269
Articles
Public Perceptions of Health Care Problems An Analysis From Arizona BRADFORD L. KIRKMAN-LIFF, DrPH, Tempe, Arizona
Public perception of 17 health problems was assessed by telephone and in-person interviews in Arizona. Drug abuse (64.70/o), the costs of health care (62.80/o), and drunk driving (60.6%) were considered the most serious health care problems. Elderly and rural residents tended to view drug abuse, drunk driving, teenage pregnancy, and economic aspects of health care as less serious than did the younger and urban respondents, while the poor thought these problems were more serious. Respondents in this survey were less concerned with the lack of specific clinical services for high-risk groups-the old and frail, pregnant women, people with the acquired immunodeficiency syndrome, suicidal teenagers, and abused children. (Kirkman-Liff BL: Public perceptions of health
care
problems-An analysis from Arizona. West J Med 1991 Sep; 155:269-273)
At a time of increasing national debate over the merits of alternative forms of universal health care coverage or national health insurance, coupled with calls from industry and labor for effective cost-containment strategies, it is essential for physicians and other health care policymakers to have accurate assessments of the opinions of the general public on a variety of health issues. Rochefort and Boyer stated that polls can assist in "identification of priorities among competing social values, analysis of the social environment in which public programs must operate, and evaluation of programmatic impacts."' I present the results of one statewide effort to assess the public's perception of various health problems.
Methods The data for this analysis were collected by Louis Harris and Associates, Inc, as part of a larger statewide survey on health care in Arizona. These data are drawn from a threestage sample of 3,104 adults surveyed by telephone and inperson interviews. Of the total adult interviews, 3,004 were conducted by telephone from the Harris firm's headquarters in New York from February through May 1989. These telephone interviews were conducted in two stages. In stage one, interviews were conducted with a representative cross section of 2,000 adults contacted through random digit dialing followed by random selection of one adult in each household, using Troldahl-Carter-Bryant grids. In stage two, additional telephone interviews were conducted with 1,004 adults at or below the poverty level. This oversample of low-income persons was obtained by screening additional households drawn from the same bank of telephone numbers in which lowincome persons had been found in the cross section. A household was screened out if its income exceeded the poverty level. There was an overall refusal rate of 22% and an interview termination rate of 6%. In both stages of the telephone interviews, rural areas were oversampled to provide more extensive information about less populated areas, while Maricopa County, with more than half the population of the
state, was undersampled. Finally, 100 in-person adult interviews were conducted in households without telephones. These in-person interviews were done in selected census tracts in Phoenix, Tucson, and Yuma that had the lowest proportion of households with telephones and the highest proportion of households below the federal poverty line. All telephone and in-person interviews were conducted in English or Spanish. The oversampling of poor and rural households and the in-person interviews were corrected by weighting.2 Surveyors asked all adults for their view of the extent to which each of 17 health issues was a problem in their community. The specific question was, "Would you say that X is a major problem, a minor problem, or not a problem in your community?" The 17 problems were selected from a longer list after advice from members of the Arizona Medical Association and six other health-related organizations. The final items represented those issues for which there were active efforts at state legislative action in Arizona. They represent a list of politically sensitive health issues and exclude issues such as cigarette smoking, which at the time of the survey was not receiving political attention. The order in which these issues were presented to each respondent was varied randomly to avoid possible bias by asking the issues in a fixed order. Surveyors also collected information on six demographic variables. There were two residence categories: urban (Maricopa and Pima Counties, which include Phoenix and Tucson, respectively) and rural (the rest of the state). Household income was categorized as poor (below the federal poverty line, which is based on actual household income and family size), near-poor (between the federal poverty line and 185% of the federal poverty line), and nonpoor (over 185% of the federal poverty line). There were three education categories: less than high school, high school, and more than high school, and four ethnicity categories: anglo, Latino, African American and Native American, using the suggestions of Hayes-Bautista and Chapa.3 Age was grouped into three cate-
From the School of Health Administration and Policy, College of Business, Arizona State University, Tempe. This study was supported by a grant from the Flinn Foundation, Phoenix, Arizona. The views expressed in this article are solely those ofthe author and do not necessarily represent the views of the Flinn Foundation. Reprint requests to Bradford L. Kirkman-Liff, DrPH, Associate Professor, School of Health Administration and Policy, Arizona State University, Tempe, AZ 85287-4506.
PUBLIC PERCEPTIONS OF HEALTH CARE PROBLEMS
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270PUBLIC PERCEPTIONS OF HEALTH CARE PROBLEMS
TABLE 1.-Perception and Ranking of Health Care Problems in Arizona, 1989 Rank
Problem
Major
Minor Problem
Not a Problem
Not Sure
Drug abuse.......................
