NATIONAL CENTER Series 1

I

For HEALTH STATISTICS Number 5

VITAL and HEALTH STATISTICS

PROGRAMS AND COLLECTION PROCEDURES

Plan, Operation, and

Response Results

of a Program of

Children’s Examinations

A description of the Health Examination Survey’s second cycle, examinations of a probability sample of United States

children 6-11 years of age.

Washington, 0. C. October 1967

U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

John W. Gardner

Secretary

Public Health Service

William H. Stewart

Surgeon General
NATIONAL CENTER FOR HEALTH STATISTICS

THEODORE D. WOOLSEY, ActingDirector

PHILIP S. LAWRENCE, Sc.D., Associate Director

OSWALD K. SAGEN, PH.D.,, Assistant Director for Health Statistics Development

WALT R. SIMMONS, M.A., Acting Assistant Director for Research and Scientific Development

ALICE M. WATERHOUSE, M.D., Medical Consultant

JAMES E. KELLY, D.D.S., Dental Advisor

LOUIS R. STOLCIS, M.A., Executive Officer

DONALD GREEN, lnfomation Officer

OFFICE OF HEALTH STATISTICS ANALYSIS

IWAO M. MORIYAMA, PH.D., Director

DIVISION OF VITAL STATISTICS

ROBERT D. GROVE, PH.D., Director

DlVISlObJ OF HEALTH INTERVIEW STATISTICS

ELIJAH L. WHITE, A.M., Director

DIVISION OF HEALTH EXAMINATION STATISTICS

ARTHUR J. MCDOWELL, f&e&t

DIVISION OF HEALTH RESOURCES STATISTICS

SIEGFRIED A. HOERMANN, Ditector

DIVISION OF DATA PROCESSING

LEONARD D. M&ANN, Ditectot

Public Health Service Publication No. 1000-Series l-No. 5

Library of Congress Catalog Card Number 67-61853

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PREFACE

This report is primarily a description of one

of the major programs of the National Center for

Health Statistics. It is, therefore, most appropriately classified in Series l. It is not, however,

purely a program description since it includes the

results of the execution of the program with respect to response. Thus it represents for the second cycle of the Health Examination Survey a

combination of two reports related to the first

cycle-Series 1, Number 4 (program description),

and Series 11, Number 1 (response results).

The process of planning this program has

been described in considerable detail in thisreport. This description is primarily a necessary

foundation for understanding and use of the findings

reports to be published later. It is hoped that it

will serve also as an aid to others facing somewhat similar problems in planning examination

surveys.

In the course of the description, acknowledgment is made of some of the assistance received

from individuals and groups within the Public

Health Service and elsewhere. Space does not permit anything like full recognition of those who

have participated. Mention should be made here,

however, of the important role played by the U.S.

Bureau of the Census. Under a contractual arrangement they have participated in the survey

planning and sample design, selected the sample,

conducted the initial household interviews, and

carried out part of the data processing. The examination phase of the plan was worked out and

generally supervised by Dr. Alice M. Waterhouse, then- Medical Advisor to the National Center

for Health Statistics, Dr. James E. Kelly and

Dr. Lawrence E. Van Kirk, Jr., Dental Advisors

to the Center and the Division of Health Examination Statistics, respectively, and Dr. Lois

R. Chatham, Psychological Advisor to the Division. This report was prepared by Arthur J.

McDowell.
CONTENTS

Page

Preface --------------cII-II---------------”--------------------------

Introduction ----------------------------------------------------------

General Pattern of Successive HES Programs----------------------------

The Organization by Cycles - - - - - - - - - - .-VIIIII”IIIIIIIIIIIIIIIIIIIIIII

The Three-Level Operation Concept -----------------------------------

Common Characteristics of Successive Cycles--------------------------

The Planning Phase of Cycle II------------------------------------------

Guidelines at Outset-------------------------------------------------

Developing the Detailed Plan -----------------------------------------

Preliminary Studies and Tests ----------------------------------------

The Sample Design ----------------------------------------------------

General Plan-------------------------------------------------------

Stratification and Selection of PSU*s-------------I---------------------

Further Stages of Sample Selection ------------------------------------

Special Problems---------------------------------------------------

The Logistics ---------------------------------------------------------

Mobile Examination Centers and Field Staff---------------------------

Sequencing and Scheduling Stands----I------“*------------------------

Advance Arrangements and Coordination ------------------------------

The Household Interview and Final Stages of Sampling-- - - - - - - - - - - - - - - - -

Appointment and Transportation Procedures ---------------------------

Nature of the Examination -------------------------o--------------------

General Considerations -o-------------------------------------o-----

The Examination by Physician and Nurse ------------------------------

The Dental and Vision Examinations ---o-------------------------------

Psychological Testing -------------I---------------------------------

Tests, Procedures, and Measurements Done by Technicians-- - - - - - -- - - - -

i

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1

1

‘2

2

10

10

12

13

15

17

17

17

19

20

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CONTENTS--Con.

Appendix I.

IA.

IB.

IC.

ID.

IE.

IF.

Selected Forms Used in Cycle II ~I.-.-..-.-----.---....~...

National Health Survey Questionnaire - - - - - - - - - - - - - - - - - - - - - - -

Child’s Medical History.-Parent---... - --------------------

Health Examination Survey II-Audiometry - - - - - - - - - - - - - - - - - -

Health Examination Survey II- Body Measurements- - - - - - - - - -

Supplemental Information From School- - - - - - - - - - - - - - - - - - - - - -

Child’s Medical History--Interviewer - - - - - - - - - - - - - - - - - - - - - - -

Audiometry TestingPr~ce~ures-.------.-.--..-----.-..--..

35

35

40

46

47

48

50

Appendix II, 54

23

23

24

26

27

27

28

31

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SYMBOLS

Data not available----------------------- ---

Category not applicable------------------ m**

Quantity zero ---------~*~-~~1-~-~1-~~~~~~ L

Quantity more than 0 but lees than 0,05---- 0.0

Figure does not meet standards of

reliability or precision----------------- *

: .
I

THIS REPORT IS a detailed description of the second progvam of the

national Heaith Examination Survey. This survey involved selection and

exam&&ion of a probability sample of the nation% noninstitutionalized

children between the ages of 6 and 11 years. The examination focused

particularly on fat toys related to growth and development. It included

examination by a physician, a variety of tests, procedures, and measurements, examination by a dentist, and tests administered by a psychologist. The report describes the developmentof the survey plan, the sample design, the content of the examimtion, and the operation of the

survey, including steps taken to combat measurement emoy, It also

presents the response results of the survey.

The Health Examination Survey second cycle program succeeded in examining 96 percent of the 7,417 children selected for the sample. This

very favorable response rate showed expected mriations by po@&tiondensity groups and some other variables; but the dinerences were slight.

Thus, for example, the range of variation among the 40 locations visited

was quite limited. The lowest response at any location was 90 percent,

and at two locations 100 percent of the sample children we;Ye examined.

The report discusses factors related to response rates.
PLAN, OPERATION, AND RESPONSE RESULTS

OF A PROGRAM OF CHILDREN’S EXAMINATIONS

INTRODUCTION

The Health Examination Survey is carried out

as one of the major programs of the National

Center for Health Statistics. It is a part of the

National Health Survey, authorized in 1956 by the

84th Congress as a continuing Public Health Service activity.

The National Health Survey consists of three

different survey programs> One of these, the

Health Interview Survey, is primarily concerned

with the impact of illness and disability upon

people% lives and actions and the differentials

observable in different population groups. It collects information from the people themselves by

means of household interviews. A second, the

Health Records Survey, actually is a family of

record-linked surveys. It includes folloti- back

studies based on vital records, institutional surveys to establish sampling frames as well as to

provide data, and surveys based on samples of

hospital records. The third major program of the

National Health Survey is the ‘Health Examination

Survey (HES).

The Health Examination Survey collects data

by direct physical examinations and tests and

measurements performed on the sample population studied. This is the best way to obtain definite

diagnostic data on the prevalence of certain medically defined illnesses. It is the only way to obtain information on unrecognized and undiagnosed

conditions-in some,cases, even nonsymptomatic

conditions. It is also the only way to obtain distributions of the population by a variety of physical,

physiological, and psychological measurements.

It provides these data for a known population and

simultaneously provides the demographic and

socioeconomic data required for analysis.

Because the Health Examination Survey collects a wide range of kinds of data on each of the

sample persons examined, it is possible to investigate many different interrelationships. In addition

to exploring the obvious differentials in disease

prevalence related to demographic or socfoeconomic factors (age, sex, income, education, and

the like), it is possible to relate one set of medical

findings to another or to other kinds of data collected in the examinaton. Thus data on visual

acuity can be related to school achievement, findings of an eye examination, scores on psychological tests, and other items. The possibility of

studying interrelationships is not limited to those

already known to exist. Suspected relationships

can be investigated, and exatiination of the collected data may even reveal relationships hitherto

unsuspected.

GENERAL PATTERN

OF SUCCESSIVE HE’S PROGRAMS

The Organization by Cycles

The Health Examination Survey program is

carried out as a series of separate programs,

each one with a specific set of goals. These successive programs are referred to as ‘*cycles.”

Each cycle is concerned with some specific segment of the total U.S. population and with certain

specified aspects of the health of that subpopulation. Thus the first cycle obtained data on the prevalence of certain chronic diseases and on the

distribution of various measurements and other

1
characteristics in a defined adult population. The

second cycle concerns a different population, children between the ages of 6 and 11 years, and the

examination focuses on factors related to growth

and development. The third cycle covers a sample

of youths between 12 and 17, years of age.

The first cycle began examinations in November 1959 and completed the last of the field work

3 years later; in 1962. The examination was designed to determine the prevalence of the several

cardiovascular disease s, arthritis and rheumatis’m, and diabetes.. Various meas urement data

were gathered, incl.uding visual and auditory

acuity, blood pressures, electrocardiograph ic

t ratings, and numerous body measurements. A

dentist examined teeth and mouths. The sample

population was representative of the total civilian, noninstitutionalized U.S. population between

the ages of 18 and 79 years inclusive. Reports

already published from the first cycle include

the program description,2 various methodological

reports,*l” and a growing group of reports of findings.11-35

The Three-Level Operation Concept

The plan of operation *which has developed for

the Health Examination Survey involves what is

referred to as three-level operation. This expression describes a pattern whereby in any given

period the survey is operating simultaneously on

three different levels-data collecting, cycle

planning, and analysis of findings. At a particular

time, for example, when the examinations are

being carried out for Cycle II, the work of tabulation, analysis, and publication of findings from

Cycle I is also proceeding. During that same period

of time the planning and preparing for Cycle III

is being worked on so th-at when all examinations

are completed in Cycle II the process of examining

in Cycle III can begin. There are a number of

reasons for this three-level operation, but the

principal one is to avoid complete dismantling of

a field apparatus between examining phases of

successive cycles.

Comri,on Characteristics of

Successive Cycles

In addition to the broad mission and general

operating pattern which have been described, a

number of basic characteristics are common to

all the cycles of the Health Examination Survey.

Sotie of these are strengths; others are limitations.

All HES programs make use of probability

sampling. This is a sine qua mn for a national

health examination survey since the examination

process obviously involves time, skill, and cost

factors that preclude its use on any but a rather

limited scale. Probability samples make possible

generalizations concerning the population from

which the sample is drawn with some knowledge of

how reliable the generalizations are.

All the programs collect cross- sectional data

on a national sample of the noninstitutionalized

population: The numbers involved in the national

sample permit some analysis by broad geographic

region or by population-density groups or other

major subgroups of the total sample, but they do

not permit detailed geographic breakdown of the

data. No information by State, for example, will

be forthcoming from these programs. The data

collected relate to a particular pbint in time; no

longitudinal data are presently being collected

through any followup of examined persons. The

samples studied in each of the cycles are limited

to the noninstitutional population.

The programs all represent a multidisciplinary approach to research. In each of them members of many different professions combine their

efforts, including statisticians, physicians of various specialties, dentists, psychologists, nurses-,

educators, sociologists, and management specialists. The programs also involve interagency

collaboration. The U.S. Bureau of the Census isa

partner in many phases of the survey. Many other

agencies advise and assist in various waysFederal agencies such as the National Institutes

of Health, the Office of Education, and the Children% Bureau, to name but a few, and agencies
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,

outside the Government such as medical research

centers, schools of public health, and survey research agencies.

A basic premise underlying all the programs

of the National Center for Health Statistics is

that findings should be made available to all interested persons as rapidly as possible, This is

done primarily through the publication of reports

prepared in a form usable by large numbers of

consumers of health statistics and yet at the same

time organized so that a medical research worker

interested in particular problems can obtain relevant data by looking at a minimum of data in which

he is not interested. The principal reports are

published in the various Vi td and Health Stu tis tics

series.

THE PLANNING PHASE

OF CYCLE II

Guidelines at Outset

The foregoing description of the generalpattern of successive cycles of the Health Examination Survey indicates some of the broad guidelines

that were available at the outset of the planning

phase of Cycle II. Thus it was clear early in 1961

that the second cycle would study a probability

sample of a segment of the national population,

would exclude institutionalized persons, and would

collect cross- sectional data related to health

which require direct .examination, testing, and

measuring of the individuals in the sample. The

first step in establishing the basic guidelines specific to the plan for the second cycle was to add to

these general guidelines the specific targets for

Cycle II.

The determination of the broad targets for the

second cycle, the ‘population segment to be studied

and the generalobjectives of the study, was made

arbitrarily but only after widespread consultation

with many users of the kinds of data which the

Health Examination Survey is able to produce. One

formally constituted body, which played an important part in the process, was the Advisory Committee to the Surgeon General on the National

Health Survey. This was a broadly based group

of experts who represented a wide range of interests in the health field. In addition advice was

obtained from an advisory group composed of representatives of various agencies within the DepartBroad guidelines for the second cycle, in addition to those already discussed, included the following:

1. The data collection mechanism developed

and proved through the first cycle will be

used with appropriate modifications.

2. Experienced and qualified personnel in the

field staff will be retained to the extent

necessary to perform the data collection

operation in Cycle II.

3. The total period of data collection for

Cycle II will be between 2 and 3 years.

4. Certain cost factor limitations such as

the budget loads projected for each of the

fiscal years 1962 and 1963 will be observed.

5 l The schedule developed will take account

of climate and will provide a safety factor

so that if the operation terminates prior

to completion of all examinations, a

smaller but still representative subsample will have been included.

6 0 The Bureau of the Census will collaborate

in the sample design and selection work

and will carry out the first phase of the

field interviewing in the survey.

7. The detailed plans developed for the study

will be tried out in at least one full-scale

pilot project operation prior to initiating

the data collection for the sample.

sJ/_ . I I IL .

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, ‘. , ’ ,

’ ‘, , . ’

ment of Health, Education, and Welfare and a like

group of representatives of manyiother Federal

Government departments. Apart from consulting

with formally established groups, there were a

considerable number of contacts with individuals

prominent in the field of medical and health statistics throughout the country, A number of schools

of public health, medical research centers, and

like agencies were also contacted.

During the early stages of this consulting,

the individuals contacted were asked to indicate

the different kinds of studies which they felt were

most needed and were appropriate to the method.

They indicated their relative priorities for different kinds of studies, and these were considered

along with other general guidelines to determine

the broad targets.
By mid-1961 a determination had been made

that the second cycle program would involve the

examination of a probability sample of children

and that the focus would be primarily upon factors

related to growth and development. The aim of

the survey would be to collect considerable information on health characteristics and to obtain

distributions of the population by various physical

and physiological measurements.

Developing the Detailed Plan

Throughout the latter part of 1961 and early

part of 1962 the work of planning the second cycle

proceeded and intensified. The process of consulting with numerous interested individuals and

agencies was continued, butnow the inquiries were

more specific. It having been determined to collect data on growth and development in children,

such questions as these had to be answered: **What

specific body measurements should be made and

in what manner?” **How should visual acuity be

determined?” I*What kind of information should be

collected in the medical history?”

During the process of developing the more

detailed plan, it became necessary to modify the

original concept in various ways. At the beginning

it had been tentatively decided that the age group

to be studied in Cycle II would be persons between

the ages of 6 and 17 years inclusive. As the detailed planning proceeded, however, it became

apparent that the differences between persons in

different age segments of this population group

were so great as to require separate programs.

Such matters as feasibility of self-administered

tests, type of motivational approaches to beused,

sizes of some of the supplies and equipment, and

adverse effect on participation on the part of

teenagers in a program that seemed to be a “children* s” examination-all these and other considerations led to a decision to limit the age range.

It was decided to redefine the Cycle II target

population as children between the ages of 6 and

11 years inclusive and to follow this program

with a third cycle which would have youth at ages

12 to 17 years inclusive as its target population.

The development of the sample design was,

of course, an important aspect of the planning

process. It was carried out concurrently with the

determination of the content of the examination

and the detailing of the operating procedures.

These are discussed later in this report in some

detail. Here it may be noted that thespecific universe to be sampled was defined as consisting of

all children who were

1.

2a

3 a

4,

Between the ages of 6 alld 11 years inclusive regardless of whether they attended school.

Residents of the United States (including

Alaska and Hawaii).

Not confined to an institution.

Not residing upon any of the reservation

lands set aside for use of American Indians.

The determination as to appropriate status with

respect to conditions 1, 2, and 3 madeon the date

of the household interview (the first contact in

which the necessary information was obtained)

wzis to govern in establishing sample versusnonsample status.

While the process of developing.the detailed

plan for the second cycle resulted in some delimitation of the orginal concept (as with the age

range), it also produced some expanding of the

goal of the examination. It was recognized from

the beginning that the lowness of prevalence rates

of chronic disease in the age group considered

meant that the focub would have to be on measurements and on factors related to growth anddevelopment. As the plan focused more sharply- on the

most important factors to be studied, it became

apparent that in this age group it would be essential

to collect some data relevant to the intellectual

growth and development of the children. It ap--

peared desirable also to obtain some sort of

measure of factors related to the development of

personality.

The decision to include collection of some

psychometric data in the second cycle plan involved the addition of yet another discipline to

the already multidisciplinary research team. Consultations were begun with psychologists, and a

number of experts in this field joined with the

physicians, dentists, anthropologists, statisticians, management specialists, and others in developing the plan. Within each of the named disciplines there were various specialty subgroups

4
involved-pediatricians, otolaryngologists; child

development specialists, orthodontists, physicists

specializing in the optics of vision, statisticians

1 specializing in sample design, psychologists expert in behavior of children, and anthropologists

skilled in human engineering problems. The list

is not complete, but it is long enough to suggest

the extent to which comfiromises had to be made

and priorities assigned since all that everyone

felt was necessary could not possibly he included.

Preliminary Studies and Tests

The planning ljhase of Cycle II included a

number of different kinds of preliminary studies

and tests, some of them involved’and some fairly

limited. In a few instances it was possible to take

advantage of work that had already been,, done in

some other connection. Thus one of theimportant

areas of interest concerned the levels of auditory

acuity. It had been recognized that there was need

for new standards with respect to hearing levels

in children. The American Academy of Ophthalmology and Otolaryngology had established the

Subcommittee on Hearing in Children to work in the

development of such new standards, This group

had carried out a series of studies of school children in the Pittsburgh area, had developed the

detailed content and form of the examination and

the kinds of equipment required, and had acquired

considerable experience in measuring auditory

acuity in children. This group was interested in

the survey because it would afford the chance to

establish norms for the total national population.

From the viewpoint of the Health Examination

Survey, the work which this subcommittee had

completed provided extremely valuable developmental work. Arrangements were made for executive director of the Subcommittee on Hearing in

Children, Dr. Eldon Eagles, to serve as a consultant to the Health Examination Survey, The

audiometric portion of the second cycle examination was based on the work that had been done in

the Pittsburgh studies. Dr. Eagles supervised the

training of the technicians for the Health Examination Survey, and the Acoustical Laboratories of

the University of Pittsburgh agreed to perform

the calibration of the instruments used. ‘Various

other benefits accrued to the program as a result

of the cooperative arrangement. In this instance,

the survey had essentially no developmental work

to do because this had all been done in connection

with the subcommittee activity.

With respect to the medical history instrument to be used, a methodological study was

carried out to determine the form and to develop

the exact wording of the inquiries. This was done

for the survey by the Survey Research Center,

affiliated with the, University of Michigani and was

under the direction of Dr. Charles Cannell.

The determination to include psychometric

tests in the second cycle program was not made

until the planning was fairly well under way.

Because of this late start, some of the methodological work in this area had to be delayed until

after the second cycle was actually in the data

collection phase. An example is a contract study

to develop recommended methods of evaluating

and analyzing the results of the modified Thematic

Apperception Test which was being used. This

study was undertaken by the Institute of Behavioral

Research, Texas Christian University, and was

under the direction of Dr. S. B. Sells.

Preceding the institution of actual data collection in Cycle II, there were two separate pilot

test operations carried out. The first of these

was an early Partial pilot test conducted in December 1962 in Rocky Mount, North Carolina. This

location had been the last of the 42 areas to be

surveyed in connection with the Cycle I operation

and the pilot test was carried out to get information on the attitudes which parents would have

toward their children% participation in such a

program, to gain more information on how well

the children could perform certain tests, to explore ways in which arrangements could be made

with schools for necessary released time, to determine the pattern of scheduling which would be

most effective, to try out the proposed medical

history questionnaire, and to gain some experience

in carrying out a survey in the age group 6-11

years.

Approximately 70 children were examined in

the Rocky Mount Pilot Test. The operation provided answers to some of the questions that were

being asked and gave a basis for further planning

work on many other items.

