NATIONAL CENTER Series 1 

For HEALTH STATISTICS I Number 

VITAL and HEALTH STATISTICS 

PROGRAMS AND COLLECTION PROCEDURES 

plan and initial program of the 

Health Examination Survey 

A description of the first-cycle program of the Survey, including the statistical design, the pattern of 

examination, and the field procedures. 

bashington, D.C. July 1965 

U.S. DEPARTMENT OF 

HEALTH, EDUCATION, AND WELFARE 

Anthony d. Celebrezze 

Secretary 

Public Health Service 

Luther L. Terry 

Surgeon Genera B 
NATIONAL CENTER FOR HEALTH STATISTICS 

FORREST E. LINDER, PH. D., Director 

THEODORE D. WOOLSEY, Deputy Director 

0. K. SAGES, PH. D., hsirtant Director 

WALT R. SIMMONS, MA,, Statistical Advisor 

il~~~~ M.WATERHOUSE,M.D., Medical Advisor 

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

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

OFFICE OF HEALTH STATISTICS ANALYSIS 

IWAO 11. MORIYAMA, PH. D., Chief 

DIVISION OF VITAL STATISTICS 

ROBERT D. GROVE, PH. D., Chief 

DIVISION OF HEALTH INTERVIEW STATISTICS 

PHILIP S. LAWRENCE, SC. D., Chief 

DIVISION OF HEALTH RECORDS STATISTICS 

MONROE G. SIRKEN, PH, D., Chiej 

DIVISION OF HEALTH EXAMINATION STATI.STICS 

ARTHUR J. MCDOWELL, Chief 

DIVISION OF DATA PROCESSING 

SIDNEY BINDER, Chiej 

Public Health Service Publication No. 1000Aeries l-No. 4 
PREFACE 

A description of the Health Examination Survey plan and the “first-cycle” program is presented in this report. The Health Examination 

Survey is a part of the program of the U. S, National Health Survey. The first cycle consists of 

the administration of a specialized health examination to a probability sample of the adult, 

civilian, noninstitutional population of the United 

States. This will be succeeded by other cycles 

dealing with different age groups of the population 

or different types of examination, but all making 

use of the same general procedure-direct examination of national probability samples of 

persons. 

The impetus for and direction of the Health 

Examination Survey’s first-cycle plans and operations was initially in the hands of Dr. Oswald IS. 

Sagen, who has since been succeeded by Mr. 

Arthur J. McDowell as Chief, Health Examination 

Survey Branch. The examination phase of the plan 

was worked out by Dr. Alice M. Waterhouse, 

Medical Advisor to the U. S. National Health 

Survey, Dr. James E. Kelly, Dental Advisor, 

and Dr. Lawrence E. Van Kirk, of the Division 

of J->ental Publie Health and Resources, Public 

Health Service. Mr. Walt R. Simmons, Statistical 

Advisor, was responsible for the sample design. 

Many other aspects of the plan and the field 

procedures were developed, tested, and carried 

out by Dr. Ruth E. Dunham, Assistant Medical 

Advisor, Mr. Marshall C. Evans, Chief Health 

Survey Representative, and Mr. Elijah White, 

Survey Statistician. 

In the planning and operation of the first 

cycle, valuable assistance was received from 

many individuals and groups within the Public 

Health Service and elsewhere. In particular, however, mention should be made of the staff of the 

Bureau of the Census who participated in building 

the survey design and have since been carrying 

out several important parts of the Survey on behalf of the National Health Survey, as will be detailed later. Special acknowledgment also is 

made of the contributions to the Survey from 

Dr. Joseph J. Bunim, Clinical Director of the 

National Institute of Arthritis and Metabolic 

Diseases, National Institutes of Health, and members of his staff; Dr. R. C. Arnold, Former 

Chief, and Dr. Arthur Rikli, Chief, of the Heart 

Disease Control Branch, Division of Chronic 

Diseases, Bureau of State Services; Dr. Gerald 

R. Cooper, Chief, Standardization Laboratory of 

the Heart Disease Control Branch, and his staff; 

Mr. Ad Harris, Director, Venereal Disease Research Laboratory, Communicable Disease Center, and his staff; Dr. Thomas R. Dawber, Director, Framingham Heart Project, National 

Heart Institute, National Institutes of Health, 

and his staff; and Dr. Aram Glorig, Director of 

Research, Subcommittee on Conservation of 

Hearing, American Academy of Ophthalmology 

and Otolaryngology. 

A large share of the staff nursing services 

in the field operation of the Survey was provided on a reimbursable arrangement with the 

Division of Hospitals and with the Medical Officer in Charge and the Director of Nurses of 

the San Francisco Hospital of the Public Health 

Service. Through their co-operation, staff nurses 

were detailed on a rotating basis, thus providing 

a source of nursing personnel for the Survey, 

and a unique experience for the nurses who 

participated. 

Space does not permit acknowledgment, either 

individually or by organizational affiliation, of 

all of the many persons who have given advice 

and assistance in the work of the Survey. Mention 

must be made, however, of the outstanding contribution of one group whose excellent performance was a sine qua non of success, namely, the 

field staff of the Health Examination Survey. 

This report was prepared by the following 

members of the National Health Survey staff: 

Mr. Walt R. Simmons, Dr. Ruth E. Dunham, 

Mr. Tavia Gordon, Dr. James E. Kelly, Mr. 

Nicholas E. Manos, Mr. Marshall C. Evans, Dr. 

Alice M. Waterhouse, Mr. Theodore D. Woolsey, 

and Mr. Arthur J. McDowell. Mr. McDowell also 

served as editor. 

. . . 

111 
CONTENTS 

Page 

Preface ---------II---LL---------------“-----------”-----------“---~- 

Introduction -ILIIIII--III--I--I-----------------------------------“-- 

The Role of the Health Examination Survey in the National Health SurveyGeneral Plan of First-Cycle Examinations --I---LII-----I--I------------ 

Concepts and Purposes -----------I-I--c-LI-------------------------- 

Logistic Considerations------------------ ---L----------III--C------- 

Meth~ological Studies in Planning------------------------------------ 

Advance Arrangements in Each Area -----L-I---L-III-II---------------- 

Professional Relations ---l-----------I--c--------------------------- 

General Publicity l-Ll1l-----l-1-1l-L-------------------------------- 

Other Advance Arrangements -----------1-1-------------------------- 

Selecting and Contacting the Sample Persons QIIILIIIIIIIIIII--l--------- 

Identifying the Sample Persons ------LII--CIIIIII--------------------- 

The Household Interview -----II-------LIILII------------------------ 

The Appointment Procedure 1----------1--1---1---------------------- 

The Examination and Examining Process ---LIIILIIIII------------------ 8 

Pattern of the Examination ----1------111--1------------------------- 8 

Measures to Insure Standardized Examinations------------------------ 10 

Post-Examination Procedures at the Examination Center----------------- 

The Data Collected C-I----~~----ILl--~l-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 

The Medical History Data --1------1--------11-----------~------------ 

Medical Data Related to Special Interest Conditions-------------------- 

Additional Data From the Examination -----------1---11--1------------ 

Other Data Collected in the HES Operations -l--l--l--------l--L------- 

Quality Control ----------------11------------------------------------ 

Study of Characteristics Associated With Nonresponsc------------------ 

Measures to Insure Uniformity and Reproducibility of Data-------------- 

Special Calibration Studies I---III---L-I---l-l----------------------- 

Statistical Design and Estimation ----l----l----l---11------------------ 15 

Introductory Note --------L-I--l-------------~---------------~-~----- 15 

The Design Problem II--IILI-------I---------------~----------~----~ 15 

Summary of the Sample Design ----c-II-------I-------~--~--~--------- 16 

Estimation Technique --111----------e------------------------------- 18 

Reliability and Evaluation of Results --1--------l----L----------------- 19 

Plans for Analysis and Publication of Data --IL--I------l--l--l---------- 

. . * 

111 

1 

1 

II 

11 

11 

11 

12 

12 

13 

13 

14 

14 

20 
CONTENTS-Continued 

Appendix I. Areas in the Health Examination Survey’s Sample---------- 

Appendix II. Routes Followed by Mobile Health Examination Centers 

in Moving From One Location to Another----------------- 

Appendix III. A. Floor Plan- Mobile Examination Center-Caravan I----- 24 

B. Floor Plan-Mobile Examination Center-Caravan II---- 25 

Appendix IV. Example of L,eaflet Distributed in Advance of Interviewer’s 

Visit ------~-uuIu~LIIIIu~uu~uu~uu~uuu~uuuuu~~~~u~uuuu~u 

Appendix V. Household Interview Questionnaire of the Health Examination Survey ~Iu~~uu~~u~~~~uu~~~~~~uu~~~~~~u~~~~u~~~~u 

Appendix VI. Leaflet Given Examinee When Appointment is Made-------- 

Appendix VII. Selected Medical History Questions---------------------- 

Appendix VIII,, Notes on Statistical Design --------u-1u--u-1u---------u-- 40 

Outline of Design Development u~~~~1~~u~u1u1u1~~1~~u~u~uu 40 

D&fit-Jon of Universe--------- I-~~~uu~u~uu~~~~~~~~~~u~~ 41 

On Basic Estimation Technique- ~~uu~~uu~u~~~l~lul~~u~~uu 41 

Within pS(J Sampling Variations ~lu~~~~u~uuuu~~ul~~u~~u~u 41 

me Master Cont-rol C~du-u~u~-uu I~uu~u~uu~u~~u~~~~~~uu 42 

Illustration of Selection of a Stand------------------------ 42 ; 

Page 

22 

23 

26 

28 

34 

35 

, 
PLAN AND INITIAL PROGRAM OF THE 

HEALTH EXAMINATION SURVEY 

INTRODUCTION 

The Role of the Health Examination 

Survey in the National Health Surve:y 

The National Health Survey Act (P. L. 652, 

84th Congress), the legislative authorization for 

the U. S. National Health Survey (NW), states 

that “it is . . . the purposeof this Act to provide 

(1) for a continuing survey and special studies to 

secure on a non-compulsory basis accurate and 

current statistical information on the amount, distribution, and effects of illness and disability in 

the United States and the services received for or 

because of such conditions; and (2) for studying 

methods ‘and survey techniques for securing such 

statistical information, with a view toward their 

continuing improvement.” 

In fulfilling the purposes of the Act the U. S. 

National Health Survey is attempting to meet the 

need for a wide variety of morbidity and related 

data for use in many types of public and private 

endeavors. Even before the passage of the Act it 

was recognized that these needs could not all be 

met by a single method or from a single source. 

The report of the Subcommittee on NationalMorbidity Survey, of the U. S. National Committee on 

VitaI and Health Statistics, published in October 

1953, recommended: ‘I. . . that a series of ‘special studies be undertaken in addition to the continuing national [household] survey. The principal 

purposes of these studies would be as foll0ws: 

(a) To obtain data on undiagnosed and nonmanifest disease, by means of laboratory 

screening, detection, and physical examinations of subsamples drawn from the 

general surveys. 

(b) To provide other types of auxiliary data, 

and to study methodological problems relating to the measurement of morbidity.” 

Thus, from the outset it was an accepted 

principle that the program of the National Health 

Survey would consist of, not one, but several surveys designed to meet diverse statistical needs. 

Further thou@t on this problem and the actual 

day-to-day experience of supplying statistics on 

morbidity and related data, since the program was 

established, have led to the conclusion that it is 

necessary to produce statistics of at least three 

entirely different types collected from three different sources. 

The three sources are: first, the people 

themselves, by means of direct interviews; second, clinical tests, measurements, and physical 

examinations, by means of direct application of 

such techniques to samples of persons; and, third, 

the places where people receive medical care, 

particularly hospitals and doctors’ offices, by 

means of sampling records of patient care in such 

establishments. 

