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This paper reviews the author's experience in becoming a medical sociologist before the field had become formalized. The contributions to medical sociology of sociologist Selden D. Bacon and physician and medical educator William R. Willard are described. The relationship of medical sociology to medical behavioral science, as experienced at the University of Kentucky, is discussed. Finally, the thesis of the author's 1957 paper on the nature and status of medical sociology is re-examined. [ABSTRACT FROM AUTHOR]

The introduction to this special issue of the Journal expands the scope of research on "the sociology of medical education" to include studies of the institutions in which physicians are trained as well as studies of the socialization of the physician throughout the life cycle. Research since the 1960s is reviewed briefly and the papers in this issue are discussed. Studies of the macropolitics and micropolitics of academic medicine are called for as well as comparative analyses of the settings in which physicians are trained and research on the relative effects on physicians' attitudes and behavior of different sets of experiences, professional and nonprofessional, over the course of their life cycle-all in the context of massive changes in the organization of health care. [ABSTRACT FROM AUTHOR]

Over the last 25 years, national Health Maintenance Organization (HMO) and hospital firms attempted to enter local markets, either by acquiring formerly independent, locally based HMOs and hospitals or by directly entering local markets. While national HMOs have been relatively successful, national hospital firms have had much less success. This paper explores the reasons for this difference. It reviews changes in presence of national HMO and hospital firms in markets, discusses common conceptual lenses through which national entry into local markets typically has been viewed, and shows how social network theory can be used to develop a better understanding of why the entry experience of national HMO and hospital firms varies across markets. The paper concludes with a research agenda that addresses issues raised by social network theory and its application to national firm entry into local markets. [ABSTRACT FROM AUTHOR]

Drawing from an institutional-theory perspective on innovations in organizations, this paper examines the use of human immunodeficiency virus (HIV) prevention practices by the nation's outpatient substance abuse treatment units during a critical period from 1988 to 1995. An institutional perspective argues that organizations adopt new practices not only for technical reasons, but also because external actors actively promote or model the use of particular practices. We examine the extent to which treatment units use several practices to prevent HIV infection among their clients and among drug-users not in treatment. Results from random-effects regression analyses of national survey data show that treatment units significantly increased their use of HIV prevention practices from 1988 to 1995. Further, the results show that treatment units' use of prevention practices was related to clients' risk for HIV infection, unit resources available to support these practices, and organizational support for the practices. Implications are discussed for an institutional view of organizational innovation as well as for research on HIV prevention. [ABSTRACT FROM AUTHOR]

Drawing from theory on institutionalized organizational environments, this paper analyzes the actions of community-based service programs providing care for people with AIDS. The focus is on the interorganizational relations developed by the lead agencies in demonstration projects attempting to coordinate services in three communities. The paper identifies differential styles of organizational response to developmental and operational issues. These differences are related to the conceptual distinction between organizational responses to technical environments and those to normative, or "institutional," environmental features. Various factors are identified that appear to promote a higher degree of institutionalization in interorganizational relations. Coordination as a reform strategy is seen to have become, in itself, an institutionalized myth to which organizations must subscribe in order to gain legitimacy. [ABSTRACT FROM AUTHOR]

This paper probes two aspects of the medical profession in Singapore: its structure and its social position. The first section reviews the relevant concepts concerning the structure and the social position of the professions that may be applied to medicine in Singapore. The second section looks into the structure of the medical profession in Singapore from an historical perspective. The third section deals with the internal organization of the medical profession. The fourth section focuses on its social position. The paper concludes with a summary of the main points and a brief comparison of the situation in Singapore with that in other countries. [ABSTRACT FROM AUTHOR]

Emphasis on rural health problems has led to a relative neglect of urban health issues in developing societies. Yet the fact that a large proportion of the limited financial and human resources is allocated to urban health care makes it imperative for researchers and health planners to evaluate the effectiveness of the urban health care system. This paper examines data on health care utilization from a sample survey of 1500 households conducted in three areas of Accra, Ghana in 1982. The factors that influence the use of three types of health care services (clinics, drug vendors, and traditional healers) are examined. Suggestions are made for increasing the effectiveness of the health care system in Accra, with the aim of making medical care more accessible to all families. [ABSTRACT FROM AUTHOR]