The work of planning the second cycle continued during the next 3 months, and inMarch and

April of 1963 a further pretest of the examination

5
plan was carried out in Wilmington, Delaware.

Certain modifications in plans that had been made

on the basis of the first pretest were put into effect

for this major pilot project, in which about 180

children were examined. Following this pilot

study some further modifications were made and

the second cycle data collection phase was initiated

in July 1963.

THE SAMPLE DESIGN

General Plan

The sample design for the second cycle of

the Health Examination Survey is quite similar to

that used for Cycle I, The National Center for

Health Statistics set specifications for the sample,

developed the overall design, and carried out some

of the steps of drawing the sample. Other steps

in the sample selection were performed by the

Bureau of the Cens‘us under a contract arrangement.

The. sample design is that of a multistage,

stratified probability sample of loose clusters

of persons in land-based segments. The successive elements dealt with in the process of sampling

are primary sampling unit (PSU), census enumeration district,, segment (a cluster of households),

household, eligible child, and finally, sample child.

The total number of children in the United

States (including Alaska and Hawaii) who met the

general criteria for inclusion in the universe

sampled was about 24,000,OOO. This was theestimated U.S. population between the ages of 6 and

11 years inclusive as of mid- 1964 excluding small

numbers who were residing in institutions or residing outside the United States. It was decided to

select a sample of close to 8,00Opersons, a sampling fraction of about l/3000, The distributionof

the population in the 6- 11 age group is fairly even

over this range, and so there should be about 1,000

persons in each of the single years of age. Since

the second cycle places much emphasis on factors

related to growth and development and since

year-by-year change is important in this period

of growth, it was felt necessary to have a large

enough sample to permit analysis of much of the

data by single years of age.

Stratification an,d Selection

of PSU’S.

The first stage of this multistage pwocess

consisted of the selection of PSU’s. It was in this

stage that stratification was carried out. In connection with the Current Population Survey and

the Health Interview Survey the entire United

States had been divided into nearly 2,000 PSU’s

and these had.been grouped into 357 strata. (Each

PSU is a standard metropolitan statistical area

(SMSA), a county, or a group of several contiguous

counties.) The sample selection process for the

second cycle started with these 357 strata and

grouped them into 40 superstrata which are referred to as the strata of HESCycleII. The average size of each Cycle II stratum was 4.5 million

persons, and all fell between the limits of 3.5 and

5.5 million. The grouping into 40 strata was done

in a way that maximized homogenity of the PSU’s

included in each stratum, particularly with regard

to degree of urbanization, geographic proximity, ’ and degree of industrialization. The 40 strata into

which they were grouped were classified into 4

broad geographic regions (each having 10 strata)

and cross-classified into 4 broad population-density groups (each having 10 strata). Eachof the 16

cells resulting from the 4x4 cross-classification

on geography and population density contained

either 2 or 3 strata. A si.ngle stratum then might

include only one PSU (ok even only part of a PSU

as, for example, in the New York City SMSA which

was determined to represent two strata), or it

might include several score PSU’s.

The four broad geographic regions into which

the HES’ strata were classified were groupings of

States which approximated the Bureau of the Census regional groupings. The HES northeastern

classification was identical to the corresponding

Census region. The HES midwestern group differed from the Census North Central Region in

that it did not include Kansas, Nebraska, and the

Dakotas. The HES southern classification differed

from the Census South Region in that it did not

include Texas and Oklahoma. The six States specified above were included in the HES western

grouping along with other States in the Census

West Region. Figure 1 shows the sample areas.

6
IIIIIIBWIIJII Carovon I

mm Corovon, II

I- Combined SInglo Toom

WESTERN REGION MIDDLEWESTERN REGION NORTHEASTERN R

SOUTHERN REOION

Figure I. Map showing sample areas and itinerary: Health Examination Survey Cycle I I.

The four population-density groups divide

the United States into four roughly equal parts.

It was necessary to combine some urban counties

with rural areas because of the continuing diminution of the rural portions of the country. The

population-density groups were defined differently

for the four geographic regions, the attempt being

to obtain a reasonable division of each region into

the following four classes:

1. The largest metropolitan areas

2. SMSA*s of specified size

3. Other SMSA’s or specified highly urban

areas

4, Other and rural areas

For the Northeast Region, New York City’s

two SMSA% and Philadelphia made up the entire

three strata in Class 1. Class 2 in that region consisted of other SMSA* s of over 1 ,OOO,OOO population

grouped in two strata. Class 3 consisted of the

remaining SMSA’s and Class 4 of all other urban

and rural areas.

For the Middle West the strata in Class 1 consisted solely of the Chicago and Detroit SMSA%.

Class 2 was made up of the other larger SMSA’s,

most of them over 500,000 in population. Class 3

and Class 4 were other SMASs and all other areas,

respectively.

In the South, the largest metropolitan areas

class included all SMSA*s over 700,000. Class 2

7
included all other SMSA%. Class 3 consisted of a

specified group of highly urban areas. The other

areas made up Class 4.

In the West Class 1 was definedas consisting

of three strata, two of them the two Los Angeles

SMSA% and the other including San Francisco and

Seattle SMSA%. Class 2 included all other SMSA%

over 550,000 population. The other SMSA*s were

grouped into two strata in Class 3, and all other

areas made up Class 4.

Table 1 shows the number of strata in the

second cycle classified according to populationdensity groups and broad geographic regions,

] There was a third axis of stratification used

in selecting the 40 PSU*s for the second cycle. This

pertained to the rate and direction of change in the

population between the 1950 and 1960 census. The

rationale here was that two localities in the same

geographic region and with the same population

density may differ markedly in ways related to

health status if they have different rates of population change. A midwestem city of 400,000 may

be quite different if on the one handits population

has remained constant over the past decade or on

the other hand it has doubled its population during the past 10 years.

To take account of rate of change of population,

the design specifications provided that within each

region the 10 PSU*s would be further classified into four classes ranging from those with no increase

in population to those with the greatest relative

increase. Each such class contained either two

or three PSU%.

Having classified the PSU% into 40 strata

with the subgroupings indicated above by region,

population-density groups, and rate of change of

population, the selection of PSU% for the HES sample was made by selecting one PSU from each of

the 40 strata. The technique used was one of

controlled selection with the probability of selection of a particular PSU being proportionate to its

1960 population. In the controlled selection technique the attempt was made also to maximize the

spread of PSU*s among the States, subject however

to all the limitations already laid down for the

sample, It will be evident that the complete

stratification implies a three-dimensional 4x4x4

grid, and that not every one of the 64 cells contributes a PSU to the sample of 4OPSU’s. Nevertheless, the controlled selection technique ensures

the sample’s matching the marginal distributions

in all three dimensions and being closely representative of all cross-classifications.

Further Stages of Sample Selection

Having selected the 40 sample PSU’s, the

further successive stages of sample selection

called for selecting census enumeration districts

(ED), segments, households, eligible children

(EC), and finally, sample children (SC). All but

the last two of these steps were carried out at.

headquarters prior to actually beginning the survey in a particular PSU.

In selecting the ED, segments, and households, account was taken of the PSU*s 1960 population in the age group 5-9 years. Thus the probability of selection of a particular one of the ED

was proportional to its population in that age group

at the 1960 census date, which by 1963 roughly

Table 1. Nudnber of HES Cycle 11~ strata, b

8

population-density group and geographic

area, 1 63-65

Population-density group

Total---------------------------------------

Largest metropolitan areas------------------------

SMSA’s of specified size -----------i--------------

Other SMSA’s or specified highly urban areas------

Other and rural areas -----------------------------

Number of strata

40 10

10 3

10 2

10 3

10 2

Midd le

West

10

2

3

2

3

South West

10

2

3

3

2

10

3

2

2

3
approximated the population in the age group that

is the target of the second cycle. (The use of the

5-9 group was, of course, dictated by convenience

since information about this group was readily

available.)

Generally in a particular lPSU, 10 ED were

selected by a controlled selection technique. Then

a similar selection was made of two segments in

each one of the ED. Each of the resultant 20

segments was either a bounded area or a cluster

of households (or addresses). The size of a segment was variable and was related to the 1960

population of children aged 5-9. It was expected to

yield approximately 10 children in the age range

6-11 years at the time of the survey. Thus the

expected yield per PSU was approximately 200,

This feature of the sample design resulted in con-

_ siderable variation among the PSU% in the number

of households selected, In many of the sample

PSU*s this number was about 500, or about 25 per

segment; in some, the number was more than double this. Thus, for example, in Sarasota, Florida,

the sample design produced more than 1,000

households, and in Grand Rapids, Michigan, it

produced fewer than 500. The total number of EC

in each of these locations, however, was nearly the

same.

The final stages of the sample selection,

identification of EC and designation of SC, were

carried out in the field immediately prior to the

start of examinations in the particular PSU. The

earlier steps in the sample selection process

generally produced lists which identified each

individual household selected in terms of the address and the name of the head of the household

at the time of the 1960 census. (This last item

was for convenience in those cases where it was

still relevant; the household presently occupying

that address was the one within scope of the survey.) Each of the households was visited and a

listing of all members of the household provided

the information on EC. All children in the age

range properly resident at the address visited

were EC. When the visits to households had been

completed to the point where the total number of

EC could be estimated fairly closely, a determination was made as to the pattern tobe followed in

reducing that number to the desired number of SC.

The EC to be excluded from the SC group were

determined by systematic subsampling.

Special, Prob ems

s Early in the work of planning the second cycle

it became apparent that the schools should play

an important role in the program. Almost all of

the’ population in the age group 6-11 years are in

school for a large part of the time they could be

examined. Thus, at a minimum, it would be necessary to have cooperation of school officials in

releasing the children chosen to participate in the

program. Beyond this, however, it was felt that

a sample design which used the school populations

as an element of stratification might have operational advantages. If, for, example, in a particular

PSU it was possible to classify the total 6-11

population according to various groups of schools

attended (including, of course, as one group the

not-in-school children), a sample consisting of

some appropriate number of sample children

from one or more schools in reach group might

minimize the number of specific locations from

which the sample children would come. It would,

of course, be necessary to take proper account

of various types of schools (public, parochial,

private, and the ‘like), of schoolsize (number of

students), and of some kind of socioeconomic

classification of the schools (in terms of the

predominant socioeconomic characteristics of the

students enrolled), as well as other factors such

as segregation in the regions where schools are

segregated. Although some consideration was

given to using the schools in this way as a sampling frame, the idea was abandoned. The principal

reason for this decision was the unavailability of

the necessary classificatory data concerning the

schools.

Another scheme considered in the early

stages of planning was to utilize two different

size samples with the smaller one a subsample

of the larger. The concept was that it might be

desirable to select an original sample of 15,000

to 25,000 children and to make certain observations on all of this sample. The simpler elements

of the examination-certain body measurements,

for example-might be done on the larger sample.

The smaller sample would be selected from this

group and would be subjected to the additional

examination and tests which require pediatrician

time or special equipment and elaborate testing

(e.g., audiometric tests). An important advantage

9
of such a scheme is that it would permit a ‘twophase selection of the smaller sample and would

provide poststratifying information that would reduce sampling variance. In the further development of the plan this idea was dropped, however,

largely because of the operational problems which

it seemed to present.

One other modification of the basic sampling

designed to minimize the geographic spread of

the sample persons was considered and was actually used in a number of PSU*s where examining

was carried out in the first months of the second

cycle. This was a subsampling stage involving

the subdivision of a PSU into a number of districts-usually one central city area and four to

six satellite areas. A random selection of some

of the satellite districts was then made and all

the sample in the central city and in the selected

subareas or satellite districts was used for the

household visit and final sampling. It was decided

after a numh,er of months’ experience that the

operational. .&ains (in terms of further concentration of sample persons in limited areas) werenot

essential to. carrying out the survey, and so this

subsampling stage was abandoned in later stands,

Another special problem considered irp the

design of the HES sample for the second cycle

concerns one of the effects of the clustering &nvolved in the multistage sampling process. The

sample children were chosen from among thee.

in particular segments, those segments had been

selected from sets of similar segments which

taken together constituted the selected ED, the

selected ED in turn had been chosen from among

the sets of ED which taken together constituted the

PSU’s, and so on. Typically, the result of clustering of this type is to produce a sample having a

somewhat higher sampling error than would be

expected from a simple random sample of the

same size. The introduction of clustering, however, reduces unit costs and this permits an increment in sample size which more than offsets

the loss in sampling efficiency.

While there was no question but that clustering

should be used in the survey, some consideration

was given to whether the design should include

some provision to control the selection of siblings.

Since the household is one of the elements of the

sample design, the number of related children in

the resultant sample is greater than would come

from a design which sampled children 6- 11 years

old without regard to household. This merited

some special attention since many of the statistics

collected in the survey are affected by genetic

facws. If a sample child is smallof stature, say,

or h myopic or is high on an IQ scale, a sibling

of &at child is somewhat likely to deviate in the

same direction.

Under the design used, it was necessary to

visit about five households to obtain one household with any eligible children. Of the households

having children in the 6-M years range, a little

less than half had two eligible children or more.

If only one of these had been taken in each case

and if overrepresentation of one-child households

were to be avoided, it would have been necessary

to increase the original group of households

visited by more than 100 percent and would have

considerably increased , work of picking up and

delivering the children. It was decided theadvantage of obtaining a some*Nhat smaller variance

by doing this - was not great enough to justify the

increased cost and difficulty. The chosen design

contains the correct proportion of children from

fames having only one eligible child, from

those having two eligible children, and so forth.

The sample as a whole is properly representative

of average measurement of the total population

641 years old. The fact that the sample contains

a higher proportion of. siblings than there would

be in a systematic sample of every kthchild does

lead to some increase in variance but shouldproduce no bias in the various estimated mean measurements, for example.

THE LOGISTICS

Mobile Examination Centers and Field Staff

The examinations in the first cycle had been

c.med out in specially constructed mobile examwtj;on centers and it was decided to use the

same plan for the second cycle. Eachof these two

centers consisted of a set of specially designed

tr&&rs, The individual trailers making up a set

were drawn by detachable truck tractors in

map&g the move from one area to another. Then

the trailers were set up side .by side and covered

passageways connected them to make the examination center (fig. 2).

10

;
PSYCHOLOBIGAL

EXAMINATION

VITAL GAFYICITY

GRIP STRENGTH

BODY

MEASUREMENTS

I 1 1 X-RAY GAAK

WEIGHT LJROOM

l4ElGHf

Pt4ommAPl4

WASH ROOM

PHYSICAL

EXAMINATION

I

EGG

PHGNO-

---I

VISUAL ACUITY

WASH STAFf ROOM

ROOM

PSYGHOLOWAL

EXAWNEE ENTRANCE

Figure 2. Mobile examination center.
The trailers which had been used in Cycle I

were renovated and modified for the Cycle II examinations. In addition it was found necessary to

add a new trailer to each set in order to provide

a better environment for carrying out the hearing

test. The decision to cooperate with the Subcommittee on Hearing in Children has already been

noted. Their work had established that the expected

hearing levels in the age group 6-11 years were

substantially below (better than) those for adults

and that precise measurement of these levels

would require a soundproof room-not merely the

soundproof booth that had been used for adult testing. The Subcommittee made available to the survey two specially constructed trailers (one for

each set) which included a soundproof room along

Iwith other examining space.

The field staff of the second cycle consisted

of three elements. One of these elements was the

examining staff operating within each of the mobile examination centers. This included a physician, a nurse, a dentist, two psychologists, two

technicians, a technician* s aide, and a coordinator.

The second element of the field staff consisted

of field office managers, administrative assistants, and HES representatives, all of whom worked

either in or out of an office established’near the

site of the mobile examination center. This eecond

element of the field team arrived earlier than the

examination period, carrying out certain household visits, scheduling, and related activities

which are described later. There were one field

office manager, two or three HES representatives,

and one administrative assistant on duty at each

location, Since some operations at: a new stand

began before all examinations at a preceding stand

were concluded, the+ staffing pattern had to indlude

some extra persons to provide for this overlap

period. The third element, which also arrived

ahead of the examining grdup, was a team of

Census interviewers (usually five to seven persons) and a supervisor. Their work was completed

during the week before the start of the examina- ;

tions. . The examining physician was in all cases

either a senior resident or fellow in pediatrics.

This staff member, .unlike the others, was generally employed only for a particular location, although some served later at other locations.

Following visits by HES medical staff members *

to numbers of medical schools and medical centers, arrangements were made well in advance for

a physician to examine at a future stand. He was

then given special training in the techniques of

the particular survey. The examiriing dentist was

a commissioned officer of the Public Health Service who continued on duty for 1 or 2 years in this

position. The psydhologists wefe temporary civilian employees of the Public Health Service and

generally served from 3 to 9 months at various

locations. Other members of the field staff (except

for the Census employees) were full-time regular

civilian employees of the Public Health Service.

Sequencing and Scheduling Stands c

Among the general guidelines set forthabove

as constraints upon the plan of the survey were

the requirements that the schedule take account

of climatic variation and that it insure against

the possibility. of unrepresentativeness in the

event the e&e survey could not be completed.

The former is a fairly obvious operational necessity; it would be impractical to conduct an examination survey such as this in the northern

parts of the United States in the middle of the

winter. The sample areas in the northern states

were scheduled for compl&ion during the midsummer months, and the areas in the Deep South

were visited in the winter.

This characteristic of the stand sequencing

pattern is advantageous from an operational viewpoint, but it prbduces certain limitations in. the

resultant data. Because the sequencing of stands ‘

is controlled in this way the survey data cannot

yieldl valid comparison? by geographic region for

conditions which have a seasonal pattern. This is,

perhaps, not too serious a limitation for many

of the characteristics of particular interest in the

second cycle because they are not likely to exhibit

seasonal variations. It seems likely that visual

acuity levels, for example, will not be much different regafdless af the season of the year in which

they are measured. It is obvious that this could

no! be said for &ch conditions as acute respiratory

disorders. Even some of the body measurements

taken such as weight may exhibit some seasonal

variation, and this possibility must be taken into

account in analysis of these data.

12
The other major consideration which entered

into the determination of the sequence and schedule

of the various locations or stands was provision

against possible termination of the program before

all of the locations had been visited. The action

taken was to make a subsample selection of 32 of

the 40 stands which would provi.de a less desirable

but somewhat representative smaller sample and

then to aim at a schedule which would include most

of those stands in the first three quarters of the

schedule. Then if it had become necessary to cut

back the total sample it would have been possible

with very little rescheduling to end up having

completed all of those 32 stands along with a

minimum number of other stands.

Another main constraint on the schedule and

sequence was economy of operation. An effort

_ was made to minimize the amount of travel necessary in moving from one stand to the next by

sequencing with regard to geographic proximity.

The map (fig. 1) and the schedule (shown below) which was followed in the survey illustrate

the moves. Cycle 11 used two caravans, two complete examining teams, and two administrative

teams. It will be noted that during the latter part

of the survey only one mobile examination center

was used,

Advance Arrangements and Coordination

The conduct of the survey in any specific

location is, of course, a responsibility lof the

Public Health Service, not shared with States or

local health authorities or with others in the area.

As a matter of policy, however, steps were always

taken to fully inform the State and local health

departments, and the medical, dental, and osteopathic:professional organizations in the States and

in the communities. In addition, since this program involved school children, the State and local

officials concerned with public schools were always contacted, as were the appropriate local and

diocesan officials of the parochial schools.

Typically, these contacts were made initially

by a letter or telephone call giving a little information about the program and arranging an appointment for a personal visit to discuss the plan in

detail. The representative of the survey who visited the health officials was usually a medical

. advisor to the program. The dental advisor always

wrote the dental association in the area and frequently arranged a visit as well. The visits to State

school officials were always preceded by a general

information and introductory letter from the Office

of Education, which had been kept informed

throughout the planning of the program. The

assistance given by Dr. Fred F. Beach, Director

of Elementary and Secondary School Organization

and Administration Branch, is gratefully acknowledged. Visits to the various officials at the

State level were followed by visits at the county

and city levels.

The success of the survey owes much to the

generous support it was given by health and education officials at every level, both public and

private. This is exemplified, for example, in the

June 1964 resolution passed by the House of Delegates of the American Medical Association Ifto

express its approval of the program of the U.S.

National Health Survey and to recommend cooperation by State medical associations and component

medical societies.‘* At the State and local levels

support was manifested in the cooperation obtained

in informing physicians of the survey. Frequently

this was done by means of an article in a professional publication distributed to all the physicians in the area such as the monthly bulletin of

the county medical society; sometimes it was done

through individual mailings of a leaflet provided

by the survey. Correspondingly, communication

from the dental society usually went to its members and the superintendent of schools sent letters

to school officials who might be contacted individually later. All of these steps increased the likelihood that the occasional inquiry about this program

directed by a parent to the family physician or to

the school principal, for example, would receive

an immediate informed and favorable response.