1
64.7
7.1
3.9
Cost of health care....................
2
62.8
11.7
Drunk, driving ..................... Pe-ople with no health insurance .............. Teenag,ed pregnancy ...................
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
60.6 54.8 53.5 52.3 45.3 42.4 37.9 32.9 30.9 29.9 27.1 23.3 18.9 16.0 13.3
24.1 19.7 26.1 21.8 26.5 16.7 29.2 25.8 28.3 29.8 32.0 34.1 39.5 34.2 25.5 33.4 27.9
5.8 4.7 12.4 9.5 17.2 8.8 15.0 10.7 16.3 14.0 11.6 7.2 6.5 15.9 21.1 8.2
Health Care Problem
Cost of medical malpractice inSUrance............ Child abuse............I........... 'Lack of services~for the ~mentally ill ............. Lack of services for the old and frail ............ Prenant women not getting prenatal medical care ...... People who have AIDS.................. Teen suicide ...................... People not knowing w'here to go for the services they need Lack of transportation to get to doctors and hospitals ..... Lack of dental services for children ............. ...
Infant,mortality .................... Emergenc and ~ambulance service..............
8.5 10.9 10.5 13.7 16.6 16.7 22.9 20.7 23.2 24.2 26.1 36.0 39.6 29.4 50.6
AIDS - acquired immunodeficiency syndrome
TABLE 2.-Perception and Ranking of Selected Health Care Issues, by Age Age of Respndent Health Care Problem
17 to 39 years 'i, Rank
Drug abUse ..................... 1 Cost of health care .................. 2 Drunk driving .................... 3 Pe-ople with no health insurance .............4
63.3 60.0 59.5 56.8 55.8 46.8 46.8 36.6
Tengdpregnancy...5 Cost of medical malpractice ~insurance....I....... 6 Ch'ild abuse..................... 6 Pregnant women not getting prenatal medical care .....8
gories: 17 through 39, 40 through 64, and 65 and older. The employment status of the household's main wage earner was categorized as employed (either full-time or part-time), unemployed, and not in the labor force (retired, full-time student, full-time homemaker). The analysis of these questions took several directions. The overall distribution of responses allows a rank order to be assigned to each of these 17 problems. Cross-tabulations of each item with each demographic measure were used to test for significant differences among demographic subgroups as to the perceived seriousness of these problems. These analyses were also used to develop a rank ordering of the problems for each subgroup within the state. Results Table 1 presents the overall public perception of the 17 health problems in Arizona. Nearly two thirds of the surveyed adults in Arizona (64.7%) thought that drug abuse was a serious problem in their community, and only 7% thought that it was not a problem. Close behind were the cost of health care, which was seen as a major problem by 62.8% of those surveyed, and drunk driving, which was considered a major problem by 60.6%. Some 11.7% of the respondents thought that the costs of health care were not a problem, while only 8.5% of the general public thought that drunk driving was not. I used the percentage who thought that an issue was a major problem as the basis for rank ordering, and
40 to 64 years 'if, Rank
2 1 3 5 6 4 8 11
69.8 73.4 66.9 62.2 55.9 64.7 48.5 33.5
2t 65 years 'if, Rank
2 3 1 6 5 4 6 13
51.3 50.9 52.6 34.5 42.5 46.4 34.5 20.3
x2 P< .001
131.0 66.2 63.8 78.1 115.5 78.6 111.5 85.5
so the cost of health care has been ranked as the second most important problem and drunk driving as the third most
important. These findings should be interpreted with caution. For example, the relatively high percentage of adults who think that teenaged suicide is not a problem in their community (24.2%) may be due to a lack of awareness of the number of cases of teenaged suicide. The small percent who thought that infant mortality was a major problem may not have understood the issue, as indicated by the 2 1.1I% who were not sure on that question. The same analysis was conducted for various demographic subgroups of adults, by doing cross-tabulations of each of the 17 problems with each of the six demographic measures. The XI tests for each of these 102 analyses were used to identify significant differences among demographic subgroups as to the perceived seriousness of these problems. These analyses were also used to develop a rank ordering of the problems for each subgroup within the state.
