Welfare Status, Illness and Subjective Health Definition EDGAR 0. PRINCE, BA, MA
Abstract: The self-defined health status of welfare recipients hospitalized for illness during the preceding year was compared to that of persons not on welfare but hospitalized for illness during the same period. Data were derived from a systematic probability sample of household residents of the Harlem Hospital inpatient district population surveyed July 1967-June 1970. Welfare recipient respondents were more likely to perceive their health as fair/poor than were persons not on welfare. This difference persisted when the data
were analyzed by sex, age, reported levels and type of illness, hospital days and number of stays, and current usual activity; usual activity was a major explanatory variable but only partially accounted for the relationship. It has been hypothesized that in achievement-oriented societies, illness may be used as justification for a culturally-induced sense of personal failure to fulfill socially prescribed role obligations. The data are consistent with this hypothesis. (Am. J. Public Health 68:865-870, 1978)
Introduction
lated to social stratification,10-13 cultural differentiation,14-16 and individual differences in the significant others who influence decisions.'7-20 From a sociological perspective, a person is sick when he or she "acts" sick, the emphasis being on a person's behavior. The physiological state of the body is not a necessary condition for evoking sick role behavior. A corollary is that the conditions that motivate people to view themselves as sick or healthy are of major importance. Medical doctors and social scientists are becoming increasingly aware of the interrelationship between physiological conditions of the body and the social psychological forces which intertwine in determining objective and subjective states of health.21-25
This research takes as its point of departure the work of Stephen Cole and Robert Lejeune, 1972.1 Cole and Lejeune, addressing the problem of taking the "sick role," argued that one may use illness to justify welfare dependency and a culturally-induced sense of personal failure to fulfill sociallyprescribed role obligations. According to them, "many welfare mothers accept the dominant cultural view that being on welfare is a result of personal failure. When women accept this view and give up hope of getting off welfare, they are prone to adopt the sick role to legitimize their welfare dependency and self-defined failure." The study of illness behavior from a sociological perspective began in earnest with Parson's formulation of the sick role, derived from the emphasis of modern industrial societies on instrumental activism.2 While Parson's formulation may be useful when the focus is on society as a whole,3 it tells us nothing about normative variations among various sub-societal populations. Several studies, none of which were specifically oriented toward the sick role formulation, have demonstrated variations in both perception of illness4'5 and in illness behavior.6-9 These variations have been reAddress reprint requests to Mr. Edgar 0. Prince, Senior Research Analyst, Office of Program Evaluation and Research, Suffolk County Department of Health Services, H. Lee Dennison Executive Office Building, Veterans Memorial Highway, Hauppauge, NY 11787. This paper, submitted to the Journal September 17, 1975, was revised and accepted for publication November 10, 1977. The original version was presented at the 103rd Annual Meeting of the American Public Health Association, Chicago, 1975.
AJPH September, 1978, Vol. 68, No. 9
Method The data for this study were obtained from the Harlem Community Health Survey* of the Harlem Hospital District population during the period extending from July 1967 to June 1970. The District is a poverty area. A structured questionnaire elicited information on each household resident's personal characteristics, health status, and health-care-related behavior. The respondent providing the data was re-
* For a detailed description of the setting, sample design, sampling frame, field operations, etc., consult "Sampling and Field Operations of the Harlem Community Health Survey," Patricia Collette, Director, Office of Patient Care and Program Evaluation, Harlem Hospital Center, Columbia University, New York, NY, 1971. An unpublished report.
865
PRINCE
quired to be a household resident, 18 or more years of age, mentally competent, and reporting for himself/herself or related to the individuals for whom he/she reported. A systematic probability sample of housing units within the Harlem Hospital District with sampling rates of one housing unit in 25 within the Central Harlem Health District portion and one in 50 outside of it were drawn.** Data were gathered on 8,817 housing units and 22,199 residents; 12 per cent (2,673) of the residents had been hospitalized at least once during the 12 months preceding the interview. Hospitalized sample respondents were more likely to have received welfare assistance some time during the year preceding interview than non-hospitalized sample respondents.*** The study data derive from a subsample of 2,673 respondents who were hospitalized at least once during the year preceding interview. Specifically excluded from analysis were hospitalizations not considered as illness-related: accidents, injuries, deliveries, complications of pregnancy, and surgery for non-specified conditions. In addition to the respondent requirements already specified, subsample respondents were required to be self-respondents, since it was necessary that they define their own health status perception. These additional requirements reduced the number of responses to be analyzed to 723. Of all subsample respondents analyzed excluding missing responses (N=723), 82.0 per cent (590) were black; 62.0 per cent (448) were women; 55.0 per cent (395) were between 18 and 50 years old; 67.0 per cent (481) had less than a twelfth grade education; 37.3 per cent (270) had received welfare assistance sometime during the year preceding interview; and 65.0 per cent (473) were currently unemployed and/or unemployable. Thus we are comparing two subgroups within an overall underprivileged poverty population; one of the subgroups receives welfare assistance, the other does not. The dependent variable in this study, respondent subjective definition of health, was measured by responses to the question: "To begin with, how is your health now? Would you say it is excellent, good, fair or poor?" This response was dichotomized into "excellent/good" and "fair/ poor." The independent variable is receipt versus non-receipt
** It should be noted that the differential sampling rates employed require all interview data pertaining to housing units, households, and individuals selected from the low sampling rate zones-I in 50-to be weighted up in tabulations pertaining to the total hospital district. All estimates for the hospital district as a whole must be based on weighted distributions, but the reliability of a given statistic is a function of the number of actual cases, the unweighted N in tabulations. *** Of the 2,673 hospitalized sample respondents, 1,150 (43.0 per cent) had received welfare assistance sometime during the 12 months preceding interview; of the 19,526 non-hospitalized sample respondents, 5,362 (27.5 per cent) had received welfare assistance sometime during the 12 months preceding interview. Thus, the proportion of hospitalized sample respondents who had received welfare assistance sometime during the 12 months preceding interview was 15.5 per cent greater than the proportion of non-hospitalized sample respondents who had received welfare assistance. Chisquare equals 267.47 with one degree of freedom significant at the .001 rejection level.