It is clear that each of these sources provides information which “cannot be obtained as 

well or at all from the others. The interview is 

the best source for comprehensive statistics on 

disability, including work and school absenteeism, 

bed-days, and morbidity; the incidence of acute 

illness and injury of a minor nature, particularly 

untreated conditions of this kind; the circumstances of accidental injury; volume of use of 

medical and dental care; and similar types of 

health statistics. Furthermore, the family interview affords an especially useful and versatile 

source of demographic, social, and economic information regarding the population to which the 

health characteristics are to be related. 

The direct examinations coupled with clinical 

tests and measurements are the only source of 

diagnostic data regarding unrecognized and untreated diseases, and are by far the best source 

when standardized clinical, physical, and physiological data are desired. In general, it can be said 

that whenever the requirements of the statistics 

call for uniform appraisals by physicians or dentists, or the performance in a standardized manner of a test or measurement, the direct examination of a sample is necessary. 

Finally, if what one needs is quantitative information about treatment and the details of services provided in medical, dental, or nursing care, 

the logical place to look is in records created by 
hospitals and other establishments, or persons, 

providing the care. These records may have been 

prepared for other uses, or they may have to be 

created for the purposes of the statistics. 

The National Health Survey will be making 

use of all three of these basic sources as a part 

of its continuing program. Already, the Health Interview Survey (HIS) has produced a number of 

reports on the subjects covered in the family interviews. A description of this survey, whichwas 

set underway in July 1957, has been published:? 2 

The Health Records Survey, which will utilize data from the third source described above, is still 

in the planning and pretesting phase. 

The Health Examination Survey (HES), following three field pretests, began the examination of 

a sample of the civilian, noninstitutional, adult 

population of the United States in November 1959. 

At the time of this writing more than half of the 

first sample, or “cycle, ‘I has been examined. However, the rate at which persons in the sample 

were being examined did not reach the planned 

full-scale level until the spring of 1961. Completion of field work on this cycle is expected in the 

last part of 1962. Statistical processing of data is 

underway, but final analysis will not begin until 

all the data are collected. The tempo of field work, 

analysis, and publication is slower in the Health 

Examination Survey than in the Health Interview 

Survey. 

This report depicts the sampling plan, examination, and other field procedures as they were 

being carried out in the latter part of 1961. There 

were minor differences in plan when the examination for the first cycle began on a small scale 

in November 1959. No further changes of anyconsequence are contemplated before the first cycle 

comes to an end late in 1962. 

GENERAL PLAN OF FIRST-CYCLE EXA,MINATIONS 

Concepts and Purposeis 

The over-all plan of the Health Examination 

Survey is to identify separately specific segments 

of its broad goal and to concentrate onthese segments through separate cycles of examinations. 

Thus, the broad primary purposes are: (1) toprovide statistics on the medically defined prevalence in the total U. S. population of a variety of 

specific diseases, using standardized diagnostic 

criteria; and (2) to secure distributions of the 

general population with respect to certain physical and physiological measurements. The segment 

selected for study in the first cycle of examination, however, is limited to the adult population, 

defined as those persons between the ages of 18 

and 79, inclusive. Moreover, this first cycle 

focuses attention particularly upon certain cardiovascular diseases, arthritis and rheumatism, and 

diabetes. This, of course, in no way implies lack 

of, or less, interest in other .groups in the population or in other diseases. Successive cycles in 

the program will study other segments. 

A key characteristic of the plan of theHealth 

Examination Survey is to make actual physical 

1 U. S. National Health Survey. The Statistical Design of the 

Heuhh Household-interview Survey. Health Statistics. Series. A-2, 

PHS Publication No. 384-AZ. Public Health Service, Washington 

DC., July 1938. 

2 U. S. National Health Survey. Concepts and Definitions in the 

Health Household-Interview Survey. Health Statistics. Series A-3, 

PHS Publication No. 584-A3. Public Health Service, Washington, 

D.C., September 1958. 

examinations of, and tests upon, the individuals 

selected in the sample. Such examinations and 

tests can yield morbidity information unobtainable 

through the other mechanisms of the National 

Health Survey. They can provide information not 

only about diagnosed conditions which persons fail 

to report or are incapable of reporting in a survey based upon individual interviews, but they can 

also reveal previously undiagnosed, unattended, 

and nonmanifest chronic .diseases. In addition to 

serving this primary purpose, the first-cycle examinations are intended to obtain baseline data 

on certain physical and physiological measurements, such as blood pressure, serum cholesterol, 

auditory and visual acuity, skinfolds, various 

heights, weight, and electrocardiographic tracings. Data such as these on a defined population 

have been either nonexistent or inadequate. They 

are needed to understand departures from normal, 

as well as to carry out certain specific programs 

dependent upon human engineering information,, 

Another key characteristic of the Health 

Examination Survey, one which is shared with 

other NHS programs, is the use of a nationwide 

probability sample of the population in order to 

obtain the desired statistics in an efficient way, 

and in such a manner that the statisticalreliability of results is determinable. A description of 

the sample design and the sampling method is 

given elsewhere in this report. Here it need be 

described only in terms of the general concepts.. 

The basic decision to limit the first-cycle 

examinations to the adult population was followed 

by decisions on certain additional limitations. 

Persons on active duty with the Armed Forces 

2 
were not to be included, nor were persons in 

Alaska or Hawaii. Likewise excluded were persons resident in institutions (penitentiaries, hospitals for long-term treatment of chronic disease, 

etc.). The size of the sample to be selected was 

keyed to the numbers necessary to yield reliable 

data on the conditions studied. Actually, of course, 

the determinations of the size of sample and of 

the conditions to be studied were interrelatedand 

interdependent, and a factor in these determinations was the number of examinations which could 

be accomplished within three years. The sample 

size is also a function of the available budget and 

of the structure of the examining process and of 

the statistical design. The selection process provided that the sample be stratified with respect to 

broad geographic region and size of placeof residence (rural areas, small cities, etc.). The method 

is generally like that used for the Health Interview 

Survey, and, in fact, the sample is drawn by the 

Bureau of the Census from among the Primary 

Sampling Units (PSU’s) used for this Survey. 

The national sample selected for the first 

cycle of examinations is a probability sample 

representative of the adult, civilian, noninstitutional population. It includes approximately 7,500 

individuals, a number which should result in about x 

6,300 examinations of sample persons after allowance is made for persons who will not be 

examined. These individuals are located in 42 

different areas, with each area consisting of a 

county or a small group of contiguous counties. 

These 42 areas in which the examining is done 

are located in 29 different states. They aregrouped into three subsamples of 14 areas, each representative of the total population. 

The plan of the first cycle calls for special, 

single-visit examinations of each individual selected in the sample. It also provides that data 

like those collected in the Health Interview Survey 

be obtained for the households which include each 

of the sample persons. These .interviews are conducted prior to the special examination and, in 

fact, the interview process is used as the means 

for the last stage of selection of the sample of 

persons included in the Health Examination Survey; This process is described in more detail 

later in this report. 

Logistic Considerations 

The logistic problems involved in conducting 

the examinations are considerable. It is necessary 

to carry out special medical examinations in a 

standardized manner, involving tests and procedures requiring special equipment, and to do 

this on thousands of persons located from one end 

of the United States to the other. *About 150 of these 

examinations are accomplished in each of the 42 

different areas (or “stands” as they have been 

designated) throughout the country. The examining 

is done in a Mobile Health Examination Center 

which is moved into the area for a period of 

about three weeks. The Health Examination Survey has two such Centers in operation simultaneously. The routes followed in making the moves 

are shown in Appendix II. One consists of three 

specially built tractor-drawn trailers, one of 

which contains the X-ray and laboratory facilities. The other, containing the same facilities, 

consists of two somewhat larger specially designed tractor-trailers. The floor plans of each 

of these mobile centers are shown in Appendix III. 

A Mobile Health Examination Center is 

manned by a staff consisting of two physicians, 

one dentist, two nurses, two X-ray-laboratory 

technicians, and two receptionist-interviewers. 

The above staff constitutes what is referred to as 

a full team. For the two Centers there areonly 

one and one-half full teams. This is made possible by a carefully planned Teap-frog” pattern of 

scheduling. It involves grouping the staff into 

three “half teams,” each consisting of oneof each 

of the above kinds of personnel, except that one of 

the half teams has no dentist,. One of these two 

Health Examination Centers, say Caravan I, will 

operate on a full-examination schedule with a full 

team (two of the three half teams, but only one 

dentist) for roughly the first half of the threeweek period it is at a particular stand. Meanwhile, 

at another stand, the other Health Examination 

Center, Caravan II, is in the last half of its 

examining period and is operating on a reduced 

schedule with only a half team. Then, one half 

team from Caravan I will move to a new stand to 

join there the half team with Caravan11 which has 

now completed operations at its previous stand, 

and together they will conduct .full-schedule operations at the new stand. The pattern is then repeated. The above description is, of course, oversimplified; for example, it does not consider such 

factors as travel time between stands. It will, 

however; -suggest the kind of carefully scheduled 

pattern which has made it possible to operate 

effectively Gith a limited staff. 

The field staff which accomplishes the Health 

Examination Survey is a team composed of three - 

elements. One of these is the examining staff 

which has already been described. A second element is the Bureau of the Census interviewer 

group, while the third is the HES field administrative staff. The Census interviewer group includes 

from four to seven individual interviewers and a 

supervisor. The personnel vary from stand to 

stand. They are selected from among the experienced Census interviewers used on the Healtb Interview Survey, and receive additional training 

for the special problems of the Health Examina3 
tion Survey. Their task is to complete the last 

stage of the sample selection process, to conduct 

the household interview, and to invi,te the selected 

sample persons to arrange an appointment for 

examination. The logistics of the survey make it 

desirable that the interviewing be conducted within the space of a few days immediately prior to 

the period scheduled for the examinations. 

The third component of the field. team, the 

HES field administrative staff, consists of an 

Administrative Officer in Charge, an Administrative Assistant, and from two to five Health Examination Representatives. The scheduling of the administrative staff represents a “leap-frogging” 

arrangement similar to that described for the 

examining staff, In the first part of the period 

of the Survey in a particular location, more 

Health Examination Representatives are needed; 

then some move on to join others at another location, while part stay until the examining in the 

area is completed. These Health Examination Representatives complete any unfinished portion of 

the Census interviewers’ work and-most important -assist in producing the maximal examination response by rescheduling broken appointments and making additional efforts to explain 

the Survey to, and obtain the co-operation of, 

those persons who have .not initially accepted an 

appointment. The Administrative Officer in 

Charge carries out extremely varied and complex duties, such as completing all of the arrangements for the trailer site, contracting for the 

utilities, supervising the work of the administrative staff, and acting as administrative officer for 

the entire field staff. 

Methodological Studies in Planning . 

Prior to undertaking the first cycle of examinations, it was recognized that certain methodological studies needed to be made to provide the 

basis for planning the survey. Moreover, the survey plan needed to be pretested and modified on 

the basis of actual experience, and the plan, finally designed, tried out in pilot studies. Four 

such methodological studies were carried out 

and appropriate interviewing techniques for use 

in this first cycle of examinations.3 A second 

study was aimed at the development of a singlevisit cardiovascular examination: The other two 

studies were concerned with the problems of response, co-operation, and attitudes toward cooper ation in examination surveys. 5 9 6 

On the basis of the findings of the methodological studies and general knowledge of the problems involved, tentative plans for the first cycle 

were developed and pretested in Washington, D.C., 

in June 1958. The results of this pretest were 

carefully studied and some’ modifications of the 

survey plans were made on the basis of this experience. Pilot studies of the revised survey plan 

for the first-cycle examinations were made in 

1959 in Ft. Wayne, Indiana,’ and Cresco, Iowa, 

after which the final survey plan was formulated. 

Actual operations in examining sample persons 

selected for the first cycle of the Health Examination Survey were begun shortly thereafter. 

