or
b3 or b5). In columns two through six the disequalities are even more marked.
Accordingly, these data demonstrate that the discrete comprehensive health sta-
tus measures have more utility or clarity than the single summary measure. Sub-
sequent papers will assess severally the equality and additivity assumptions in
greater detail (Wolinsky, 1980b), and will also explore and identify the distinct
behavioral patterns associated with the inhabitants of each of the eight theoretical
health states (Wolinsky and Wolinsky, 1980).
Discussion
Although these data provide considerable support for the comprehensive health
status measures presented herein, there are two caveats that warrant further dis-
cussion. The first caveat deals with the problem of measurement error. Although
the scales used to measure the three dimensions of health have all been used be-
fore, and although we have been able to demonstrate their reliability and validity,
there is still room for improvement (cf. Brook et al., 1979). For example, al-
though the Kisch et al. (1969)Health Status Proxy is a good measure of the phy-
sical dimension of health, it has one potentially serious drawback. That drawback
is that the Kisch et al. (1969) measure requires respondents not only to recall
their symptoms, but also to be able to associate those symptoms with their cor-
responding medical conditions. Such a procedure may not be well-suited for use
in areas with relatively low educational levels, where respondents would have
greater difficulty in associating symptoms with the appropriate medical condi-
tions. Accordingly, a physical health scale which requires only symptom report-
ing (such as the Symptoms-Response-Ratio constructed by Taylor et al., 1975)
might be a more suitable measure.
Another aspect of the measurement problem is that only the short forms of
the limited activity and mobility scales were used. Although these short forms
are widely used and have been shown to be reliable and valid, the more precise
longer versions developed by Reynolds et al. (1974) might produce more varia-
tion between respondents. This would reduce the measurement error imposed by
using discrete rather than continuous scaling. Similarly, although the feeling
thermometer of psychological health represents an improvement over the tradi-
tional subjective health status measure, a multiple item psychological health scale
including more emotive items might increase its discriminating power.
The second caveat is related to the specific character of the present sample.
While the sample is, in fact, representative of the population in the county, the
county is predominantly a rural one. Rural residents (especially farmers) have
traditionally tended to overrate their health as long as they are physically capable
of working. To the extent that there is a different conceptualization or intuitive
meaning of health among rural residents, the results reported here may be atypi-
cal of the national population. Unfortunately, the data at hand do not allow us to
assess this possibility.
Despite these two caveats, an important implication has emerged from the con-
struction and application of the comprehensive health status measures. Although
either of the comprehensive health status measures significantly increased our
ability to predict health service utilization, the set of discrete health state mea-
sures showed much more utility than the summary measure. In fact, the simple
additivity and equality assumptions underlying the summary measure were
shown to be false (when considered together). This suggests that future research
on comprehensive health status measures should focus on the unique nature of
the different combinations of the three dimensions of health status, rather than
on the pursuit of a single summary measure. Finally, the magnitude of the incre-
ments to the explained variances of the models predicting health service utiliza-
tion clearly demonstrates the considerable utility of the general comprehensive
health status measurement approach.
REFERENCES
Aday, LuAnn, Ronald Andersen, and Gretchen Fleming. 1980. Health Care in the United S
for Whom? Beverly Hills: Sage Publications.
Beiser, Morton. 1974. "Components and correlates of mental well-being." Journal of Health and Social
Behavior 15:320-27.
Brook, Robert, John Ware, Jr., Allyson Davies-Avery, Anita Stewart, Cathy Donald, William Roge
leen Williams and Shawn Johnston. 1979. "Overview of adult health status measures fielded in Rand's health
insurance study." Medical Care 17 (7 supplement):1-131.
Carlton, Charles and Ron Miller. 1971. "Kisch's health status proxy: two suggested improvements." Health
Services Research 6:184-86.
Chen, Martin K. (ed.). 1976. "Health status indexes: work in progress." Special Issue. Health Services Re-
search 11:330-528.
Dohrenwend, Bruce and Barbara Dohrenwend (eds.). 1974. Stressful Life Events: Their Nature and E
New York: Wiley.
Fanshel, S. and J. W. Bush. 1970. "A health-status index and its application to health service outcomes."
Operations Research 18:1021-66.
Freidson, Eliot. 1970. The Profession of Medicine. New York: Dodd, Mead.
Gurin, Gerald, Joseph Veroff, and Sheila Field. 1960. Americans View Their Mental Health. New York:
Basic Books.
Holmes, T. H. and R. H. Rahe. 1967. "The social readjustment rating scale." Journal of Psychosoma
search 11:213-18.
Kaplan, Robert M., J. W. Bush, and Charles C. Berry. 1976. "Health status: types of validity and th
of well-being." Health Services Research 11:478-507.
Kisch, Arnold, Joel Kovner, Leona Harris, and George Kline. 1969. "A new proxy measure for health sta-
tus." Health Services Research 4:184-86.
Nunnally, Jum C. 1967. Psychometric Theory. New York: McGraw-Hill.
Parsons, Talcott. 1951. The Social System. New York: Free Press.
. 1972. "Definitions of health and illness in the light of American social structure." Pp. 97-117 in
E. G. Jaco (ed.), Patients, Physicians, and Illness. 2d ed. New York: Free Press.
Patrick, Donald L., J. W. Bush, and Milton M. Chen. 1973. "Toward an operational definition of health."
Journal of Health and Social Behavior 14:6-23.
Reynolds, Jeff W., William A. Rushing, and David L. Miles. 1974. "The validation of a function status in-
dex." Journal of Health and Social Behavior 15:271-88.
Rogers, Paul. 1976. Introduction. In A Discursive Dictionary of Health Care. Washington, D.C.: United
States Government Printing Office.
Selye, Hans. 1956. The Stress of Life. New York: McGraw-Hill.
Stewart, A. L., J. E. Ware, Jr. and R. B. Brook. 1977. "The meaning of health: understanding functional
limitations." Medical Care 15:939-52.
Taylor, D. Garth, LuAnn Aday, and Ronald Andersen. 1975. "A social indicator of access to medical care."
Journal of Health and Social Behavior 16:39-49.
Twaddle, Andrew. 1974. "The concept of health status." Social Science and Medicine 8:29-38.
Williams and Wilkins. 1972. Stedman's Medical Dictionary, 22d ed. Baltimore: Williams and Wilkins.
Wilson, Robert N. 1970. The Sociology of Health. New York: Random House.
World Health Organization. 1958. The First Ten Years of the World Health Organization. Geneva: The
World Health Organization.
Wolinsky, Fredric D. 1978. "Assessing the effects of predisposing, enabling, and illness-morbidity charac-
teristics on health service utilization." Journal of Health and Social Behavior 19:384-96.
1980a. The Sociology of Health: Principles, Professions, and Issues. Boston: Little, Brown.
. 1980b. Assessing the effects of the physical, psychological, and social dimensions of health on heatlh
service utilization. Working paper, Center for Health Services Research and Development, American Medical
Association.
Wolinsky, F.D. and S.R. Wolinsky. 1980. Background, attitudinal, and behavioral patterns of individuals
occupying eight discrete health states. Sociology of Health and Illness. In Press.