The staff in the Washington headquarters

routinely prepared professional releases concerning the program and provided them for the

uses described above in informing physicians and

dentists. In addition general news releases were

prepared concerning each location operation and

distributed to local news media timed to precede

by a few days the beginning of the field operation

in that area. As a result at most of the locations

there were from one or two to half a dozen or

more news items or feature stories published concerning the program. In some areas local radio -

13
Cycle 11 schedule of stand operations

Stand # Caravan I Date Caravan II Stand &

1

3

5

7

9

11

13

15

17

19

Portland, Maine----------- July-Aug. 19630

Poughkeepsie, New York---- Aug.-Sept------

Boston, Massachusetts----- Sept.-Oct------

Philadelphia,

Pen~sy~vania------m------ Oct~mN~vI~m--ICharleston, '

South Caro~~na~--mm--w--w No~~-Dec~------

Sarasota, Florida--------- Jan-Feb. 19649

Atlanta, Georgia---------- Feb.-Mar-------

Baltimore, Maryland------- Mar.-Apr-------

New York, New York-------- Apr.-May-------

New York, New.Yorkl------- May-June-July

Ashtabula, Ohio----------- 2

()t-uaa, Iowam~mcIwmmmImmmm 4

Denver, Colorado---------- 4

Lamar, Colorado----------- $

Los Angeles, California--- 10

Los Angeles, California--- 12

San Francisco, California- 14

Mariposa, California------ 16

Moses Lake, Washington---- 18

Cycle III

pretest New York, New York-------- July-Aug------- Minneapolis, Minnesota---- 20

21 Grand Rapids, Michigan---- Aug.-Sept------ Neillsville, Wisconsin---- 22

23 Chicago, Illinois2-------- Sept.-Oct------ Chicago, Illinois--------- 23

25 Barbourville, Kentucky---- Oct.-Nov------- Des Moines, Iowa---------- 24

27 Marked Tree,.Arkansas----- Nov.-De&------ Wichita, Kansas----------- 26

29 Houston, Texas------------ Jan.-Feb. 19650 Brownsville, Texas-------- 283

31 Detroit; Michigan--------- Feb.-Mar.-Apr-- Birmingham, Alabama------- 30

Cycle III

pretest Detroit, Michigan---------

32* Lapeer & Marysville,

Michigan-mmmm----mmm-----

34* West Liberty and

Beattyville, Kentucky----

35 Allentown, Pennsylvania---

36* Manchester & Bristol,

~onnecticut-mmmmmmmm-----

38 Jersey City, New Jersey---

40 Columbia, South Carolina--

Ap~,-May------- Lapeer & Marysville,

Michigan mwwmmmwmmmcwwmmmm 32*

May-June------- Cleveland, Ohio----------- 33

West Liberty and

June-July------ 'Beattyville, Kentucky---- 34*

July-Aug------- Manchester & Bristol,

Connecticut mwwmmwmmwmmmmm 369~

Aug.-Sept------ Newark, New Jersey-------- 37

Sept.-Oct.-Nov- Georgetown, Delaware------ 39

Nov.-Dec.

'Both examining and administrative teams,Caravan I only, in New York. Trailers were

at 3 separate locations.

2Both examining and administrative teams,CaravansI and 11,in Chicago;two locations.

3Beginning with Stand #28, use was made of both Caravans, but only one examining

team was used. The additional administrative staff enabled the succeeding stand to be _

set up while‘examinations were in process at a given location.

*Examinations held at 2 locations.

Typical schedule for a stand

Office setupIIIIIIIIIIIIII

Census interviewing-------

HER followup--------------

Trailer arrival-----------

Trailer setupIIIIII-II--IStaff setup and training--

Dry ~un~IIIIIIIIIIIImmmmmm

E~aminations-------------~

Dismantle-----------------

Trailer and staff move----

1/22 Friday

l/25 Monday-l/29 Friday (5 days)

2/l Monday-To close of stand

2/2 Tuesday

2/3 Wednesday

214 Thursday

2/5 Friday

2/8Monday-3/l Monday (16 days)

3/2 Tuesday

3/3 (Number of days dependent on distance)

NOTE: Stand locations are cities in which trailers were located. Sample areas consisted of the PSU's which may have included several counties.

14
or television stations initiated contacts and the

survey staff cooperated in providing the basis for

programs concerning the survey or participating

in them. The publicity efforts were kept at a fairly

low-key level since volunteers not only were not

sought but could not be accepted and since cooperation of parents was excellent without any extensive

publicity. It did prove useful occasionally, however, for the interviewer to have a clipping from a

local newspaper to quickly indicate the authenticity

of the program.

Another kind of advance arrangements also

had to be made in each area. These involved a

visit by a survey staff member to determine an

appropriate location for the mobile examination

center and to initiate the many logistical actions

required to conduct the survey. Arrangements

-were made for necessary electrical, plumbing,

telephone, laundry, and other contractual services. Information on possible living arrangements

was obtained and made available in advance to the

staff, who then individually arranged their housing.

Various local authorities such as the mayor and

the chief of police were informed concerning the

pending activities. The list of logistical measures

which were required was a long one and the

scheduling of the various steps had to be set far

in advance to insure the smooth operation of the

survey.

The Household Interview and

Final Stages of Sampling

The foregoing discussion of the sampling plan

had indicated that at the time the survey began

operation at a particular location there was a

list. of addresses of households in particular

clusters throughout the area: The Bureau of the

Census sent a letter to each of these households

informing them that they would shortly be visited

by an interviewer collecting some information

in connection with a health survey being made by

the Public Health Service. At each of the listed

households a Census interviewer made a visit

and asked certain questions. The questionnaire

used is shown as Appendix IA. Its contents are

discussed in more detail later, but it may be noted

here that the first group of questions asked of all

households identified the composition of the household. If there were no eligible children in the

household (no children between the ages 6 and 11

years), the interviewer completed the interview

with a few questions related to the possiblepresence of another household on the premises. These

abbreviated interviews required only about 5 minutes.

In the households in which the interview indicated there were eligible children, additional

information was collected. The full interview

usually required about 15 to 20 minutes. The

final questions were asked only of the parent or

guardian of the eligible child, the interviewer

going back again if a parent was not present initially. At the end of Jhe full interview the interviewer gave the parent a medical history form to

complete for each eligible child. She explained

that a representative of the Public Health Service

would come to the house in about a week to pick

up the completed medical history. This form

is shown as Appendix IB.

When the household questionnaires have been

completed by the Census interviewers, they are

edited by the census supervisor for omission or

inconsistencies and then turned in to the HES field

management office. At this point the final stage

of sample selection is carried out. A master list

of all eligible children is prepared andis ordered

according to segment and serial number. It will

be recalled that the sample design provided for

a variable number of households per segment,

with the total number for any given location

expected to yield approximately 200 eligible children. The actual number of eligible children

was a variable which ranged from about 150 to

250, While the survey could tolerate some variation in numbers of sample children at a location,

operational considerations limited the maximum

to about 200. At this final stage of sampling therefore the. actual yield of eligible children was the

basis for a decision’ as to further sampling to reduce the size to manageable limits. If the number

was 200 or less no further reduction was made

and all eligible children were regardedas sample

children. If on the other hand the number of eligible

children was over 200, the rule for random reduction in sample size was used. (The rule prescribed

the deletion of every n.th name in the list as ordered above, starting with the yth name, y being

a number between 1 and n selected randomly.)

15
ue*umlNo ewAmlNo cA?AClw

*e~wu~o me nun un

Ame uetaee

I-HE HEAL~EXAMINATIO~~~VEY

The Health Examination Survey ie part of the U.S. Natlonnl Health

Survey authorized by Cangreaa in 1956. ‘Ihe purpoee of the National

Health Survey ie to collect information about the health of AmFricanr.

Thir isformation will be ured by medical researchers. educator&

phyriciane, dentiets, and many public and private agencier.

Some informad& ie collected by asking people queeticns about themeelvee and their health. Other needed informeticn can be obtained

tiy by an actual health examination.

In 1961 the Health Examinati~ Survey completed a survey of health

condidona of persons 18 through 79 years of age. About 7,ooO adulte

thrcughout the United States particlpaoad in the special health examination which wae a part of that survey.

During 1963 through 1965, the Health Examination Survey is canducting a survey of the health of cNdren who are 6 through 11 yeare

ct age.

Thoueande of parente throughout the WUon will be aeked quesdons

abotJt their chitdren’s health. Many of there parents wfll be asked

to have their child come to a Health Examinaticn Center for a epecia’

health examination. Thir examinadon is designed to provide information about the grow& and development and the health of children

at ager 6 through 11 year@.

The examination ir given in a Health Examination Center which

ccs~rirta of &eral rpecially built mobile trailer unite. Traneportadon to and from thb Center ir provided by member6 of the Health

Examinadon Su&ey. Arrangemeno are made with echool officials

wkn examinadcne are scheduled during school bourr.

All informadcn obtained in tlw interview and in the health

nation ir held in ccnfidence.

DESCRlPTlON OF THE HEALTH EXAMNATION

The rpecial health examination of the Health Examination Survey is

derigned to provide informaticn about the growth and development

cf children.It cauirte of the following:

An examinadaa by a pediatrician of eye& ear8, noee and thront,

heart, and nerve and mu&e eyoteme.

An electrcsa~di~rrm and a pbonocardiogram of the heart.

YOUR CHILD

and the

Health Examination

Survey

U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

Fublic HoaM krvico

National Cantor Cr Haalth Statistics

National Ho&h Sunor

WAlklNOlON, D.C. 10101

An examination by a dendet of the teeth and mouth.

Peychometric meaeuremente by a peychologiet.

Terte of vieion and hearing.

X-raye of the &eat, hand and wrist.

An exercise teat, pedaling a bicycle-like machine.

A grip-strength test.

Meaeurement of breathing capacity.

Height, weight and o&r body meaeurementa.

‘Ihe examinadaa laete about 3 hour& Each day there will be two

examining periods-morning and afternoon. Six children will be

examined during each period. Usually, the children will be from the

same rchool and will know each other. Chlldren who are examined

during the morning period will be served lunch.

Children who parucipate in the special health examination Wffl

find it an interesting and enloyable experience.

HOW YOUR CHlLD WAS SELECTED ‘IO

PARTICIPATE lN ‘THE SURVEY

The U.S. Bureau of the Ceneue, working with the Health Examinadcn

Survey, has eelected 40 areas in the United States which, taken altogether, are repreeentative of the entire Nation. Each of theee

areas ccneiete of one or more coundee. These areas are located in

the North, South, Eaot and Weat. Some are urban and others are

rural.

Within each of these 40 areas, approximately 500 house8 are eelected

by eciendflc eampling methcde. Every child in the 6-through-llyear age group living in cne of these houee6 automatically becomes

a part of a naticnal sample group of about 9,000 children on whom

health historiee are obtained. The sample ie then reduced by another

sampling operadon to give a eample of about 8,ooO children to be

examined. This national sample ie representative of the roughly

2S,OOO,ooO children in the United States in thie age group.

The information obtained from the examinadone of children in thie

sample will make it poesible to make good eetimatee of what information would have been obtained if all children in the 6-through-11

year age group had been examined.

rlgure 3. Leaflet describing the program.

16
,

, ’ ~

The remaining names were then taken as the group

of sample children.

Appointment and

Transportation Procedures

About a week after the Census interviewer.had

left a medical history form with the parents of

each eligible child, an HES representative (affectionately called a HER, and appropriately so since

most of these individuals are women) visited the

household to pick up the form. That visit was designed to accomplish a number of things. If the

form had not been completed, the HERattempted,

usually successfully, to assist the parent in completing it at that time. If it had been completed

or partly completed, the HER performed a quick

review and edit and classified any incomplete or

patently inconsistent entries. The HER then administered an additional interview, collecting a

number of bits of information which it had been

decided. could be obtained better by an interviewer than by means of a self-administered

questionnaire.

If the eligible child had been determined to

be a sample child, the HER also explained the

plan and nature of the examination program. She

obtained the written consent of the parent for the

child’s participation in the examination, for the

survey to transport the child to and from-the mobile examination center, and for the survey to

obtain additional information from school personnel, from a physician’s, dentist’s, or hospital%

records, and from other official sources such as

State registrars. She also indicated to the parents

that the Public Health Service would be glad to

forward to their physician and dentist the findings

of the medical and dental examinations if the

parents so wished and recorded such a request

if it was made, Finally she explained that survey

personnel would notify the parent of the date and

time of the child’s examination and she left a leaflet which described the program (fig. 3).

The field management Ioffice worked out the

examination schedule, consulting with the various

school principals whose students were involved

concerning times when the children might bepermitted to be away from school. In the scheduling,

attempts were made to arrange the appointments

so that transportation workload was minimized. A

note was sent to the parent both to inform him as

to the specific examination time and to serve as

a reminder of the program. On the appointed day

a representative of the survey, usually one of the

HER%, called for the sample child either at home

for morning appointments or at school in the afternoon and drove him to the mobile examination center. After the examination had been carried out the

child was taken back to school or to lhis home.

NATURE OF THE EXAMINATION

General Considerations

It has been pointed out that the primary focus

of Cycle II was on measurements and health factors

related to growth and development. The low incidence of chronic disease in the age group examined

resulted in some lessening of the relative importance of the physician% role compared with the

roles of other members of the examining team

(technicians, dentist, psychologist, and so forth).

This is reflected in the time allocations for the

examination seen in the flow chart (fig. 4). The

physical examination by the physician (assisted

by the nurse) required about 30 minutes of the

total time of approximately 3 hours. About the

same amount of time was required for the work

of the dentist, which, in addition to the dental

examination, included certain tests and measurements related to vision. The other 2 hours were

equally divided between the battery of tests administered by a psychologist and the series of tests,

procedures, and measurements carried out by

specially trained technicians.

The pattern of scheduling examinees with

respect to time of day differed in Cycle II from

that used in the earlier adult examination program.

In Cycle I examinees were brought into the mobile

examination center on a staggered pattern, with

two examinations beginning at half-hour intervals.

Each examinee went through the same sequence of

examination elements. In the early pilot test work

for Cycle II it was decided that the child would be

more at ease if a number of children came in for

examination at the same time. After some experimenting it was decided to bring inat one time all

six children who would be examined in each halfday. It then became necessary to vary the sequence

of their examinations since, for example, the six

17
Date

HEALTH EXAMINATION S’JRVEY

Daily Flow Chart

A. M.0 P. M.0

0 hour

1 hour

2 hours

T

T

HEART 2

T

T

HEART 2

T

T

HEART 2

Vision Audio Physical Body M.

Psych Psych Dental Xray - Audio

- Bike Vision Xray

i Physical Body M. Dezital Bike

J J J ,

Dental Audio Xray

Vision J

Xray Psych Psych Bike Physical

4 Bike Body M. Vision

Physical Body M. Audio Dental

J J

,w.

Audio Physical Xray

Xray Body M. Dental D D

Body M. Vision Bike *h

Psych Psych

A

‘I and I[1 the youngest, III and IV next

211, IV,c and VI must have preliminary

Xray includes height and weight

heart exatiination

Body Measurement includes vital capacity

and may include grip strength

T includ8s'temperature and undressing may J-juice, D-dress

be done at 0 hour or later. In A.M. an additional 10-15 minutes is

Physical includes ECC and phonocardiogram required for lunch

Dental and vision may include grip

strength

Figure 4. Ddly flow &art,

could not be examined by one physician at the same

point in the sequence of examination elements if all

examinees started together. In determining the

sequence, a number of factors in addition to staff

composition had to be considered. It was necessary, for example, to have a preliminary heart

examination carried out for those examinees

whose sequence called for the exercise tolerance

test (shown as “bike” on the flow chart) in advance

of the physician’s examination. Another consideration was the desirabilitv of having the’younger

children take the psychological tests early in their

sequences so that their responses would be less

likely to be affected by physical weariness.

When the children first arrived at themobile

examination center, they were greeted by the nurse

and (he coordinator, a staff member with special

reeponsibilities in the area of management of flow

of emminees, records preparation, and the like. A

brief explanation of the examination . w&s given.

Temperatures were taken and name tags provided.

The children changed from their street clothes into

18
the examination uniform provided. It consisted of

gymnasium-type shorts and a terry-cloth robe for

the boys. The girls were provided with similar

shorts, a specially designed blouse, and a terrycloth robe. The examinees wore cotton socks on

their feet. This uniform was designed to facilitate

and standardize various elements of the examination such as the physician’s examination, body

measurements, and X-rays,

The Examination by Physician and Nurse

Each “Child’s Medical History-Parent*’ form

(Appendix IB), which had been completed in the

household prior to making the appointment, was

reviewed by the examining physician on the day

before the scheduled examination. He paid special

attention to any entries which suggested any lim-

-itation on the child’s ability to perform any of the

tests or procedures and to medical history items

which required further followup in the course of the

examination.

Before the standardized physical examination

was begun, the physician examined any child whose

temperature was 100’ or over. If he determined

the child was too sick to be examined further or

if he suspected a contagious disease, the child was

taken home without further examination. (In such

cases the examination was rescheduled for another

date.) Before the exercise tolerance test was taken

by the child, the physician listened to the heart

in order to exclude from exercise any child who

might have heart disease.

The pediatrician% examination included a

general inspection, examination of joints and

muscles and neurological examination, eye examination, ears, nose, and throat examination, and

cardiovascular examination. The nurse was present during the examination and assisted thephysician. The examining procedure followed was a

standardized one, but after the physician had completed the prescribed elements, he was free to

follow leads or pursue particular points as he

judged appropriate.

The general inspection included observation

of gait, general appearance, and observable physical deformities, observation for tics or mannerisms and for evidence of finger sucking or nail

biting, and notation as to evidence of breast development and presence of axillary hair.

With regard to examination of joints and

muscles, the examinee performed various specified movements and the physician watched especially for any evidence of abnormality. When

abnormality was noted or suspected the physician introduced additional procedures to confirm

or rule out the condition.

The eye examination included careful inspection for evidence of styes, conjunctivitis,

blepharitis, nystagmus, ptosis, and strabismus.

In testing for strabismus, the pediatrician used

the Hirschberg’s method (cornea1 light reflex),

the moving light test, and the cover test. When

strabismus was found, the location, type, and

confirming tests were recorded.

The examination of the ear, nose, and throat

was the subject of special interest because of

the possible relevance of findings in this examination to the audiometric data. The pediatrician

was provided with a Welch Allyn pneumatic

otoscope (in addition to a Siegle*s otoscope

and headlight) and had been given specific training in this particular technique. The examination

included evaluation of the condition of the drum,

auditory canal, and external ear, as well as

inspection of the oral pharynx, tonsils, and

nose.

The cardiovascular examination included the

pediatrician’s listening for and recording a detailed description of the heart sounds, innocent

as well as significant murmurs. It also included

recording a phonocardiogram and a lo-lead

electrocardiogram. Two blood pressure readings

were taken in a specified manner by the nurse

(fig. 5).

The physician prepared a summary of findings

and a report form to be used in sending a summary

report on the examination to the child’s physician. The selection of findings to be reported to

the physician was limited to the results ofprocedures not ordinarily done in the usual pediatric

examination such as electrocardiogram and audiometric examination and any medical conditions

which were not already reported as known in the

parent’s medical history for the child. On occasions when the physician tentatively diagnosed a

previously unsuspected condition which he felt

required special followup (e.g., heart disease

with X-ray or electrocardiogram findings), he

communicated by telephone with the child’s own

19
The dental examination was conducted in

a standardized manner by the examining dentist,

a PHS commissioned officer. It included determining and recording the status of each tooth

space or of each tooth occupying a tooth space.

Objective criteria for the examination were

established to classify teeth as normal, carious,

filled, filled-defective, nonfunctional carious, retained deciduous teeth and roots, missing, missing-space closed, or replaced. In addition, the

eruption status of each permanent tooth not

scored on the above scale was noted. An evaluation of oral hygiene was made basedon amounts

of debris and calculus on selected tooth surfaces.

A periodontal index score was recorded for each

tooth determined by the presence and extent of

gingival inflammation and pocket formation. A

rating was given for nonfluoride opacities and

fluorosis. Any fractures of permanent incisors

were noted. Finally a detailed assessment of the

status of occlusion was made (fig. 6).

An adjustable examining chair and a standard

light source were used in the examination by

mouth mirror and explorer of the teeth andgums.

A staff member recorded the observations called

out by the dentist. The examination required about

10 minutes. The procedure differed in sevejral

respects from that given patients seeking dental

care. Teeth under inspection were not dried or

isolated, oral calculus and debris were not

removed, and tooth surfaces w&e not generally

probed. All of these differences tend to produce

some understatement in the number of defective

teeth found.

The examining dentist completed a report

form to be sent to the child’s private dentist if

such a report had been requested and authorized

by the parent.

Figure 5. Blood pressurk reading.

physician to apprise him of the findings. This,

of course, was done only if the parent had given

the signed consent to contact the physician. If

not, the parent was notified by telephone if some

acute condition requiring medical care was found

in the examination.

The Dental and Vision Examinations

Figure 6. Dental asses sment of the status of occlu sion,

20
The fact that the administration of certain

vision tests was by the examining dentist reflected

operational considerations, since this member of

1 the examining team had the requisite available

3. Human figure drawing

4. Selected cards from the ThematicApperception Test

given, was highly adept at administering the test.

The vision examination included tests for

color vision (Ishihara’s screening test followed

by Hardy-Rand-Rittler’s test to establish fact,

type, and degree for children failing), tests for

monocular and binocular visual acuity at near

and far distances (Bausch and Lombe Orthorater

instrument with special Armed Forces plates

supplemented by Landolt ring charts for illiterates), tests for distant and near lateral phoria

and for distant vertical phoria, a test for accommodation (diopter test), and tests for binocularity

(orthorater plates and “Worth 4-dot” tests).

Except for color vision tests, the tests were made

without glasses for those children who normally

wore glasses. Administration of these tests usually required about 15 minutes.