This is a "state of the issue" paper about gender and physical health. It organizes the hypotheses proposed for male-female differences in physical health status, therapeutic health behaviors, and longevity and it summarizes empirical research, especially sociological research, on the topic over the past 10-15 years. Capsule summaries of sex differentials in health and of recent trends in health and morality are also presented for American (U.S.) men and women. The central theoretical viewpoint of this paper is that sex differences in health are principally the outcome of differential risks acquired from roles, stress, life styles, and preventive health practices. Psychosocial factors—how men and women perceive and evaluate symptoms, and their readiness and ability to take therapeutic actions—are important as well, but typically secondary to acquired risks. Other factors such as prior health care, biological risks, health reporting, and caretaker effects (for example, physician sex bias) have even smaller importance. We hypothesize that the relative weight of acquired risks and psychosocial factors varies for different types of health problems as follows: (1) Psychosocial factors have their greatest weight in responses to chronic, nonfatal, or low severity diseases and injuries and (2) gender differences are also greatest in responses to these; that is, men and women differ more in their perception, evaluation, and treatment of prolonged, mild conditions than of acute, life-threatening, or severe ones. The paper suggests some strategies for social science research on male-female health differences in the next decade or two. [ABSTRACT FROM AUTHOR]

The proposition that medical treatment decisions can be modified by altering the structural conditions of medical practice has been advanced, but seldom demonstrated empirically. This paper examines the structural conditions under which obstetricians personally opposed to abortion will offer abortion services. Data were obtained in a survey of all private obstetricians practicing in one state during 1975-76. Results of this study indicate that obstetricians with liberal attitudes toward abortion will offer abortion services regardless of the normative structure in which they are located; the treatment decisions of conservative obstetricians, however, are dependent on normative climate. In a practice environment where prevailing professional norms favor abortion, the majority of conservative obstetricians will offer abortion services, despite their personal opposition to this procedure. In an unfavorable climate, however, the behavior of conservative obstetricians is consistent with their attitudes, and relatively few provide abortion services. [ABSTRACT FROM AUTHOR]

The contention that retirement may have an adverse effect on health has become increasingly popular with the recent categorization of this phenomenon as a stressful "life event." The small number of empirical studies examining the health outcomes of retirement, however, appear neither to support nor to refute this hypothesis. Moreover, the serious methodological problems inherent in most of these studies caution against the generalization of findings. o This paper examines the existing research on the health and retirement relationship within the theoretical context of Atchley's process approach to retirement. Recent refinements in the study of life events (e.g., a focus on the timing of the event and the degree of control experienced) are seen as offering important potential contributions both to our understanding of retirement and to the development of more incisive and conceptually sound research in this area. At the same time, the inadequacy of existing life-events scales when applied to an older age group, and the genera/failure to view life changes within a broad sociostructural context are emphasized as weaknesses of the life-events approach that should be taken into account in future research on the complex retirement and health relationship. [ABSTRACT FROM AUTHOR]

This paper empirically examines the reliability and validity of three measures of the health of the elderly: an index measuring the ability to perform the activities of daily living without help (Index of Living Skills), an index measuring functional disability (Shanas's Index of Disability), and an index measuring chronic health conditions (the index subsequently used in the U.S. Health Insurance Study). The data involve a random sample of elderly persons living in Manitoba in 1971. The analyses used -- correlational matrices, factor analyses, internal consistency reliability coefficients, and construct validity -- are reported separately for those living in conventional housing in the community, in subsidized housing, and in institutions providing some form of medical care. The results suggest that the Index of Living Skills measures not one but two underlying constructs (heavy and light tasks), Shanas's Index of Disability is reliable and valid when used among those living in the community and in institutions but not among those in subsidized housing, and the index of chronic conditions is relatively unreliable among all three groups of elderly persons. [ABSTRACT FROM AUTHOR]

Empirical evidence does not support the claim that task delegation to nonphysicians is greater in large medical organizations than in small office practices. Can the behavior of physicians in these organizations he explained through reference to professional attitudes? This paper reports a study which examined simultaneously two sets of variables as predictors of physicians' delegation behavior: (1) paramedical resources available in the organization, and (2) physicians' professional attitudes. A comparison of multiple regression analyses of delegation behavior in traditional work settings and in modern, formally organized settings is presented. In modern settings, in contrast to traditional settings, physicians' delegation behavior was found to be only weakly related to paramedical resources, and it was unrelated to professional attitudes. [ABSTRACT FROM AUTHOR]