866
of welfare assistance in the year. Respondents were asked: "In the past 12 months has anyone here including yourself received any welfare assistance, not counting Social Security?" Each individual was then coded as to whether he/she had received welfare assistance.T Health care status and utilization were also measured by three self-reported indicators: a) average length of inpatient stay per discharged patient which was trichotomized into short, medium, and long stay categories, and computed by dividing the total number of hospital days for a specified group by the total number of discharges for the same group; b) number of inpatient stays in the 12 months preceding interview which was dichotomized into 1 stay versus 2-5 stays; and c) main condition of inpatient stay which was dichotomized into acute versus chronic conditions.tt Age and sex of subsample respondents were analyzed for their possible independent and interactive effects on subjective health states.26-28 The relationship between welfare status and subjective health definition was also analyzed by usual activity which is taken as an indicator of current employment status/employability. Respondents were asked, "What do you usually do most of the time-work, keep house, work and keep house, go to school, or something else? What?" This variable was dichotomized into "work/don't work." The "work" group includes worker only, and worker/homemaker. The "don't work" group includes homemaker only, retired, and sick/ disabled. The relationship between welfare status and subjective health definition was examined only among hospitalized, as opposed to non-hospitalized, respondents because hospitalization experiences or illness episodes may have an independent effect on employment status and welfare dependency. All hospitalized respondents had "officially" been defined as being medically sick (hospitalized). Therefore, their claim to evoking the "sick role" under conditions of overall self-reported poor health care status or health care customs has been legitimized. If there are statistically significant measured differences in subjective health states between hospitalized welfare versus hospitalized non-welfare recipients experiencing similar levels of overall poor health care status or health care customs, then these differences are less likely to be attributable to differences in illness episodes and are more likely to be due to factors of a sociopsychological nature. Without longitudinal data, we do not know whether the t While the health status question specifically asked the respondent for a personal response, the question on welfare status does not, i.e., "anyone here received any welfare assistance?"; subsample respondents were required to be self respondents so that the same person was providing the data on both his/her own welfare status and his/her own subjective health perception. t1 Acute conditions were usually contagious or infectious in origin: e.g. pneumonia, influenza, chicken pox, etc. Chronic conditions have one or more of the following characteristics: permanent, leaves a residual disability, caused by nonreversible pathological alterations, requires special training of patients for rehabilitation, and are expected to require long periods of supervision, care or observation, e.g. asthma, hay fever, chronic bronchitis, etc. AJPH September, 1978, Vol. 68, No. 9
SUBJECTIVE HEALTH DEFINITION TABLE 1 -Subjective Health Definition of Hospitalized Respondents by Welfare Status. Welfare
Status
Receipt Non-Receipt
Subjective Health Definition (Fair/Poor) (Excellent/Good)
25.9% ( 70)* 48.1% (218)
74.1% (200) 51.9% (235)
TABLE 2-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Sex. Welfare Status
Total (N)
100.0% (270) 100.0% (453)
Receipt Non-Receipt
Sex Male
Female
80.0% ( 85)* 54.7% (190)
71.4% (185) 49.8% (263)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected chi-square (1 d.f.) applied down columns = 33.86; p < .001 one test missing observations equal 14
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (2 d.f.) = 34.85; p < .001 two tests missing observations equal 14
hospitalization experiences precede or follow a person's welfare status, nor whether the assumption of the sick role occurred prior to or after going on welfare.
Respondents who are unemployed/unemployable while simultaneously receiving welfare assistance sometime during the year preceding interview, a group more likely to be 36-64 years of age, may have a greater need to define their health as fair/poor in order to legitimize to themselves and to the rest of society their welfare dependency and culturallyinduced sense of personal failure to fulfill socially prescribed role obligations. Table 4 empirically supports this hypothesis. Usual activity is significantly related to both welfare status and subjective health definition. However, with the exception of those 65 years of age and older, the proportion of the "don't work" group defining their health as fair/poor is greater than the proportion of the "work" group defining their health as fair/poor (see also H. Levin29). The most striking contrasts are in age groups 36-50 and 51-64. Table 4 shows that although usual activity or employment status may be a major explanatory factor partially accounting for the strength of the original relationship, welfare status itself continues to have an independent effect on perceived health
Findings According to Table 1, the proportion of hospitalized welfare recipients describing their health as fair/poor was 22.2 per cent greater than the proportion of hospitalized nonwelfare recipients describing their health as fair/poor. In Table 2, the marginal frequencies show that sex is slightly related to welfare status but not to subjective health definition. Among male respondents, the proportion of hospitalized welfare recipients describing their health as fair/ poor was 25.3 per cent greater than the proportion of hospitalized non-welfare recipients describing their health as fair/ poor. The corresponding percentage difference among female respondents equals 21.6 points (Table 2). In Table 3, the relationship between self-perceived health status and welfare status was analyzed by age of hospitalized respondents. Although age of hospitalized respondents is slightly related to welfare status, this relationship was not statistically significant at the .05 rejection level. Age of hospitalized respondents is significantly related to subjective health definition, but at all ages welfare recipients are more likely to perceive their health as fair/poor. The largest percentage point difference in subjective health definition between hospitalized welfare recipients and hospitalized non-welfare recipients occurred within the 36-50 and 51-64 age groupings respectively.
status.
Perceived health status among respondents in this subsample was also analyzed by age and average length of inpatient stay (Table 5). Regardless of age and average length of inpatient stay, the proportion of hospitalized welfare recipients describing their health as fair/poor was significantly greater than the proportion of hospitalized non-welfare respondents describing their health as fair/poor. In all but three of the 12 instances (18-35 year olds hospitalized for a short and long stay, and 65 year olds and over hospitalized for a long stay) the differences are statistically significant. In Table 6, the relationship between welfare status and
TABLE 3-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Age. Age
Welfare Status
Receipt Non-Receipt
(18-35 yrs)
(36-50 yrs)
(51-64 yrs)
(65 yrs old and over)
46.6% ( 58)* 32.5% (114)
76.8% ( 95) 47.7% (128)
86.4% ( 81) 61.8% (110)
83.3% ( 36) 68.3% (101)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (4 d.f.) = 36.03; p < .001 four test missing observations equal
14
AJPH September, 1978, Vol. 68, No. 9
867
PRINCE
TABLE 4-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status, Age, and Usual Activity. Age Welfare Status
Receipt NonReceipt
Usual Activity Don't Work Work
Usual Activity Don't Work Work
Usual Activity Don't Work Work
Usual Activity Don't Work Work
(65 yrs old and over)
(51-64 yrs)
(36-50 yrs)
(18-35 yrs)
40.0% (15)*
48.8% (43)
63.2% (19)
80.3% (76)
( 5)
89.5% (76)
** ( )
83.3% (36)
31.7% (60)
33.3% (54)
36.1% (72)
62.5% (56)
47.5% (61)
79.6% (49)
72.2% (18)
67.5% (83)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (7 d.f.) = 13.69; .10 > p > .05 seven test missing observations equal 14 ** Too few cases
subjective health definition is analyzed by nature of condition (acute or chronic) for which hospitalized and age of hospitalized respondents. Acuteness or chronicity of the condition was not related to welfare status, but respondents hospitalized for chronic conditions were more likely to describe their health as fair/poor than were respondents hospitalized for acute conditions. Regardless of condition and age, the proportion of hospitalized welfare recipients describing their health as fair/poor was significantly greater than the proportion of hospitalized non-welfare recipients describing their health as fair/poor. This finding was true for every subgroup except those respondents 18-35 years of age who were hospitalized mainly for chronic conditions, where the trend was the same although the difference was not significant. In Table 7 the relationship between welfare status and subjective health definition was analyzed by number of inpatient stays in the prior 12 months. Number of inpatient stays was not significantly related to welfare status, but was significantly related to subjective health definition. Regardless of welfare status, respondents hospitalized for 2 to 5 stays were more likely to describe their health as fair/poor than were respondents who were hospitalized only once during the year preceding interview. The proportion of hospital-
ized welfare recipients in all age and stay groups describing their health as fair/poor is significantly greater than the proportion of hospitalized non-welfare recipients describing their health as fair/poor.