ADVANCE ARRANGEMENTS ‘IN EACH AREA 

Professional Relations 

The first step toward conducting the Survey 

in any given sample area consists of fully informing the health professions at the state level 

and in the particular locality selected. Typically, 

this takes the form of a series of meetings with 

representatives of the State Health Department, 

Medical Society, Osteopathic Society, and Dental 

Society, and with counterpart local organizations. 

At these meetings a complete description of the 

objectives and method of operation is given, The 

individual private practitioners in the sample 

area are also informed of the Survey by means of 

an article in their own state or countyprofessional society publication or by individual mailings, 

according to the advice of the professional- societies. 

In addition to a detailed description of the 

content of the special examination, operating policies of the survey are presented at these professional meetings. Several of these policies have 

proved to be important factors in eliciting thecooperation of the’ professional organizations as 

3 U. S. National Health Survey. A Study of Special Purpose Medical-History Techniques. Health Statistics. Series D-l. PHS Publication No. 584-Dl. Public Health Service, Washington, D. C., 

January 1960. 

4 U. S. National Health Survey. Evaluation of a Single-Visit 

CardiovascuZar Examination. Health Statistics. Series D-7. PHS 

Publication No. 584-D7. Public Health Service, Washington, D.C., 

November 1961. 

5 U. S. National Health Survey. Co-operation in Health Ewmination Surveys. Health Statistics, Series D-2. PHS Publicatk 

584-D2. Pub1 ic Health Service, Washington, D.C., June 1960. 

No. 

6. U. S. National Health Survey. Attitudes Toward Co-operatron zz 

a _cleaZth Examination Survey. Health Statistics. Series D-6. PHZ 

Publication No. 584-D6. Public Health Service, Washington, D. C. 

July 1961. 

4 
well as that of the sample persons. The policies 

include: (1) confidentiality, guaranteed to all par - 

ticipants in the Survey; names or other information which would identify individual participants 

cannot be revealed; (2) information is not given to 

examinees on any findings of their examinations; 

(3) each examinee is encouraged to sign an authorization to have a report of the findings of his 

examination sent to the physician and dentist 

whom he names; (4) these reports are objective 

rather than interpretative (e.g., simultaneous 

duplicate electrocardiograms are obtained, and 

one complete tracing, rather than an interpretation, is sent to the private physician); and (5) the 

private physician is notified by telephone in the 

event of any *finding which the examining physician 

believes is “urgent.” 

local newspapers. However, a release is provided to the newspapers, timed to appear just before the visits to the households begin. Besides 

serving the usual purpose of providing general 

information, the resultant articles provide clippings from a local source for the Survey staff to 

use in contacts with the sample persons. 

The persons who are in the neighborhoods of 

the population segments from which the sample 

persons will be chosen also receive advancepublicity in the form of a leaflet announcing the fact 

of the Survey and giving some general information 

about it. Such a leaflet, specific to the particular 

stand area, is distributed, either by mail or by 

direct-to-door distribution, a few days before the 

start of the Survey in each of the neighborhoods 

selected for household interviews. An example of 

these leaflets is shown in Appendix IV, 

General Publicity 

Other Advance Arrangements 

In addition to this publicity directed toward 

members of th .e health professions, moderate 

amounts of general publicity are obtained through 

the news media in each area. Because volunteers 

cannot be accepted for examination, and because 

a relatively small number of sample persons are 

involved, no attempt is made to obtain large 

amounts of space or long series of articlesin the 

Prior to operations at each of the stand 

areas, letters are sent to various authorities in 

the area (e,g., the Chief of the Police Department) 

to inform them about the pending activities. A 

member of the HES staff also makes advance arrangements for space for trailers, utilities, other 

office space, and other administrative matters. 

SEL’ECTING AND CONTACT’ING THE SAMPLE PERSO’NS 

Identif>i’ing The Sample Persons 

The operation which identifies specific sample persons might be regarded as the first step in 

the process of data collection. As noted above, 

this operation is one in which selectedhouseholds 

are visited and the interviews are conducted and 

this process is used as the means of the last 

stage of selection of the sample persons. 

The entire sampling process is described in 

more detail later in this report. At the time the 

first element of the HES field team moves into a 

particular location, this process has produced a 

list of households in particular subsegments of 

the PSU, which is the area for that stand or location. The list which the HES field team takes 

into the location will include about four households for each of the subsegments. It is the address, the house, or other dwelling unit‘ in which 

each of these households lives, that is the starting 

point of the Survey. The households currentlyresiding at each of these addresses are the “sample 

households’ to be interviewed and out of which the 

sample persons are to be selected. 

The sample households are visited by specially trained Census Bureau interviewers who 

conduct an interview to determine who lives in 

the households and to gather information on the 

personal characteristics, health status, and attitudes toward health surveys of these persons. 

Everyone living in the sample household at the 

time of the interview is eligible to be a sample 

person if he meets the criteria of the Survey(l& 

79 years of age, not an active member in any military service, etc.). Of those eligible, every other 

one is designated as a sample person. 

The Household Interview 

The household interviewing begins about nine 

days before the date of the first examination. The 

Census interviewer knocks on the door, introduces herself, and asks for the headof the household. If the head of the household is not present, 

she will conduct the first portion of thehousehold 

interview with any responsible adult member of 

the household. The questionnaire used is shownin 

Appendix V. It contains four kinds of questions: 
(1) household, (2) personal, (3) health, and (4) 

attitudes. 

The interviewer will have entered information 

for some of the household questions beforehand. 

After necessary additional questions about the 

household as a whole have been asked, the interviewer asks questions about the individuals whose 

names appear on the second page of the form. 

After she has asked questions l-7 and written 

down the name, relationship, age, and other personal information for each member of the household, she pauses to check those who are eligible, 

and, in addition, to circle every alternate eligible, 

thus indicating that they are sample persons. She 

then asks questions 8- 17 ,which are related to the 

health of members of the household. Each adult 

person who is at home is interviewed for himself. 

Any responsible adult, however, can answer these 

questions for children and for other adults who are 

not at home, provided they are related. Unrelated 

household members who are not at home must be 

interviewed for themselves on return visits by 

the interviewer. The general interview ends with 

questions 18-21 which cover some additional personal information, and question 22 on the total 

family income. 

If there are no sample persons in the household, the interview is terminated. The remaining 

questions, 23-34, are asked only of sample persons and each sample person must be interviewed 

for himself. Questions 23-33 concern his attitudes and background knowledge about health and 

health surveys. One purpose of this series of 

questions is to create the necessary rapport for 

a favorable response to question 34, the invitation 

to come to the Health Examination Center for an 

examination. Another important purpose is to obtain some insight into the attitudes of those who 

at first refuse the offer of an examination. This 

may be of use in the follow-up efforts to persuade 

. iJim to accept. 

The questions on health, attitudes, etc., are 

all asked before the person is informed thathe is 

a sample person; this order is followed to avoid 

bias in the answers. 

The household interviews are conducted in 

the same manner as those in the regular Health 

Interview Survey of the National Health Survey. 

The basic core questions from the questionnaire 

of the regular Health Interview Survey have been 

incorporated in the questionnaire for the Health 

Examination Survey with the wording unchanged. 

The HES questionnaire (Appendix V) differs in 

that questions on attitudes have been added, and 

questions on special subjects such as X-rays, 

medical insurance, etc., have been deleted. 

Since the Census interviewers who administer 

the household questionnaire are selected from 

those who are working on the regular Health Interview Survey, they have already had intensive 

training and experience in maintaining standard 

procedures and in asking the questions uniformly. 

Those selected are interviewers expected tohave 

the aptitude for handling the complicated procedures of this survey and for establishing rapport 

while inviting the sample person to come in for 

an examination. At each stand, the first effort is 

to borrow qualified interviewers from the Census 

Regional Office in which the stand is located, in 

order to minimize travel costs. It is often necessary, however, to bring others from nearby 

regional offices Q Good interviewers may be kept 

on for more than one stand so that there is some 

continuity in the interviewing staff. However, because of the constant turnover in a large portion 

of the staff, special efforts are taken to achieve 

homogeneity by training. One full day is devoted 

to training on the day before interviewing begins. 

The purpose of this training is not only to familiarize these experienced interviewers with the details of this particular survey, but also to establish and maintain standardized procedures. After 

the interviewers have completed one day of interviewing they meet for a half day of discussion of 

the problems encountered, in order to standardize 

the way in which the problems are to be met. The 

Census operation in all stands is supervisedcentrally from the Washington office of the Census 

Bureau and there is a Census supervisor at each 

stand who co-ordinates the work with the Washington office. This supervisor is one of a small 

group of three or four persons that the Census 

Bureau has designated as eligible to be a field 

supervisor for this operation. Thus, the supervisor at a stand is usually a person who has had 

considerable experience in this work. In those 

stands where the supervisor is new, a Census 

representative is sent from the Washington office 

to teach him the procedures. 

The Appointment Procedure 

If the sample person accepts the offer to 

make an appointment for a survey examination, 

the Census interviewer telephones the Health 

Examination Center and confirms arrangements 

for a time that is convenient to the sample person. She then fills out an appointment slip and 

leaves it with the sample person. This slipshows 

the date and time of the appointment and the address of the Health Examination Center. A duplicate copy of this appointment slip is mailed to 

the sample person, as a reminder, two days before the date of his appointment. Duplicate copies 

of the appointment slips are also used for record-keeping purposes at the Health Examination 

Center. At the time the appointment is made, the 

6 
sample person is also given a leaflet containing 

L some general information on what the examination is like (see Appendix VI). 

In order to provide maximum convenience 

for the sample persons, many of whom are employed, the Health Examination Center is open on 

Saturdays, and, on some days, in the evenings. 

There are about 14 examining days at a stand out 

of which the sample person usually can select a 

convenient time. An attempt is made, however, 

to schedule appointments during the early part of 

the two-week period, insofar as possible. This is 

done so there will be more time in which broken 

appointments can be rescheduled, The examining 

hours are from 9 a.m. to 5p.m. on some days and 

from 1 p.m. to 9 p.m. on others. During the interviewing operation there is someone available 

at the Center from 9 a.m. to 9 p,m, to receive 

the calls from the interviewers and to keep a central record of appointment times filled and the 

ones still available. For each appointment that is 

phoned in, two kinds of records are made. The 

name and address of the sample person, the date 

and time of the appointment, and the name of the 

interviewer, all are entered in an “Appointment 

Log, q falong with a notation concerning the mode 

of transportation the sample person has chosen to 

use. (Frequently, transportation by taxi is provided by the Survey, although in some instances 

the individual chooses to provide his own transportation.) The second entry is in the ‘Schedule 

of Appointment” where the fact that this particular appointment time has been filled by the specific sample person is recorded. 

If the sample person is not at home at the 

time of the household interview the interviewer 

makes return visits in an attempt to interview 

him. Since the Census interviewing work is limited to a period of about five days; there may be 

some sample households and some sample persons for whom the interviewing is still incomplete at the end of this phase of operations. The 

Census supervisor refers uncompleted work to 

the HES Administrative Officer in Charge so that 

the Health Examination Representatives may 

make further follow-up visits. In instances where 

the sample person does not accept the CensusInterviewer’s offer to arrange an appointment, the 

interviewer makes no effort to persuade the sample person. It is recognized that many of the persons who show initial reluctance can nevertheless 

be examined, but the process of resolving their 

doubts and misapprehensions may require considerable time and skillful handling and this follow-up effort is made by the Health Examinatidn 

Representatives. 

me Health Examination Representatives per - 

form three .principal functions. The first is to continue and complete the unfinished portions of the 

work of the Census interviewers. The second and 

most important is to contact the persons who have 

been interviewed but have not agreed to come for 

an examination. The third function is to visit and 

reschedule for examination those persons who 

made but did not keep their appointments. It is expected that at the average stand between two 

thirds and three fourths of the sample persons 

will accept the initial offer of an appointment. The 

majority of the remaining sample persons will 

agree to be examined after one or more visits by 

the Health Examination Representative. Perhaps 

15 percent of all those who make an appointment 

will fail to keep it, sometimes telephoning to cancel the appointment and sometimes simply not 

appearing; more than bne half of these persons 

can be rescheduled (perhaps several times) and 

finally examined. Thus the work performed by 

the Health Examination Representatives greatly 

lessens the possibility that the findings of the 

examination will be markedly biased by nonresponse. 