This paper has two primary purposes. The first involves the empirical assessment of a general framework for theory and research in health service utilization studies, developed as a modification of Aday and Andersen's (1974) causal structure of access to medical care. My analysis of this framework uses multiple regression techniques on data from a regional cross-sectional survey of 487 households conducted in 1972. The data demonstrate support for the general framework. The second purpose centers around the extant findings that health maintenance organization (HMO) subscribers are less satisfied with their health care than are the conventionally insured. Using the general framework to see what health service utilization characteristics were likely to predispose one to join an HMO, I found that would-be joiners are more likely to be high users of preventive services. Because the main purpose of the HMO is to increase the use of preventive services, and assuming a reasonable rate of diminishing returns of such care, then a "ceiling effect" takes place in which the would-be joiner cannot increase use of preventive care very much, and hence is plausibly and expectably less satisfied with the HMO. [ABSTRACT FROM AUTHOR]

This paper develops hypotheses regarding the impact of select organizational factors on the distribution of service among applicants to health or welfare agencies. It is hypothesized that agencies with more control over exchange with their environments, i.e. more "boundary control," will under conditions of surplus applicants choose to serve smaller and more homogeneous applicant populations. Also, applicants will tend through referral and rejection processes to flow from agencies with high boundary control to agencies with low boundary control. The extensiveness of agency domains is hypothesized to be directly related to both the size of the applicant populations and the number of applicants serviced. Finally, the size of "domain discrepancy" is seen as directly related to the proportion of applicants rejected and referred. The necessity to relate other organizational characteristics to referral and rejection patterns is stressed. [ABSTRACT FROM AUTHOR]

This paper evaluates and describes methods for making psychiatric distinctions. It is by means of psychiatric distinctions that individuals are labeled mentally ill or mentally well. Within the mentally ill category, patients are differentially placed according to the severity and type of their mental illness. The placement of individuals into psychiatric categories is an essential prerequisite not only to the clinical treatment of patients but also to any research where the objective is to determine empirical regularities associated with mental illness. Until the patient is categorized, the practitioner has no logical guide for how to perform treatment or even whether he should treat the patient—i.e, the patient may not be a patient. Similarly, unless the psychiatric researcher has categorized his subjects according to some notion of mental illness he has no way of making comparisons or of assessing change, the two essential processes in research. Thus, the logical first step for arty discovery of new knowledge in the field of mental illness is to appraise the reliability and validity of methods for making psychiatric distinctions. No research findings can be more reliable or valid than the psychiatric distinctions used in carrying oat the research. [ABSTRACT FROM AUTHOR]

Much research has been done in the past fifteen years on the effects of medical education, viewed as professional socialization. Although the significance of social origins, viewed as early sources of socialization, is recognized, there has been little empirical research on the effects of specific background characteristics on specific attitudes, behavior, and careers of professionals. This paper examines the effects of practicing physicians' socioeconomic and religious background on their concern with success values and on their political ideology, including their attitudes toward government participation in medical care. [ABSTRACT FROM AUTHOR]

This paper proposes a theoretical framework and an empirical example of the relationship between the civic stratification of immigrants in the United States, and their access to healthcare. We use the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey, a nationally representative survey of U.S. Latinos (N = 2,783 foreign-born respondents) and find that immigrants who are not citizens or legal permanent residents are significantly more likely to be excluded from care in both the United States and across borders. Legal-status differences in cross-border care utilization persisted after controlling for health status, insurance coverage, and other potential demographic and socioeconomic predictors of care. Exclusion from care on both sides of the border was associated with reduced rates of receiving timely preventive services. Civic stratification, and political determinants broadly speaking, should be considered alongside social determinants of population health and health care. [ABSTRACT FROM AUTHOR]

This article responds to the comments of Edward E. Brent on the article "Processes of Continuity and Change During Socialization for Medicine in Israel," by Judith T. Shuval and Israel Adler, in the 1977 issue of the "Journal of Health and Social Behavior". It seems the Brent misunderstands the nature of correlations and is therefore led to a further nonsensical conclusion. This concerns his criticism of the proposed strategy to induce change. His suggestion that influence should best be exercised over a long period of time is contradicted by the data which show that whatever change is induced at any early time is largely wasted, since it is unlikely to show much carry-over to later times, i.e., correlations between distant times are weak. On the other hand, recency shows that change introduced at any given time is best carried over the next subsequent time.