Discussion This study has examined the self-perception of health status within a poverty population, living at home, who have been hospitalized for illness at least once during the prior year. It has compared the perception of those respondents currently on welfare with those not currently on welfare. When analyzed by sex, age, current activity status, average length of hospital stay, number of hospital stays, and nature of condition causing hospitalization (acute or chronic), welfare recipients were more apt to perceive their health as fair/ poor than were respondents not on welfare. There are certain limitations of the data which need to be pointed out. The subsample respondents do not represent all welfare recipients but only those who were hospitalized during the prior year. Thus the findings cannot be generalized to all those on welfare. For the hospitalized group, how-
TABLE 5-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status, Age and Average Length of Inpatient Stay* Age (36-50 yrs)
(18-35 yrs)
Welfare Status
Receipt
Non-Receipt
Length Of Inpatient Stay Medium Short Long
Length Of Inpatient Stay Medium Short Long
(51-64 yrs)
(65 yrs and over)
Length Of Inpatient Stay Medium Short Long
Length Of Inpatient Stay Short Medium Long
83.3% 79.0% 90.0% 62.5% 66.7% 78.6% 79.0% 70.8% 85.2% 96.6% 33.3% ( 8) (19) (12) (27) (27) (24) (28) (38) (27) (16) (20) (21)** 32.4% 57.1% 50.0% 34.8% 59.4% 53.5% 61.3% 75.8% 45.0% 71.1% 72.5% 25.4%
(59)
(34)
(21)
(48)
(46)
(32)
(43)
(31)
(33)
(20)
(38)
(40)
Average length of inpatient stay was defined as the total number of acute and chronic days for a specified group divided by the total number of acute and chronic discharges for the same group. A short stay is defined as being hospitalized less than 10 days. A medium stay ranges from 11-21 days, and a long stay is 22 days and more. The numbers in the parentheses refer to individuals with no duplications. By combining acute and chronic days and dividing by the total number of acute and chronic stays or discharges, we resolve the problem of mutliple hospitalization experiences or illness episodes. This procedure allows us to compute an average length of stay for each respondent without duplications. ** The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (12 d.f.) = 36.03; p < .001 twelve test missing observations equal 25 *** Too few cases.
868
AJPH September, 1978, Vol. 68, No. 9
SUBJECTIVE HEALTH DEFINITION TABLE 6-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Statues, Age, and Main Condition of Inpatient Stay. Age
Welfare Status
Receipt Non-Receipt
Acute
(18-35 yrs) Chronic
46.2% (13)* 21.7% (46)
45.5% (44) 41.2% (68)
Acute
(36-50 yrs) Chronic
56.3% (16) 35.3% (17)
80.5% ( 77) 48.6% (109)
Acute
(51-64 yrs) Chronic
80.0% (10) 64.7% (17)
83.8% (68) 62.2% (90)
(65 yrs and over) Acute Chronic
72.7% (11) 61.5% (13)
78.6% (28) 67.1% (85)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (8 d.f.) = 33.28; p < .001 eight test missing observations equal 25
ever, the data are consistent with the Cole-Lejeune hypothesis.1 The paper's aim was not to test the validity of this hypothesis since no independent data were presented to show that welfare recipients actually do or feel any of the things implicit in legitimizing failure. In mixed capitalistic, modem industrial, achievementoriented societies, such as our own, where the spirit of laissez-faire, rugged individualism, and the Protestant Work Ethic are ingrained features of the dominant cultural belief system, failure to fulfill socially prescribed role obligations is generally viewed as resulting from individual idiosyncrasies, laziness, low intelligence, lack of initiative, and degenerate moral character. Most individuals are supposed to have a moral and social responsibility to strive and get ahead. Failure to do so is regarded as a sign of individual or personal failure rather than societal failure resulting from a repressive social structure.30 It is medically recognized that the symptomatology and organic changes resulting from a psychosomatic ailment are "real." In like manner, the taking of the sick role by welfare recipients in order to legitimize a culturally-induced sense of personal failure might also be viewed as a "real" adaptation to structural conditions of stress and anxiety. Actual as well as perceived differences in opportunity structures may lead to heightened feelings of anxiety and frustration from which follow increased feelings of powerlessness, alienation and apathy, bringing about changes in self-worth or self-esteem and ultimately resulting in sick role behavior to legitimize feelings of culturally-induced self-defined failure.31 Most welfare recipients would prefer to get off the welfare rolls and work, but because of education, previous job experience, race, intelligence, "objective health" and age, they are forced literally to remain on the welfare rolls generation after generation.31 Consequently, the taking of the sick role TABLE 7-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Number of Inpatient Stays in Prior 12 Months. Welfare Status
Receipt Non-Receipt
Number of Inpatient Stays 2-5 Stays 1 Stay
70.0% (237)* 50.6% (409)
80.0% (35) 64.6% (48)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (2 d.f.) = 34.21; p < .001 two test missing observations equal 8
AJPH September, 1978, Vol. 68, No. 9
in attitude, if not in overt behavior, may become a permanent adaptation to a structural condition of anomie.32 Such an hypothesis is consistent with the data presented in this study.