Psychological Testing

The decision to include some measures relevant to intellectual and personality growth and

development has already been mentioned. When

this decision was reached, the staff survey sought

advice from persons skilled in the area of psychological testing of children. With the assistance of

the National Institutes of Mental Health, a meeting

was arranged at which child psychologists from

five leading universities considered the kinds of

psychological data which a program such as the

Health Examination Survey should attempt to

collect. The consensus of this group was that

the survey should include some measures of

intelligence, including but not limited to verbal

tests, along with some tests designed to get at

some personality factors.

After first performing some pilot test work,

it was decided to adopt the following tests as the

battery for the survey:

1, Vocabulary subtest from the Wechsler

Intelligence Scale for Children

2. Block design subtest from the Wechsler

Scale

5. Wide Range Achievement Tests (1963

revisions of the arithmetic and reading

sections)

The psychometric battery was administered

by psychologists who had been trained at least at

the level of the master’s degree and who had had

some experience in administering tests to children. The time required to test a singlechild was

approximately 1 hour. None of the tests required

the use of specially developed Health Examination

Survey forms. Except for the Thematic Apperception Test, the test forms which are commercially available include space for the required

answers or entries. In the case of the stories

produced on the basis of the Thematic Apperception Test cards, the psychologist made tape

recordings which were later transcribed and

available for reading and evaluation.

A methodological study was carried out in

order to obtain a critical objective evaluation of

the psychological procedures chosen for the

second cycle. This study included a literature

review concerning each test component, recommendations concerning the kinds of inferences

which could appropriately be made from the

test results, and recommendations for further

research which were felt necessary in order to

make proper use of the data collecyed. Thisstudy

was done on a contract basis by Dr. S. B. Sells

of the Institute of Behavioral Research, Texas

Christian University, and the results have been

published in the Center’s methodological series?6

Tests, Procedures, and Measurements

Done by Technicians

Each of the two field teams of the survey had

two technicians who carried out the following operations: audiometric test, X-rays of chest and of

han.d and wrist, recordings of height and weight,

spirometry, grip strength test, a series of body

measurements, including skinfold thickness, and

an exercise tolerance test. Each of the two technicians was trained to carry out all these opera21
Figure 7. Audiometric testing.

film of the chest at a distance of 2 meters,

and the other was a 10x12 film of the right

hand and wrist for the determination of skeletal

age. All recommended precautions to minimiqe

radiation hazard were taken, including use of a

special “no scatter” cone, use of lead-rubber

apron shields, conduct of dosimetry field surveys,

and wearing of film badges by technicians. The

X-rays were immediately developed in the mobile

examination center to permit a retake of any film

judged to be technically inadequate. No reading

or interpretation of the X-rays was done at the

mobile examination center, however, the physician

looked at the chest film prior to recording his

summary of findings. The reading of both chest

and hand-wrist X-rays was done by special

readers-after the records had been transmitted

to the Washington headquarters office.

Spirometry was administered by a technician

using a Collins Miter vitalometer. The examinee

was instructed to take as deep a breath as possible and *blow it all back through the tube. The

vitalometer traces the maximal forced expiratory volume (or vital capacity) on a timed rotating cylinder which can be measured to show

the desired parameters such as peak flow rate.

Three separate recordings were made for each

examinee. The examinmg room temperature and

barometric pressure at the time of examination

were recorded.

the sound was presented separately to each ear

tions, and the children were assigned to one or the

in the order p&scribed on the recording form

other by the coordinator. A third staff member,a

technician aide, assisted the technicians in some

of the procedures requiring services of a second

. . person.

The audiometric testing was done in a specially constructed soundproof room large enough

for ihe technician to be in the room with the child

being examined (fig. 7). Each child was tested at

eight different frequencies, and the 4000.c.p.s.

frequency was repeated a second time. However,

when the child showed fatigue, testing at the last,

two frequencies was omitted. For each frequency

A test of grip strenqth was made, using a

dynamometer -three separate tests for each

hand, The examineeis statement as to his “handedness” was recorded at this time.

The survey used a special self-balancing

scale to record the examinee’s weight directly

on the record form. A special device was also

used in measuring height. The examinee stood

(Appendix IC). This was arranged so that for

about half the children the first ear tested was

the right and for the others it was the left. The

technician recorded for each frequency the lowest

decibel level at which a response was obtained

in at least 50 percent of the trials (two out of

three trials or three out of five). The audiometry

testing procedures shown as Appendix II are part

of the instructions to the technician contained in

the staff instruction manual.

Two X-ray films were taken by the tech-

, nicians; one was a 14x17 posterior-anterior

on a platform; he was backed against a vertical

bar to which an adhesive strip with his examination number was fastened (fig. 8). He stood

under a movable horizontal arm which was

adjusted to fit snugly on top of the examinee’s

head while he stood up straight with feet together

and head in the Frankfort plane. When the technician had positioned the examinee, he pressed

the button attached to a camera mounted on the

movable arm and focused on the scale and

pointer arrow. This camera delivered a finished

print 10 seconds later which became part of the

22
Figure 8. Measuring standing height.

examinee’s record. The measurements of height

and weight were made with the examinee wearing

the special uniform and only the socks provided

on his feet.

Body measurements on each examinee were

made by one of the technicians with the technician

aide serving as recorder. In addition to the standing height and weight measurements already

described, they made 30 separate measurements.

Sixteen of these had been made in the adult

program of Cycle I; the other fourteen were new.

The measurements made included a wide variety

of skinfold thicknesses, girths, heights, breadths,

and lengths. The recording form used indicates

the specific items (Appendix ID).

The equipment used included several anthropometers (Siber Hagner & Co., Inc., New York,

New York), sliding calipers (Hudlicka type, 30

cm.), skin calipers, steel tape measures, footstools, and a specially designed body measurement

table for examinations requiring that the examinee

be seated. Measurements were recorded to the

nea’rest millimeter.

Finally an exercise tolerance test was carried

out. This test made use of a bicycle ergometer,

a bicycle-like device on which the examinee sat

and pedaled while holding onto handlebars. The

equipment could be set for the desired workload,

and the amount of work being performed was

thus a known quantity. The end point of the test

was the examinee’s pulse rate, which was monitored and recorded by means of special equipment

(Kenelco) fastened to the examinee by an electrode

attachment. A reference table specific for age,

sex, and weight of the child was provided so that

the technician could determine the appropriate

load setting for the equipment, The examinee

made a l-minute-test run; then if the pulse

rate had advanced appropriately, he continued

for the 2-minute-test ride. If the test run indicated underloading or overloading, the load was

adjusted, and then the test was continued. Variables recorded directly on the case record

included the pulse rate before exercise, the

pulse rate at 2 minutes after end of exercise,

the maximum pulse rate during the 5 minutes

directly after exercise, and the rate at the end

of the S-minute rest after exercise. The technician also recorded the workload adjustment

and the temperature and humidity of the examining room at the start of the test. In addition,

the equipment traced a timed graph of the pulse

rate throughout the test.

THE ANCILLARY DATA COLLECTED

General Considerations

In describing the logistics of the survey,

mention has been made of several questionnaires: the household questionnaire administered

by the Census interviewer at all households

visited and the child’s medical history and the

HER interviewer-administered questionnaire for

sample children. An attempt was made to obtain

information for sample children on a questionnaire sent to the schools (Appendix IE). In addi23
tion a copy of the birth certificate of each sample

child was requested from the appropriate State

office.

It should be recognized that data obtained

on the questionnaires were intended to serve

various purposes. In some cases the data were

desired to classify health information and examination findings such as data on income or educational class of the parent. In other cases the

information was requested to facilitate subsequent

survey operations. Examples of this are information on the grade and school of the child or on the

name and address of the child’s physician. Other

items were included to assist the physician inhis

examination of the child. Thus the physician was

alerted to the occasional child who had some

physical limitation which would require special

handling in the examination (e.g.$ a limitation

on physical exercise imposed by the child’s

physician would be a contraindication for the

exercise tolerance test).

Sometimes the medical history suggested

to the physician the necessity for his paying

particular attention to some part of the clinical examination, It was recognized that this

would result in the physician’s examination not

being quite the same thing for every examinee.

A blind-type design in which the physician did

not see the medical history would produce somewhat different results in some cases. It was felt,

however, that the advantages of an examination

procedure more nearly like that in clinical practice outweighed any disadvantages. So the physician not only reviewed the medical history in

advance of the examination, but he wasinstructed

to go on to administer further special examinations

in some instances where his initial examination

made him suspect the presence of a defect such

as a neurological abnormality.

Frequently the reason for collecting data on

the questionnaires was the desire to relate that

information to some specific part of the examination findings. Thus the child’s medical history

provides information concerning injuries to the

ear, past operations, earaches, and the like which

can be examined in relation to the results of the

audiometric testing.

Relatively few items were collected on the

questionnaire in order to describe the total

universe sampled with respect to the characteristic covered by a specific question, but there

are some such items, An example of such a question is the one which asks whether the parent

feels that the child’s teeth need straightening, Of

course, here there was also interest in relating

the response to this question to the findings on

the child’s dental examination with respect to

occlusion status.

Description of Separate Source Documents

The household questionnaire was the basic

source document which provided required demographic data concerning the population sample as

well as serving in the final stage of sample selection. This form, which has already been referred

to briefly, is shown as Appendix IA. The form

was administered by a Census interviewer who

had already filled in the identifying numbers of

the PSU, segment, and so forth (items 2-6, page

1) prior to visiting the household. The interviewer

began with question 1 on pages 2and 3 of the form

and inquired about the household composition. A

column was completed for each member of the

household, and age, sex, race, and relationship

to household head were recorded. For all children

between ages 5 and 12, the exact dateof birth was

recorded. The target population was children

between 6 and 11 years of age, inclusive, but

pilot studies indicated the desirability of special

checking on the ages of children within 1 year

above or below this range. For households in

which there was one eligible child or more, the

additional information called for in questions

6 through 14 was obtained. These include information on the school attended and the grade for

each eligible child as well as information on -

education, county of birth, handedness, working

status, and marital status for each of the parents.

In addition, questions were asked which provide

total family income and a basis for further questions in a subsequent interview to elicit a complete history of all marriages for each of the

parents. Another question (No. 13 on page 2)

gets at the occurrence of certain specified

events such as a death in the family which

might be regarded as potentially traumatic in

the child’s life. At the conclusion of the interview

the interviewer leaves the medical history r’orm

to be completed by the parent (Appendix IB). This

24
form was designed to be self-administered. The

operation plan, however, provided that it would

be picked up personally by one of the HES inter1

viewers. This afforded an opportunity for the

staff member to do an on-the-spot edit of the

completed form and to ask about any missing or

questionable entries. In something like 10 percent

of the cases, the form had not been filled out

when the interviewer called back. In such cases

the’ interviewer assisted the parent in completing

it then and there, and in those instances the form

was regarded as HER interviewer-administered,

In all the other cases the interviewer reviewed

the form and asked about any problem entries,

The instructions for completing the intervieweradministered questionnaire indicate how this was

done (see Appendix IF for both form and instructions).

- The HER interviewer-administered questionnaire collected four kinds of data: (1) some information on the child* s eating habits and the parent’s

perception thereof, (2) a record of all marriages

with dates and reasons for termination in the case

of broken or multiple marriages of either parent,

(3) characterization of twins as identical or fraternal, and (4) a number of items concerning the

behavior of the child and the parents perception

of that behavior (e.g., tense or relaxed, strong

temper, and time spent in watching TV). Thepartitular characteristic of questions included in

this group, as distinct from those on the selfadministered child’s medical history-parent form,

was that they either required special handling on

the part of the interviewer or concerned subjects

which were thought to be sensitive and so better

handled through discreet personal inquiry.

Another set of ancillary data was contained

in a questionnaire obtained from the school at

which the sample child was a student (Appendix

IE). This form was intended to serve several

purposes. For one, it provided official information on the child’s grade placement, an item

collected from the parent but subject to potential error. More important, it served as a measure

of the child’s success in a major part of his real

life situation (going to school) and so afforded an

independent evaluation of the child which could

be compared with the findings of the examination.

It attempted to identify the child whose health

(including mental ability) problem or difference

had come to the attention of school teachers, Thus,

for example, the child who was known to have a

vision or hearing problem was identified. Moreover, it attempted to obtain subjective ratings

from the teacher as to various aspects of the

child’s behavior and adjustment. These could

then be examined in relation to the results of

various tests given in the survey. The form was

given to the school principal, who was asked to

have it filled out by the child’s teacher or whomever the principal believed to be the best informed respondent. In those locations visited

during the summer months when school was not

in session, the questionnaires were mailed to

the school in the early fall with a request that

they be completed and returned. Mail followup

was made when the questionnaire was not received

within a reasonable time. The overall results were

that school questionnaires were obtained for about

95 percent of the sample children,

The final source document for ancillary data

was the birth certificate of the sample child. After

an examination was completed, a request was

sent to the registrar of vital statistics in the

State reported on the parent’s questionnaire as the

birthplace of a child to obtain a copy of the birth

certificate. Arrangements had been made in advance with the States to do this on a fee basis

and consents had been obtained from the parents

during the household contacts. The birth certificate copies were desired for several reasons.

It was important, particularly in connection with

the scoring of psychological tests but also in connection with the analysis of all the growth and

development data, to have the exact and correct

age for each child. It was also felt that the

mother’s age at the birth of the child could be

obtained more accurately from this document than

from reconstruction from the age reported in the

household interview along with the child’s age.

Finally, the birth certificate provided some information related to the child at birth (birth weight,

congenital conditions noted at that point, and complications of delivery) which could be related to

some of the findings of the survey examination.

25
QUALITY CONTROL

In a program like the Health Examination

Survey the problems of nonsampling variability,

or measurement error, loom large. The data recorded for each sample child are inflated in the

estimation process to characterize the larger

universe of which the sample child is the representative. In any measurement process, here

thought of as encompassing all aspects of obtaining

and recording the desired data, there is inevitably some measurement error. Considerable attention was given to this problem in this nrogram.

‘the attack on mc?asurement error *began with

a concerted effort to minimize it. Decisions as

to what would be included in the examination took

account of the expected feasibility of collecting

reliable and valid data. The procedure for conducting each part of the examination was standardized, and written instructions spelled out in

detail how each step was to be performed. The

staff was carefully selected. and elaborate programs of training and retraining were carried

out. Some of these were formal training programs

like the special 2-week period of training in audiometric testing given to technicians prior to their

undertaking this work. Others were %+houserf

retraining efforts such as those carried out on a

day set aside at the beginning of each operation

at a new location. On this day, for example; examinations were performed on nonsample persons

under the supervision of headquarters staff. Similar retraining of both Census and HES household

interviewers was done at the beginning of operations in each new location. The necessity for uniformity, accuracy, legibility, and completeness

in the recording process was constantly stressed.

To the maximum feasible extent the recording

process was mechanized by the use of such devices

as tape recorders, automatic printing of results,

and photographic recording of scale readings

(fig. 9). Such methods not only reduce recording

errors but provide “hard” documents for replicate

reading. Of course the use of instruments not

only for recording but also for measuring introduces another source of possible variation, and

so systematic calibration and recalibration must

be carried out. This was done in the Health Examination Survey for a &wide variety of instruments

Figure 9. Automatic recording of scale readings.

from audiometers to self-balancing scales and

sliding calipers.

Despite all precautions there is a degree

of residual measurement error. Because this

was recognized, an effort was made to monitor

the measurement errors that could be identified

as the survey was carried out. This was done

in many ways and for two basic reasons; first,

by becoming aware of certain kinds or causes

of measurement error it was possible to further

reduce it in the subsequent survey operation;*

second, in monitoring it, some measurement of

its extent was frequently obtained. This monitoring

was done sometimes by observing the process and

noting deviations from the prescribed procedures,

sometimes by reviewing and comparing recorded

data and noting differences among technicians

which suggested examiner differences, and sometimes in other ways,

An illustration of how this occurred and led

to corrective action follows. In observing the

taking of body measurements in the standing position, the observer noted that the technician

26
I ‘

. -

making the measurements was not always able of the measurement error is included in the calto observe that the examinee had deviated from culation which yields a “standard error” and thus

an erect vertical stance. A procedure was sub- is consolidated with sampling error.

, sequently initiated whereby responsibility for

observing this specific fact was placed upon the

recorder who was better located to notice any

deviation.

RESPONSE RESULTS

Whenever the end product of a particular

examination element is a “hard document” (such as

the X-ray film or the electrocardiographic tracing), the reading and interpretation of that record

can be done independently more than once.

Differences, then, are brought to light and can be

resolved through appropriate measures. This repLevel 01 Participation Achieved

The sampling plan, making use of known

p.robabilities of selection, assured that the sample

selected would be representative of the total

target population. Although the design did not

call for stratification by sex, separate years of

age, or race, post-stratification adjusrmecr,s

which will be made in the estimation procedure

will result in the distributions being identical

in these regards (Appendix III). The sex, age,

and race distributions of the total target population are shown in table 2. Even though the sample

be perfectly representative, however, the survey

results might be seriously biased if a high proportion of those selected in the sample were not

examined. The response rate may be critical in

assessing the success of a voluntary sample

survey of this sort.

lication of the step not only can be used to provide

resolution of differences but examination of the

extent of initial differences can give a measure

of the measurement error that would have been

involved had only the initial reading been used.

extending this same process and by replicating certain parts of the examination at times,

it is possible to learn something about the extent

of the examiner% contribution to variability in

the data. To a limited extent some replication of

parts of the examination was done at various

times in the survey. Sometimes this was done

by having repeat examinations of the same subject

ta nonsample person) during the retraining sessions, or a part of the examination on a sample

child was later repeated independently, sometimes

by the same examiner and sometimes by a different

one. Whenever replicate examinations of sample

persons were done, the original observation was

retained as the datum to be included in the survey.

The second measurements were made only touse

as a basis for determining (by comparison with

the original measurements) something about the

extent of measurement variability in the data.

The findings of the survey will be published

in the Vital and Health Statistics series of reports.

In general, each of these reports will present the

findings with respect to some one or several aspects of the examination. In these reports attempts

will be made to apprise the reader of the extent

to which the data may be affected by measurement

error and to call attention to this problem. In some

instances the measurement process and the recorded evidence permit computation of particular measurement error; in other cases a part

The sample actually selected for the second

cycle program consisted of 7,417 children at ages

6- 11 years. The proportion of this sample finally

examined was 96 percent (7,119). This high level

of participation- only 4 percent nonresponsegives striking evidence of the willingness of parents of children in the United Stat es to cooperate in

Public Health Service programs involving medical

examination of children. The level of response in

the first cycle, which involved adults, was considerably lower (86.5 percent), and that result is

regarded as highly successful. The high response

rate is also evidence of the outstanding skill, devotion, patience, and effort demonstrated by the

field staff of the program during the 3 years required to carry out the operation.

The range of level of participation throughout

the 40 stands at which examinations were conddcted was fairly limited. The mean response

rate (96.0 percent) represents individual stand

response rates ranging only from 91 to 100

percent. There were two locations at whichevery

one of the sample children was examined. The

numbers for each individual location are shown

27
Table 2. Percent distributionofthe total U.S. noninstitutionalized population between

6 and 11 years, by age, color, and sex: Health Examination Survey, 1963-65

Age in years

Total Total 6-11 6-11 6 7 8 9 10 11

Color and sex

Total Percent distribution

106.0 16.3 15.9

100.0

100.0

100.0

100.0

100.0

100,o

Both sexes mmamma~~mmmmmmm-m-m 17.2 17.2 16.8 16.6

17.2 17.2 16.8 16.7

17.2 17.2 16.7 16.6

16.2 15.9

16.3 16.0

17.2 17.2 16.7 16.6 16.3

17.2 17.1 16.7 16.7 16.3

17.2 17.2 16.7 16.6 16.3

16.0

16.0

16.0

17.4

17.5

17.4

17.4 16.9 16.7 16.1 15.5

17.3

17,4

17.0 16.7 16.0

lL9 16.7 16.1

15.5

15.5

50.8

49.2

85.8

White

43.7

42.1

Nonwhite

Both sexes ~r~~m~~rn-mrn~-~m~rn-~ 14.2

Male

F100.0

100.0

Male

Fema

7.1

7.1

NOTE: Data are based on estimates for August 1,1964, whfch are unpublished figures

from the Bureau of the.. Census.

in table 3. By way of contrast, the range of

response rate for the Cycle I adult examination

program was considerably wider, from 66 to 98

percent. I

that serious bias will result, but it. is still

appropriate to ask whether the group of children

actually examined in the survey differed from

those who shotild have been but were not examined.

This cannot be answered, of course, for the fact&s that were obtained only by the process o f

examination; however, the survey did collect considerable demographic data on almost all the

sample children, and so some comparison can be

made.

Differentids iir Response

Among Demographic Subgroups

The findings of the Health Examination Survey will be presented separately by sex and by

single years of age and, frequently, by certain

other demographic characteristics, notably race,

geographic region, population density groups, parents* educational level, and family income. The

response levels for the subgroups involved in each

of these axes of classification show no marked

differentials in response rates. It appears unlikely

The possibility of data from a sample survey

being biased by a high rate of nonresponse is, of

course,related to the possible differences between

the nonrespondents and the respondents. Even a

high nonresponse rate would not bias the findings

if the nonrespondents were completely like the

respondents with respect to all of the characteristics being studied. Conversely a low nonresponse

rate might bias the findings in some respects if

there were marked differentials in response

among the subgroups being examined. A high

level of response greatly reduces the likelihood

28
Table 3. Number of sample children, number and percent examined, by stand number and

location: Health Examination Survey, 1963-65

Stand location!

Portland, Maine ------I-------L"-------------------------

Ashtabula, Ohio----"----------I--------"----------------

Poughkeepsie, New York---------------------------------- .