This paper uses an institutional perspective (Scott, 1994; 2001; DiMaggio and Powell, 1991) to analyze the history and current state of the American health care field in terms of the alignment of its normative, cognitive, and regulatory elements. I depict the relation between institutional elements in each of three historical eras of the health care field (Scott et al 2000): the era of professional dominance (1945-1965), the era of federal involvement (1966-1982), and the era of managerial control and market mechanisms (after 1983 to the present). I argue that a weakening of alignment between these elements, beginning in the 1970s and increasing in the 1980s, led to consumer and provider dissatisfaction with managed care, and that the state of the field in the beginning of the 21st century suggests that a new era is emerging with renewed alignment between normative beliefs and values, cognitive models, and regulation. Implications for the future of health care and institutional theory are discussed. [ABSTRACT FROM AUTHOR]

Over the past decade, different parties in the health care field have developed and disseminated clinical practice guidelines as part of evidence-based medicine. These formal tools based on a scientific evaluation of the research literature purport to tell health care professionals how to practice medicine. Because clinical practice guidelines shift the knowledge base in the health care field through standardization, they remain con troversial within and outside medicine. In this paper, we evaluate the predictive accuracy of four medical professionalization theories-functionalism, Freidson's theory of professional dominance, deprofessionalization theory, and the theory of countervailing powers- to account for (1) the shift from pathophysiology to epidemiology with guidelines, (2) the creation of practice guidelines, and (3) the effects of clinical practice guidelines on the autonomy of health professionals. In light of the mixed predictive record of professionalization theories, we conclude with a need for "evidence-based sociology" and a recalibration of basic premises underlying professionalization theories. [ABSTRACT FROM AUTHOR]

This paper examines the impact of changes in the medical marketplace on medicalization in U S. society. Using four cases (Viagra, Paxil, human growth hormone and in vitro fertilization), we focus on two aspects of the changing medical marketplace: the role of direct-to-consumer advertising of prescription drugs and the emergence of private medical markets. We demonstrate how consumers and pharmaceutical corporations contribute to medicalization, with physicians, insurance coverage, and changes in regulatory practices playing facilitating roles. In some cases, insurers attempt to counteract medicalization by restricting access. We distinguish mediated and private medical markets, each characterized by differing relationships with corporations, insurers, consumers, and physicians. In the changing medical environment, with medical markets as intervening factors, corporations and insurers are becoming more significant determinants in the medicalization process. [ABSTRACT FROM AUTHOR]

The United States is the only western industrialized nation that fails to provide universal coverage and the only nation where health care for the majority of the population is financed by for-profit, minimally regulated private insurance companies. These arrangements leave one-sixth of the population uninsured at any given time, and they leave others at risk of losing insurance as a result of normal lVe course events. Political theorists of the welfare state usually attribute the failure of national health insurance in the United States to broader forces of American political development, but they ignore the distinctive character of the health care financing arrangements that do exist Medical sociologists emphasize the way that physicians parlayed their professional expertise into legal, institutional, and economic power but not the way this power was asserted in the political arena. This paper proposes a theory of stakeholder mobilization as the primary obstacle to national health insurance. The evidence supports the argument that powerful stakeholder groups, first the American Medical Association, then organizations of insurance companies and employer groups, have been able to defeat every effort to enact national health insurance across an entire century because they had superior resources and an organizational structure that closely mirrored the federated arrangements of the American state. The exception occurred when the AFL-CIO, with its national leadership, state federations and union locals, mobilized on behalf of Medicare. [ABSTRACT FROM AUTHOR]

The context for contemporary research and policy is set through a theoretically informed history of the modern American health care system that draws on the concept of countervailing powers and Fligstein's theory of control In this context, the papers of this special issue are then introduced. [ABSTRACT FROM AUTHOR]

Racial inequity in the provision of healthcare is widely recognized. In this paper I assess the role of social distance from healthcare providers in accounting for whites' higher rating of healthcare providers. Using data from the Detroit Area Study, I test whether having higher socioeconomic status, like most healthcare providers, and racial concordance with healthcare provider account for the gap in satisfaction between whites and African Americans. I find that socioeconomic status and racial concordance variables account for a portion of whites' higher rating of the respect shown by their healthcare provider Racial differences in evaluation of time spent with healthcare provider are accounted for by socioeconomic status, but not racial concordance. As researchers explore the causes of and remedies for the racial disparity in use and evaluation of healthcare, the subtle and indirect effects of race on the patient-healthcare provider relationship must be considered. [ABSTRACT FROM AUTHOR]