REFERENCES 1. Cole, S. and Lejeune, R. Illness and legitimation of failure. American Sociological Review 37:347-356, 1972. 2. Parsons, T. and Fox, R. The Social System. Glencoe, IL: The Free Press, 1951. 3. Gordon, G. Role Theory and Illness. New Haven, College and University Press, 1966. 4. Baumann, B. Diversities in conceptions of health and physical fitness. Journal of Health and Human Behavior, 2:1:39-46, 1961. 5. Freidson, E. The Sociology of Medicine. Current Sociology, x/ xi:3, 1962. 6. Mechanic, D. Perception of Parental Responses to Illness: A Research Note. Journal of Health and Human Behavior, 6:4:253-257, 1965. 7. Davis, F. Passage Through Crisis. Indianapolis: Bobbs-Merrill, 1963. 8. Barker, R., et al. Adjustment to Physical Handicap and Illness. New York Social Science Research Council, 1953. 9. Roth, J. Timetables. Indianapolis: Bobbs-Merrill, 1963. 10. Mechanic, D. The Concept of Illness Behavior. Journal of Chronic Diseases, 15:189-195, 1962. 11. Koos, E. L. The Health of Regionville. New York: Columbia University Press, 1954. 12. Lynd, R. and H. Lynd. Middletown. New York: Harcourt, Brace, 1929. 13. Brightman, I., et al. Knowledge and Utilization of Health Resources by Public Assistance Recipients. Am. J. Public Health, 48:188-199, 319-327, 1958. 14. Ross, J. Social Class and Medical Care. Journal of Health and Human Behavior, Spring: 35-40, 1962. 15. Paul, B. D. Health, Culture and Community. New York: Russell Sage Foundation, 1955. 16. Wolff, H. Disease and the Patterns of Behavior, in MacIver, R. Ed. The Hour of Insight. New York: Institute for Religious and Social Studies, p. 29-41, 1954. 17. Zborowski, M. Cultural Components in Response to Pain. Journal of Social Issues 8:16-30, 1952. 18. Freidson, E. Patients' Views of Medical Practice. New York: Russell Sage Foundation, 1961. 19. Knutson, A. The Individual, Society;, and Health Behavior. New York: Russell Sage Foundation, 1%5. 20. Mechanic, D. Some factors in identifyifli and defining mental illness. Journal of Mental Hygiene 46:1:66-74, 1962. 21. Bloom, S. The Doctor and His Patient. Glencoe, IL: Free Press, 1965. 22. Crandell, D. L. and Dohrenwend, B. Some relations among psychiatric symptoms, organic illness, and social class. American Journal of Psychiatry, 123:1527-1537, 1967. 23. Hinkle, L. E., Jr., Pinsky, R. H., Bross, I. D. J., and Plummer, N. The distribution of sickness disability in a Homogeneous
869
CORNELY
24. 25. 26. 27.
28.
29. 30.
Group of 'healthy' adult men. American Journal of Hygiene 64:220-242, 1956. Mechanic, D. and Volkart, E. H. Stress, illness behavior and the sick role. American Sociological Review 26:51-58, 1961. Wolff, H. Disease and Patterns of Behavior. pp. 54-61 in E. Gartly Jaco, Ed. Patients, Physicians, and Illness. Glencoe, IL: The Free Press, 1958. Cumming, E. and Henry, J. Growing Old: The Process of Disengagement. New York: Basic Books, 1961. Coser, R. L. Life in the Ward. East Lansing, MI: Michigan State University Press, 1961. Coser, R. L. and Rokoff, G. Women in the occupational world: social disruption and conflict. Social Problems 18 (Spring): 535554, 1971. Levin, H. Work, The Staff of Life. Journal of Social Action (Winter): 1976. Weber, M. The Protestant Ethic and the Spirit of Capitalism. trans. T. Parsons. New York: Scribner, 1958.
31. Cole, S. and Lejeune, R. Illness, Welfare Retreatism and the Legitimation of Failure, project report, Center for Research on the Acts of Man, Philadelphia, PA. (unpublished report). 32. Merton, R. K. Social Structure and Anomie. In Social Theory and Social Structure, pp. 131-160. Glencoe, IL: The Free Press, 1957.
ACKNOWLEDGMENTS I want to acknowledge the efforts of Professors Margery Braren and Jack Elinson, and Staff Associate Caron Todd, from the Sociomedical Sciences Division of Columbia University who provided me with the data and computer services needed to analyze them. Acknowledgment is also extended to Mary Stabile for her diligent efforts in typing and assistance in editing the drafts for this paper. Special thanks are extended to Professors Stephen Cole and Rose Laub Coser from the Department of Sociology, S.U.N.Y. at Stony Brook whose very own research, teachings, and constructive criticisms helped contribute to this study.
Comments on 'Welfare Status, Illness and Subjective Health Definition' Welfare recipients individually and as a group continue to be the subject of investigation and concern by social scientists. This writer has no quarrel with these efforts as long as they are not used to explain the incidence or prevalence of illness in such a population group. The article, "Welfare Status, Illness and Subjective Health Definition," which appears in this issue of the Journal' is careful not to draw such conclusions. As the author points out, the sample of 723 and consequently the subsamples are small and precisely confined to those who are hospitalized. I believe that it would have been more meaningful to have studied the perceptions of a sample of welfare recipients who know they are sick but who work daily with much pain and disability, travel long distances to their jobs, and continue to care for their families after they come home. One wonders whether it was appropriate for the author to have included "retired" in the "don't work" group along with the sick/disabled. One of the limitations which must be emphasized whenever one talks about the welfare segment of our population is the assumption that welfare clients constitute a group of individuals who, once having entered the welfare rolls, remain in this status for life. Rein and Rainwater2 have reiterated, as a result of a recent study, that the hard core "welfare class" represents less than 10 per cent of all those who ever go on welfare and a little more than one-fifth of those already on welfare at any given time. The typical welfare recipient is in Address reprint requests to Dr. Paul B. Comely, System Sciences, Inc., 4720 Montgomery Lane, Bethesda, MD 20014.