Ottumwa, Iowa -------------------------------------------

Boston, Massachusetts ----------------------------------- '

Denver, Colorado ----------------------------------------

Philadelphia, Pennsylvania -I----------------------------

Lamar, Colorado-----------------------------------------

Charleston, South Carolina ------------------------------

Los Angeles, California ---------------------------------

Sarasota, Florida --------------------LIIIIIIIIIIIIIIIIII

Atlanta, Georgia I------------------c--------------------

San Francisco, California -------------------------------

Baltimore, Maryland-------------------------------------

Mariposa, California --~-----LIIIIIIIIIIIIIIIIIIIIIIIIIII

New York, New York --------------------------------------

Moses Lake, Washington ----------------------------------

Minneapolis, Minnesota ----------------------------------

Grand Rapids, Michigan ----------------------------------

Neillsville, Wisconsin----------------------------------

Chicago, Illinois ----I----------------------------------

Des Moines, Iowa----------------------------------------

Barbourville, Kentucky----------------------------------

Wichita, Kansas -----------------------------------------

Marked Tree, Arkansas -----------------------------------

Brownsville, Texas --------------I-----------------------

Houston, Texas------------------------------------------

Birmingham, Alabama -------------------------------------

Detroit, Michigan ---------------------------------------

Lapeer and Marysville, Michigan-------------------------

Cleveland, Ohio-----------------------------------------

West Liberty and Beattyville, Kentucky------------------

Allentown, Pennsylvania ---------------------------------

Manchester and Bristol, Connecticut---------------------

Newark, New Jersey--------------------------------------

Jersey City, New Jersey---------------------------------

Georgetown, Delaware------------------------------------

Columbia, South Carolina --------------------------------

Stand

number

Number

sample

children Number

l l l 7,417 7,119

1 200 198

2 is5 175

3 193 190

4 196 195

5 192 174

6 192 189

7 192 174

8 183 183

9 186 171

10&12 285 266

11 188 185

13 191 187

14 189 i87

15 193 186

16 188 186

17&D 421 390

18 193 189

20 201 194

21 191 186

22 201 201

23 361 283

24 160 159

25 196 185

26 188 178

27 186 182

28 179 175

29 186 181

30 149 144

31 168 162

32 179 175

33 175 166

34 172 160

35 173 159

36 174 167

37 177 167

38 175 163

39 163 159

40 156 148

Examined

Percent

-

96eO

99eO

94e6

98e4

99e5

9Oe6

98e4

9Oe6

1OOeO

91e9

93.0

98e4

97e9

98e9

96e4

98e9

92e6

97e9

96e5

97.4

1OOeO

94.0

99e4

94e4

94e7

97e8

97.8

97.3

96e6

w 96e4

97.8

94e9

93eO

91e9

96eO

94e4

93el

95e5

94e9

lCities in which trailers were located. Sample areas consisted of the PSU's which

may have included several counties.

NOTE: Sample "take" for Los Angeles was deliberately somewhat low for "two stand

locations" because that area should be only slightly over l-1/2 stands on a Population

basis. Chicago, on the other hand, was oversampled in comparison with other 'one stand

locations," since it should be represented by slightly under l-1/2 stands.

29
Table 4. Number of sample children and number of children examined, by age, sex, and

color: Health Examination Survey, 1963-65

Age in years

Se% and color

8

--

-

9 10 11

1,161 1,293 1,281

596 655 649

565 638 632

1,231 1,208 1,243

618 594 653

613 614 590

1,08i 1,065 1,059 1,068

565 539 526 566

516 526 533 502

200

84

116

166 .149 175

Total

6-11 6 7

995

79 68 87

87 81 88

1,231 1,184 1,160

Number of sample children

Both sexes rr~---rrrrrrrrrr-rrr

1,112

3,765

3,652

White

Both sexes aa--caca-aaaaaaaaaaa 6,380

Boys aaaaaI-a=aa-aaaaaaLaaaaaaaa~aaaa

Girls aaaaaaCaa"a-a-Ca-aI~va~a-aa-aaa

3,276

3,104

Nonwhite

Both sexes aaLa-a--Ia-aaaa-aaaa 1,037

508 572

487 540

166 181

88 83

78 98

1,111

575

536

-

1,241

632

609

618 603 576

613 581 584

1,192

628

564

950 1,063 1,035 1,019 1,014 1,019

Boys a-~-Laaaa-aIaaaaa-aI-a~aaaaaaaaa 489

548

Number examined

Both sexes “aaaaIa”ma--a---“a-a 7,119

Boys aa-aaaaaaa--a-ama-mama-a--a-am-a

Girls aa-"a"aa~a~-aa-a-~aL-~-~-"-aa-a

3,632

3,487

White

Both sexes aCaaaaaaaa---L-a-a-a 6,100

489 551 537 525 509 542

461 512 498 494 505 477

161 178 196 165 146 173-

Boys aaa-Laaaaa-aaa-aa~aaaa-aaaa"~--a

Girls aa-a"~~aaaaaaLIaIaIaIIIIIIIIIII

Nonwhite

Both sexes aaamaam--“aa---aaaaa

479

540

86 81 81 78 67 86

75 97 115 87 79 87

Boys aLaCaaaaaaa-aa-aaaaaaaaaa--a-aaa

that nonresponse could bias the findings much in

these respects (table 4).

The differentials in response rates that did

occur among the various demographic subgroups

all varied within a fairly limited range. Thus the

range of percentages examined for single years

of age was only between 94.8 and 97J’percent.

The proportion of males examined was 96.5 percent and the proportion of females 95.5 percent,

Examinations were carried out on 95.6 percent

of all white sample children and on 98.3 percent

of nonwhite sample children (largely Negro). Even

when age, race, and sex are considered together,

the range of response was only from 93.9percent

30
to 100.0 percent. (Both of these extreme values

happened to be for 9-year-old girls, the first

white, the secondnonwhite,) The other parameters

1 named show about the same limited range of variation in response. Thus the variation by regionis

only from 93.9 to 97.3 percent. On the basis of

population-siz,e classes the range is from 93.1 to

98.6 percent when the data are classified in fullest

detail (eight groups, from 3 million and over to

rural). Similarly the range of variation response

rates through six groups by total family income is

only from 92.4 to 97.5 percent. Finally the variation in percentage cooperating was only from 94.1

to 97.1 when broad groups by education of head of

family (no more than elementary school, some

high school, some college) were compared, and

when single years .of schooling was examined, the

range was from 92.1 to 100.0 percent. , * The differentials which were observed in the

demographic or socioeconomic subgroups, though

relatively small, were generally in the expected

direction. Thus the response rate, though high

everywhere, was even higher in the rural areas

and smaller towns than in the large metropolitan

centers. It .was lower in the northeastern part of

the United States th,an in other regions. The nonwhite group had a higher rate of participation than

the white sample children, and the response rate

was a little better for all boys than for all girls,

All of these differences are in the same directions

as the larger differences which prevailed in the

adult examination program of Cycle I, The differentials pertaining to income and education in Cycle

II did not present an entirely consistent pattern

throughout the range. The highest income group

($15,000 and over), however, had the poorest

record of cooperation, and the lowest income

group (under $3,000) had the highest response

rate. The intermediate groups were all roughly

equal. This is generally similar to the Cycle I

results. When education of head of family was

the variable examined; it appeared that response

‘was highest amohg children whose parents had

no more than elementary school education and

response was poorest among persons with 5 years

or more of college or with 1-3 (but not 4) years

of college completed. (Persons with 4 years of

college had a higher level of cooperation than the

foregoing two groups though lower than that for

the elementary level only.)

Reasons for Sample Persons

Not Cooperating

Only 298 of the 7,417 children who were selected in the survey sample were not examined.

Even though the foregoing section has indicated

that this level of nonresponse was probably not

particularly biasing insofar as analysis of the

data by various demographic subgroups goes, it

is still of considerable interest to investigate the

reason for lack of cooperatj .on on the part of this

4 percent of the sample. The interest comes partly

from needing to understand nonresponse to plan

to minimize it in other surveys. An addedimportance of understanding the character of the nonresponse in the children’s survey is the light

it may shed on possible biases in particular elements of the examination collected. Thus, even

though the number of noncooperating children

is so small as to have negligible effect on most

distributions, it might have an effect on some particular item in the data collected if reasons for

noncooperation were frequently related to that

item.

The survey operating procedures were such

that if there was any opposition to participation

in the examination, it usually became manifest at

the time the health examination representative

explained the full plan and asked for the signed

consent. In a very small number of cases the

l wer during the earlier visit may

ome indication of uncooperativeness, but in any case the decision to participate

in the examination was not called for until the

second visit referred to above. An appointment

record card, completed immediately after, the

visit, included comments concerning the reasons

given for reluctance to participate in cases where

there were any. The survey operations usually

involved some further contacts with such a household in an effort to explain more fully the nature

of the program and gain cooperation. In each of

the successive visits or other contacts (which may

have involved different staff members), records

were completed concerning the appointment process. These entries included not only any stated

reasons for unwillingness to participate but also

any relevant judgments by the staff member as

to factors that might be involved.

r

31
Table 5. Number and percent of children

not participating and reasons given:

Health Examination Survey, 1963-65

Reason for not

participating

All reasons-----------

Unable to assign any

reason aaaaaaaaaaaaaaaaaaa

Reasons unrelated to potential examination

findings a~aaaLaaaIaaaIaIa

Temporarily out of

the areaaa-aaaaaaaa-aaa

Parent opposed to such

Federal activity-------

Private medical care

sufficient -aaaaaaaaaaaa

Schedule too filled to

find time aaaaaaaaaaaaaa

Other reasons-------------

Illness of child--------

Child or parent fearful

of doctors . am-a-a--a-a-a

Child generally uncooperativeaaaaaaaaaaaaaaaa

Parental concern for

child's welfare--------

Illness or death of

family member----------

Examination started but

not completed----------

Religious objectton to

medical examination----

Number

of

children

298

44 14.8

145 48.6

39 -aa

42 aaa

33 aaa

31 aa109 36.6

17 aa26 a-a

27 aa15 aa8 aam

8 aam

8 maa

Percent

100.0

The survey records, then, on each of the

298 peksons who were in the sample.but were

not examined should include one ormore statements concerning the reason for nonparticipation.

In over half the cases there was more than one

reason listed. It is recognized that in some cases

the reason given may not be the real reason. The

health examination representative and the field

operations manager were highly skilled, however,

in the art of obtaining cooperation and this required that they be able to assess correctly the

factors that were involved. Their appraisals as

to the reason most likely to be really involved

have been taken into account in this analysis.

The information available for the 298 unexamined children was first classified into about

a hundred separate ?eason” categories, and then

these were combined by grouping essentially similar statements of reasons. (If several reasons

were listed, the one which seemed to be the main

obstacle was used.) The 12 categories finally

arrived at are shown in table 5. These were

grouped into three general classes: ‘Unable to

dssign any reason” (44), “Reasons unrelated to

potential examination findings” (145), and “Other

reasons” (109). It is not implied that inclusion

in the last category means that the case is

necessarily typical with regard to what the examination findings would have been, but only that it

is possible that some of the cases in that category may have been atypical with respect to some

aspect of the ejtamination. Thus some of the cases

not examined because of ?llness of child’* represent cases of the usual acute communicable

diseases of childhood which happened to occur

at a time which prevented the child from being

examined; some on the other hand represent

children whose illness was chronic and who were

therefore unlike the examined group.

For about one-fourth of the cases of *Unable

to assign any reason,‘* the survey records failed

to show a reason. In some cases this was a lost

or incomplete administrative record; in others

the parent simply refused to give any reason and

the survey staff had no basis for inferring what

was back of the refusal. In another one-fourth of

the cases the lack of cooperation was attributed

to objections (unknown as to grounds) on the part

of some third party-neither the parent nor the

child. Thus an individual would not cooperate

because “one of his friends” advised him not to

do so. The remaining’half of this unknown reason

group represents cases where the record showed

a variety of miscellaneous reasons which were

obscure and unclassifiable in terms of the categories shown above or any other clearly meaningful categories.

The reasons which were presumed to be

unrelated to any possible findings of the examination (had it been made) are partially explained

by the four subcategories shown in the tabulation.

There were 39 instances when either the entire

family or the sample child were out of the area

at the time for examination, some for sue-h

32
’ !

c

I ’

. I<

reasons as vacation trips and summer camp

periods. There were a number of instances

where it was clear that the major reason for

refusal was a negative attitude toward the.Federal

Government--either the Administration or the

Federal Government’s participation in such activities as the Health Examination Survey. In some

other cases where such points were raised, the

health examination representative was successful

in explaining the research nature of the program,

the bipartisan basis for the original legislation

authorizing the surveys, and the appropriateness

of the activity. For 42 of the 298 nonrespondents,

however, this attitude remained a barrier toparticipation. The “private medical care sufficient”

category included such cases as ones where the

parent insisted that because their child received

regular and complete care from a* private physician the examination was unnecessary. The

schedule-filled group included some instances

where the child was scheduled for examination

but other activities resulted in a broken appointment and there was insufficient time for rescheduling.

The category labeled “Other reasons” in table

5 includes 109 unexamined sample children where

the basis for the refusal was one which might have

some relationship to one or more of the kinds of

information gathered by the survey program. Thus

since the survey includes some behavioral items

designed to get at the social adjustment of the child,

it is important to be aware of the fact that a

number of sample children were not included by

reason of the apprehensiveness they or their

parents had about examination by a strange doctor.

In much of the information collected by the survey, such a child might not be at all different

from other sample children, but on the specific

questions asked about behavior he might well be

atypical. This needs to be taken into account in

later analysis of data.

In summary, then, it is believed that the degree of cooperation achieved in the survey was so

high that the problem presented by nonresponse

is minimal. At the same time it is recognized

that the person on whom no data are available

always presents the possibility of being unlike

the others on whom data were collected and the

analyst must always be aware of the possibility

of bias.

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Health Statistics. PHS Pub. No. 1000~Series l&No. 11. Public Health Service. Washington. U.S. Government Printing

Office, Oct. 1965.

‘2ktional Center for Health Statistics. Periodontal disease in adults, United States, 1960-1962. Vital and Health

Statistics. PI-IS Pub. No. 1000Series 11-No. 12. Public Health

Service. Washington. U.S. Government Printing Office, Nov.

1965.

23National Center for Health Statistics: Hypertension and

hypertensive heart disease in adults, United States, 1960-1962.

Vital and HeaZtA Statistics. PHS Pub. No. 1000~Series 11.

NO. 13. Public Health Service. \Irashington. U.S. Government

Printing Office, May 1966.

24National Center for Health Statistics: Weight by height

and age of adults,United States, 1960-1962. Vftab and HeaZtA

Statistics. PHS Pub. No. 1000~Series 11-No. 14. Public Health

Service. Washington. U.S.’ Government Printing Office, May

1966.

25National Center for Health Statistics: Prevalence of osteoarthri tis in adults by age, sex, race, and geographic area,

United States, ‘1960-1962. VitsZ and Health Statistics. PHS

Pub. No. lOOO-Series 11-No. 15. Public Health Service. Washington. U.S. *Government Printing Office, June 1966.

26National Center for Health Statistics: Oral hygiene in

adults, United States, 1960-1962. Vital and HeaZtA Statistics.

PHS Pub. NO. lOOO-Series l&No. 16. Public Health Service.

Washington. U.S. Government Printing Office, June 1~66.

27National Center for Health Statistics: Rheumatoid arthritis in adults, United States, 1960-1962. Vital and HeaZtA

Statistics. PHS Pub. No. 1000~Series l&No. 17. Public Health

Service. Washington. U.S. Government Printing Office, Sept.

1966.

28National Center for Health Statistics: Blood glucose

levels in adults, United States, 1960-1962. Vital and HeaZtA

Statistics. PHS Pub. No. 1000~Series ll-No. 18. Public Health

Service. Washington. U.S. Government Printing Office, Sept.

1966.

29National Center for Health Statistics: Age at menopause,

United States, 1960-1962. Vitai and Health Statistics. PHS

Pub. NO. 1900~Series ll-No. 19. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1966.

30National Center for Health Statistics: Osteoarthritis in

adults by selected demographic characteristics, United States,

1960-1962. Vital and Health Statistics. PI-IS Pub. No. lOOOSeries l&No. 20.’ Public Health Service. Washington. U.S.

Government Printing Office, Nov. 1966.

“National Center for Health Statistics: Childbearing and

diabetes mellitus, United States, 1960-1962. Vital and Health

Statistics. PHS Pub. No. 1000~Series 11-No. 21. Public Health

Service. Washington. U.S. Government Printing Office, NOV.

i966.

32National Center for Health Statistics: Serum cholesterol

levels of adults, United States, 1960-X962. Vita2 and HeaZtA

&ati8tic8, PHS Pub. NO. 1000Series ll-No. 22. Public Health

Service. Washington. U.S Government Printing Office, Mar.

1967.

33National Center for Health Statistics: Decayed, missing,

and filled teeth in adults, United States, 1960-1962. Vital and

HeaZtA Statistics. PHS Pub. No. 1000~Series 11-No. 23. Public Health Service. Washington. U.S. Government Printing

Office, Feb. 1967.

34National Center for Health Statistics: Mean blood hematocrit of adults, United States, 1960-1962. Vita2 and HeaZtA Statistics. PHS Pub. No, 1000~Series 11-No. 24. Public Health

Service. Washington. U.S. Government Printing Office, Apr.

1967.

35National Center for Health Statistics: Binocular visual

acuity of adults by region and selected demographic characteristics, United States, 1960-1962. Vital and HeaZtA StatiSt&M. PHS Pub. No. 1000-Series l&No. 25, Public Health

Service. Washington. U.S. Government Printing Office, June

1967.

36National Center for Health Statistics: Evaluation of psychological measures used in the health examination survq of

children ages 6-11. Vita2 andHeaZtA,Statistics. PHS Pub. NO.

100OSeries ~-NO. 15. Public Health Service. Washington. U.S.

Government Printing Office, Mar.’ 1966.

000

3 4
APPENDIX I, SELECTED FORMS USED IN CYCLE II

APPENDIX I A

CONFIDENTIAL - The National Health Survey is authorized by Public Law 652 of the 84th Congress (70 Stat.

489; 42 U.S.C. 305). All information which would permit identification of the individual will be held strictly BUDGET BUREAU NO. 68-R62044.3

confidential, will be used only by persons engaged in and for the purposes of the survey and will not be dis- APPROVAL EXPIRES JULY 31, 1965

closed or released to othe:s for any other purposes (22 FR 1687).

~52 ;tJS.HES-2 U.S. OEPARThtENT OF COMMERCE 1. Questionnaire

. . BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR THE

U.S. PUBLIC HEALTH SERVICE

NATIONAL HEALTH SURVEY of

Questionnaires

(a) Address or description of location (include city, zone, and State) 3. L$d$fication 4. PSX

num et

S,,Seg ent

num% et 6. Serigl

num et

c

(b) Mailine address if not shown in 2(a) OR m Sar$e as shown in 2(a)

If this questionnaire is for an “EXTRA” unit in a B or

NTA Segment, enter:

Serial No, of

E

original Item No. by If in NTA Segment, also

Sample Unit which found enter for FIRST unit

listed on property

Segment List

Sheet No. Line No.

‘ --’ (c)3ame of specral dwelling place 1 Code 7. Type of living quarters (Chsck ona box)

I

n Housing unit 0 Other unit

~.y.::.:.:: .:y::.,:.. ..: ,r:; .: ..!,:I:.:-.~ .I .:: ,. .:;. -. .-. . . . . . . . . . i,.

.:: ::‘:‘.‘:‘::,:: ._.,.. :: ..:: .:,: .;, : ,, .: ::. ‘_‘, ,,....:, . _.. ..:.:/,y.. ,, _.:. _. . .

. . . . . . . . . .,._ ,._ ._, : :

‘.“.:,:....:::..:.:::::;.t. ::I’::::.:i:j:::~:::,:::::,.

._ ..i ..,:_: 1;:: :_I :.: ::

1.

Ask items 8 and g only if ‘iRural” box .gy;-.$ ALC segments (ask if Item 2(a) address identifies a SINGLE-UNIT structure).

1 a Rural

A:. 10. Are there any occupied or vacant living quarters BESIDES YOJJR OWN.. 2 Cl Alj other (Skip to Item 10) $!

.:..

:.: : --In tho bassment? . , . . [1 Yes--S _.

,. . . . _ L -INo

8. Do you own or rent this place?

#. I

.:..,_ :.:.: L .,: :

--on thir floor? . . . . . . . a Yes--S I_-III No

10 Own

(Ark P(s))

2 L_I Rent 3 u Rent free ::: l - on any othor floor 1

(Ask 9(b)) (Aek 9(a)) $i of this building? . . . . 0 Yes--S - - L INo

.:+:

0. (a) If Own or Rent free, ask - Does this plocr have 10

(Pill Tcbls X for each qrrattere NOT fimted)

or more acres? ALL segments (a’sk if Item 2(a) identifies entire floor or unn* qbered part of

(b) If Rent, ask - 000s the place you rent hwo 10 floor in a MULTI-UNIT structure),

or moro acr?r?

11, Are there any occupied or vacant living quarters B@SIDCS YOUR OWN .-

1 11 Yes 2 (--J No If Item 2(a) identifies entire floor

J 1

.-on this floor? \. 0 Yes --S,-. L -aNo

’

If Item 2(a) identifies part of the floor,

. . . . (Fill Tablti X for ecloh qua&m NOT fioted.)