This paper examines the factors that influence a Health Maintenance Organization (HMO) to shift risk to doctors through an incentive arrangement called capitation, where physicians are paid a fixed amount per patient for a period of time for any and all medical services required by the patient. Multispecialty-medical-group (Group) HMOs are more likely to shift risk than Independent Physician Associations (IPA) HMOs. Within IPA HMOs, larger enrollment per physician is positively associated with more risk shifting. We find that institutional factors signaling legitimacy play an important role in determining risk shifting. For-profit HMOs are less likely to shift risk, which we interpret as reflecting consumer distrust of for-profit HMOs. However, for-profit HMOs that are federally qualified, which we interpret as a signal of legitimacy, are more likely to shift risk. [ABSTRACT FROM AUTHOR]

This paper reviews various theoretical perspectives on organizational change which have been and could be applied to medical organizations. These perspectives are discussed as both filters influencing our observations (research) and mirrors of the shifting dynamics of delivery system reform (policy). We conclude with an examination of how such theories can provide useful insights into our rapidly changing health care system. [ABSTRACT FROM AUTHOR]

In this paper we examine the hypothesis that health differences between Blacks and Whites in later life are related to socioeconomic status. Using the 1984 panel of the Survey of Income and Program Participation, we construct four measures of health and two measures of health care service utilization. Multivariate analyses show that the racial differences are eliminated in some measures of health and health care service utilization after homing constant individual-level socioeconomic characteristics and resources. However, even after accounting for differences in socioeconomic status, Black self-rated health is poorer than that of Whites. Further, Blacks report more visits to medical personnel but do not report higher rates of hospitalization when levels of health and economic resources are controlled. Additional analyses suggest that the impact of socioeconomic status on health is different for Blacks than for Whites. [ABSTRACT FROM AUTHOR]

In the late 1950s American pediatricians began to place increased emphasis on psychosocial and behavioral issues in medical training and research. An intraprofessional movement for psychosocial pediatrics led to alterations in the specialty's stated jurisdiction. One explanation for the movement's origins is that demand for treating sick children was eroding; primary-care providers took up the delivery of behavioral services to avoid extinction. This paper shows that routinization of work, not market decline, preceded psychosocial pediatrics. Academicians rather than community practitioners spearheaded boundary expansion. The movement's major consequence appears to be a new division of labor between pediatricians and other health care professionals rather than increased pediatric treatment of children's psychosocial disorders. [ABSTRACT FROM AUTHOR]

This paper explores the effects of computerized medical information systems on the occupational communities of health care professionals in hospitals. Interviews were conducted with informants from the pharmacy and nursing departments at two hospitals currently using medical information systems for communicating physicians' medication orders from the nursing station to the pharmacy. Results showed changes in tasks for both pharmacy and nursing, resulting in increased interdependence between the two departments. This interdependence was accompanied by improved communication and cooperation, providing an opportunity to encourage better working relationships between departments. The use and maintenance of the common computerized data base became a superordinate goal for the two groups, with the computer system itself as the topic of communication. [ABSTRACT FROM AUTHOR]

Using recent first-hand accounts by Klass (1987), Konner (1987), LeBaron (1982), and Reilly (1987), this paper examines "insiders' "experiences of medical school. Medical education emphasizes disease, technical procedures, and technological medicine, with scant attention to "caring" aspects of doctoring. Students struggle to learn medicine and to maintain a humanistic or patient-oriented perspective, but the social environment of medical training militates against humanistic doctoring. Toward the end of medical school, students undergo a transformation by adopting the medical-clinical perspective and shifting their identification from patients to doctors. The doctors who maintain a humanistic orientation to medical care appear to be individuals who had developed this orientation before they arrived at medical school. Thus, to increase the number of humanistic physicians, the best strategy may be to alter medical school recruitment and selection policies. [ABSTRACT FROM AUTHOR]