870
and out of welfare rolls, depending upon the varied crises such as unemployment or marital disruption which do appear in his life, as well as in yours or mine. Thus a different type of study is needed in order to give credence to the Cole/ Lejeune hypothesis that taking the "sick role" is a way of legitimizing welfare dependency.3 This brings us to the central or crucial point of this statement. There is an axiom in academic medicine as well as in practice that, whenever one is faced with the diagnosis and care of any illness, it is mandatory that all possible organic causes be ruled out before considering psychosomatic or psychiatric causes. By the same token, it would appear that before social scientists construct fanciful sociological theories concerning the etiology of disease in groups of people, they determine whether the individuals making up the group are organically sick. Prince's own data clearly suggest that the welfare recipients who considered themselves to have fair/poor health suffered in greater proportion from both acute and chronic illnesses (Table 6). One wishes more data were available on the extent and types of these illnesses. Data are available which show that people on welfare are sicker, and there is no need to look for sociological concepts as causative agents for medical problems. Romm, et al.,4 in 1971 published a rather detailed analysis of a baseline survey of 17,080 low income families composed of 54,744 individuals. Table A reproduced below represents an analysis of three health indicators for six urban and two rural areas representing about one-half of the population studied. The three population groups under each geographical area were categorized as follows: AJPH September, 1978, Vol. 68, No. 9
Abstract: The self-defined health status of welfare recipients hospitalized for illness during the preceding year was compared to that of persons not on welfare but hospitalized for illness during the same period. Data were derived from a systematic probability sample of household residents of the Harlem Hospital inpatient district population surveyed July 1967-June 1970. Welfare recipient respondents were more likely to perceive their health as fair/poor than were persons not on welfare. This difference persisted when the data
were analyzed by sex, age, reported levels and type of illness, hospital days and number of stays, and current usual activity; usual activity was a major explanatory variable but only partially accounted for the relationship. It has been hypothesized that in achievement-oriented societies, illness may be used as justification for a culturally-induced sense of personal failure to fulfill socially prescribed role obligations. The data are consistent with this hypothesis. (Am. J. Public Health 68:865-870, 1978)
Introduction
lated to social stratification,10-13 cultural differentiation,14-16 and individual differences in the significant others who influence decisions.'7-20 From a sociological perspective, a person is sick when he or she "acts" sick, the emphasis being on a person's behavior. The physiological state of the body is not a necessary condition for evoking sick role behavior. A corollary is that the conditions that motivate people to view themselves as sick or healthy are of major importance. Medical doctors and social scientists are becoming increasingly aware of the interrelationship between physiological conditions of the body and the social psychological forces which intertwine in determining objective and subjective states of health.21-25
This research takes as its point of departure the work of Stephen Cole and Robert Lejeune, 1972.1 Cole and Lejeune, addressing the problem of taking the "sick role," argued that one may use illness to justify welfare dependency and a culturally-induced sense of personal failure to fulfill sociallyprescribed role obligations. According to them, "many welfare mothers accept the dominant cultural view that being on welfare is a result of personal failure. When women accept this view and give up hope of getting off welfare, they are prone to adopt the sick role to legitimize their welfare dependency and self-defined failure." The study of illness behavior from a sociological perspective began in earnest with Parson's formulation of the sick role, derived from the emphasis of modern industrial societies on instrumental activism.2 While Parson's formulation may be useful when the focus is on society as a whole,3 it tells us nothing about normative variations among various sub-societal populations. Several studies, none of which were specifically oriented toward the sick role formulation, have demonstrated variations in both perception of illness4'5 and in illness behavior.6-9 These variations have been reAddress reprint requests to Mr. Edgar 0. Prince, Senior Research Analyst, Office of Program Evaluation and Research, Suffolk County Department of Health Services, H. Lee Dennison Executive Office Building, Veterans Memorial Highway, Hauppauge, NY 11787. This paper, submitted to the Journal September 17, 1975, was revised and accepted for publication November 10, 1977. The original version was presented at the 103rd Annual Meeting of the American Public Health Association, Chicago, 1975.
AJPH September, 1978, Vol. 68, No. 9
Method The data for this study were obtained from the Harlem Community Health Survey* of the Harlem Hospital District population during the period extending from July 1967 to June 1970. The District is a poverty area. A structured questionnaire elicited information on each household resident's personal characteristics, health status, and health-care-related behavior. The respondent providing the data was re-
* For a detailed description of the setting, sample design, sampling frame, field operations, etc., consult "Sampling and Field Operations of the Harlem Community Health Survey," Patricia Collette, Director, Office of Patient Care and Program Evaluation, Harlem Hospital Center, Columbia University, New York, NY, 1971. An unpublished report.
865
PRINCE
quired to be a household resident, 18 or more years of age, mentally competent, and reporting for himself/herself or related to the individuals for whom he/she reported. A systematic probability sample of housing units within the Harlem Hospital District with sampling rates of one housing unit in 25 within the Central Harlem Health District portion and one in 50 outside of it were drawn.** Data were gathered on 8,817 housing units and 22,199 residents; 12 per cent (2,673) of the residents had been hospitalized at least once during the 12 months preceding the interview. Hospitalized sample respondents were more likely to have received welfare assistance some time during the year preceding interview than non-hospitalized sample respondents.*** The study data derive from a subsample of 2,673 respondents who were hospitalized at least once during the year preceding interview. Specifically excluded from analysis were hospitalizations not considered as illness-related: accidents, injuries, deliveries, complications of pregnancy, and surgery for non-specified conditions. In addition to the respondent requirements already specified, subsample respondents were required to be self-respondents, since it was necessary that they define their own health status perception. These additional requirements reduced the number of responses to be analyzed to 723. Of all subsample respondents analyzed excluding missing responses (N=723), 82.0 per cent (590) were black; 62.0 per cent (448) were women; 55.0 per cent (395) were between 18 and 50 years old; 67.0 per cent (481) had less than a twelfth grade education; 37.3 per cent (270) had received welfare assistance sometime during the year preceding interview; and 65.0 per cent (473) were currently unemployed and/or unemployable. Thus we are comparing two subgroups within an overall underprivileged poverty population; one of the subgroups receives welfare assistance, the other does not. The dependent variable in this study, respondent subjective definition of health, was measured by responses to the question: "To begin with, how is your health now? Would you say it is excellent, good, fair or poor?" This response was dichotomized into "excellent/good" and "fair/ poor." The independent variable is receipt versus non-receipt
** It should be noted that the differential sampling rates employed require all interview data pertaining to housing units, households, and individuals selected from the low sampling rate zones-I in 50-to be weighted up in tabulations pertaining to the total hospital district. All estimates for the hospital district as a whole must be based on weighted distributions, but the reliability of a given statistic is a function of the number of actual cases, the unweighted N in tabulations. *** Of the 2,673 hospitalized sample respondents, 1,150 (43.0 per cent) had received welfare assistance sometime during the 12 months preceding interview; of the 19,526 non-hospitalized sample respondents, 5,362 (27.5 per cent) had received welfare assistance sometime during the 12 months preceding interview. Thus, the proportion of hospitalized sample respondents who had received welfare assistance sometime during the 12 months preceding interview was 15.5 per cent greater than the proportion of non-hospitalized sample respondents who had received welfare assistance. Chisquare equals 267.47 with one degree of freedom significant at the .001 rejection level.