Age When the results are examined for the three age groups
(Table 2), the 65-and-older group tends to view all health problems as being less serious than do the younger age groups. Some 52.6% of the elderly ranked drunk driving as a major health problem, the highest ranking of the 17 problems. In contrast, 66.9% of the 40-through-64-year-old
THE WESTERN JOURNAL OF MEDICINE
SEPTEMBER 1991
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*
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3
*
Education There are only a few differences in problem ranking when the education of the respondents is considered (Table 3). The cost of malpractice insurance was the second most serious problem for those with more than a high school education: it was rated a major problem by 64.4% of the population in this category. The issue is perceived differently by the other groups. Slightly more than half (50.7%) of respondents with a high school education thought that the cost of malpractice insurance was a serious problem. Relative to the other issues, that subgroup ranked it sixth in importance. Only 38.1% of those with less than a high school education thought that it was a major problem, which gave it a rank of 9. Those with less than a high school education considered the lack of services for the frail and elderly, people with the acquired immunodeficiency syndrome (AIDS), and people not knowing where to go for services to be more important than did the other groups. Those with more than a high
and 59.5% of the 17-through-39-year-old group thought that drunk driving was a major problem. The younger groups gave drunk driving a higher rating, yet this problem was only the third most important among these groups, with drug abuse and the cost of health care having even higher ratings and rankings. The oldest group surveyed gave two issues much lower rankings and lower ratings than did the other groups. First, the number of people with no health insurance was seen as a major problem by only 34.5% of the 65-and-older group, as opposed to 56.8% of the 17-through-39-year-old group and 62.2% of the 40-through-64-year-old group. Second, the number of pregnant women not receiving prenatal care was seen as a major problem by only 20.3% of the 65-and-older group, as opposed to 36.6% of the 17-through-39-year-old and 33.5% of the 40-through-64-year-old group. Much smaller percentages of the 65-and-older group rated teenage pregnancy a serious problem than did other groups. group
TABLE 3.-Perception and Ranking of Health Care Problemns, by Education Level Education of Repondent Less Than High School Rank 9b
Health Care Problem
Cost of medical malpractice insurance .9 Lack of services for the old and frail .7 Pregnant women not getting prenatal medical care.13 10 People who have AIDS ............. 11 People not knowing where to go for the services they need
38.1 44.1 31.2 37.7 36.5
High Schol& Rank
9b
6 9 10 11 12
50.7 35.2 29.1 27.2 25.6
MoMr Than High School Rank
'N
2
64.4 36.4 38.3 30.0 22.2
10 9 12 14
%
P
Articles
Public Perceptions of Health Care Problems An Analysis From Arizona BRADFORD L. KIRKMAN-LIFF, DrPH, Tempe, Arizona
Public perception of 17 health problems was assessed by telephone and in-person interviews in Arizona. Drug abuse (64.70/o), the costs of health care (62.80/o), and drunk driving (60.6%) were considered the most serious health care problems. Elderly and rural residents tended to view drug abuse, drunk driving, teenage pregnancy, and economic aspects of health care as less serious than did the younger and urban respondents, while the poor thought these problems were more serious. Respondents in this survey were less concerned with the lack of specific clinical services for high-risk groups-the old and frail, pregnant women, people with the acquired immunodeficiency syndrome, suicidal teenagers, and abused children. (Kirkman-Liff BL: Public perceptions of health
care
problems-An analysis from Arizona. West J Med 1991 Sep; 155:269-273)
At a time of increasing national debate over the merits of alternative forms of universal health care coverage or national health insurance, coupled with calls from industry and labor for effective cost-containment strategies, it is essential for physicians and other health care policymakers to have accurate assessments of the opinions of the general public on a variety of health issues. Rochefort and Boyer stated that polls can assist in "identification of priorities among competing social values, analysis of the social environment in which public programs must operate, and evaluation of programmatic impacts."' I present the results of one statewide effort to assess the public's perception of various health problems.