Despite a half century of radical changes in medical practice, the teaching/learning experience of medical students has remained remarkably similar. At the same time, medical educators have frequently instituted curricular reforms. To analyze this history of reform without change, this paper first establishes what the content and the structure of medical education in the United States are, and how they came to be that way. Then it traces a process whereby the scientific mission of academic medicine has crowded out its social responsibility to train for society's most basic health care delivery needs. The main argument is that medical education's manifest humanistic mission is little more than a screen for the research mission which is the major concern of the institution's social structure. [ABSTRACT FROM AUTHOR]

This paper is a revision of the address given upon receipt of the Leo G. Reeder Award for distinguished Scholarship in Medical Sociology. It was presented on August 19, 1987 to the Medical Sociology Section of the American Sociological Association during its annual meeting held in Chicago. [ABSTRACT FROM AUTHOR]

This paper presents a cohort analysis of the use of health services by elderly Americans. Standard cohort tables are constructed using data on approximately 50,000 individuals from the 1972, 1976, and 1980 Health Interview Surveys. Six 4-year age cohorts are tracked: the youngest, 56-59 years old in 1972: the oldest, 84-87 years old in 1980. Significant age and period effects on physician and hospital contact have been detected; for example the aging effect reflects an increase in the percentage of individuals who either saw a physician on an outpatient basis or were hospitalized in the previous year. Analysis of the volume of physician visits reveals an inverse J-curve relationship with age, with the pivotal point occurring at or about age 80. Consideration of nine alternative explanations of the J-curve phenomenon shows that three are plausible on either conceptual or empirical grounds. Two of these explanations suggest the substitution of either (1) hospital-based services for ambulatory-based services or (2) social supports (especially in the form of older children as care givers) for physicians' services: the third explanation focuses on the involuntary severance of patient-practitioner relationships. resulting from the retirement or death of longstanding family physicians. Finally, competing policy implications of these explanations are discussed. [ABSTRACT FROM AUTHOR]

Hospitals are being transformed from a cottage industry in which each institution is relatively autonomous to a series of multihospital systems where a network of individual institutions are directed from corporate headquarters. The present paper examines the impact of adding a hierarchical level to the top of the hospital on the role of the hospital's chief executive officer (CEO). We report results of CEO functioning (201 from multihospital systems and 188 from traditional freestanding hospitals) relative to (1) division of labor, (2) need for coordination, and (3) managerial autonomy. We show that multisystem CEOs' activities are more standardized. but not more specialized, than those of freestanding hospital CEOs; however, we show only moderate support for the increased involvement in coordination activities for those in multihospital systems. Finally, while CEOs in multihospital systems exhibit less actual autonomy in their roles as managers, they perceive themselves as having more autonomy than CEOs in freestanding hospitals. These findings arc considered with respect to the administrator's credo of balancing the need of communities for healthcare with the organization's need to remain financially viable. [ABSTRACT FROM AUTHOR]

Although the dramatic rise in national expenditures for medical services the past quarter century is due to a number of factors, this paper investigates the hypothesis that an increase in the supply of physicians is one major factor. Longitudinal analysis of trends for the United States from 1940 to 1981, and the cross-sectional analysis of eight industrialized countries and nine census regions in the United States, support the hypothesis. Since the increase in physicians is largely due to deliberate policy decisions in the past, the increase in costs, which policymakers are now trying to contain is in large part the result of actions that policymakers themselves have made. The increase in the supply of physicians (the "physician surplus") will put upward pressures on the national expenditures for medical care in the years ahead. [ABSTRACT FROM AUTHOR]

This paper addresses three questions related to the use of in-home care by persons 75 years of age or older: (1) Is there a hierarchy or dimensionality to types of care received in the home? (2) Can the number of in-home services received be explained by the background characteristics, the mental or physical status, or the level of functional impairment of the individual? (3) What factors distinguish users of formal services from those who rely exclusively upon informal sources? Findings indicate that service use by very old community residents follows a pattern reflecting a hierarchy of need. Four characteristics—better education, more social resources, worse mental health, and worse functional status—account for a large portion of the variance in number of services used. Use of formal services is more likely among persons who are better educated, live in urban areas, are, in better condition regarding instrumental activities of daily living (ADL) and have more physical ADL problems. [ABSTRACT FROM AUTHOR]