866
of welfare assistance in the year. Respondents were asked: "In the past 12 months has anyone here including yourself received any welfare assistance, not counting Social Security?" Each individual was then coded as to whether he/she had received welfare assistance.T Health care status and utilization were also measured by three self-reported indicators: a) average length of inpatient stay per discharged patient which was trichotomized into short, medium, and long stay categories, and computed by dividing the total number of hospital days for a specified group by the total number of discharges for the same group; b) number of inpatient stays in the 12 months preceding interview which was dichotomized into 1 stay versus 2-5 stays; and c) main condition of inpatient stay which was dichotomized into acute versus chronic conditions.tt Age and sex of subsample respondents were analyzed for their possible independent and interactive effects on subjective health states.26-28 The relationship between welfare status and subjective health definition was also analyzed by usual activity which is taken as an indicator of current employment status/employability. Respondents were asked, "What do you usually do most of the time-work, keep house, work and keep house, go to school, or something else? What?" This variable was dichotomized into "work/don't work." The "work" group includes worker only, and worker/homemaker. The "don't work" group includes homemaker only, retired, and sick/ disabled. The relationship between welfare status and subjective health definition was examined only among hospitalized, as opposed to non-hospitalized, respondents because hospitalization experiences or illness episodes may have an independent effect on employment status and welfare dependency. All hospitalized respondents had "officially" been defined as being medically sick (hospitalized). Therefore, their claim to evoking the "sick role" under conditions of overall self-reported poor health care status or health care customs has been legitimized. If there are statistically significant measured differences in subjective health states between hospitalized welfare versus hospitalized non-welfare recipients experiencing similar levels of overall poor health care status or health care customs, then these differences are less likely to be attributable to differences in illness episodes and are more likely to be due to factors of a sociopsychological nature. Without longitudinal data, we do not know whether the t While the health status question specifically asked the respondent for a personal response, the question on welfare status does not, i.e., "anyone here received any welfare assistance?"; subsample respondents were required to be self respondents so that the same person was providing the data on both his/her own welfare status and his/her own subjective health perception. t1 Acute conditions were usually contagious or infectious in origin: e.g. pneumonia, influenza, chicken pox, etc. Chronic conditions have one or more of the following characteristics: permanent, leaves a residual disability, caused by nonreversible pathological alterations, requires special training of patients for rehabilitation, and are expected to require long periods of supervision, care or observation, e.g. asthma, hay fever, chronic bronchitis, etc. AJPH September, 1978, Vol. 68, No. 9
SUBJECTIVE HEALTH DEFINITION TABLE 1 -Subjective Health Definition of Hospitalized Respondents by Welfare Status. Welfare
Status
Receipt Non-Receipt
Subjective Health Definition (Fair/Poor) (Excellent/Good)
25.9% ( 70)* 48.1% (218)
74.1% (200) 51.9% (235)
TABLE 2-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Sex. Welfare Status
Total (N)
100.0% (270) 100.0% (453)
Receipt Non-Receipt
Sex Male
Female
80.0% ( 85)* 54.7% (190)
71.4% (185) 49.8% (263)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected chi-square (1 d.f.) applied down columns = 33.86; p < .001 one test missing observations equal 14
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (2 d.f.) = 34.85; p < .001 two tests missing observations equal 14
hospitalization experiences precede or follow a person's welfare status, nor whether the assumption of the sick role occurred prior to or after going on welfare.
Respondents who are unemployed/unemployable while simultaneously receiving welfare assistance sometime during the year preceding interview, a group more likely to be 36-64 years of age, may have a greater need to define their health as fair/poor in order to legitimize to themselves and to the rest of society their welfare dependency and culturallyinduced sense of personal failure to fulfill socially prescribed role obligations. Table 4 empirically supports this hypothesis. Usual activity is significantly related to both welfare status and subjective health definition. However, with the exception of those 65 years of age and older, the proportion of the "don't work" group defining their health as fair/poor is greater than the proportion of the "work" group defining their health as fair/poor (see also H. Levin29). The most striking contrasts are in age groups 36-50 and 51-64. Table 4 shows that although usual activity or employment status may be a major explanatory factor partially accounting for the strength of the original relationship, welfare status itself continues to have an independent effect on perceived health
Findings According to Table 1, the proportion of hospitalized welfare recipients describing their health as fair/poor was 22.2 per cent greater than the proportion of hospitalized nonwelfare recipients describing their health as fair/poor. In Table 2, the marginal frequencies show that sex is slightly related to welfare status but not to subjective health definition. Among male respondents, the proportion of hospitalized welfare recipients describing their health as fair/ poor was 25.3 per cent greater than the proportion of hospitalized non-welfare recipients describing their health as fair/ poor. The corresponding percentage difference among female respondents equals 21.6 points (Table 2). In Table 3, the relationship between self-perceived health status and welfare status was analyzed by age of hospitalized respondents. Although age of hospitalized respondents is slightly related to welfare status, this relationship was not statistically significant at the .05 rejection level. Age of hospitalized respondents is significantly related to subjective health definition, but at all ages welfare recipients are more likely to perceive their health as fair/poor. The largest percentage point difference in subjective health definition between hospitalized welfare recipients and hospitalized non-welfare recipients occurred within the 36-50 and 51-64 age groupings respectively.
status.
Perceived health status among respondents in this subsample was also analyzed by age and average length of inpatient stay (Table 5). Regardless of age and average length of inpatient stay, the proportion of hospitalized welfare recipients describing their health as fair/poor was significantly greater than the proportion of hospitalized non-welfare respondents describing their health as fair/poor. In all but three of the 12 instances (18-35 year olds hospitalized for a short and long stay, and 65 year olds and over hospitalized for a long stay) the differences are statistically significant. In Table 6, the relationship between welfare status and
TABLE 3-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Age. Age
Welfare Status
Receipt Non-Receipt
(18-35 yrs)
(36-50 yrs)
(51-64 yrs)
(65 yrs old and over)
46.6% ( 58)* 32.5% (114)
76.8% ( 95) 47.7% (128)
86.4% ( 81) 61.8% (110)
83.3% ( 36) 68.3% (101)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (4 d.f.) = 36.03; p < .001 four test missing observations equal
14
AJPH September, 1978, Vol. 68, No. 9
867
PRINCE
TABLE 4-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status, Age, and Usual Activity. Age Welfare Status
Receipt NonReceipt
Usual Activity Don't Work Work
Usual Activity Don't Work Work
Usual Activity Don't Work Work
Usual Activity Don't Work Work
(65 yrs old and over)
(51-64 yrs)
(36-50 yrs)
(18-35 yrs)
40.0% (15)*
48.8% (43)
63.2% (19)
80.3% (76)
( 5)
89.5% (76)
** ( )
83.3% (36)
31.7% (60)
33.3% (54)
36.1% (72)
62.5% (56)
47.5% (61)
79.6% (49)
72.2% (18)
67.5% (83)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (7 d.f.) = 13.69; .10 > p > .05 seven test missing observations equal 14 ** Too few cases
subjective health definition is analyzed by nature of condition (acute or chronic) for which hospitalized and age of hospitalized respondents. Acuteness or chronicity of the condition was not related to welfare status, but respondents hospitalized for chronic conditions were more likely to describe their health as fair/poor than were respondents hospitalized for acute conditions. Regardless of condition and age, the proportion of hospitalized welfare recipients describing their health as fair/poor was significantly greater than the proportion of hospitalized non-welfare recipients describing their health as fair/poor. This finding was true for every subgroup except those respondents 18-35 years of age who were hospitalized mainly for chronic conditions, where the trend was the same although the difference was not significant. In Table 7 the relationship between welfare status and subjective health definition was analyzed by number of inpatient stays in the prior 12 months. Number of inpatient stays was not significantly related to welfare status, but was significantly related to subjective health definition. Regardless of welfare status, respondents hospitalized for 2 to 5 stays were more likely to describe their health as fair/poor than were respondents who were hospitalized only once during the year preceding interview. The proportion of hospital-
ized welfare recipients in all age and stay groups describing their health as fair/poor is significantly greater than the proportion of hospitalized non-welfare recipients describing their health as fair/poor.