Methods The data for this analysis were collected by Louis Harris and Associates, Inc, as part of a larger statewide survey on health care in Arizona. These data are drawn from a threestage sample of 3,104 adults surveyed by telephone and inperson interviews. Of the total adult interviews, 3,004 were conducted by telephone from the Harris firm's headquarters in New York from February through May 1989. These telephone interviews were conducted in two stages. In stage one, interviews were conducted with a representative cross section of 2,000 adults contacted through random digit dialing followed by random selection of one adult in each household, using Troldahl-Carter-Bryant grids. In stage two, additional telephone interviews were conducted with 1,004 adults at or below the poverty level. This oversample of low-income persons was obtained by screening additional households drawn from the same bank of telephone numbers in which lowincome persons had been found in the cross section. A household was screened out if its income exceeded the poverty level. There was an overall refusal rate of 22% and an interview termination rate of 6%. In both stages of the telephone interviews, rural areas were oversampled to provide more extensive information about less populated areas, while Maricopa County, with more than half the population of the
state, was undersampled. Finally, 100 in-person adult interviews were conducted in households without telephones. These in-person interviews were done in selected census tracts in Phoenix, Tucson, and Yuma that had the lowest proportion of households with telephones and the highest proportion of households below the federal poverty line. All telephone and in-person interviews were conducted in English or Spanish. The oversampling of poor and rural households and the in-person interviews were corrected by weighting.2 Surveyors asked all adults for their view of the extent to which each of 17 health issues was a problem in their community. The specific question was, "Would you say that X is a major problem, a minor problem, or not a problem in your community?" The 17 problems were selected from a longer list after advice from members of the Arizona Medical Association and six other health-related organizations. The final items represented those issues for which there were active efforts at state legislative action in Arizona. They represent a list of politically sensitive health issues and exclude issues such as cigarette smoking, which at the time of the survey was not receiving political attention. The order in which these issues were presented to each respondent was varied randomly to avoid possible bias by asking the issues in a fixed order. Surveyors also collected information on six demographic variables. There were two residence categories: urban (Maricopa and Pima Counties, which include Phoenix and Tucson, respectively) and rural (the rest of the state). Household income was categorized as poor (below the federal poverty line, which is based on actual household income and family size), near-poor (between the federal poverty line and 185% of the federal poverty line), and nonpoor (over 185% of the federal poverty line). There were three education categories: less than high school, high school, and more than high school, and four ethnicity categories: anglo, Latino, African American and Native American, using the suggestions of Hayes-Bautista and Chapa.3 Age was grouped into three cate-
From the School of Health Administration and Policy, College of Business, Arizona State University, Tempe. This study was supported by a grant from the Flinn Foundation, Phoenix, Arizona. The views expressed in this article are solely those ofthe author and do not necessarily represent the views of the Flinn Foundation. Reprint requests to Bradford L. Kirkman-Liff, DrPH, Associate Professor, School of Health Administration and Policy, Arizona State University, Tempe, AZ 85287-4506.
PUBLIC PERCEPTIONS OF HEALTH CARE PROBLEMS
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270PUBLIC PERCEPTIONS OF HEALTH CARE PROBLEMS
TABLE 1.-Perception and Ranking of Health Care Problems in Arizona, 1989 Rank
Problem
Major
Minor Problem
Not a Problem
Not Sure
Drug abuse.......................
1
64.7
7.1
3.9
Cost of health care....................
2
62.8
11.7
Drunk, driving ..................... Pe-ople with no health insurance .............. Teenag,ed pregnancy ...................
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
60.6 54.8 53.5 52.3 45.3 42.4 37.9 32.9 30.9 29.9 27.1 23.3 18.9 16.0 13.3
24.1 19.7 26.1 21.8 26.5 16.7 29.2 25.8 28.3 29.8 32.0 34.1 39.5 34.2 25.5 33.4 27.9
5.8 4.7 12.4 9.5 17.2 8.8 15.0 10.7 16.3 14.0 11.6 7.2 6.5 15.9 21.1 8.2
Health Care Problem
Cost of medical malpractice inSUrance............ Child abuse............I........... 'Lack of services~for the ~mentally ill ............. Lack of services for the old and frail ............ Prenant women not getting prenatal medical care ...... People who have AIDS.................. Teen suicide ...................... People not knowing w'here to go for the services they need Lack of transportation to get to doctors and hospitals ..... Lack of dental services for children ............. ...
Infant,mortality .................... Emergenc and ~ambulance service..............