It was recognized, a priori, that the proportion of persons willing to be examined andthe extent to which appointments would be brokenvould 

vary considerably from one stand to another. 

There is, however, a compelling reason for wanting to know what the response characteristics are 

at a specific stand at the time operations at that 

stand are in an early stage. This reason is that 

the number of PSU subsegments assigned at a 

particular stand is variable, depending in part 

upon the number of eligible households and eligible sample persons per subsegment, and in part 

upon the proportion of the selected sample persons which will be examined. It is desired to obtain approximately 150 examinations at each location. This will be accomplished at a stand at 

which 90 percent of the sample persons are 

examined if the total number of sample persons 

is only 165, but if the response rate falls to, say, 

75 percent, this number of examinations requires 

that there be about 200 sample persons. The subsegments within the PSU’s have been randomly 

ordered and as many as are required can be included in the sample, but each one which is added 

must be completed. Thus the critical determination desired is the number of subsegments which 

will yield approximately the required number of 

examinations without overtaxing the capabilities 

of the Health Examination Center and the examining staff, and without spreading too thinly the 

efforts of the Health Examination Representatives. 

The more sample persons there are to bevisited, 

the less time per person is available for the repeated visits often necessary to obtain a high response rate. The day-by-day reports of early 

stand operations are watched very carefully and 

projections, based on the experience at the stand 
considered along with all the previous experi- additional subsegments (beyond the initial sureence, are made in order to determine how many to-be-needed ones) are to be assigned. 

THE EXAMINATION A.ND EXAMINING PROCESS 

Pattern of the Examinati,on 

The special examination was developed during the presurvey period of planning, consultation, 

methodologic studies, and pilot studies. It is not 

intended to be a complete physical examination, 

but is tailored to the objectives and the limitations of the Survey. These include: (1) interest in 

chronic conditions and in certain physical and 

physiological measurements; (2) examination procedures which can be performed in a standardized 

way and which can produce medically significant 

information from a single-visit examination; (3) 

exclusion of procedures to detect conditions which 

occur too rarely to provide reliable prevalence 

data from a sample of the’given size (about 6,000); 

(4) exclusion of certain procedures which are not 

acceptable to some of the public (e.g., genital 

examination), and which might therefore decrease 

participation in the Survey; and (5) limitation to 

an average of two hours for the entire examination of each individual. 

The procedures included and the approximate 

time required for each group of procedures are 

shown in table 1 in the sequence usually followed 

in this examination. The basis for grouping is that 

all of the procedures in a group are performed at 

one examination station, or location within the 

Mobile Health Examination Center. 

The following is a brief description of each 

procedure of the examination. 

Identification data .-The information collected is minimal, limited to verifying name and 

address, and adding sex and date of birth. Other 

identifying information has been recorded in connection with the household interview, 

Table 1. Approximate time required forexamination,by procedure group 

Specific procedure, or part of examination 

Obtain identification data 

Obtain authorization for M.D.-D.D.S. reports 

Take glucose drink 

Medical history- self administered and supplemental-------------- 

X-rays, chest, hands, and feet 

Height and weight 

Audiometry 11--1~---1~--~--1--1-----------~-------------~-------- 

Body measurements -------------I-~-~----------------~---~-------- 

Physician’s review of history 

Physician's examination 

Venipuncture 

Electrocardiogram 

Collect urine specimen ----1-~---------1-----------"------------- 

Dental examination 

Vision examination ------------1-1-1--------------------------*-- 

Exit interview -1----------11---1-"----"---~~------*--~---------- 

Total examination ---~-~-I-~"------------------------------ 

1 

Group 

number 

I 

II 

III 

IV 

V 

VI 

Time in 

minutes 

25 

15 

10 

40 

15 

5 

1201 

‘Includes an additional 10 minutes allowed for dressing and undressing. and for movements between examination statlons. 

8 
Authorization to send findings to personal 

physician and dentist.-Each examinee is encouraged to sign such an authorization. Names 

and addresses of physicians and dentists named 

by the examinees are verified by means of directories and local contacts. 

Glucose drink. -The first medical question 

asked is about a history of diabetes. All examinees except known diabetics under regular care 

(as determined by the examining physician) are 

given a modified glucose tolerance test-50 grams 

of glucose solution diluted to 150 cc. are administered orally. Since the examinations occur without control of previous intake of food, this glucose 

administration occurs at various times after eating. Time elapsed since the most recent meal, 

and broad categorization of content of that meal 

and of any subsequent “snack,” are recorded, 

however. A venous blood specimen is obtained 

one hour later, and a urine specimen from 1% to 

2 hours after the glucose challenge. 

History.- This is in two parts: severalquestions asked by the receptionist-interviewer, and a 

larger number of items included in a self-administered history. The examinee is shown how 

to indicate his answers by checkmarks, The history is not a complete one, since it is tailored to 

the special examination. When necessary, the receptionist-interviewer reads the questions to the 

examinee; she does not provide help in the way of 

defining terms, etc. Provision is made for the 

examinee to indicate ‘Donrt Know” or qf?q’ when 

this is appropriate. Questions so marked will be 

explored with the examinee later by the physician 

during his examination. The receptionist-interviewer reviews the completed history for completeness only, and asks and records theanswers 

to any overlooked questions. 

Examinee undresses . -Since the examination 

is not a general one and does not include abdominal or internal examinations, the examinee undresses (in the examining room) only down to the 

waist, and wears a short patient gown and paper 

slippers for the rest of the procedures. At this 

point the nurse describes to the examinee the 

content of the several parts of the examination to 

follow. 

X-rays of chest, hands, and feet.*-A 14 x 17 

P-A film of the chest is taken at a 6.foot distance; 

*Pregnant examinees are not x-rayed. The recommendations of 

the American College of Radiology for the control of radiation hazards have been followed in the X-ray equipment and procedures, . 

The X-ray unit has a short ,exposure time and the primaqbi:;mi;s 

confined to the x-rayed area. The aluminum filter has 

creased to a thickness of 3 mm. Lead rubber shielding protects the 

gonadal area of the examinee during the chest X-ray. Shielding is 

also used in the X-rays of the hands and feet. periodically, radia- . 

tion surveys of the equipment are done to guard against excess 

stray radiation. 

a film of both hands and one of both feet are 

made. A bone s tandard is x-rayed with each of 

these latter two films, for comparison of bone 

density with the standard. The three X-ray films 

for each examinee are developed immediately, 

while he moves on to other parts of the examination. At a later time, a copy of the chest film is 

made and sent with other findings to the examinee * s physician. 

Heie;ht.- This is automatically recorded. A 

camexich produces a finished print in 10 seconds records the height and the identifying number of the examinee, for later reading under office 

conditions. The height of the examinee is measured without shoes, 

Weight.- An automatic-balancing. automaticprint*le is used to print the weight directly 

on the examinee’s record. The weight is taken 

with the examinee partially dressed and without 

shoes. 

Audiometry .-A pure-tone audiometer is 

used to measure air conduction hearing thresholds at, five frequencies in each ear. The examinee is seated in a soundproof booth during the procedure. 

and 

Body measurements. -In addition to height 

weight, 16 other body measurements are 

made. In the standing position these include 

girths of the right upper arm, chest and waist, 

and skinfolds of the right upper arm andthe right 

infrascapular area. A series of anthropometric 

measurements are also taken-(standing) biacromial diameter; (seated, in a veryprecise position), sitting height normal, sitting height erect, 

knee height, popliteal height, thigh clearance 

height, buttock-knee length, buttock-popliteal 

length, seat breadth, elbow-to-elbow breadth, and 

elbow-rest height. 

Physician’s review of history.-The physician goes over the completed history before he 

sees the examinee, then reviews significant 

answers with him to get additional data and, if 

necessary, clarification. 

Phvsician’s examination - As is true for all 

other parts of the examination, standardized 

techniques are used for the physical examination. 

The examination is concentrated on cardiovascular disease and the arthritides. The cardiovascular examination includes: (1) three blood pressure determinations spaced over about 30 minutes; 

all are performed on the same arm, with the 

examinee in a sitting position; the arm is supported at atria1 level’, and the sphygmomanometer 

is supported at eye level for accurate reading by 

the ’ physician; the systolic and both diastolic 

readings are recorded in intervals of two millimeters of mercury; (2) funduscopic examination; 

(3) palpation of peripheral arteries for sclerosity, 

tortuousity, and quality of pulsation; and (4) pal9 
pation and auscultation of the cardiac area in a 

very thorough, detailed, and standardized way. 

The arthritis examination progresses joint by 

joint, and includes inspection, palpation, percus- 

, sion, active and passive motion to detect tenderness, swelling, deformity, limitation of motion, 

pain on motion, and other manifestations of arthritis and periarthritic diseases. Other portions 

of the physical examination are an otoscopicprocedure and palpation of the thyroid gland. Addi- I tional abnormalities noticed during the examination are also recorded. 

Venipuncture. - The time of theglucosedrink 

has been recorded and a timer set when the examinee enters the examining room, so that the examination can be interrupted for the one-hour venous 

blood specimen for glucose determination. At the 

same time, blood specimens are obtained for determination of serum cholesterol, serum bentonite flocculation test for rheumatoid factor, serologic tests for syphilis, and microhematocrit. 

Electrocardiogram.-A 1%lead electrocardiogram is obtained. A dual-writing instrument 

is used, which provides two simultaneous tracings of each lead. One tracing is used for survey 

purposes, and the other is sent to the examinee’s 

physician as part of the objective report of the 

findings of the examination, 

Examinee dresses-urine specimen.-At this 

point, the patient dresses and a urine specimen 

is taken. Later, the presence of sugar is determined by the Testape method, and, in malesonly, 

the presence of albumin, using the Bumintest 

method. 

Dental examination. - The dental examination 

consists of determining the condition of each 

tooth, and of assessing through the use of indexes, 

periodontal disease, oral hygiene, and malocclusion. To determine the condition of the individual 

teeth on a uniform basis, objective criteria have 

been established and are followed throughout the 

entire examination procedure. 

The indexes that are included in the examination are objective assessments of the oral 

hygiene status and of the severity of malocclusion 

and periodontal disease in individuals. The oral 

hygiene assessment is based upon the amount of 

debris and calculus on selected teeth. The assessments of malocclusion and periodontal disease 

are based, respectively, upon the number ofmalaligned teeth and their degree of malalignment, 

and upon the presence and extent of gingival inflammation and pocket formation. 

The presence or absence of fluorosis and 

nonfluoride opacities of the maxillary anterior 

teeth is also recorded. A portable dental chair 

and a standard source of light areusedduring the 

mouth mirror and explorer examination of the 

teeth and gums. 

Vision examination. -Visual acuity is measured with the Sightscreener. Both monocular and 

binocular acuity are obtained, for far and near 

distances. The examination is made ‘without 

glasses, and appropriate parts are then repeated 

if the examinee wears glasses and has them with 

him. 

fre 

Exit interview. -The exam .inee is offered reshments before leaving the Examination Center, and is asked a few questions about his reactions to the examination, and his reasons for 

and any problems about coming for the examination. Throughout the examination, stress is put 

on cordial handling of examinees. Many favorable 

comments are received from the examinees on 

this point. It is another part of the essential effort 

to build and to keep good will and co-operative 

relationships in the Survey areas. 