Discussion This study has examined the self-perception of health status within a poverty population, living at home, who have been hospitalized for illness at least once during the prior year. It has compared the perception of those respondents currently on welfare with those not currently on welfare. When analyzed by sex, age, current activity status, average length of hospital stay, number of hospital stays, and nature of condition causing hospitalization (acute or chronic), welfare recipients were more apt to perceive their health as fair/ poor than were respondents not on welfare. There are certain limitations of the data which need to be pointed out. The subsample respondents do not represent all welfare recipients but only those who were hospitalized during the prior year. Thus the findings cannot be generalized to all those on welfare. For the hospitalized group, how-
TABLE 5-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status, Age and Average Length of Inpatient Stay* Age (36-50 yrs)
(18-35 yrs)
Welfare Status
Receipt
Non-Receipt
Length Of Inpatient Stay Medium Short Long
Length Of Inpatient Stay Medium Short Long
(51-64 yrs)
(65 yrs and over)
Length Of Inpatient Stay Medium Short Long
Length Of Inpatient Stay Short Medium Long
83.3% 79.0% 90.0% 62.5% 66.7% 78.6% 79.0% 70.8% 85.2% 96.6% 33.3% ( 8) (19) (12) (27) (27) (24) (28) (38) (27) (16) (20) (21)** 32.4% 57.1% 50.0% 34.8% 59.4% 53.5% 61.3% 75.8% 45.0% 71.1% 72.5% 25.4%
(59)
(34)
(21)
(48)
(46)
(32)
(43)
(31)
(33)
(20)
(38)
(40)
Average length of inpatient stay was defined as the total number of acute and chronic days for a specified group divided by the total number of acute and chronic discharges for the same group. A short stay is defined as being hospitalized less than 10 days. A medium stay ranges from 11-21 days, and a long stay is 22 days and more. The numbers in the parentheses refer to individuals with no duplications. By combining acute and chronic days and dividing by the total number of acute and chronic stays or discharges, we resolve the problem of mutliple hospitalization experiences or illness episodes. This procedure allows us to compute an average length of stay for each respondent without duplications. ** The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (12 d.f.) = 36.03; p < .001 twelve test missing observations equal 25 *** Too few cases.
868
AJPH September, 1978, Vol. 68, No. 9
SUBJECTIVE HEALTH DEFINITION TABLE 6-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Statues, Age, and Main Condition of Inpatient Stay. Age
Welfare Status
Receipt Non-Receipt
Acute
(18-35 yrs) Chronic
46.2% (13)* 21.7% (46)
45.5% (44) 41.2% (68)
Acute
(36-50 yrs) Chronic
56.3% (16) 35.3% (17)
80.5% ( 77) 48.6% (109)
Acute
(51-64 yrs) Chronic
80.0% (10) 64.7% (17)
83.8% (68) 62.2% (90)
(65 yrs and over) Acute Chronic
72.7% (11) 61.5% (13)
78.6% (28) 67.1% (85)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (8 d.f.) = 33.28; p < .001 eight test missing observations equal 25
ever, the data are consistent with the Cole-Lejeune hypothesis.1 The paper's aim was not to test the validity of this hypothesis since no independent data were presented to show that welfare recipients actually do or feel any of the things implicit in legitimizing failure. In mixed capitalistic, modem industrial, achievementoriented societies, such as our own, where the spirit of laissez-faire, rugged individualism, and the Protestant Work Ethic are ingrained features of the dominant cultural belief system, failure to fulfill socially prescribed role obligations is generally viewed as resulting from individual idiosyncrasies, laziness, low intelligence, lack of initiative, and degenerate moral character. Most individuals are supposed to have a moral and social responsibility to strive and get ahead. Failure to do so is regarded as a sign of individual or personal failure rather than societal failure resulting from a repressive social structure.30 It is medically recognized that the symptomatology and organic changes resulting from a psychosomatic ailment are "real." In like manner, the taking of the sick role by welfare recipients in order to legitimize a culturally-induced sense of personal failure might also be viewed as a "real" adaptation to structural conditions of stress and anxiety. Actual as well as perceived differences in opportunity structures may lead to heightened feelings of anxiety and frustration from which follow increased feelings of powerlessness, alienation and apathy, bringing about changes in self-worth or self-esteem and ultimately resulting in sick role behavior to legitimize feelings of culturally-induced self-defined failure.31 Most welfare recipients would prefer to get off the welfare rolls and work, but because of education, previous job experience, race, intelligence, "objective health" and age, they are forced literally to remain on the welfare rolls generation after generation.31 Consequently, the taking of the sick role TABLE 7-Percentage of Hospitalized Respondents Defining Health as Fair/Poor by Welfare Status and Number of Inpatient Stays in Prior 12 Months. Welfare Status
Receipt Non-Receipt
Number of Inpatient Stays 2-5 Stays 1 Stay
70.0% (237)* 50.6% (409)
80.0% (35) 64.6% (48)
* The numbers in parentheses in each cell represent frequencies from which the percentages were derived. Corrected weighted chi-square applied down columns (2 d.f.) = 34.21; p < .001 two test missing observations equal 8
AJPH September, 1978, Vol. 68, No. 9
in attitude, if not in overt behavior, may become a permanent adaptation to a structural condition of anomie.32 Such an hypothesis is consistent with the data presented in this study.