8.5 10.9 10.5 13.7 16.6 16.7 22.9 20.7 23.2 24.2 26.1 36.0 39.6 29.4 50.6
AIDS - acquired immunodeficiency syndrome
TABLE 2.-Perception and Ranking of Selected Health Care Issues, by Age Age of Respndent Health Care Problem
17 to 39 years 'i, Rank
Drug abUse ..................... 1 Cost of health care .................. 2 Drunk driving .................... 3 Pe-ople with no health insurance .............4
63.3 60.0 59.5 56.8 55.8 46.8 46.8 36.6
Tengdpregnancy...5 Cost of medical malpractice ~insurance....I....... 6 Ch'ild abuse..................... 6 Pregnant women not getting prenatal medical care .....8
gories: 17 through 39, 40 through 64, and 65 and older. The employment status of the household's main wage earner was categorized as employed (either full-time or part-time), unemployed, and not in the labor force (retired, full-time student, full-time homemaker). The analysis of these questions took several directions. The overall distribution of responses allows a rank order to be assigned to each of these 17 problems. Cross-tabulations of each item with each demographic measure were used to test for significant differences among demographic subgroups as to the perceived seriousness of these problems. These analyses were also used to develop a rank ordering of the problems for each subgroup within the state. Results Table 1 presents the overall public perception of the 17 health problems in Arizona. Nearly two thirds of the surveyed adults in Arizona (64.7%) thought that drug abuse was a serious problem in their community, and only 7% thought that it was not a problem. Close behind were the cost of health care, which was seen as a major problem by 62.8% of those surveyed, and drunk driving, which was considered a major problem by 60.6%. Some 11.7% of the respondents thought that the costs of health care were not a problem, while only 8.5% of the general public thought that drunk driving was not. I used the percentage who thought that an issue was a major problem as the basis for rank ordering, and
40 to 64 years 'if, Rank
2 1 3 5 6 4 8 11
69.8 73.4 66.9 62.2 55.9 64.7 48.5 33.5
2t 65 years 'if, Rank
2 3 1 6 5 4 6 13
51.3 50.9 52.6 34.5 42.5 46.4 34.5 20.3
x2 P< .001
131.0 66.2 63.8 78.1 115.5 78.6 111.5 85.5
so the cost of health care has been ranked as the second most important problem and drunk driving as the third most
important. These findings should be interpreted with caution. For example, the relatively high percentage of adults who think that teenaged suicide is not a problem in their community (24.2%) may be due to a lack of awareness of the number of cases of teenaged suicide. The small percent who thought that infant mortality was a major problem may not have understood the issue, as indicated by the 2 1.1I% who were not sure on that question. The same analysis was conducted for various demographic subgroups of adults, by doing cross-tabulations of each of the 17 problems with each of the six demographic measures. The XI tests for each of these 102 analyses were used to identify significant differences among demographic subgroups as to the perceived seriousness of these problems. These analyses were also used to develop a rank ordering of the problems for each subgroup within the state.
Age When the results are examined for the three age groups
(Table 2), the 65-and-older group tends to view all health problems as being less serious than do the younger age groups. Some 52.6% of the elderly ranked drunk driving as a major health problem, the highest ranking of the 17 problems. In contrast, 66.9% of the 40-through-64-year-old
THE WESTERN JOURNAL OF MEDICINE
SEPTEMBER 1991
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*
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271
3
*
Education There are only a few differences in problem ranking when the education of the respondents is considered (Table 3). The cost of malpractice insurance was the second most serious problem for those with more than a high school education: it was rated a major problem by 64.4% of the population in this category. The issue is perceived differently by the other groups. Slightly more than half (50.7%) of respondents with a high school education thought that the cost of malpractice insurance was a serious problem. Relative to the other issues, that subgroup ranked it sixth in importance. Only 38.1% of those with less than a high school education thought that it was a major problem, which gave it a rank of 9. Those with less than a high school education considered the lack of services for the frail and elderly, people with the acquired immunodeficiency syndrome (AIDS), and people not knowing where to go for services to be more important than did the other groups. Those with more than a high
and 59.5% of the 17-through-39-year-old group thought that drunk driving was a major problem. The younger groups gave drunk driving a higher rating, yet this problem was only the third most important among these groups, with drug abuse and the cost of health care having even higher ratings and rankings. The oldest group surveyed gave two issues much lower rankings and lower ratings than did the other groups. First, the number of people with no health insurance was seen as a major problem by only 34.5% of the 65-and-older group, as opposed to 56.8% of the 17-through-39-year-old group and 62.2% of the 40-through-64-year-old group. Second, the number of pregnant women not receiving prenatal care was seen as a major problem by only 20.3% of the 65-and-older group, as opposed to 36.6% of the 17-through-39-year-old and 33.5% of the 40-through-64-year-old group. Much smaller percentages of the 65-and-older group rated teenage pregnancy a serious problem than did other groups. group
TABLE 3.-Perception and Ranking of Health Care Problemns, by Education Level Education of Repondent Less Than High School Rank 9b
Health Care Problem
Cost of medical malpractice insurance .9 Lack of services for the old and frail .7 Pregnant women not getting prenatal medical care.13 10 People who have AIDS ............. 11 People not knowing where to go for the services they need
38.1 44.1 31.2 37.7 36.5
High Schol& Rank
9b
6 9 10 11 12
50.7 35.2 29.1 27.2 25.6
MoMr Than High School Rank
'N
2
64.4 36.4 38.3 30.0 22.2
10 9 12 14
%
P