Measures to Insure 

Standardized Examinations 

All the examining team members are Public 

Health Service staff, with the exception of the 

examining physicians, who are recruited on a 

temporary basis. They are residents or fellows 

in internal medicine in medical teaching centers 

throughout the United States. Usually they have 

just had at least two full years of residency, or 

have completed such a residency within the past 

few years. The usual arrangement with a medical teaching center allows the residents to work 

with the Survey during their vacations, which 

might cover all or parts of one, two, or three 

stands. Thus, there is a constant turnover of 

examining physicians; e.g., 18 consecutive stands 

in one calendar year had 27 different physicians. 

All new examining. staff members are trained in 

the particular techniques developed for the Survey. 

Since relatively few examining dentists are 

used in the Health Examination Survey-only 5 

in the first 18 stands-the reduction of examiner 

differences is an unusually important consideration. Before joining the examining staff, each 

dentist is trained intensively in the various procedures of the examination. A final part of his 

training, the independent examination of at least 

150 persons by the new examiner and by an 

original examiner, provides a means both of 

attaining greater uniformity in the examination 

procedures and of measuring persisting interexaminer differences. 

Except for this specialized. training of the 

dentists, most of the training of new staff members is provided by ,medical staff from headquarters and is given at the Mobile Health Examination Center. Any experienced personnel in the 

same category are included in the training, in 

10 
order to provide refresher training; however, to 

avoid drifts in technique, examining staff members do not train each other. Typically, for 

example, for the new examining physician, this 

consists of one day of training and practice in 

examination techniques, in recording, and in review and probing of the medical history. The following day the entire team participates in Wryrun*’ examinations, for the practice of all team 

members and for testing equipment. These are 

actual examinations but are scheduled with more 

than the usual 30.minute interval, and the examinees are not sample persons. The *dry-runt* 

examinees may be members of local health department staffs who are often asked to assist the 

Survey in this way. The headquarters medicaladvisor observes and supervises the dry-run examinations and the first few days of sample-person 

examinations at a stand. 

In the training and retraining of all examining 

staff members, stress is repeatedly put on (1) 

collection of high quality data in a uniform, 

standard, and prescribed way, and (2) accurate, 

complete, and legible recording. Each staff member who records data reviews that section of the 

basic document immediately for omissions; in 

addition, at the completion of an examination the 

entire individual record is reviewed for omissions 

and for legibility. 

POST-EXAMINATION PROCEDURES 

AT THE EXAMINATION CENTER 

Blood specimen. - The venous blood samples 

are refrigerated in the Examination Center overnight, On the following day, the hematocrit is determined by the micromethod. Two capillary tubes 

are filled at the time of venipuncture in case of 

breakage of one tube. The clotted specimen is 

centrifuged and the serum separated. The portion 

for serum cholesterol is frozen; those for serum 

bentonite flocculation and for the serologic tests 

for syphilis (STS) are kept refrigerated, as is the 

THE DATA 

Ths Medical History Data 

As noted in the previous section, the. m&ical examination is initiated by a brief history 

(HES-203) obtained by the receptionist-interviewer. The first questions asked concern diabetes. 

After this the examinee is handed a questionnaire (HES-204) to complete. This questionnaire 

is the chief means for obtaining the medical 

history. It contains 74 questions which are, in 

general, completed by checking the appropriate 

entry. The chief areas of the questionnaire are 

the following: 

1. Cardiovascular disease-23 questions 

(see Appendix VII, A) 

2. Arthritis and rheumatism-7 questions 

(see Appendix VII, B) 

3. Diabetes-4 questions (see Appendix VII, 

C) 

4. Mental health-9 questions 

5. Vision and hearing-6 questions 

6. Miscellaneous diseases and conditions25 questions 

The questions in this last group are scattered 

fluoridated specimen for glucose. Twice a week 

these specimens are airmailed to centrallaboratories for determinations; the serum cholesterol 

with dry ice, the serum bentonite flocculation and 

the glucose with water ice. 

Urine specimen.- The determinations for 

presence of sugar (Testape method) and for the 

presence of albumin in males (Bumintestmethod) 

are made in the Examination Center shortly after 

the specimen is obtained. 

COLLECTED 

through the history; a large proportion are designed to parallel the information on chronic 

diseases and conditions obtained for the same 

person by the household interview. 

If a tryesrr or tl?lf is checked by the examinee for any of the key questions on cardiovascular disease or arthritis and rheumatism, 

the examining physician probes the answer, 

first using a standard probe question and then 

querying as he judges appropriate. He then 

modifies the record accordingly. He also completes any history questions which have been 

missed, resolves inconsistent entries, and tries 

to convert any entries of “?ll to a definite 

tryesrt or “no” by additional questioning, Other- 

‘wise, the examinee’s undiscussed entry constitutes the source of historical information. 

Medicma Data Related to 

Special Interest Conditions 

The medical examination focuses on two 

main areas of chronic disease-the cardiovasI1 
cular diseases and arthritis and rheumatism, 

The cardiovascular diseases that are the chief 

objectives of this examination are the heart 

diseases, hypertension, peripheral vascular disease, and cerebrovascular disease. Rheumatoid 

arthritis and osteoarthritis are the chief diagnostic categories on which the arthritis andrheumatism examination concentrates. In addition, tests 

are made to detect cases of diabetes, 

For the heart diseases the chief sources of 

diagnostic information are the history, the physical examination of the heart, the chest X-ray 

(for heart enlargement), and the electrocardiogram. The three blood pressures taken during 

the physical examination will serve as the primary basis for diagnosing hypertention, supplemented by the history and the findings of 

the funduscopic examination. Peripheral vascular 

disease will be diagnosed chiefly by an examination of the peripheral arteries, but the history will provide a supplementary basis for 

diagnosis. The history will constitute the chief 

basis for diagnosing cerebravascular disease, 

but it will be supplemented by whatever findings are noted on the physical examination; 

this part of the physical examination, however, 

is not standardized. 

For rheumatoid arthritis, information obtained by the history is supplemented by the 

findings from the inspection and examination 

of the joints, the X-rays of the hands and feet, 

and the bentonite flocculation test of the serum. 

The X-rays of the hands and feet provide the 

primary information on the presence of osteoarthritis, but this is supplemented by the physical examination and history. 

As already noted, a blood specimen is obtained from most examinees, one hour after 

glucose challenge. This is measured for blood 

glucose concentration, and this measurement 

is supplemented by a test for urine sugar. 

These findings, together with the information 

obtained from the history, provide an index of 

the prevalence of diabetes in the population. 

Additional Data From the Examination 

The dental examination will yield considerable detailed information not heretofore available on a representative sample of the total adult 

population. This examination has already been 

described. The data it yields will include, in 

a,ddition to a determination of the condition of 

each individual tooth, an assessment of periodontal disease, the oral hygiene status, an indication of the severity of malocclusion if present, 

and the presence or absence of fluorosis and 

nonfluoride opacities, 

In addition to the medical and dental examinations, some supplementary determinations are 

made during the course of the examination. These 

will make possible a scaling of the population 

by acuity of hearing and of vision, and distributions of some basic anthropometric measurements. There will be interest in relating some 

of these characteristics-in particular, height, 

weight, and skinfold thickness-to various medical findings, but a description of these population characteristics will be of interest by itself. 

The foregoing account of the examination has 

already indicated the specific measurements 

which are made. 

Other Data Collected 

in the HES Operations 

Certain demographic data are available from 

the interview questionnaire. Each household is 

designated as **rural** or *‘other’* before the 

interview, on the basis of the area in which 

it is located. During the interview, data are 

gathered on whether the house is on a farm 

and, if so, the size of the farm. For each person, there are data on age, sex, race, marital 

status, family composition and income, schooling, 

and military experience. In addition, there are 

data on whether the person is working and if so, 

the occupation and industry in which he is engaged. 

Certain health data are also available from 

the interview questionnaire. For each acute or 

chronic condition elicited by the exploratory 

questions 8-17, a line entry is made in Table I 

of the questionnaire. For each such condition, 

there are data on the number of days of restricted 

activity, number of days of bed disability, and 

number of days of work loss during the preceding two weeks. For each chronic condition, 

additional data are gathered on the number of 

bed-disability days over the past year, and the 

limitation of activity due to the condition. For 

each condition listed, the person is askedwhether 

it was medically attended and, if so, the diagnosis 

given by the physician. For each hospitalization 

during the past year that is elicited by question 

15, a line entry is made in Table II. For each 

such entry, there are data on the duration of the 

hospitalization, the date of entry to the hospital, 

and the name of the hospital. The person is also 

asked about the diagnosis which was made for 

the condition. If any operations were performed, 

he is asked the names of them. 

The health data described above are similar 

to those collected in the Health Interview Survey. 

Thus, some comparisons may be made, and determining the extent to which the HES interview 

data reproduce certain findings of the larger 

I2 
study may aid in evaluating the effectiveness 

with which the representative probability sample 

design has been carried out in the Health Examination Survey. These data will also aid in the 

analysis of some of the parts of the sample, 

as for example, the nonrespondents. Perhaps the 

principal utilization of the HES interview data, 

however, will be in conjunction with corresponding 

HIS data to improve the process of estimating from 

the HES examination data. This possibility is 

discussed in more detail in the section, *‘On 

Basic Estimation Technique, * ’ in Appendix VIII. 

are gathered on the sample person’s opinion about 

The attitude questions on the interviewquestionnaire are asked only of those persons who 

have been selected to be in the sample. Data 

the state of his own health and about the importance of regular checkups. There are data on 

whether the sample person has a physician and 

how often he consults him. Then there are data 

on the person’s attitude toward health surveys 

and the need for co-operation in such surveys. 

The interview questionnaire provides data 

the date of the appointment. All of these data 

on whether the sample person made an appointment with no persuasion. Auxiliary records are 

related to response are analyzed for two difkept to show the appointment record of the 

sample person. These records provide data on 

ferent purposes: 

the number of appointments made, the number 

kept, and the number which resulted in canto guide the conduct of the 

cellations or which the sample person did not 

keep,, There are data on the number of contacts 

survey in subsequent operations by providing 

made with the sample person for the purpose 

more insight into the response problem, and 

of persuasion. Special effort is made to gather 

data on the circumstances of the first appointto aid in evaluation of the impact of nonresponse 

ment, such as: day of week, time of day, and 

date of the appointment, and the number of days 

on sample data. 

between the date the appointment was made and 

QUALITY CONTROL 

The Health Examination Survey is unusual, 

if not unique, not only in the group studied 

(a probability sample of the entire U. S. population) but also in the amount of effort devoted to problems of standardization of observations, validation of the measurement processes, 

and other aspects of quality control. Because 

this effort extends to all phases of the operation, 

it has been partially described in many parts 

of this report. The attention given to the sampling problem is discussed later in considerable 

detail. The response problem has received, 

deservedly, much attention. But even if the 

sample were perfectly representative of the 

total population and if every one of the sample 

persons could be examined, there would remain, of course, many problems in the area of 

standardization of the data collected and validation of the measurement processes used. 

Study of Characteristics 

Associated With Nonresponse 

It has been pointed out that methodological 

studies were conducted to help design the survey to maximize response and that the field 

staff of the Health Examination Survey is constantly concerned with this same effort. It is 

recognized, however, that in this Survey as in 

any such voluntary survey, there will be some 

persons who fell into the sample but were not 

included in the data collected, that is, in this 

case, were not examined. It was expected on the 

basis of previous survey experience and from 

the findings of the methodological studies that 

response would vary with the size of the place 

of residence, with better response in rural 

areas and small towns, and poorer response in 

large urban centers. Experiences also indicated 

that response would probably be better in the 

western and central parts of the United States 

and poorer in the eastern portion. Differences 

of this kind can be allowed for, quantitatively, in 

the estimating procedures, but no procedure will 

remove all risk from nonresponse. If the notexamined persons differ from the comparable 

examined persons with respect to any characteristic covered by the examination, the usual 

estimating procedures will lead to a biased estimate for that characteristic. In addition to 

attempting to minimize the size of the nonresponse group, therefore, it is necessary to 

be able to make some evaluation of the extent 

to which it differs, qualitatively, from the examined group. 