REFERENCES 1. Cole, S. and Lejeune, R. Illness and legitimation of failure. American Sociological Review 37:347-356, 1972. 2. Parsons, T. and Fox, R. The Social System. Glencoe, IL: The Free Press, 1951. 3. Gordon, G. Role Theory and Illness. New Haven, College and University Press, 1966. 4. Baumann, B. Diversities in conceptions of health and physical fitness. Journal of Health and Human Behavior, 2:1:39-46, 1961. 5. Freidson, E. The Sociology of Medicine. Current Sociology, x/ xi:3, 1962. 6. Mechanic, D. Perception of Parental Responses to Illness: A Research Note. Journal of Health and Human Behavior, 6:4:253-257, 1965. 7. Davis, F. Passage Through Crisis. Indianapolis: Bobbs-Merrill, 1963. 8. Barker, R., et al. Adjustment to Physical Handicap and Illness. New York Social Science Research Council, 1953. 9. Roth, J. Timetables. Indianapolis: Bobbs-Merrill, 1963. 10. Mechanic, D. The Concept of Illness Behavior. Journal of Chronic Diseases, 15:189-195, 1962. 11. Koos, E. L. The Health of Regionville. New York: Columbia University Press, 1954. 12. Lynd, R. and H. Lynd. Middletown. New York: Harcourt, Brace, 1929. 13. Brightman, I., et al. Knowledge and Utilization of Health Resources by Public Assistance Recipients. Am. J. Public Health, 48:188-199, 319-327, 1958. 14. Ross, J. Social Class and Medical Care. Journal of Health and Human Behavior, Spring: 35-40, 1962. 15. Paul, B. D. Health, Culture and Community. New York: Russell Sage Foundation, 1955. 16. Wolff, H. Disease and the Patterns of Behavior, in MacIver, R. Ed. The Hour of Insight. New York: Institute for Religious and Social Studies, p. 29-41, 1954. 17. Zborowski, M. Cultural Components in Response to Pain. Journal of Social Issues 8:16-30, 1952. 18. Freidson, E. Patients' Views of Medical Practice. New York: Russell Sage Foundation, 1961. 19. Knutson, A. The Individual, Society;, and Health Behavior. New York: Russell Sage Foundation, 1%5. 20. Mechanic, D. Some factors in identifyifli and defining mental illness. Journal of Mental Hygiene 46:1:66-74, 1962. 21. Bloom, S. The Doctor and His Patient. Glencoe, IL: Free Press, 1965. 22. Crandell, D. L. and Dohrenwend, B. Some relations among psychiatric symptoms, organic illness, and social class. American Journal of Psychiatry, 123:1527-1537, 1967. 23. Hinkle, L. E., Jr., Pinsky, R. H., Bross, I. D. J., and Plummer, N. The distribution of sickness disability in a Homogeneous
869
CORNELY
24. 25. 26. 27.
28.
29. 30.
Group of 'healthy' adult men. American Journal of Hygiene 64:220-242, 1956. Mechanic, D. and Volkart, E. H. Stress, illness behavior and the sick role. American Sociological Review 26:51-58, 1961. Wolff, H. Disease and Patterns of Behavior. pp. 54-61 in E. Gartly Jaco, Ed. Patients, Physicians, and Illness. Glencoe, IL: The Free Press, 1958. Cumming, E. and Henry, J. Growing Old: The Process of Disengagement. New York: Basic Books, 1961. Coser, R. L. Life in the Ward. East Lansing, MI: Michigan State University Press, 1961. Coser, R. L. and Rokoff, G. Women in the occupational world: social disruption and conflict. Social Problems 18 (Spring): 535554, 1971. Levin, H. Work, The Staff of Life. Journal of Social Action (Winter): 1976. Weber, M. The Protestant Ethic and the Spirit of Capitalism. trans. T. Parsons. New York: Scribner, 1958.
31. Cole, S. and Lejeune, R. Illness, Welfare Retreatism and the Legitimation of Failure, project report, Center for Research on the Acts of Man, Philadelphia, PA. (unpublished report). 32. Merton, R. K. Social Structure and Anomie. In Social Theory and Social Structure, pp. 131-160. Glencoe, IL: The Free Press, 1957.
ACKNOWLEDGMENTS I want to acknowledge the efforts of Professors Margery Braren and Jack Elinson, and Staff Associate Caron Todd, from the Sociomedical Sciences Division of Columbia University who provided me with the data and computer services needed to analyze them. Acknowledgment is also extended to Mary Stabile for her diligent efforts in typing and assistance in editing the drafts for this paper. Special thanks are extended to Professors Stephen Cole and Rose Laub Coser from the Department of Sociology, S.U.N.Y. at Stony Brook whose very own research, teachings, and constructive criticisms helped contribute to this study.
Comments on 'Welfare Status, Illness and Subjective Health Definition' Welfare recipients individually and as a group continue to be the subject of investigation and concern by social scientists. This writer has no quarrel with these efforts as long as they are not used to explain the incidence or prevalence of illness in such a population group. The article, "Welfare Status, Illness and Subjective Health Definition," which appears in this issue of the Journal' is careful not to draw such conclusions. As the author points out, the sample of 723 and consequently the subsamples are small and precisely confined to those who are hospitalized. I believe that it would have been more meaningful to have studied the perceptions of a sample of welfare recipients who know they are sick but who work daily with much pain and disability, travel long distances to their jobs, and continue to care for their families after they come home. One wonders whether it was appropriate for the author to have included "retired" in the "don't work" group along with the sick/disabled. One of the limitations which must be emphasized whenever one talks about the welfare segment of our population is the assumption that welfare clients constitute a group of individuals who, once having entered the welfare rolls, remain in this status for life. Rein and Rainwater2 have reiterated, as a result of a recent study, that the hard core "welfare class" represents less than 10 per cent of all those who ever go on welfare and a little more than one-fifth of those already on welfare at any given time. The typical welfare recipient is in Address reprint requests to Dr. Paul B. Comely, System Sciences, Inc., 4720 Montgomery Lane, Bethesda, MD 20014.
870
and out of welfare rolls, depending upon the varied crises such as unemployment or marital disruption which do appear in his life, as well as in yours or mine. Thus a different type of study is needed in order to give credence to the Cole/ Lejeune hypothesis that taking the "sick role" is a way of legitimizing welfare dependency.3 This brings us to the central or crucial point of this statement. There is an axiom in academic medicine as well as in practice that, whenever one is faced with the diagnosis and care of any illness, it is mandatory that all possible organic causes be ruled out before considering psychosomatic or psychiatric causes. By the same token, it would appear that before social scientists construct fanciful sociological theories concerning the etiology of disease in groups of people, they determine whether the individuals making up the group are organically sick. Prince's own data clearly suggest that the welfare recipients who considered themselves to have fair/poor health suffered in greater proportion from both acute and chronic illnesses (Table 6). One wishes more data were available on the extent and types of these illnesses. Data are available which show that people on welfare are sicker, and there is no need to look for sociological concepts as causative agents for medical problems. Romm, et al.,4 in 1971 published a rather detailed analysis of a baseline survey of 17,080 low income families composed of 54,744 individuals. Table A reproduced below represents an analysis of three health indicators for six urban and two rural areas representing about one-half of the population studied. The three population groups under each geographical area were categorized as follows: AJPH September, 1978, Vol. 68, No. 9