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Toward Comprehensive Health Status Measures

Author(s): Fredric D. Wolinsky and Marty E. Zusman

Toward Comprehensive Health Status Measures*

. . there is a diversity of opinion among authors or designers of health status indexes

01980 by The Sociological Quarterly. All rights reserved. 0038-0253/80/ 1500-0607$00.75

Toward a Three Dimensional Conception of Health

Table 1. The Composition of the Eight Health States

Psychological Physical Social

1 Normally well well well well

vidual's overall health statu

Data on 500 respondents were gathered through personal interviews conducted

Measuring Social Health. Based on Parsons' (1951) original conception of

Measuring Psychological Health. The psychological dimension of health has

Reliability and Validity for Each Dimension

Physical Health Scale. As previously mentioned, a modified version of the

Table 2. Means, Standard Deviations, and Coding of the Variables

Acute conditions 2, 5, or 10 points for each 14.8195 29.7606

Limited Mobility 0. confined to bed 4.7889 0.8346

Feeling Thermometer 0 percent (very 76.9080 23.0347

Table 3. Correlation Matrix for the Physical Health Scale

Drug Hospitali- Acute Chronic

Drug Use 1.00

items). While this is lower than desirable,

Psychological Health Scale. To measu

Constructing the Single Summary Measu

After standardizing all of the items and su

to allow for the identification of up to four principal factors. Table 4 contains

Table 4. Factor Pattern of the Health Items

Chronic drug use -.02 .19 .01 .66

Table 5. Inter- and Corrected Item-Total Correlat

Physical Social Psychological Corrected

Physical Health Scale 1.00 .46

Constructing the Discrete Comprehensive Measures

Table 6. Frequency Distributions of the Discrete Health States

*144 cases had missing data on one or more

mistic, socially ill, and physically

Assessing the Utility of the Co

To assess the utility of the compre

troduced into the analyses as a result of using hospitalization experience a

Model* Physician Hospital Dentist

Interval' Volume2 Contact:, Volum

P + E + He .135 .200 .065 .156 .099 .176

P + E + Hs .232 .302 .081 .103 .111 .218

Table 8. Partialled Metric Regression Coefficients of the Discrete Health Status

Discrete Physician Hospital Dentist

1 Interval since the last visit to a physician.

the largest increments to R2 occur for physician utilization measures is consistent

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