(c) During the past 12

I ’

d) During the post 12

specify part

months did soles of months did soles of

crops, livestock, .ond !

i.1 l - in the -+ of this floor?

crops, livestock, ond j” ’ -’

.I.-. ., _- ,

other farm product8 I

other form products

TA and NTA segments (ask at all units EXCEPT APARTMENT HOUSES),

from the ploco omount I from the place amount .. 12. Is there ony other building on this property for people to live.in - either occupied

to $50 or more? t

to $250 or more?

. “Ior vacant?

I

: ( Yesv-S - - L Cl No

‘NTERVIEWER): If eligible child in household enter child’s name,

segment, serial, and column number on Medical

History Form.

14, What would be the best time of day for the

roprosentativo to coma? . . . . . . . ..**.......

WAD TO RESPONDENT)

In addition to the information you have alt

to Ioavo this form to be filled out obout -.

tory. A ropnsentotlyo of thv U.S. Public

to pick up the form in a weok w SO. (Ask

. . . Medrcal hlstortes left for-c

Column No(s).

Person with whom form left--

4

Column No. and relationship

5, RECORD OF CALLS At HOUSEHOLD

Item 1

Date

Entire household I- ‘. 1 Time

‘. - Corn. 2 Corn, 3 Corn. 4I

Corn. I 5 Corn;

4

6. REASON FOR NON.INTERVIEW

‘VP8 A 9 c 2

0 Refusal (0socdbe in footnotes> 0 Vacant - - non-seasonal 0 Demolished Interview not obtained for

IOSORI f--J No one at home--

repeated calls

I ,

( Vacant - - seasonal 0 In sample by mistake

c-00 ro L_1 Usual residence elsewhere 0 Eliminated in sub-sample Cols. --m-y

0 Temporarily absent I 7)

0 Other (speclfyj

0 Other (specify) ( Other (specuy)

because:

7. TYPE A FOLLOW-UP PROCEDURE 18, Signature of interviewee 19. Cocle

: final call results in a Type A non-interview (except Refusals)take the following steps:

1, Contact neighbors (caretakers, etc.) until you find someone who knows the family;

2. Find out the number of people in the household, their names and ap

if names of all members not known, ascertain relationships.’ RecorB

roximate ages;

this ‘information in the regular spaces inside the questiononire.

USCObtM-DC 22318 P-68

35
1. (a) What is the name of the head of this household? (~n:~r name tn rirai column.)

(b) What are the names of all other persons who Iiw hue? (Z,I~I l ll persona who IIVO IW~.J

(c) I have listed (Read names) is there anyone also staying here now such as friends, relatives,,

or roomers? . . . . . . ..~..........~.............................................

(d) Have I missed anyone who usually lives here but is now --‘i

0 Yes (rifat) 0 N o

anporarily in a hospital? 0 Yes (Lfet) 0 No

- -Away on business?. . . . . . 0 Yes (Lf8r)

- -ok 0 Visit 01 VOCatiUB?. . . 0 YCS (Lf8t)

0 No

0 NO

(e) Do any of the people in ihis hous+old have a hame mywhere else?

Last name

0

1

M-m- --------w

First name

0 Yes (Appfy houoehold member8hfp IUf88, If nof 8 hou88hofd m8mber d8f8t8) 0 No (&88v8 on qu88tfOm8fr8)

2 How are(is)- -related to the head of the household? Relationship

(ht8r r8kffOnehfp to h88d, for 8~8mp18: Wff8, d8u&hhr, 8t8p8on, @md8on, mofh8r-fn-f8w, p8rfn8r, room8r’8 Wff8, 8tC.) HEAD

3. Race (M8rk on8 box fat 88Ch fB8rOOn)

0 White 0 Negro

0 Other

4. SeX (hfark on8 box for 88ch p8roon) 10 Male 0 Female

5. (o) How old were you on your last birthday?

0 Under

1 year

For each child age S-12 listed on the questionnaire, ask:

(b) What is the month, day, and i)ear of- - ‘I birth?

Month Day Year

(Check wfth (!ue8Lfon S(8) for con8f8tency) I I

D mT’ERvI&wER: Mark “EC” box fat each eli

ask coveta e questions on If

ible child (age 6-11) listed on the questionnaire. If no EC,

8 1

e 1.

NOTE: Questions -14 must be aske only of parent(s) or guardian(s) of EC. If no parent or ’ *I EC 0 Not

EC

guardian is at home, arrange to call back when they will be home.

Ask only for EC (children 6-l 1 years of age)

Name and location

6. What is the name and’location of the school -- goes to?

(a) Mot grade is - - in?

I

7. Where were you born?

(Check U.S. box or wrfte In n8me of country)

0 l&s.

.

Foreign c ouatry

8. Are you primarily right handd, primarily left handed, or both?

0 Right 0 Left

0 Both

9. What is the highest grade you attended in school?

(CM18 hfphe8t dI8de 8ttended or m8rk ~‘ffone.~~)

(If attended, ask):

(a) Did you finish this grade (yeor)?

IO. What were you dohg mast of the past 3 months -working, keeping house, or doing something else?

0 None

Elem.. . , 12345678

High.... 1 2 3 4

College 1 i 3 4 5t

0 Working 0 Keepin hous

0 Somethin else

(If “Doing so-thing else,” ask): ------w-----M

I -

(a) What WOm you doing? (Ent8r reply verb8tfm 8nd 88k IO(b)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..*....... I

(If “Keeping house” OR “Doing something else,” ask):

---------w--w

(b) Did you work ot o job or business at any time during the post 3 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I OYes 0 No

(If “Working” in 10 OR “Yes” in 10(b), ask):

I

----------w-w

(4 Did you work full-time or part-time? . . . . . . . . . . . ..~...4......................................,........ 0 Full-time 0 Part-time

Il. Are you now married,. widowed, divorced, or separoted?

(If “Married.” ask):

ia) Have yo;(your husbond) her, married mare than once?

12. Besides (Rea names of children d entered in Question 1) have you md(or) your husband(wife) ever hod

my other children?

0 Married 0 Divorced

0 Widowed 0 Separated ---C-k-------

0 Yes ~NO

Name

0 Yes INO n No parent

I

If “Yes,” ask):

a) Whot ore their names?

(b) How old is - -? (If now deceased enter date of birth) I -

(C) Where does he(she) live now? (If now deceased enter “deceased”)

b .

I

Please look at this co;d (H&d redpondent HES-2(a) card and pencil). Statement No.

13. Do any of the grestions on thot c-d apply to oly members of the family? Pleo*e mark “Yes” or “No”

for each question.

(For each “Yes” marked, ask): . I

(a) You hove checked- -. Who was this?

NOTE: If “1” marked, enter name

(b) When wos this?

of hospital or institution.

. b

I!. Which of these income qoups.represents your total combined f&ily income for the fast 12 monthsl,thot is,

your’s, your - - ‘I, l tc? (Show Income Flash Card HES-2(b).) Include income from a I sources, sue as wages,

salaries, rents from property, Social Security, or retirement briefits, Mp (rem relotives, etc.

Group

A

ORM NHS-HES-2 (1 l-1 a-68)

(GO to Question 15 on Pose 41.

Page 2

I

36
Last name Last name Last name

.

r;i--t-n;m; - - - - - - - - -F-7 iame- - - - - - - - “First-amQ - - - - - - - - First-.-m; - - - - - - - - First-n;m; - - - - - - - -

Relationship Relationship Rclat ionship Relationship Relationship

0 White 0 Negro 0 White 0 Negro 0 White 0 Negro 0 White 0 Negro 0 White 0 Negro

0 Other 0 Other 0 Other (-J Other 0 Other

0 Male /-J Female 0 Male 0 Female 0 Male 0 Female /-J Male 0 Female 0 Male 0 Female

ABe 0 Under ABe 0 Under A8e 0 Under ABe 0 Under Age 0 Under

1 year 1 year 1 year 1 year 1 year

Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year

3 EC u !g 0 EC I ;g.t

1 No school 0 No school

Name and location Name and location

cl EC 0 Not

EC

0 No school

‘Name and location

I EC og

0 No school

Name and location

cl EC 0 !g

.

0 No school

Name and location

Foreign country Foreign country Foreign country Foreign country -- Foreign country

7 Right 0 Left 0 Right 0 Left 0 Right m Left m Right 0 Left 0 Right 0 Left

0 Both 0 Both 0 Both 0 Both 0 Both

0 None ( None 0 None 0 None 0 None

Elem. . . 12345678 Elem.. . 12345678 Elem. . . 12345678 Elem.. . 12345678 Elem.. . 12345678

High.. . 1234 High.. . 1 2 3 4 High... 1 2 3 4 High. . . 1234 Hi&h.. . 1 2 3 4

College 1 2 3 4 5t College 1 2 3 4 5t College 1 2 3 4 5t College 1 2 3 4 St College 1 2 3 4 5t

3YeS

--jNo-----nkes--mN; ----- uycs--=i-~o ---- --dyes--d~o------d’les--53~o ----

0 Working 0 Keeping house

0 Something else

0 Working 0 Keeping house ‘I Working 0 Keeping house 0 Workine 0 Keeping house m Working (-J Keeping house

0 Something else 0 Something else 0 Something else 0 Something else

-------------~------S.--------,-d ---------- -------------------------

-------------------------------------------_______ ----me-----e---w3 Yes cl No El yes cl No 0 Yes 0 No n Yes 0 No 0 Yes 0 No

----------------------------------,-,,-,,,,,’,,,,,,,,,,,,,, ---m---vz] Full-time 0 Part-time 0 Full-time 0 Part-time 0 Full-time 0 Part-time 1 Full-time 0 Part-time 0 Full-time n Part-time

-Married 0 Divorced 0 Married 0 Divorced 0 Married 0 Divorced 0 Married 0 Divorced 0 Married 0 Divorced

1 Widowed ~1 Separated LJ Widowed 0 Separated 0 Widowed 0 Separate: -0 Widowed ( Separated 0 Widowed 0 Separated

=J %e; --w---.-- - -m No m-y;s- - - -a Gos - - - ‘i-yes - - -a-No - - a Tes - - -nwN; - - - -i=i ye; - - ‘m-No-B-m

Age Present whereabouts

- -

Name Relationship Y-t(s) Name of Institution

Group

4

Group Group Group Group

Page 3 USCDMM-DC 22314 P-62
15. Is any language other than English spoken hers in your home?

(If “Yes,” ask):

What language(s)? Language(s) spoken

(Complete front page of questionnaire)

COflUWntS: (Include here any information which might be ueeful to the PffS representative when she calls to pick up the Medical History F0m.)

tA6Le x - LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS

Are these USE OF CHARACTERISTICS CLASSIFICATION It; HU IN B SEGMENT, ASK

(SpscIfy location)

quarters for

Occupied All Quarters Not a

2 mare than one Location of unit ~n;~o;ccu- Do these((Specity IOCP- fzg Fill In whot year

ii! .i ’

group of people? tion) quarters have: were these (If before July 1960)

4 . unit separate (Specify location)

s Yes

(Examples: these (Specify

Xocatlon) Direct oca No

A kitchen (Add

questionnaite quarters

Basement, qwrters live coss from or cooking and created?

What was the name of

3 .sg

occu- the household head

(Fill one 2nd floor, etc.1 and eat witIt the outside wbment pents

any other or through for exclu- to thie

interview (If 1959 or 2 960,

ale0 specify**F’* of these quarters on

0” lfne for

&

each group of a common rive use? ques. if ffret heff or April 1, 19601

8-P) people? hall? tion- .

“L’# if 1864

Yes No Yes No Yes No naire)

HU Other half)

unit

1) 0) (34 (3W (4) (Sa) (5b) (Ga) (6b) (7a) (7b) (8) @a) (9b) (10) (11)

1

38
\‘I ’ - \

. >

lLsD DEPARTnEWT OF COMMERCE

mJRLAlJ OF TNL CCNSUS

TlNC AS COLLLCflNO AOCNT FOR

lJ.sm Pueuc HEALTti SERtiICrr

Please look at the questions oo this card.

Wrk (x) “Yes” or WO” for each one listed.

1. Outing the past ten years has anyone in the family been in a

hospital, institution or any other rimilor place for more than

a three-month comsecutive period?

Cl Yes c l No

2. During

to bed

the past ten years has anyone in the family been confined

at home for more than a three-month consecutivd period?

Cl Yes c l No

3. bring the past ten years has anyone in the family been unable

to work or carry on his usual activities for more than a six-month

period-that is, in terms of health?

0

YCS c l No

4. During the past ten years has any relative of yours’died while

living in yaw household?

c l Yes c l No

FORM NHS-HESSb

ta-14dm)

U.S. DEPARTMENT Of COMMERCE

BUREAU OF THE CENSUS

ACTINO AS COLLECTING AGENT FOR THE

-U.S. PUBLIC HEALTH SERVICE

NATIONAL HEALTH SURVEY

Total combined family iricome during part 12 morrthr

Group A.. . Under $500 (Including loss)

Group B . . . $ 5~4 999

GroupC.. . $ I;000 - $ 1,999

Group D . . . $2,~4 2,999

Group E . . . $ 3,000 - $ 3,999

Group F . . . s 4,000 - $ 4,999

Group G. . . # 5,m - $ 6,999

Group H . . . $ 7@Q - $ 9,999

Group I . . . $lO,ooo - $14,999

Group J . . . $IS,OOO and over

FOR CENSUS WREAU USE ONLY

EiS-lGi(rsx-~~

39
APPENDIX IB

CONFIDENTIAL - The National Health Surrey is autboria## by Public LazhSJ2 of FORhI APPROVED

the 84th Congress (70 Stat. 489; 42 U. S.C. 242~). All infomation which would DUDGET BUREAU N O . 22-R220-24.4

permit identification of the individual .will be held strictly confidential, will be used only by petso- engaged in .

and for the purposes of the survey and will not be disclosed or released to others for any other purposes (22 FR 1687).

DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

HES-256

PUBLIC HEALTH-SERVICE

NATIONA L HEALTH SURVEY (1 l El

NAME OF CHILD (tat, First, Middle)

CHILD’S MEDICAL HISTORY - Pormt

SEGMENT SERIAL COL. NO.

w-111

NOTE: Please complete this form by checking the correct boxes and/or.filling in the blanks where applicable.

When you have, completed it, keep it until the representative of the Health Examination Survey calls on you

within a few days. If there are some questions you do not understand, please complete the others and the person who

comes for the form will help you with the ones that were unclear.

1. SEX 2. AGC 2. DATE OF BIRTH

Male

(Month, Day, Yew)

(12-l 41 1 0 2 0 Female

(16)

(II)

(181

(2 1)

(22)

(25)

4. PLACE OF BIRTH (tilyot Tou;n, %ate)

I

1. WAS THIS CHILD BORN IN A HOSPITAL?

1 fJ Yes 2 0 No 8 0 Don’t know

IF YES: (Question 5)

A. About how long did you (the mother) stay in the hospital after the baby was born?

t 0 1 week or less 2 0 1 to 2 weeks 8 0 Over 2 weeks 4 0 Don’t know

B. If mother stayed ox 1 week, what was the reason for staying that long?

C. About how long did the baby stay in the hospital?

1 0 1 week or less 2 ~3 1-2 weeks a 0 Over 2 weeks 4 0 Don’t know

1 week, what was the reason for staying that long?

6. ABOUT HOW MANY POUNDS DID THE BABY WEIGH AT BIRTH?

I 0 Under 5 2 05-10 3 0 Over 10 4 0 Don’t know

7. WAS THE BABY BORN ABOUT WHEN HE(SHE) WAS EXPECT.ED, OR EARLIER, OR LATER?

I 17 Earlier than expected 2 0 When expected 8 0 Later 4 0 Don’t know

If the baby was born earlier than expected, about how early?

I 0 Less than 4 weeks early 2 0 4 or more weeks early s 0 Don’t know

6. WAS THERE ANYTHING UNUSUAL OR WAS ANYTHING WRONG WITH THE BABY WHEN HE( SHE) WAS BORN?

1 0 Yes 2 0 No 8 0 Don’t know

IF YES:

A. What was the matter?

B. What did the doctor say caused this?

9. ‘WHILE YOU (THE MOTHER) WERE PREGNANT WITH THlS.CHILD DID YOU HAVE ANY MEDICAL PROBLEbdS

OR COMPLICATIONS7

t 0 Yes 2 ONO a 0 Don’t know

IF YES, what kind of trouble did you have?

10. HOW MANY TIMES HAD YOU (THE MOTHER) 8EEN PREGNANT BEFORE, INCLUDINC’PREVIOUS

MISCARRIAGES AS WELL,AS DELIVERIES?

11. BEFORE THIS BABY WAS BORN, WHILE YOU (THE MOTHER) WERE PREGNANT WITH THIS CHILD, DID YOU

(THE MOTHER) SEE A DOCTOR?

1 0 Yes 2 0 No 3 0 Don’t know

IF YES:

A. About how many months pregnant were you when you first saw a doctor?

I 0 Less than 3 203to6 soOver . 4 0 Don’t know

B. About how many times altogether did you see a doctor while you (the mother) were pregnant?

I 0 None 2 0 1 to 3 s 0 4 or more 4 0 Don’t know

4 0
,

‘

’

12. DID YOU (‘THE MOTHER) HAVE ANY TROUBLE WITH THE PREGNANCY OR BIRTH OF THIS CHILD?

1 0 Yes 2 0 No 3 0 Don’t know

IF YES, what was the trouble?

13. WHEN HE(SHE) WAS A BABY, THAT IS BEFORE HE WAS A YEAR OLD, WOULD YOU SAY HE WAS lN GOOD

HEALTH, IN FAIR OR POOR HEALTH?

1 0 Good health 2 C] Fair health s 0 Poor health 4 0 Don’t know

14. WAS THERE ANYTHING WRONG WITH HIM(HER) WHEN HE(SHE) WAS A BABY?

1 0 Yes 2 0 No s 0 Don’t know

A. If the baby was not in good health or had anything wrong, what was the trouble?---.---.

B. Did you see a doctor about it?

1 0 Yes 2 0 No 3 0 Don’t know

C. IF YES, did he say what caused the trouble?

15. WAS THE CHILD BREAST FED?

1 0 Yes 2 0 No 3 0 Don’t know

A. IF YES, for about how many months was he(she) breast fed?

t 0 Less than 1 2 0 I to 6 a 0 Over 6 4 0 Don’t know

B. When breast feeding was stopped, how easily did the baby accept the change?

1 0 No problem 2 0 Some problem 3 0 Considerable problem

16. ABOUT HOW OLD WAS THE CHILD WHEN HE(SHE) FIRST WALKED BY HIMSELF?

I 0 Under 1 year old 2 0 Between 1 and 1% years old

3 0 Over 1% years old 4 0 Don’t know

17. ABOUT HOW OLD WAS THE CHILD WH’EN HE(SHE) SPOKE HIS FIRST REAL WORD?

1 0 Under 1 year old 2 0 Between 1 and 1% years old

s 0 Over 1% years old 4 [7 Don’t know

16. CHILDREN LEARN TO ‘DO THINGS LIKE EATING BY THEMSELVES AND TALKING AT DIFFERENT AGES. DO

YOU THINK THIS CHILD WAS ESPECIALLY m IN LEARNING TO DO THINGS, ABOUT AVERAGe, OR SOMEWHAT &$Jjy~ THAN OTHER CHILDREN?

1 0 Faster than other children p 0 About the same a 0 Slower 4 0 Don’t know

19. DID HE(SHE) GO TO KINDERGARTEN OR NURSERY SCHOOL BEFORE ENTERING THE FIRST GRADE? \.

I 0 Yes 2 m No s 0 Don’t know

_..__--p--.---m

20. NOW TURNING TO THE PRESENT TIME. HOW WOULD YOU DESCRl8E THE CHILD’S HEALTH NOW?

I 0 Very good 2 0 Good s 0 Fair 4 0 Poor

IF FAIR or POOR, what is the trouble?

21. IS THERE ANYTHING ABOUT HIS(HER) HEALTH THAT BOTHERS YOU OR WORRIES YOU NOW?

1oYcs 2 0 No

IF YES, what is the trouble?

22. DOES THE CHILD AT PRESENT EVER SUCK HIS(HER) THUMB. OR FINGERS, EITHER DURING THE DAY OR AT

NIGHT? 1 OYes 2 0 No a 0 Don’t know

IF YES, about how often?

t 0 Almost every day or night 1 0 Just once in a while 8 0 Don’t know

23. DOES THE CHILD TAKE ANY MEDICINE REGULARLY, NOT COUNTING VITAMINS?

1 0 Yes 2 ONO 8 0 Don’t know

IF YES:

A. What is the medicine for?

B.. What is the name of the medicine?

C. Did a doctor say for him(her) to take it)

I OYes 2 0 No 8 0 Don’t know

24, AT THE PRESENT iHE DOES THE CHILD EVER WET THE BED?

1 0 Yes 2 0 No a 0 Don’t know

IF YES, about how often does this happen?

1 0 Several times a week 2 0 Not every week but several times a month

a 0 About once a month 4 0 Less often than once a month

Here are a few questions about any accidents or injuries the child may have had from the time he was a baby

to today.

25. HAS HE(SHE) EVER BROKEN ANY BONES?

t OYes 2.0 NI a 0 Don’t know

41
(47)

(80)

(81)

(83)

(84)

163)

(64)

(6 9)

(731

26. HAS HE(SHE) EVER BEEN KNOCKED UNCONSCIOUS?

I 0 Yes 2 0No a 0 Don’t know

IF DON’T KNOW, do you have any reason to think he(she) may have been?