. 

Some information on this can be obtained 

from the household interview data referred to 

above, Comparisons will be made of the interview (household questionnaire) data collected in 

the course of the Health Examination Survey 

for the examined part of the sample and for 

the not-examined part, since questionnaire information is available on nearly all of the sample persons. These comparisons will be made 

with respect to the demographic data included 

(age, sex, etc.) and with respect to the health 

data (recent history of illnesses, etc.). For 

all of the examined sample persons and for 

13 
the great majority of the not-examined, the 

data produced by the attitudinal questions can 

also be compared. These include such items 

as the individual’s evaluation of his own health 

and his statements as to regularity of visits 

to a physician. (This last category of information is not available on as high a proportion 

of not-examined persons as the other questionnaire information.) From the comparisons of the 

interview data it may be possible to reach some 

conclusions about differences between examined 

and not-examined persons. 

Even more relevant information concerning 

possibly biasing differences is obtained by means 

of a special study of the not-examined group. At 

the conclusion of the household interview, a medical authorization is usually obtained Which names 

the individual’s physician and permits him to 

release information from the particular patient’s 

medical records for use in the Health Examination 

Survey. Thus, for most of the not-examined persons, some information that is directly related to 

their health can be sought from the physicians. 

This is done for all not-examined persons for 

whom a medical authorization could be obtained. 

In the remaining instances the not-examined person is asked to forward the request for this 

information to his physician. In addition, for 

comparison, inquiries are sent to the physicians 

of a matched sample of examined persons. 

Measures to Insure Uniformity 

and Reproducibility of Data 

While the microhematocrit test for packed 

cell volume of the blood and the tests on the 

urine are performed in the Mobile Health Examination Centers, the other laboratory tests 

are performed for the Health Examination Survey at central laboratories. The serological 

tests for syphilis are performed by the Venereal Disease Research Laboratory, Communicable Disease Center, Public Health Service. 

Each specimen is tested by the VDRL, Mazzini, 

and Kolmer methods. The serum cholesterol 

determinations are made at the Standardization 

Laboratory of the Heart Disease Control Branch, 

Division of Chronic Disease, Bureau of State 

Service: Public Health Service. A ferric chloride 

method is used. The laboratory of the Arthritis 

and Rheumatism Branch, National Institute of 

Arthritis and Metabolic Diseases, Public Health 

Service, determines the serum bentonite flocculation. Blood glucose is determined by the 

Somogyi-Nelson method at the Diabetes Research 

Unit, of the Diabetes and Arthritis Branch, 

Division of Chronic Disease, Bureau of State 

Services, Public Health Service. Periodically, 

aliquots of the blood specimens taken from 

examinees are sent to an independent laboratory 

for a parellel measurement of serum cholesterol 

or blood glucose. Thus, in the case of these tests, 

the procedure and the interpretation is carried 

out in a standard, highly controlled manner. 

There are a great many quality control 

steps taken in the course of the examining oper ation in addition to such measures as retraining of examining staff referred to in the 

description of the examining process. Thus, 

for example, the audiometers are checked and 

recalibrated regularly, the scales are checked 

at each stand, the anthropometry measurements 

are made by one person and recorded by another 

who is also familiar with the technique, and the 

X-rays are reviewed before the examinee leaves 

the Center. The fact that consultants have been 

brought in periodically to observe specific aspects of the examination (e.g., audiometric measurements) might be mentioned as another example of the efforts to insure that the recorded 

data will be of high quality. 

The X-rays and electrocardiograms taken 

in connection with the Health Examination Survey are read and interpreted centrally by panels 

of expert consultants according to established 

classifications and defined criteria. In the case 

of the chest X-ray films, each member of a 

panel of three specialists independently reads 

each film for pulmonary and cardiovascular 

pathology, The electrocardiograms are each read 

independently by three readers; any disagreements are resolved in conference with a consulting cardiologist. A panel of three specialists 

in arthritis read the hands and feet X-ray 

films on each examinee, each reading independently, and then again review and resolve in conference any disagreements among the three results, Through these safeguards it is hoped to 

obtain an unusually high degree of standardized 

precision in the results of these examinations. 

Despite the fact that many measures are 

taken throughout the Survey to insure that the 

findings are arrived at in a standardized and 

correct manner, it may be assumed that some 

amount of variability in the findings will be due, 

not to real differences in the subjects examined, 

but to differences in the examining physicians. 

Despite the safeguards to prevent or minimize 

the physician’s contribution to variability in the 

data, some will inevitably remain. The specific 

examining physician is identified in the record 

and the analysis of the collected data will include consideration of this variable. 

Specia’l Calibration Studies 

The tests for visual acuity are made by 

using a Sightscreener machine which eliminates 

14 
the need for the usual 20.foot distance between 

the examinee and the letters read. In order to 

be able to interpret the results of these tests 

in a standard manner, a special methodological 

study was arranged. This study, made with the 

Pennsylvania State College of Optometry, calibrates the results obtained by this kind of a 

test in terms of the results one would get with 

Snellen-type charts. The equipment used for 

audiometric testing is calibrated and checked 

regularly after each stand; the soundproofed 

booth in each of the mobile examination units 

has been tested by means of a special sound 

survey. The modified test for glucose tolerance 

is the subject of a special calibration study 

being conducted by the School of Public Health 

of the University of Michigan,, 

STATISTICAL DESIGN AND ESTIMATION 

Introductory Note 2. 

The statistical design of the Health Examination Survey is almost classic in the sense 

that it is a blend of substantive purposes, explicit specifications, budgetary resources, logistical considerations, formal mathematical models, and organized speculation concerning population parameters and unit operating costs. 

Any comprehensive account of the design process 

would be much too extensive for inclusion in 

this report. The present chapter exhibits an 

outline and most of the key features of the 

design. Other chapters of the report discuss 

more fully several of the factors that had a 

significant influence on the design. Appendix 

VIII offers additional detail on a group of technical aspects of sampling and estimation. 

3. Y 0” 

4. 

5. 

The Design Problem 

A rational survey design rarely if ever 

springs full-blown into existence at some instant 

in time. Yet if the undertaking is to be efficient 

in any useful sense, it must be planned in considerable detail prior to inauguration of operational stages. A project is likely to be successful to the degree that initial planning and design 

can take account of relevant factors and circumstances. There is no simple formula by 

which this accounting can be done, particularly 

for an undertaking as complex as the Health 

Examination Survey. From the statistician’s point 

of view, the Health Examination Survey is an 

especially attractive problem because of the 

variety of conditions or specifications that encompass the subject. Leaving aside the broadest 

of administrative considerations, the leading 

characteristics or general specifications for 

the Health Examination Survey were these: 

6. 

7. 

1. The coverage should be the entire adult, 

civilian, noninstitutional population of the 

United States. 

The primary products should be of two 

kinds: 

(1) distributions of the population by 

specified characteristics such as height, 

weight, and blood pressure; and (2) estimates of prevalence in the population 

of selected chronic conditions, particularly those in the arthritic and cardiovascular groups. 

The measurement processes mainly 

should be those obtained from a limited 

very highly standardized clinical examination., 

The first cycle should be completed in 

approximately two to three years, although the Health Examination Survey 

is a continuing activity. 

Results should be interpreted as being 

national averages for the two- to threeyear period, rather than as showing trend ----- 

over time, or differentials among geographic, economic, or sociological sub- , 

groups of the population. Yet it was 

apparent that analysis and understanding 

of collected data would be possible only 

in terms of age and sex of persons, and 

probably only when persons examined 

were classified by other sociodemographic factors. 

Despite extensive efforts to standardize 

the examination process, it might be expected that substantial measurement variation would remain in collected data., 

For some of the measures there might 

be biases when compared with other 

measurement criteria. 

While total budget was not rigidly specified, the general dimension of available 

resources was fixed. From the design 

point of view, an important fact was that the 

unit cost for examining an individual person was certain to be relatively great as 

compared with the cost of obtaining a single 

measurement in most social surveys. 
8. All evidence pointed to a variety of 

difficulties in securing the co-operation 

of a representative sample of persons, 

and accordingly indicated the heavily 

weighted desirability of a design which 

provided data for a maximum number 

of persons chosen in the sample, or at 

least did not inhibit response. 

9, Maximum target tolerances for sampling 

variability were set for several key statistics, 

10. The Health Examination Survey definitely 

was not to be considered a technique for 

evaluating the Health Interview Survey 

of the National Health Survey. But there 

were compelling reasons for so planning 

the Health Examination Survey that some 

of its measurements could be relatable 

to those of the Health Interview Survey, 

since such a course might lead to better 

estimates or to better-understood estir 

mates in either or both of the surveys, 

11. The above requirements made it essential 

that the Health Examination Survey be 

conducted under a probability sampling 

design, in contrast to some possible 

alternative of a more subjective or volunteer selection of examinees. Perhaps 

the unique contribution of the Health 

Examination Survey would be that it would 

present findings that were carefully standardized measurements for a probability 

sample of the national, civilian, noninstitutional adult population. 

12. An added specification-or planning decision perhaps- was that the design have 

flexibility. This was the label given a requirement that the over-all sample be 

divided into three subsamples in such a 

way that any one of the three was a 

representative sample of the defined population for the United States. There were 

several reasons for this requirement. 

One was that one subsample-to be examined early in the cycle-should be used 

experimentally to discover methods of 

maximum effectiveness in processing data 

and preparing estimates. A second reason 

was that this first third might produce 

highly preliminary estimates for a few 

characteristics common in the population. 

Such an outcome would be desirable since 

data from the entire cycle would not be 

available until perhaps five to six years 

after the project was initiated. A third 

reason was the possibility in a multiyear 

project that expected appropriations might 

not become available, or that costs might 

;,.:duly exceed expectation. The three-part 

design would make it possible to salvage 

something from the undertaking if it had 

to be curtailed at the point of one third or 

two thirds of completion. 

13. Study of examining requirements and ’ 

available facilities for examination led 

to another major logistic decision which 

initially had not been a design specification. This added condition was that the 

examinations would have to be conducted 

in mobile trailer caravans, and that funds 

available for capital expenditure, along 

with associated availability of professional 

personnel, gave considerable weight to the 

use of precisely two caravans. 

No effort is made here to show exactly how 

each of these specifications made its impact 

on the design. But each was taken into consideration. The reader will be able to see most 

of them reflected in the final statistical pattern. The pattern became a highly stratified 

multistage probability design with clustered 

groups of examinees, randomized in several 

dimensions. Considerable effort was devoted to 

optimization of design in the sense that maximum 

reliability of estimates would be secured within 

budgetary limitations. In the basic design every 

eligible person in the defined population had an 

equal chance for inclusion in the sample. Relatively minor modifications of this self-weighting 

feature were introduced to handle particular 

situations in the population, but in all situations 

adjustments were made so that the probability 

of inclusion of every sample person was known 

over the entire population. 

Summary of The Sample Design 

Building blocks. -The design is most easily 

understood when described in terms of a set 

of defined building blocks which are associated 

with the different stages of sample selection. 

The first of these is the Primary Sampling Unit. 

For use in the Health Interview Survey, the geographical territory of the mainland United States 

had been divided Each area is 

a county or a sma contiguous counties. 

With minor modifications, these areas became the 

PSU*s of the Health Examination Survey. The 

PSU was divided geographically into segments, 

each containing an expected six households. 