This paper presents evidence from three samples, two of college students and one of participants in a community smoking-cessation program, for the reliability and validity of a 14-item instrument, the Perceived Stress Scale (PSS), designed to measure the degree to which situations in one's life are appraised as stressful. The PSS showed adequate reliability and, as predicted, was correlated with life-event scores, depressive and physical symptomatology, utilization of health services, social anxiety, and smoking-reduction maintenance. In all comparisons, the PSS was a better predictor of the outcome in question than were life-event scores. When compared to a depressive symptomatology scale, the PSS was found to measure a different and independently predictive construct. Additional data indicate adequate reliability and validity of a four-item version of the PSS for telephone interviews. The PSS is suggested for examining the role of nonspecific appraised stress in the etiology of disease and behavioral disorders and as an outcome measure of experienced levels of stress. [ABSTRACT FROM AUTHOR]

This paper reexamines the impact of preparation for childbirth on birth-related attitudes and events. Data were collected from approximately 300 obstetric patients before and immediately following childbirth. These data are used to demonstrate that working class and middle class women (in this study, defined on the basis of highest level of education) who do not attend childbirth classes have different attitudes toward, and experiences during, childbirth. The data also demonstrate that the impact of childbirth education is much greater among working class women than it is among middle class women. Theoretical and practical implications of these findings are discussed. [ABSTRACT FROM AUTHOR]

Studies of patient satisfaction and compliance with medical regimens emphasize single causes, such as patient beliefs about health care, quality of the interaction between patient and physician, the organization of the setting in which health care is given, or demographic characteristics of patients, as determiners of behavior. Based on information gathered from female college students about their last experience in obtaining the pill, this paper shows that satisfaction with the pill is the result of a complex interaction between a patient's perceptions of her physician's humaneness, the organizational setting in which health care is delivered, her negative attitudes toward the pill, and her experience with side effects. Satisfaction with the pill is related, in turn, to use of the pill as a contraceptive, particularly in the most recent relationship involving intercourse when the patient has had more than one such relationship. [ABSTRACT FROM AUTHOR]

This paper examines the impact of certain attitudinal and situational factors on the use of needed and discretionary physician services. The analysis, which focuses on the low-income respondents (N = 2,551) in a 1971 national survey conducted by the National Opinion Research Center for the Center for Health Administration Studies, University of Chicago, utilizes the Goodman system of hierarchical models. In general, both attitudinal and situational factors affect the use of physicians' services. However, the variables do not always relate to utilization in the manner that would be predicted from the literature. Belief in the effectiveness of medical care has a consistent positive impact on service utilization, but trust in physicians typically is negatively correlated with the use of services. The financial variables have direct effects in only one instance, but frequently interact with other variables. Overall, the impact of the financial variables is found to be weaker than that of the attitudinal variables. [ABSTRACT FROM AUTHOR]

In this paper it is hypothesized that observed variability in hospital adoption of innovation can be accounted for, at least in part, by variability in the development of structural mechanisms which provide access to information about change in the environment. The hypothesis is tested using data from a national sample of hospitals, and on an aggregate basis the results support the theoretical perspective, although certain integration-enhancing mechanisms were much better predictors of innovation than others. The results also illustrate the importance of the relationship between the nature of the innovation and the adopting system and suggest a potential clarification of the relationship between hospital sire and innovation. [ABSTRACT FROM AUTHOR]

This paper examines the causal model which recent research suggests as a framework for research in health service utilization. Data from the 1971, 1972 and 1973 Health Interview Surveys are used to determine the effects of the predisposing, enabling, and illness-morbidity characteristics on several measures of health service utilization. Standardized regression coefficients show these characteristics to be substantively unrelated to health service utilization. The implications of these findings for existing theories of health service utilization are discussed. [ABSTRACT FROM AUTHOR]

This paper presents data showing the existence of attitudes challenging physician authority and examines the nature of the relationship between method of payment for medical services and two measures of such challenge, as well as reported compliance behavior. Data collected from a fee-for-service sample and prepaid-plan group in a large Midwestern metropolitan area indicate minor trends toward higher rates of challenge to physician authority among prepaid members, but also to higher rates of compliance, with no statistically significant differences. Controlling for age and educational level substantially diminished even these marginal variations. However, step-wise multiple regression analysis using both social-psychological and demographic predictor variables reveals differences in the structure of explanation between the two groups. While an orientation to general authority and occupation enter the equations for the fee-for-service sample on both measures of challenge, health knowledge is an explanatory factor among the prepaid. Only demographic characteristics appear in the compliance analysis. The separate effects of group-practice structure, along with predispositions as well as differences between "demanding" and "challenging" patients, are discussed as reasons for the absence of attitudinal variations between payment groups in this study. [ABSTRACT FROM AUTHOR]