29. HAS HE(SHE) EVER BEEN BURNED SO BADLY THAT’IT LEFT A SCAR?

1 OYes 2 0 No s 0 Don’t know

28. HAS HE(SHE) EVER HAD ANY OTHER ACCID’ENT OR INJURY THAT TROUBLED HIM QUITE A BIT?

I 0 Yes 2 0 No a 0 Don’t know

29. HOW ABOUT OPERATIONS: HAS HE(SHE) HAD HIS(HER) TONSIL’S TAKEN OUT?

1 0 Yes 2 0 No a 0 Don’t know

30. HAS HE(SHE) HAD ANY OTHER KIND OF OPERATION?

1 OYes 2 0 No a 0 Don’t know

IF YES, what was the operation and what was it for?

31. HAS HE(SHE) EVER BEEN IN THE HOSPITAL FOR ANY OTHER SICKNESS OR TROUBLE?

I 0 Yes 2 0 No 3 0 Don’t know

IF YES, what was the sickness or trouble?

.

32. HERE IS A LIST OF DISEASES THAT CHILDREN SOMETIMES HAVE. HAS THIS CHILD EVER HAD:

If yes, about how

old at the time?

A. Scarlet fever? I I=]Yes+ Age. 2 0 No 3 0 Don’t know

B. Rheumatic fever? 1 0 Yes+ Age- 2 0 No B 0 Don’t know

C. Polio? 1 0 Yes+ Age- 2 0 No s n Don’t know

D, Diphtheria? t 0 Yes+ Age.- 2 /---J No 3 0 Don’t know

E. Meningitis or 1 0 Yes+ Age- 2 0 No 3 0 Don’t know

sleeping sickness?

F. Tuberculosis? 1 0 Yes+ Age.+, 2 0 No 3 0 Don’t know

G. Diabetes or t 0 Yes+ Age 2 0 No 3 [23 Don’t know

sugar diabetes?

H. Epilepsy? I 0 Yes +Age- 2 0 No a 0 Don’t know

I. Chorea or 1 r)Yes+Age 2 0 No s 0 Don’t know

St. Vitus dance?

J. Cerebral palsy? 1 0 Yes- Age 2 0 No a 0 Don’t know

K. Whooping cough? 1 0 Yes+ Age- 2 0 No B n Don’t know

33. HAS THIS CHILD EVER HAD MEASLES?

1 0 Yes 2 0 No 3 0 Don’t know

IF YES:

A. At what age?

B. Was he(she) sick longer than usual?

I OYes 2 0 No 3 0 Don’t know

C. Did he(she) have to go to the hospital?

1 0 Yes 2 c] No 3 0 Don’t know

D. Did he(she) have a high fever for more than one week?

I 0 Yes 2 0 No 3 0 Don’t know

E. Did he(she) seem to be unusually drowsy (sleepy) after the illness?

t 0 Yes 2 0 No B 0 Don’t know

34. HAS THIS CHILD EVER HAD MUMPS?

1 0 Yes 2 0 No 3 0 Don’t know

IF YES:

A. At what age?

B. Was he(she) sick longer than usual?

1 0 Yes 2 0 No 3 0 Don’t know

C. Did he(she) have to go to the hospital?

1 0 Yes 2 0 No 3 0 Don’t know

D. Did he(she) have a high fever for more than one week?

I OYes 2 0 No 8 0 Don’t know

E. Did he(she) seem to be unusually drowsy (sleepy) after the illness?

I OYes 2 0 No 3 0 Don’t know (79-90) END CARD 01

42

\. .
35. HERE ARE SOME OTHER KINDS OF ILLNESSES OR CONDITIONS SOME CHILDREN HAVE. HAS YOUR CHILD

EVER HAD:

cai A. Asthma?

B. Hay fever?’

C. Any other kinds of

allergies?

D. Any trouble with his

(her) kidneys?

E. A heart murmur?

F. Anything wrong with

his(her) heart?

G. A convulsion?

H. A fit?

1 OYes

I OYes

I 0 Yes

1 OYes

I OYes

I 0 Yes

I OYes

1 OYes

2 ONO

2 ONO

2 ONO

2oNo

2 ONO

2 ONO

2oNo

2 ONO

30 Don’t know

30 Don’t know

30 Don’t know

9 0 Don’t know

s 0 Don’t know

s 0 Don’t know

9 0 Don’t know

3 0 Don’t know

35. DOES YOUR CHILD OFTEN HAVE BAD SORE THROATS?

(14) I 0 Yes 2 ONO 9 0 Don’t- know

37. IN THE PAST YEAR OR SO HAS HE(SHE) HAD MORE THAN THREE COLDS A YEAR?

I OYes 2 ONO 8 0 Don’t know

36. DOES HE(SHE) OFTEN HAVE COUGHS THAT HANG Obi?

1 OYes 2 ONO a 0 Don’t know

39. HAS A DOCTOR EVER SAID TH’AT HE(SHE) HAS BRONCHITIS?

1 OYes 2 0No a 0 Don’t know

40. WHEN THE CHILD HAS A COUGH OR COLD DOES IT GO TO HIS(HER) CHEST?

I 0 Often 2 0 Sometimes s 0 Almost never 4 0 Don’t know

41. HERE ARE SOME QUESTIONS ABOUT YOUR CHILD’S EYES.

A. Has he(she) ever had crossed eyes?

(19) 1oYes 2 ONO t 0 Don’t know

B. Has he(she) ever had an operation on his(her) eyes?

(20) i 0 Yes 2 OSJO 3 0 Don’t know

IF YES, what was it for?

C. Has he(she) ever had other trouble with his(her) eyes?

t 0 Yes 2 C]NO B 0 Don’t knop

IF YES, what kind of trouble?

D. Does he(she) wear either glasses or contact lenses?

1 OYes 2 ONO 3 0 Don’t know

42. IF HE(SHE) DOES NOT WEAR GLASSES:

A. Does he(she)& have trouble reading or doing fine work?

t2at 1 0 Yes 2 ONO 3 0 Don’t know

B. Do his(her) eyes or eyelids ever swell up or get red?

I 0 Yes 2 ONO 3 0 Don’t know

C. Does he(she) ever have styes, infections, or ‘matter’ in his(her) eyes?.

I 0 Yes no10 B [j Don’t know

D. Do his(her) eyes often water?

1 0 Yes 2oNo 3 0 Don’t know

E. Are his(her) eyes often bloodshot?

1 OYes 2oNo 9 0 Don’t know

F. Does he(she) ever say that his(her) eyes burn or itch?

I 0 Yes 2oNo 3 0 Don’tknow

G. Does bright light bother his(her) eyes?

(29) I OYes 2 ONO 9 0 Don’t know

H. Does he(she) ever see double or see things blurred?

(30) 1 0 Yes 2 ONO 3 0 Don’t know

I. Have you seen him(her) often rub his(her) eyes or blink when he(she) is reading?

1 OYes 2 ONO 3 0 Don’t know

J. Does he(she) sometimes close or cover one eye or hold his head on one side when hG(she) reads or

watches T.V.?

1 Dyes 2 ONO 9 0 Don’t know

43. DOES YOUR CHILD HAVE ANY TROUBLE HEARING?

1 Dyes 2 ONO 3 0 Don’t know

44. DOES HE(SHE) EVER HAVE EARACHES?

(341 1 OYes 2 nNo 9 0 Don’t know

45. HAS YOUR CHILD EVER HAD ANY INJURY OR DAMAGE Td HIS(HER) EARS?

(38) 1 0 Yes 2oNo 3 0 Don’t know

IF YES, in what way was his(her) ear injured?
(aa)

(ae)

(43)

(40)

149)

(80

(82)

(da)

45. HAS HE(SHE) EVER HAD HIS(HER) EAR DRUMS OPENED OR LANCED?

1 OYes 2 0 No s C] Don’t know

IF YES, how many times?

1 0 bnce only 2 0 Twice only 8 0 Three times or more

47. HAS HE(SHE) EVER HAD ANY OTHER KIND OF OPERATION ON THE EARS?

I O.Yes 2 0 No 8 0 Don’t know

IF YES, what was it for?

45. HAS THIS CHILD EVER HAD A RUNNING EAR OR ANY DISCHARGE FROM HIS EARS (Not counting wax in the

ears)? 1 C]Yes 2 0 No a C] Don’t know

IF YES:

A. How often has he(she) had this?

1 0 Once only 2 0 Twice only a 0 Three or more times 4 0 Don’t know

B. Was this his(her) left ear, right ear, or both ears?

I 0 Left 2 0 Right 3 0 Both 4 0 Don’t know

49. Hi4S HE(SHE) EVER HAD ANY OTHER KIND OF TROUBLE WITH HIS(HER) EARS?

1 0 Yes 2 0 No 3 0 Don’t know

IF YES, what kind of trouble?

50. IS THERE ANY PROBLEM WITH THE WAY HE(SHE) TALKS?

1 0 Yes 2 0No 3 0 Don’t know

IF YES, what is the problem?

t 0 Stammering or stuttering? 2 0 Lisping? 8 0 Hard to understand?

4 0 Something else? What is that?

51. DOES THIS CHILD HAVE A LIMP OR ANY TROUBLE WHEN HE(SHE) WALKS?

1 OYes 2 ONO 3 0 Don’t know

IF YES, how much trouble and what kind is it?

52. DOES HE(SHE) HAVE ANY PARALYSIS OR ANY WEAKNESS OR TROUBLE IN USING EITHER ARM bR LEG?

I OYes 2 0 No s 0 Don’t know

IF YES, what kind of trouble?

53. HAS THE CHILD’S HEALTH EVER KEPT HIM(HER) FROM HARD EXERCISE OR PLAY?

1 0 Yes 2 0 No B 0 Don’t know

IF YES:

A. Did .a doctor say he should be kept from doing this?

1 0 Yes 2 0 No 3 0 Don’t know

B. What was the condition that restricted the child?

C. Is he(she) restricted this way at present?

1 OYes 2 0 No s 0 Don’t know

54. HOW LONG HAS IT BEEN SINCE HE(SHE) HAS BEEN TO A DOCTOR?

I 0 During past 12 months 2 0 1 to 2 years

a 0 More than 2 years 4 0 Never 8 0 Don’t know

55. HOW LONG HAS IT BEEN SINCE HE(SHE) HAS BEEN TO A DENTIST?

1 0 During past 12 months 2 0 1 to 2 years

B 0 More than 2 years 4 0 Never 8 0 Don’t know

56. HAS ~~1s CHILD EVER HAD H~S(HER) TEETH STRAIGHTENED OR HAD BANDS 0~ Hls(HER) TEETH?

I 0 Yes 2 0No 9 0 Don’t know

IF NQ, do you think the child’s teeth need straightening?

9 0 Yes 2 0 No 3 0 Don’t know

Here are some questions about your child’s sleeping habits

57. ABOUT WHAT TIME DOES HE(SHE) USUA LLYGOTOBED

.

ON NIGHTS WHEN NEXT DAY IS A SCHOOL DAY?

P.M. 01 0 No usual time 02 n Don’t know

56. DO YOU FEEL THAT WATCHING OR HEAPING CERTAIN KINDS OF TV OR RADIO PROGRAMS’OR SEEING

CERTAIN KINDS OF MOVIES MAKES ANY DIFFERENCE IN HOW WELL YOUR CHILD GETS TO SLEEP OR

SLEEPS?

I OYes 2 0 No 3 0 Don’t know

IF YES, what kinds of programs or movies?

59. DOES HE(SHE) HAVE BAD (UNPLEASANT) DREAMS OR NIGHTMARES?

I 0 Yes, frequently 2 0 Yes, but not often 3 0 Never 4 0 Don’t know

60. DOES HE(SHE) WALK IN HIS(HER) SLEEP?

1 0 Yes, frequently 2 0 Yes, but not often s 0 Never 4 0 Don’t know

44
(62)

(6))

61. HAS HE(SHE) SLEPT OV

FAMILY BEING THERE?

‘ERNIGHT AT A FRIEND’S HOUSE WITHOUT YOU OR OTHER MEMBERS OF YOUR

1 0 Yes 2 ONO 3 0 Don’t know

IF YES, about how often?

1 0 Frequently 2 0 A few times

62. AT HOME, NOW, WHICH OF THESE DESCRIBE YOUR CHILD’S USUAL SLEEPING ARRANGEMENTS?

1 0 Sleeps alone in separate room

Sleeps in separate bed in room shared with another person

2 0 With brother 3 0 With sister 4 0 With parent 8 0 With other person

Shares bed with another person

6 0 With brother I 0 With sister 0 0 With parent Q 0 With other person

Q1. DOES YOUR CHILD SAY HE(SHE) IS AFRAID TO BE LEFT ALONE IN THE DARK?

1oYycs 2 ONO 3 0 Don’t know

64. WHAT IS THE NAME AND ADDRESS OF THE DOCTOR THIS CHILD USUALLY GOES TO?

Name 0 None

Address

65. WHAT IS THE NAME AND ADDRESS OF THE DENTIST HE(SHE) USUALLY GOES TO?

Name 0 None

Address

FOR GIRLS ONLY:

66. HAVE HER MONTHLY PERIODS STARTED?

I 0 Yes 2 0 No 3 0 Don’t know

IF YES, how old was she when they started? Years Months

45
APPENDIX IC

HEALTH EXAMINATION SURVEY-II

AUDIOMETRY CARD 05

AUDIOMETER NO. (6-6)

USE THIS SECTION WHEN

SAMPLE NO. IS EVEN

CPS

4000: RIL

1000: R[1(I‘

2000: R IIL

$1

250: R -1L

4000: R -1.L

$.

8000: R-IL

3000: RI--j---1‘

CONDITIONS AFFECTING TEST RESULTS: (chook)

0 2 Con d’t’ I Ions affecting test results

0 Cold at present

0 Ear discharge

0 Equipment defective*

EXAMINER (1Ml)

CARD USE THIS SECTION WHEN

COL. NOS. SAMPLE NO. IS ODD

(1245)

(16-19)

(24-27)

(-1)

(=-sB)

.

w-99)

m-w

(4447)

CPS

4;: R 1-1 L

$

1ooO: R j/ L

+

6000: R-IL

500: R /tlI L

2060: R -1 L

250: R/1/L

4ooo: ./II‘

3000: RI//L

0 Cold within past week

0 Earache within past week

0 Behavior+ [I3 Other+

*Cl Specify-----------.---------------------------------.---------------------------------------------------------------------------.------------..-----.

46

PHS-461 l-2

2-64. I

SAMPLE NO. (l-5)
APPENDIX ID

HEALTH EXAMINATION SIJRVEY--I - BODY MEASUREMENTS 52 GPO: 1664-741079

om5ERvkR (6-7)

SITTING + KDNZ. STANDING (FLOOR) l

CARD 65

COL. No.

POOT LCNOTH Cl0 BIACROM I AL DIAM.

11-13 ACROMION TO OLECRANON

14-16 CHEST BREADTH 4TH ICS

17-O CHEST DEPTH 4TH ICS

BICRISTAL DIAM.

CHEST GIRTH

WAIST QIRTH

-1

32-34

-37

41-4s

HIP OlRTn

R. UPPER ARM OIRTH

R. LOWER ARM GIRTH

SKJN FOLDS

R. uPPcR ARM ( M M )

R. INFRASCAPULAR (MM)

R. LAT. c~5sT WALL ( M M )

47-66 WEIGHT (LBS)

.-... ..--m -*.m. 0

.-1-m

-1

m7

bl*53

54-56

57.60

01-a

COOT BREADTW

KNU MltlOHT

COPLITUL iiRlonT

TnlOn CL5ARANCI

SEAT l R-K

ILDOW-W DRUDTH

.-u a---0-emSITTINQ K5IOWT--CRICT

a.-* 0 --

RUTTOCKIWICLJT L5NOTH

.- HI..-0 -

BUTTOCK-KNU L5NOTK

tLDOW-WRl5T LLNOTM

HAND L5NOTM

-

0 -w* -

HAND l R5ADTH

STANDING (ON STEP) l

A. l ICONDYLAR DIAM

R. CALF GIRTH

STANDING HltlOHt 0 . ..--m .w... -.--.m -1.1.w

ANTHRO. NO.

QOLS. l445

5ND CARD 67

END CARD 65

6In cm

MEASUREMENTS NOT DONE OR SIDE VARIED-specify which and give reason --.-.-------------.----------.-.--..--..---.----------

PM-461 l-3

R E V . 7.64 I

SAMPLE NO. (l-6)

47
APPENDIX IE

CONFlDENTIAL - The National Health Survey is’ authorized by Public Law 652 of the 84th Congress (70 Stat. 489; 42 FORM APPROVED

U.&C. 242C). Atl information which would permit identification of the individual will be held strictly conlidentiat,

will be used only by persons engaged in and /or the purposes of the survey and will not be disclosed of released to other8 for any other purposes (22 FR

1687).

DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

PUBLIC HEALTH SERVICE

National Center for Health Statistics

Health Examination Survey

H ES-243

SUPPLEMENTAL INFORMATION FROM SCHOOL

The child whose name appears below is one of the sample of children being studied in the Health Examination Survey. Please complete this form on the

basis of school records and/or information the child’s teacher or other school official may have. Please return it in the enclosed franked envelope. This

child’s parent or guardian has given us written authorization to obtain information from the school.

School Number

\

Sample Child Number

Name of child:

(Last Name) (First Name) (Middle Name)

Home address (for identification)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Birth date:

(Month) (Day) (Year)

Present grade placement of this child

NOTE: If this grade placement is qualified in any way, please so indicate. (e.g., “Fourth generally, but placed with third grade

for (speci fy”) j

Have any grades been skippedor double promotions given? (-J Yes 0 No

Have any grades been repeated for any reason? 0 Yes q NO

If “Yes” above, give reason: 0 academic failure 0 social immaturity

0 excessive absenteeism

0 other (speci fy)

Has this child been absent from school an unusual number of times or for an unusually long period in the most recent 6 months for which you

have attendance records: OYes DNo 0 Don’t know 0 Not applicable

If “Yes” above, what is the main reason for the absence?

0 Illness of child 0 Illness in family

0 Other (specify)

jJ Unknown 0 Not applicable

If the following special resources were available, check those you would recommend for this child:

a. 0 Special provision for hard of hearing.

b. 0 Special provision for “sight saving”.

c. 0 Speech therapy.

d. IJ Special provision for orthopedically handicapped.

e. •] Special provision for gifted children.

f. 0 Special provision for “slow learners”.

g. 0 Class for mentally retarded.

h. 0 Special provision for emotionally disturbed.

i. 0 Other (specify)

j. 0 None of above.

If you have checked any of the’ above items “a” thru “i”, are the particular resources checked available for this child?

0 Yes (If several checked, specify which available:

0 No 0 Not applicable

If “Yes” above, are those resources being used by the child? OYes NO

If “Yes” in item 9, but “No” in 10, what is the reason?

11. Which one of these statements most accurately describes this child?

0 A. His adjustment is at times a concern. You think of him as a problem or future problem.

0 B. Unusual in his ability to cope with normal situations. At least occasionally have thought of him as “unusually well adjusted.”

0 C. YOU rarely think of him in terms of his behavior. He is not described by .4 or R.

48
12. As you know, the ability to pay attention to a task and to sustain attention (concentrate) changes with age, although children of the same

age differ. Check the item which best describes the child in the classroom situation.

0 A. Pays attention as well as most children his age.

0 B. Characteristically is more attentive than others his age.

0 C. Characteristically is less attentive than others his age.

0 D. No basis for judging which of above fits this child.

13. In the classroom situation which one of these statements most nearly describes this child?

0 A. Almost constantly moving, inappropriately talks out loud, drops things, leaves his seat when he should not, finds reasons to be

“on-the-move”.

0 B. Slightly more restless than most children his age. But usually is not a problem in the classroom.

0 C. Shows azge amount of restlessness if fatigued, bored, etc. Motor activity level is as expected for his age.

0 D. Remains quiet long after the average child has become restless. Sometimes seems too controlled for his age.

0 E. No basis for judging which of above fits this child.

14. Below are a list of statements which may or may not describe this child. If the statement is descriptive of him/her, place a check mark

(d in front of the statement. If it does not describe this child, leave the space blank. (You may check several items).

0 A. Other children frequently accuse him of fighting.

cl B* “Accidentally” trips, shoves or hits other children. Is too “rough” with other children.

0 C. Frequently comes to your attention because he has been injured.

0 D. Aggressive behavior frequently makes disciplinary action necessary.

0 E. Children frequently complain that he uses bad words.

0 F. Parents of other children call to complain about his behavior.

0 G. No method of discipline seems to work with him.

0 H. NO basis for judging about this child in these areas.

0 I. None of above statements describe this child.

15. HOW frequently is any specific disciplinary action required for this child?

0 A. Frequently q B. Occasionally 0 C. Never q D. No basis for judging which of above fits this child.

16. When children “choose sides” is this child usually

0 A. Among the first few to be chosen.

0 B. Neither among the first nor the last ones chosen.

0 C. Almost always among the last ones chosen.

0 D. Relationship to group so changeable you can‘t predict order in which he would likely be chosen.

DE. No basis for judging which of above fits this child.