From a listing of households within the segment, 

a random sampling procedure created a subsegment of approximately four households, each 

of which was interviewed. Every alternate person in the sample households who was an eligible 

adult (civilian, in the age range 18-79, etc.) became a sample person for inclusion in the HES 

panel. Thus the successive building blocks are 

16 
person, household, subsegment, segment, and 

PSU, and the sampling process was applieci in 

successive stages to these blocks in reverse 

order to that just listed, 

Stratification.- For use in the Health Interview Survey, the 1,900 PSU’s had first been 

classified into 372 strata, and later into 500 

strata. Details of this stratification have been 

published in reference 1. For the Health Examination Survey, these J-72* strata were grouped 

further into 42 new strata. The latter stratification ernph~~i~~~~g~~~~~~hic location and population density of the PSU% in the stratum. 

As nearly as was feasible, each stratum contained 3,5 million persons in 1950 (1960 Census 

data were not available when the sample was 

designed. This was unfortunate, but was treated 

in a manner which produced no bias in the 

results). The boundaries of these strata had 

been chosen so that the strata were approximately equal sized, and so that there were 

approximately equal numbers of strata in each 

of five population-density classes, in each of 

n three geographic classes, and roughly in each 

of the 15 superstrata obtained from the crossclassification of density and geography. The 

stratification pattern is shown in table 2. 

Selection of PSU’s. -Appendix VIII outlines 

the route by which it was determined that there 

should be 42 PSU’s in the Health Examination 

Survey. That decision, and the associated one 

that in order to take maximum advantage of the 

stratification there should be as many strata 

as PSU’s, determined the number of strata. 

The 3 by 5 matrix of strata shown in table 2 had 

its origin in the flexibility requirement of the 

specifications. Within each of the three geographic categories, for the total sample, and with 

the strata quotas by population density, a sample 

of 14 PSU’s was drawn by a modified GoodmanKish controlled-selection technique, in such a way 

as to maximize spread among the States, and 

still to draw each PSU with probability proportionate to its 1950 population. After the 

42.area total sample had been drawn, it was 

divided randomly into three rounds, using the 

3 by 5 matrix. This latter step was accomplished 

effectively by exhausting the matrix through 

three replications of a pseudo-Latin-square selection of PSU’s. To close approximation, each 

subsample, or round consisted of one third of 

each of the occupied 14 superstrata in the 

matrix. Each round is a probability sample of 

the population. The sample PSU’s for each 

round are shown in table 3. The name given 

to each PSU is that of a principal town or 

city within the PSU. 

Selection of sample persons. -Appendix VIII 

sketches the derivation of a total sample size 

of approximately 6,300 persons to be examined. 

This means an average of 150 examinees in 

each of the 42 PSU’s or stands. A feature of the 

plan is that the details of a probability selection 

of a sample of about 150 examinees were adapted 

to the characteristics of the PSU, and varied 

from one place to another. Typical main features 

are set forth here. Some variations are noted in 

Appendix VIII. 

Table 2. Number of strata in the Health Examination Survey, classified by geographic 

location and population density 

Population density 

All strata --L-1-----1-~---~--1------~--~-~ 

Giant metropolitan areas -b------P-II-~---------- 

Other very large metropolitan areas 

(mostly over 500,000 population)-------------- 

Other Standard Metropolitan Statistical Areas--- 

Other urban areas ---I-----L-I-II----------------b 

Rural (typically 40 percent or more ED’s 

classified as rural) ------I----I-ILIIIIIIIIIII 

u. s. Northtotal east 

42 14 14 

9 

10 

Number of strata 

South West 

14 

. 

3 

2 

3 

2 

4 

17 
Table 3. List of sample PSU's in Health Examination Survey, arranged by round number 

and size 

Round I 

New York, N.Y.-A 

Philadelphia, Pa. 

Chicago, 111.-A 

Baltimore, Md. 

Minneapolis, Minn. 

Akron, Ohio 

Nashville, Tenn. 

San Jose, Calif. 

Muskegon, Mich. 

Midland, Tex. 

\ Valdosta, Ga. 

Oxford, Miss. 

Butler, MO. 

Grand Coulee, Wash. 

Round II 

Los Angeles, Calif. 

New York, N.Y,-B 

Detroit, Mich. 

Pittsburgh, Pa, 

Louisville, Ky. 

Savannah, Ga. 

Ft. Wayne, Ind. 

York, Pa. 

Eufaula, Ala. 

Kennett, MO. 

Biddeford, Maine 

Clinton, La. 

Newport, Ark. 

Washburn, Wis. 

Round III 

New York, N.Y.4 

Boston, Mass. 

Chicago, 111.-B 

San Francisco, Calif, 

Columbus, Ohio 

Providence, RJ. 

San Antonio, Tex. 

Topeka, Kans. 

Newport News, Va. 

Carbondale, Ill. 

Auburn, N.Y. 

Conway, S.C. ' 

Rocky Mount, N.C. 

Winslow, Ariz. 

NOTE: The New York-Northern-New Jersey territory was divided into three synthetic PSU’s and the Chicago Standard Metropolitan Statistical 

Area into two PSU’s. 

Some 60 geographically bounded segments 

were drawn by systematic selection from the 

PSU, using a serpentine path throughout the 

area, so that all parts of the PSU were given 

an equal chance of inclusion in the sample. 

These segments were reduced to subsegments 

of an expected four households each, by a random 

two-in-three selection of listed households in the 

segment. Within the chosen households, every 

alternate person in the defined population became a potential sample person. The alternation began with the first person in an ordered 

sequence in one subsegment and with the second 

person in the next subsegment, in order to avoid 

bias of sample person in relation to the head of 

household. 

The term “potential sample person” was used 

for a specific reason. For operational reasons, 

it was desired that the number of actually examined persons be close to 150. This was a 

consequence of the fact that movement of personnel and equipment was tightly scheduled, 

not more than about 16 persons could be examined in one day, and it was inefficient to 

have the examining staff idle for any extended 

period. Yet the vagaries of housing construction 

and demolition, population mobility, household 

size and composition, and response rates, meant 

that it was not possible 20 predict the exact 

number of examinees which would be produced 

18 

by a fixed number of land segments. Accordingly, 

a second element of flexibility was introduced 

into the design. The 60 subsegments were randomized in sequence. On the average, it was 

found that about 50 subsegments would produce 

150 examinees. First field assignments to interviewers included 40 subsegments. Progress 

through these segments in terms of apparent 

number of examinees determined whether 0,. 1, 2, 

3... 20 additional subsegments would be assigned and included in the sample. Since the 

subsegments had been randomized in sequence, 

the only effect of this procedure on design, was 

to alter the within-PSU sampling fraction and 

weight. 

Estimation Technique 

Conceptually, the estimation process in the 

Health Examination Survey may be identified in 

terms of three routines, 

Summary routine. - Suppose the survey and 

its basic estimation technique produce for the 

ath age-sex population class an estimate of 

y” persons in the population, of which x” have a a a 

specified characteristic. Suppose further that 

y a is the official Census independent estimate 

th of population in the a- age-sex class. The HES 
final estimate of total number of persons in the 

population with the specified characteristic will 

be xf = c xff ‘a 

a a ygl 9 and if y = c ya , 

a 

the proportion of population with the characterisX’ tic is estimated as R’ = y . 

More generally, if xiL is the basic estimate 

th for any aX- subgroup of the population, and if 

Y 

X’ .aX = 

x” a 

ah y” , then x* *h = C x’ 

a ah 

is the 

8’ a 

final estimate for the x -class of the population, 

and R* .A = 

x’ .A 

II is the proportion of 

“a 

the population in the X-class with the characteristic. Thus the purpose of the summary routine 

is to make the sample more closely representative of the population with respect to sex and 

age and thus reduce variance. 

Basic routine. -The basic routine is the 

estimation 

i-h 

technique which produc es within the 

a- L1l age-sex cell the estimates x; , y; , and 

d cl 

X" 

a . the proportion RL = - YY Exact methodology for producing these estimates will be 

determined from experimental studies conducted 

with data from the Round I-the “first third” 

of the cycle of 42 stands, A prominent possibility is described in Appendix VIII, in the 

section “On Basic Estimation Technique.” 

Editing and imputation routine.-In a survey 

of the type of the Health Examination Survey, 

the procedures adopted for editing reported 

data and for handling instances of missing data 

can be critical. These topics are not treated in 

the present report despite their importance. 

The primary reason for this course is again 

that final decisions await investigation of Round 

I data. Two comments are in order at this 

point. 

The first of these relates to the general 

Standard errors of published statistics wil? 

be presented by the National Health Survey. 

The standard error, as calculated, will include 

sampling error, and a portion of the measurement error, or measurement variation. It will 

not include any biases that may reside in the 

data. The design is such that good approximations can be secured for a number of components of variation. For example, it is expected that it will be possible to determine 

what proportion of the variance comes from the 

between-PSU component and what proportion 

from the within-community component. It is 

hoped that a rough estimate can be made of 

the contribution to variability of some items 

that arises from residual differences among 

physicians, despite efforts at standardization. 

matter of nonresponse and missing data. If Elsewhere in this report there are brief 

there are missing measurements in a set of descriptions of efforts being made to calibrate 

data, there is, of course, no way in which a and to validate some of the measurement procrisk of bias can be entirely avoided. All schemes esses. As all investigators in health and mediof estimate must include either explicit or cine know, this latter work is in an area in which 

implicit imputation for missing measurements. there is much to be done. 

In the Health Examination Survey two courses 

are being taken to minimize difficulties in this 

area. The first is assignment of extensive resources to cut nonresponse to a manageable 

size. Ever-present attention is being given to 

the nonresponse problem, since substantial non- 3 

response had been the experience in earlier 

studies offering clinical examination to sample 

groups. The other course is assembly of auxiliary data on both respondents and nonrespond- I 

ents through household interview and reports from G 

solicitant’s personal physicians, in order to 

facilitate the residual imputational process. 

A second comment is that in accord with 

policy of the National Health Survey, every 

effort will be made in publications of data 

from the Health Examination Survey to convey 

to users of the data an understanding of how 

the estimates have been produced, including 

the nature of all significant adjustments. 

Reliability and Evaluation of Results 

How good will the data from the Health 

Examination Survey be? This is a question 

to which there is, of course, no unique answer. 

Perhaps the most significant answer will be 

found over a period of time in the collective 

judgments of students and users of the data. 

It can be stressed, a priori, that the results 

will be the product of highly standardized measurements on a probability sample of the population, and that these measurements were selected initially because a good many qualified 

people thought them relevant to a wide variety 

of purposes 

19 
PLANS FOR ANALYSIS AND PUBLICATION OF DATA 

All of the data collected in the first cycle 

of examinations are coded and punched into 

cards, transferred onto magnetic tape, and then 

tabulated by an electronic computer in the National Center for Health Statistics. The coding 

of the data is done by personnel of the Bureau 

of the Census under a contract with the National Health Survey. 

In accordance with the general policies of 

the NHS program, the findings of the Health 

Examination Survey will be made available to 

interested governmental and other public and 

private agencies, to organizations or groups, 

and to the general public, as rapidly as possible. 

The size of the sample, however, and the plan 

of the first-cycle examinations require that 

most of the analysis must await collection of 

the data for the entire sample. The processing 

operation with respect to the early stages (e.g., 

coding) is going on simultaneously with the data 

collection. Likewise, the plans for the tabulations are being developed and preliminary tabulations are being made to aid in planning the final 

process of tabulation and analysis. 