This paper develops and tests a model of the health services delivery system based on an examination of the interrelationships among patient and provider variables (treated as exogenous) and access, utilization, continuity, quality, and satisfaction with medical care services (treated as endogenous). The model is tested using data collected from 106 hypertension patients enrolled in the Seattle Prepaid Health Care Project during the period February 1, 1971, through June 30, 1973. Several findings of both sociological and public policy interest emerged. Perceived access to care was among the most important predictors of patient satisfaction: patients from larger families were less satisfied with their care and experienced poorer outcomes of care; patients receiving care from independent fee-for-service practitioners experienced better outcomes than patients receiving care from prepaid group practice providers, even though the latter met a higher percentage of indicated criteria for care; and there was no relationship between perceived access to care and annualized visits. Several important interaction effects involving the nature of the provider system were predicted and supported by the data. The findings are viewed as a first step in the development of a "middle-range" theory of health services delivery systems. [ABSTRACT FROM AUTHOR]

This paper addresses the problem of the effects of a total institution (Goffman, 1961) environment on the use of medical services. The empirical focus is on a midwestern United Slates penitentiary for men. Three components of the problem are identified: the difference between the incidence of physician visits as compared with a "free" population, variations in the use of medical services among different groups of inmates, and discussion of possible reasons for differences found. For the first two component's, evidence is presented; for reasons that are discussed, however, explanation of differences found remains speculative. [ABSTRACT FROM AUTHOR]

This paper takes note of the convergence of both research and opinion supporting the assertion that perceived symptoms and ability to pay are the major determinants of health services utilization. Four reservations pertaining to this body of evidence are offered and research supporting the role of cultural factors in determining the utilization of services is cited. Several cultural barriers to the full utilization of services are discussed. [ABSTRACT FROM AUTHOR]

Increasing professionalization of the occupational structure and increasing pressures for organizational innovations of various types suggest the importance of understanding the factors influencing variability in the responses of professionals to organizational innovation efforts. This paper reports the results of a study designed to explore this issue in the context of the health care system. Variability in the responses of practicing physicians to an organizational innovation is examined in light of a number of hypotheses derived from the literature on adoption of innovation. The findings support five of the sit hypotheses tested, and suggest that receptivity to organizational innovation in professionally dominated systems is influenced by factors similar to those in other systems. [ABSTRACT FROM AUTHOR]

In this paper a behavioral model consisting of sociodemographic, economic, ecological, need, and social psychological variables is developed and used to account for differential patterns of health and illness behavior among members of a pre paid medical group. Data from a sample of students who were enrolled in a university health plan were used to estimate parameters of structural equation models for males and females. The model suggests that social-psychological factors, such as symptom sensitivity and students' appraisal of the services provided, affect the extent to which they seek outside medical care. While medical need and insurance coverage both directly affect the choice of health services, sociodemographic and ecological factors appear largely to affect utilization indirectly through their effect on intervening social-psychological variables. [ABSTRACT FROM AUTHOR]

This paper investigates the relationship between attributes of thirty-two innovative health services and their level of implementation in a national sample of hospitals and health departments. It was found that services implemented in hospitals are primarily characterized by high payoff, a low rate of cost recovery, and low social approval. For health department services perceived primarily as having high divisibility, a high association with the preventive orientation of the department, and a relatively low payoff had a high level of implementation. The respective attribute patterns accounted for 58 per cent of the variance in the implementation of health services in hospitals and 50 per cent of the variance in health departments. [ABSTRACT FROM AUTHOR]

This paper analyzes the relationships among participants' organizational affiliation, the nature of their representation, and the orientation of their attitudes within the decision making process of eight Model Cities health programs. The data were collected by means of content analysis of the Model Cities documents and personal interviews with the participants. Formal representatives of provider organizations are the most likely to have an orientation that can be predicted by their organizational affiliation. Informal representatives of provider organizations tend to act in terms of their own self perceptions and attitudes, which might be consumer or provider oriented. Representatives of consumer organizations are consistently consumer oriented in their perceived roles and attitudes regardless of the nature of their representation. The findings are discussed in terms of their implications for the selection of representatives in a community decision making process. [ABSTRACT FROM AUTHOR]