17. When a leader is chosen by the group, is this child

0 A. Chosen more frequently than the average child.

0 B. Chosen about as often as the majority of the children.

0 C. Almost never chosen.

0 D. No basis for judging which of above fits this child.

18. With respect to intellectual ability, would you judge this child to be:

0 A. About average for his age (neither in the top - about one-fourth, nor the bottom - about one-fourth).

0 B. Clearly above average for his/her age (In about the top fourth).

0 C. Clearly below average for his/her age (In about the bottom fourth).

0 D. No basis for judging this child.

19. With respect to academic performance, would you judge this child to be:

0 A. About average for his/her age (neither in the top - about one-fourth, not the bottom - about one-fourth).

0 B. Clearly above average for his/her age (In about the top fourth).

0 C. Clearly below average for his/her age (In about the bottom fourth).

0 D. No basis for judging this child.

20. How long have you (the person providing the above information) known this child?

0 Less than one month.

0 More than one but less than six months.

0 More than six months but less than one year.

0 More than one year.

21. In what capacity have you known this child?

(-J Teacher in classroom.

0 Teacher in special area (specify)

0 School principal or assistant

0 Other (specify)

22. Name of respondent providing information on this child 4’

------------------------------------

(School)

23. Date completed------------------- 49
APPENDIX IF

CONFIDENTIAL - The National Health Survey is authorized by Public Law 652 o/ the 84th Congress (70 Stat. 489; 42 U. S. C. 242~). All inlomation which

zclould permit identification o/ the individual will be beld strictly confidential, will be used only by persons engaged in and /or the purposes of the survey

and will not be disclosed or released to others for any other purposes (22 FR 1687).

HES - 257

DEPARTMENT OF

HEALTH; EDUCATION, AND WELFARE

Public Heolth Survey

Notional Health Survey

Child’s Medical History - Interviewer

NAME OF CHILD (Last, First, Middle) SEGMENT SERIAL COL. NO.

(6-l 1)

1. Were there any questions on the Health History Questionnaire that you could not answer, or questions where you were not sure what was

wanted?

OYes ON0

(If Yes)

a. Which questions?

b. What was the trouble?

[ Be sure to check over the self-administered questionnaire for completeness and for inadequately answered “open” questions.1

One of the things we want to find out is something about what children of this age eat since that is related to health.

2. Will you please try to remember as well as you can just what-ate yesterday and let me note it down?

3. How was this different from most days, or was it about the same?

4. How many definite meals were there yesterday where the child sat down with others for a period of eating, and which meals were they?

5. Which one of the statements in each of these sets best describes

a. (1) 0 Eats too much (2) OUsually eats enough (3) ODoesn’t eat enough

b. (1) 0 Eats nearly all kinds of food

(2) 0 Eats most kinds of foods, dislikes a few kinds

(3) 0 Somewhat fussy about kinds of food he (she) eats

(4) 0 Very fussy about food; won’t eat many things

c. (1) 0 On most days, eats two or more meals with others in the family

(2) 0 On most days, eats one meal with others in the family

(3) (J On most days, doesn’t eat any of his (her) meals with other members of the family

6. Marriage history (Parents’): (Enter present status from items 12 and 12a on HES-2. Complete only as indicated in instructions.)

Present status:

Wife Husband (if data different)

Year first married?:

Year ended?:

How ended?:

Married again, etc:

7. Age agreement between HES-2 and Child’s Medical History - Parent.

OYes O N0

a. If no, which is correct?

50
8. Twin status as indicated by I-ES-S.

Is this child a twin? 0 Yes 0 No

a. If yes, is the child an identical twin? 0 Yes ON0

9. Does have certain tasks as jobs he (she) is supposed to do regularly just as part of the family?

I 0 Yes q N0

a. If yes, list them (up to 3 tasks).

10. Does he (she) have a pet? OYes Cl No

a. If yes, does he (she) take care of it?

0 Usually 0 Sometimes but not often

0 Not usually but often c) Not at all

I would like to ask a few questions about ‘s friends and playmates.

11. Does he (she) have

0 a. Only a few nb. A good number 0 c. Very many other children who are good friends?

12. Are his (her) friends mostly

ma. Older q b. About the same age as he is? DC. Younger

13. How many of his (her) close friends do you know by sight and by first and last name?

ma. All ub. Most all DC. Quite a number q d. Only a few

14. When it comes to meeting new children and making new friends is

0 a. Somewhat shy 0 b. About average willingness

_ 0 c. Very outgoing - makes friends easily

15. How well would you say he gets along with other children?

Oa. No difficulty; is well liked

ab. As well as most children

UC. Has difficulty with many children

16. Has ever “run away from home”-- that is, disappeared at a time when you thought this is what he (she) might

be doing and stayed away so long that you had to have people start searching or looking for him (her)?

a. If yes, how often has this happened? .

b. If yes, what was the reason?

17. Has anything ever happened that seemed to seriously upset or disturb your child?

q Yes ON0

a. If yes-- Tell me about it.

b. How old was he (she) at the time?

18. With respect to how relaxed or how tense or nervous your child is, would you rate him (her)

a. 0 Rather high strung, tense and nervous.

b. 0 Moderately tense.

c. (J Moderately relaxed.

d. 0 Unusually calm and relaxed.

19. With-respect to your child’s temper or his (her) getting angry, would you rate him (her)

a. m Has a very strong temper, loses it easily.

b. 0 Occasionally shows a fairly strong temper.

c. 0 Gets angry once in a while but does not have a particularly strong temper.

d. 0 Hardly ever gets angry or shows any temper.

20. Aside from regular classes in school, does ~ take any special lessons or classes (e.g., music, dance, athletics)?

0 Yes cm0 0 Don’t know

IF YES: What are they?

21. Does belong to any clubs or group activities such as Cub Scouts, Brownies, etc.‘?

0 Yes 0 No 0 Don’t know

IF YES: What ones?

22. About how much time does your child spend on the usual day away from home when you do not know definitely where he (she) is?

a. 0 None at all

b. 0 Some but less than 2 hours
c. 0 Between 2 and 4 hours

d. 0 More than 4 hours

23. About how much time would you guess your child spends on the usual day doing each of the following:

(Enter number of hours or fraction of hours or zero as appropriate)

a. Watching television?

b. Listening to radio?

c. Reading newspapers, comics, magazines?

d. Reading books (except comic books)?

e. Playing with friends?

f. Playing by himself?

g. Working (doing chores, etc.)?

24. Have you ever had, over a considerable period of time, a good bit of trouble in getting your child to

a. Go to bed when you thought it was bedtime 0 Yes 0 No

b. Get to sleep after he (she) had gone to bed Cl Yes 0 No

c. Take a nap when he (she) was little c] yes 0 No

25. What would you say were ‘s best (strongest) points and worst (weakest) points?

a. Best

b. Worst

INSTRUCTIONS FOR COMPLETING ‘IHE INTERVIEWERS’ QUESTIONNAIRE

CHECKING THE CHILD’S MEDICAL HISTORY - Parent

Ask Question 1 on the Interviewer Questionnaire to ascertain whether or not the respondent had any difficulty with any questions. If therespondent reports any difficulties record the number of the question or questions and the nature of the problem. Explain the questions and obtain and

record the proper answers.

Next check over the entire questionnaire to see that all relevant items are answered. If you find blanks ask the question and record the response. Please record all of your comments and responses in red pencil.

At the same time, review and ask required probes for the open questions. Throughout the self-administered questionnaire you will find several

open questions, such as 5b and d, 8a and b,.9a, etc. The respondents may give inadequate.answers to these open questions and the interviewer will need to review each one carefully. When to probe for more information must be left to the interviewer’s judgment. Remember that

the main purpose of these questions is to provide information to the doctor who will examine the child. The doctor cannot question the mother

because she will not be present during the examination. He cannot question the child because the child will not have the necessary information in most cases. Therefore, the interviewer must be sure that the responses are sufficiently clear and complete to provide the doctor with all

the information he needs. The interviewer will, of course, not understand the medical significance of much of the information. She can, however,

decide when there is enough information to give her a clear picture of the situation. Record responses directly on the self-administered questionnaire.

Examples: Question 2la, mother reports “heart condition”. We would like to have more details about the condition.

Question 26, either a “Don’t Know” or a “Yes” answer calls for some checking. Here, as elsewhere, if “Don’t Know” merely indicates lack of

information, there is nothing to add. Whenever there is a history which the mother thinks may apply, that should be described.

Question 30a, the response is “stomach operation”. Again, a more detailed report is needed.

TO probe for more information use general “non-directive” probes. Non-directive probes are questions which ask for more information but do

not suggest any particular response patterns. Examples of such probes are: “Tell me more about that”, “Can you give me some more information about that”, etc.

One such probe is “I notice you said. . . . . ” “Can you tell me something more about that.3” It should be used to followup all open questions which are not entirely clear. Write the responses in the spaces following the question, or on the back of the page. Verbatim reporting is

important.

Review Question 32, and for questions a through k ask the additional questions below, recording the item number and answers on the reverse

side of that page of the “Child’s Medical History - Parent”.

.

Probes for use with “Yes” answers to Question 32:

a. Was he (she) sick in bed at home?

How long?

b. Was he (she) sick in bed at a hospital? How long? Where?

c. Did he (she) completely recover so that he (she) was no different from the way he (she) was before the illness? If not, describe how he

(she) was different afterwards.

5 2
ASKING ADDITIONAL INTER VIEWER’S QUESTIONS

Next, ask the series of questions about eating habits of the child. Be sure to record the diet consumed on“yesterday” -- the d.ay immediately

preceding your visit -- even if the parent says that was not the usual diet. It is important that we ask about a specific day decided in advance.

Record the items in whatever way the parent can describe them. Thus it might be for a particular child the mother could say, “he had one egg

and toast and a glass of milk in the morning; then he ate whatever the lunch was at school; then he had a peanut butter sandwich and a cake

when he came home. . . .etc.” It is not necessary for you to record the incidental wording of the mother’s statement for this: simply list all

the items named - both what they were and how much was eaten.

Refer to Question 12 on the Census Questionnaire (NHS-HES-2) and note the answer as to “present marital status” and, if relevant, “married

more than once”. Then ask the following questions, first with respect to the respondent and then separately with respect to the spouse if a

spouse is currently a member of the household.

a. In what year were you first married?

If Question 12 was checked “Married” and 12a was answered “No”, then omit the rest of the question. Otherwise, continue:

b. What year did that marriage end?

c. How did that marriage end - death of your husband (wife), divorce, or separation?

If Question 12 was checked “Married” and 12a was “Yes”, then ask:

d. In what year were you next married again?

e. Was that your present marriage?

If e above is answered “Yes” then omit following questions: If e is answered “No” go back to b above and record answers to questions b,

c, d and e for each successive marriage until e is answered “Yes”.

If Question 12 was checked “Widowed”, “Divorced”, or “Separated”, ask questions b and c above. Then ask:

f. Were you married again?

If answer to f is “No” then omit the following questions. If f is answered “Yes” then ask:

g. In what year were you next married again?

Then repeat b, c, f and g until f is answered “No”.

Compare the age recorded on the Census Questionnaire with the age on Page 1 of the Child’s Medical History - Parent. Be sure any disagreement is correctly resolved. Also examine the ages shown for other siblings on HES-2 to determine whether this child may be a twin. If so, get

the parent’s statement as to whether the twins are “identical twins” as distinct from “fraternal twins”

The remainder of the questions are of interest to the physicians and the psychologists in connection with evaluating the stage of.mental and

social development the child has reached and in obtaining information relevant to mental health.

ooo5 3
APPENDIX II

AUDIOMETRY TESTING PROCEDURES

General. -At the beginning of each day, turn on the

audiometer at least 10 minutes before performing the

daily field check on the audiometer.

Leave the audiometer turned on until the completion of testing in a day. Do second field check upon

completion of testing.

Make sure that both doors of the audiometry room

are closed when testing. Another member of the staff

may have to close the outer door after you are in the

room.

Recording.-Use left hand section of form when

sample number is even; and use right hand section of

the form when sample number is odd.

When the sample children shows signs of fatigue,

do not test the last 2 frequencies (8,000 and 3,000);

place X in these boxes and check “behavior,” specify

t ‘fatigue. t t

For any other part of the test that cannot be completed enter X in the appropriate box and indicate the

reason under ‘Conditions Affecting Test Results.”

Instructions to the examinee. -After entering the

beginning time and Technician No., on the control record

the technician’ will proceed with the following steps:

1. Detailed instructions should be given children to

stress the following points:

a.

b,

c.

d.

e.

f.

80

Earphones will be placed by the technician

and must not be touched by the child.

Sounds will be heard in one ear at a time.

Sounds will get progressively fainter.

Child should show when the sound is heard

by raising his right or left hand depending on

the ear in which the sound is heard.

Child should keep his hand up until the sound

is no longer heard,

Child should raise his hand to the sound even

though it sounds very faint.

During the test eyeglasses, earrings, and

chewing gum should be removed.

2. Examples of detailed instructions (particularly

for younger children): “You are going to listen

to some sounds from earphones inside this quiet

room. Sometimes the sounds will be like whistles, sometimes like horns. They might be easy

to hear, or they might sound tiny or soft. If you

hear the sounds in the right ear (point to the

ear), put up your right hand (point to or touch

the child’s right hand). Now, if you hear the

sounds in the left ear (point to left ear), put

up your left hand (point to or touch the child’s

left hand). You will have to listen very carefully

to hear the sounds. lt

Conduct of the Hearin. Test

1. Take the child into the test room and seat him

with his back to the window.

2. Close the test room doors.

3, Repeat the instructions briefly.

4. Make sure that the ears are not obstructedwith

cotton before placing the earphones.

5. Place the earphones on the child making sure

that the earphone opening is over the ear canal

and that the earphone has a good seal against

the child’s ear. Red earphone is placed on the

right ear, grey on the left. Girls should pull

hair back off the ear before earphone is placed.

6. Make sure the audiometer is ready for the test

bY

a.

b.

::

e.

f.

checking that it is set in the following manner:

Power on for at least 10 minutes prior to

start of test.

Interrupter switch in the Off position; output

switch at the word “right.”

Frequency dial set at 4000 cycles.

Intensity dial set at 60 decibels.

30.db switch on the 9nt’ position.

Earphone indicator on the 307db switch box

is turned to the ear being tested first as.

prescribed by the test form; when the examinee number is odd, use the right-hand

column and follow the sequence indicatedthe right ear is first; when the examinee

number is even, use the left-hand column

and follow the sequence indicated there-the

left ear is first,

7. The 4000.cycle tone is introduced to the first

ear to be tested at a level of 60 decibels for

about 3 seconds. This should be well within the

range of audibility for most chkldren and will

serve as listening practice.

54
8.

9. 1

10.

11.

12.

- 13.

14.

When the child responds, set the intensity dial

10 decibels below the previous stimulus intensity

(50 db) and present the tone for about 5 seconds.

The procedure of dropping the level of the tone

in 10 decibel steps with at least one presentation

at each level should be continued until no response is obtained.

Then raise the intensity dial 5 decibels.

If a response is obtained at this level, the intensity is reduced 10 decibels. If there is no

response, raise the intensity 5 decibels. Always

descend 10 decibels and count thenumber of responses at the threshold while ascending in intensity in 5 decibel steps.

The threshold recorded is the lowest dialreading at which 50 percent or more responses are

obtained, that is 2 out of 3 or 3 out of 5 trials.

Below this level less than SO-percent response

is obtained and above this a 100.percent response is approached.

Make the proper two-digit entry on the test

form.

15.

Repeat the procedure presenting the 4000.cycle

tone to the second ear to be tested and then

shift to the next frequency as indicated on the

test form, until the test has been completed for

all frequencies and for both ears.

Remove the earphones and immediately complete the questions pertaining to the reliability

of the test.

16. Apply disinfectant lightly to the headband and

earphones with a wad of cotton while the child

is watching.

17. Escort the child from the test room.

18. Fill in all information asked for on the form.

Procedure Necessary for Threshold Accuracy

1.

2.

3,

4.

5.

6.

7.

8.

9.

10.

11.

Avoid rhythmic presentation of signals to the

child. The child may respond to the rhythm

rather than to the sound. This is especially

true of younger children.

Avoid a long, drawn-out search for a threshold

which tends to lessen the interest and cooperation of the person being tested and to produce

fatigue. If necessary, shift to another frequency

and test, then return to the problem frequency

later. Note at the bottom of the form any change

in the order of the test on the test form.

Avoid giving visual or auditory cues when the

tone is presented; for example, looking at the

person each time a tone is presented, or making

a click with the interrupter switch, or clicking

the intensity dial. ’ Double check the dial reading.

Check whether the switch was on %P position.

Avoid activity which will distract the child.

Check the response of the child occasionally by

leaving the tone off for several seconds and then

presenting the tone to see if the child is responding consistently.

Avoid presentation of the test tone for longer

than 5 second. This may lead to a false response.

Count only the ascending responses in determining the threshold.

Avoid being influenced by the threshold obtained

for the first cycle tone when obtaining the threshold for the second presentation of this tone.

Make sure all forms are complete.

Record the time the test is finished andTechnician

number on the control record. When the test is not done

or incomplete, record reason.

000

55
APPENDIX Ill

ESTIMATION PROCEDURE

An examination finding for a sample child is included in tabulations as a weighted frequency, the

weight being a product of the reciprocal of the probability of selecting the child, an adjustment for nonresponse cases, and a poststratified ratio adjustment

which increases precision by bringing survey results

into closer alignment with known U.S. population figures by color and sex within single years of age 6

through 11.

In the second cycle of the Health Examination Survey the sample of ‘slightly more than 7,400 children was

the result of three stages of selection, the probability

of selecting an individual sample boy or girl being the

product of the probabilities of selection at each stage.

Briefly the three stages of probability selection are of:

1. A single PSU from each stratum of PSU’s.

2. Twenty segments from each sample PSU.

3. Sample children from among eligible children found in the segments.

Since the strata are roughly equal in population

size and a nearly equal number of sample children were

examined in each of the sample PSU’s, the sample design is essentially self-weighting with respect to the

target population, that is, each child 6 to 11 years old

has about the same probability of being drawn into the

sample.

The adjustment for nonresponse is intended to minimize the impact of nonresponse on final estimates by

imputing to nonrespondents the characteristics of “similar lt respondents, relating nonrespondents to respondents by ancillary data known for both. In the second

cycle the usual household nonresponse due to refusals

to be interviewed and “not at homes” was virtually

zero, so the only nonresponse category requiring some

adjustment was the “failure to be examined” nonresponses, which amounted to 4.0 percent of the 7,417

sample children. “Similar lt respondents were judged

to be children in a sample PSU having the same age

(in years) and sex as the children not examined in the

sample PSU, The weights of all respondents in a PSU

having the same age and sex were adjusted upwardto

give representation to the nonrespondents in the PSU

having that age and sex.

The poststratified ratio adjustment used in the

second cycle achieved most of the gains in precision

which would have been attained if the sample had been

drawn from a population stratified by age, color, and

sex and makes the final sample estimates of population

agree exactly with independent controls prepared by

the Bureau of the Census for the U.S. noninstitutional

population as of August 1,1964 (approximate mid-survey

point) by color and sex for each single year of age 6

through 11. The weights of every responding sample

child in each of the 24 age, color, and sex classes is

adjusted upwards or downwards so that the weighted

total within the class equals the independent population

control.

-o-

* U. S. GOVERNMENT PRINTING OFFICE : 1073 51%213/63

56
Series 1.

Series 2.

Series 3.

Series 4.

Series 10.

Series 11.

Series 12.

Series 13.

Series 20.

Series 21.

. Series 22.

,

OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS

Public Health Service Publication No. 1000

Programs and collection procedures.-Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions, data collection methods used, definitions,

and other material necessary for understanding the data.

Data evaluation and methods research. -Studies of new statistical methodology including: experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

techniques, objective evaluations of reliability of collected data, contributions to statistical theory.

Analytical studies.-Reports presenting analytical or interpretive studies based on vital and health

statistics, carrying the analysis further than the expository types of reports in the other series.

Documerrts and committee Veports. -Final reports of major committees concerned with vital and

health statistics, and documents such as recommended model vital registration laws and revised birth

and death certificates.

Data fi-om the health Interview Survey. -Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and other health-related topics, based on data collected

in a continuing national household interview survey.

Data from the Hea;lth ‘Examination Survey.- Data from direct examination, testing, and measurement of national samples of the population provide the basis for two types of reports: (1) estimates

of the medically defined prevalence of specific diseases in the United States and the distributions of

the population with respect to physical, physiolqgical, and psychological characteristics; and (2)

analysis of relationships among the various measurements without *reference to an explicit finite

universe of persons.

Data ficom the InstitutiqnuZ Population Surueys.-Statistics relating to the health characteristics of

persons in institutions, and on medical, nursing, and personal care received, based on national

samples of establishments providing these services and samples of the residents or patients.

Data j?om the Hospital Discharge Survey.-Statistics relating to discharged patients in short-stay

hospitals, based on a sample of patient records in a national sample of hospitals.

Data on mortality.- Various statistics on mortality other than as included in annual or monthly

reports- special analyses by cause of death, age, and other demographic variables, also geographic

and time series analyses.

Data on natality, marriage, anddivorce. -Various statistics on natality, marriage, and divorce other

than as included in annual or monthly reports- special analyses by demographic variables, also

geographic and time series analyses, studies of fertility.

Data ficom the National Natality and Mortality tirveys. -Statistics on characteristics of births and

deaths not available from the vital records, based on sample surveys stemming from these records,

including such topics as mortality by socioeconomic class, medical experience in the last year of

life, characteristics of pregnancy, etc.

For a list of titles of reports published in these series, write to: Office of Information

National Center for Health Statistics

U.S. Public Health Service

Washington, D.C. 20201 J