The findings of the first-cycle examinations 

made in the Health Examination Survey will be 

published in a separate series of health statistics reports. These will include presentation and analysis of the frequency distributions 

of the population for the various kinds of data 

which have been recorded in the survey; e.g., ’ 

blood pressure readings, dental findings, serum 

cholesterol determinations, etc. In addition they 

will include estimates, derived from the examination findings, of the prevalence in the population of cardiovascular disease, arthritis, diabetes, etc. There are still decisions to be made 

with respect to the way in which final determinations are made of the #diagnoses indicated 

by the findings. Consideration is being given to, 

consultant panel review of the entire relevant! 

portion of each of the records in order to arrive 

at a standard and valid diagnosis. The preliminary work to be done with the tabulations 

of data for the “first round” of the first cycle 

will aid in making the final plans in this phase 

of the operation. The diagnostic goal is a statistically satisfactory diagnosis, rather than a 

diagnosis sufficiently established in the individual case to govern the course of treatment for 

the patient. This means that the HES diagnostic 

procedure needs to be such that its expected 

value over a group of examinees is near the 

average that would be obtained for the group 

if all the individuals in the group were given 

a more comprehensive series of similar clinical 

examination-although the two sets of procedures 

would not necessarily produce identical results 

in each individual instance. 

20 
*APPENDIX I 

AREAS IN THE HEALTH EXAMINATION SURVEY’S SAMPLE 

Caravan I Caravan II 

: 

1. Philadelphia, Pennsylvania (During the early part of the Health Examination Survey only one Mobile Examination Cen2. Valdosta, Georgia ter was used.) 

3. 

4. Muskegon, Michigan 

Akron, Ohio 

I 1' ;. 

.-_ c 

r: 

_.-i”wl_, .I’. 5. Chicago, Illinois 

6. Butler, Missouri 

7. Midland, Texas 

z 

8. Los Angeles, California "'\, 

9. 

10. 

11. 

13. 

14. 

15. 

16. 

18. 

21. 

22. 

23. 

24. 

27. 

28. 

30,. 

San Jose, California -“A 

San Francisco, California 

Grand Coulee, Washington 

Minneapolis, Minnesota %' 

Chicago, Illinois 

Detroit, Michigan 

Fort Wayne, Indiana 

York, Pennsylvania 

New York, New York 

New York, New York 

Baltimore, Maryland 

Nashville, Tennessee 

Eufaula, Alabama 

Clinton, Louisiana 

Newport, Arkansas 

3;. Topeka, Kansas 34. 

35. Boston, Massachusetts 

37. Conway, South Carolina 

39. Winslow, Arizona 

12. Washburn, Wisconsin 

13. Minneapolis, Minnesota 

14. Chicago, Illinois 

15. Detroit, Michigan 

17. Auburn, New York 

19. Biddeford, Maine 

20. New York, New York 

23. Baltimore, Maryland 

_. _ 

25. Oxford, Mississippi26. Savannah, Georgia 

29. San Antonio, Texas 

31. Kennett, Missouri 

33. Louisville, Kentucky 

Providence, Rhode Island 

36. Carbondale, Illinois 

38. Columbus, Ohio 

40. Pittsburgh, Pennsylvania 

41. Newport News, Virginia 

42. Rocky Mount, North Carolina 

22 
APPENDIX II 

-. . ..)- -- 5 war a 

ROUTES FOL.LOWED BY MOBILE HEALTH EXAMINATION CENTERS IN MOVlN,G FROM ONE LOCATION TO ANOTHER 

I”“‘,,,,, 

--Route of Caravan II 

OFirst Round Stand 

0 Second Round Stand 

0 Third Round Stand 

Number enclosed in Round 
APPENDIX Ill 

A. FLOOR PLAN -MOBILE EXAMINATION CENTER-CARAVAN J 

c 

Interview Room I ntarvi ew Room 

2 18 12 

i 

Reception 1 0 

Washroom 

Office and Staff Room 

Records 

Files 

Preliminary 

Statistical 

work 

Emergency Door 

Dental Roorr 

0 10 

Visual Acuity 

0 11 

Examining Room 5 

3 8 8 

Removable Lead 

Rubber Shields 

Height 

Seals 0 4 

IX-ray Moshinel 

Lead Lined Wall 

Emergency Door 

\ 

. 0 !w Door o s 

CL 0 

*e 7 0’ 0 J 

Examining 

Room A 

0 3 

0 8 

8’ X 35’ 8’ X 35’ 

24 
B. FLOOR PLAN-MOBILE EXAMINATION CENTER-CARAVAN II 

OFFICE 

and 

STAFF 

Room 

RECORDS 

FILES 

Prel iminaty 

Statistical 

Work 

b 

0 1 

RECEPTION : 

-RVIEW INTER 

ROOM 

0 2 

0 12 

I?@3 M 

X-RAY 

DEVELOPING 

LEAD LINED WALL 4 

EXAMINIbIG ROOM A 

0 3 

0 8 

DENTAL AREA 

VISUAL ACUITY 

X-RAY HEIGHT 

MACHINE SCALE 

MOVABLE 0 

LEAD RUBBER 

Scale - Width I” 3’ 

Length 1” 5’ 

WASHROOM 

l-Yz&GAUDIOMETER 

I 

EXAMINING I3 

0 3 

0 8 

25 
APPENDIX IV 

EXAMPLE OF LEAFLET DISTRIBUTED IN ADVANCE 

OF INTERVIEWER’S VISIT 

HEALT 

@ 

1s 

NEWS in Bexar 

A HEALTH EXAMINATION CENTER will be brought to San Antonio for 

the Health Examination Survey to begin 

February 16 

U. S. Department of Health, Education, and Welfare 

Public Health Service 

U. S. National Health Survev 

Washington, D. C, 

TURN THIS PAGE FOR THE STORY...... 

26 
A MESSAGE FROM THE PUBLIC HEALTH SERVICE 

Bexar County is especially distinguished out of the 3,076 counties in the United 

States, because it is among the 109 counties which have been selected by the U. S. 

National Health Survey for its Health Examination Survey. The 109 counties, taken 

as a group, constitute a representative sample of the entire United States population, balanced between urban and rural, North and South, East and West, large 

cities and small cities. 

The Health Examination Survey will soon give health examinations to about 150 

adults from households in the County. To reach these people, interviewers from the 

U. S. Bureau of the Census are visiting the particular households in the sample to 

invite the selected persons to the health examinations. 

The purpose of these health examinations is to answer the question: “How 

healthy are the people of the United States?” In 1956 the U. S. Congress thought 

this question so important that it passed a special law, which was supported by 

members of both major political parties, to set up the National Health Survey and 

get at the facts. Some of the facts can be learned by asking people questions about 

their health. However, actual tests and measurements from a health examination 

are needed to get much of the information. 

The examinations done by the U. S. Public Health Service in the Health Examination Survey are focused on some of our most important health problems, such as 

heart trouble, diabetes, and arthritis and rheumatism. Information is collected on 

dental conditions, hearing, and vision. Also, there are various other scientific 

measurements made and laboratory tests performed by the specially trained team 

of physicians, dentists, nurses, X-ray and laboratory technicians, and medicalhistory interviewers. 

The examination is not a substitute for a check-up by one’s own physician or 

dentist. While the examination is quite thorough in some respects, it is not a complete examination; it does not require undressing below the waist, and no internal 

examinations are done. It is not painful or embarrassing in any way. None of the 

information collected about a person is revealed to anyone other than the person’s 

own physician or dentist, and then only if the person specifically requests that the 

physician or dentist be given a report. 

A good many of the people who read this handbill will either themselves be invited, or will be living close by people who will be invited, to take the health examination. It is very important that all the people invited-that is, all the people who 

are part of the sample- accept the invitation. No other persons can be accepted 

for the examination, no matter how much they would like to be examined. If you 

are one of those chosen, you will be personally informed of this fact. 

Everyone is given free transportation to and from the examination, and everything about the examination itself is free. The examinations take place in a mobile 

Health Examination Center operated by the U, S. Public Health Service and are 

given at convenient hours during the day and in the evening. The center will be 

brought to Bexar County and set up in a convenient location, where examinations 

will be given beginning Friday, February 16. 

U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE 

PUBLIC HEALTH SERVICE 

27 
APPENDIX V 

HOUSEHOLD INTERVIEW QUESTIONNAIRE OF THE 

HEALTH EXAMINATION SURVEY 

, 

The-National Health Survey is authorized by Public Law 652 of the 64th Congress (70 Stat. 487; 42 U.S.C. 305). All information which would permrt rdenttficatron of the individual will be held strictly confidential, will be used only by persons 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). 

FORM HE51 U.S. DEPARTMENT OF COMMERCE 

\SRD REVISION) BUREAU OF THE CENSUS 

1. Questionnaire 

(8-Q-61 1 ACTING AS COLLECTING AGENT FOR THE 

U.S. PUBLIC HEALTH SERVICE of 

HEALTH EXAMINATION SURVEY Questionnaires 

2. (a) Address or description of location 

- 

(b) Mailing add ress if not shown in (a): Include city and State 

3. Iden. Code 3a. R.O. Code 4. Sub -sample 

weight 

5. Sample 6. PSU No. 7. Segment No. 8. Serial No. 

fc) ~~~gof 1 0 Housing unit (d) Name of Special Dwelling Place ’ 

/ 

Code 

I 0 Other unit 9. Is this house on a farm or ranch? 

quarters , 

0 Yes 0 No 

0 All other 

11. If “Own” or “rent free” in question 10, ask: 

(a) Does this place have 10 or more acres? 

\ 

i If “rent” in question 10, ask: 

(b) Does the place you rent have 10 or more acres? 

a ,, ,, 

0 Own 0 Rent 0 Rent free 

I I 

I(c) D 

El yes7 I u No) 

I 

uring the past 12.months did sales 

of crops, 

I(d) During the past 12 months did sales 

livestock, and other farm 1 

products from the place amount to 

of crops, livestock, and other farm 

I 

products from the place amount to 

$250 or more? 

0 No 1 u Yes 0 No 

12. Are there any other living quarters, occupied or INSTRUCTIONS FOR Q. 12, 13, AND 14 

vacant, in this building (apartment)? . . . . . . . . . . . . . .I Yes [ No If “Yes,” to questions 12, 13, or 14 apply definition of a housing 

13. Does anyone else living in this building use unit to determine whether one or more additional questionnaires 

YOUR ENTRANCE to get to his living quarters?. . . .I Yes 0 No should be filled and whether the listing is to be corrected. 

Ask at all units except apartment houses: 15. :4$is the telephone number 16. In case I’ve overlooked anythin 

14. Is there any other building on this property for . what is the best time to call? 

people to live in - either occupied or vacant?. . , . . . .L_ Yes n No 0 No phone 

t I 17. RECORD OF CALLS AT HOUSEHOLDS 

\ Item 1 Corn. 2 Corn. 3 Corn. 4 Corn. ’ 5 Corn. 

Date 

Entire household IT;;;- -------- 

--a------ --------e --------r --------I 

--m----w -J --------- --------- --N-----s 

1 

. . 

Col. No. : ..: I: 

7 0 No one home 0 No one home 0 No one home 0 No one home 

. . 

0 Sample P. not home 0 Sample P. not home m Sample P. not home a Sample P. not home 

_’ 

,... 

n Unrel. P. not home 0 Unrel. p. not home 0 Unrel. p. not home b Unrel. P. not home 

Date ’ : ‘,:;‘T ‘,,“.., 

-----I --a------ ----a-- a------ 

Time ,, ,. ._ ,’ f 

3 t ? t i I- 

” .I No one home 

Col. No. ., ‘. B Sample P. 

0 Unrel. P. not home 0 Unrel. P. not home 

TYPE 1 

18. REASON FOR NON-INTERVIEW 

A I B I C I Z 

0 Refusal (Fill Item f9) 0 Vacani - non-seasonal 

u No one at homerepeated calls 

0 Vacant - seasonal 

Reason: 

0 Temporarily absent 

0 Usual residence elsewhere 

L_1 Other (specify) 

0 Armed Forces 

0 Other (specify) 

19. Reason for refusal 

7 

0 Demolished Interview not obtained for: 

0 In sample by mistake 

0 Eliminated in sub-sample Cols.- - - - 

0 Other (specify) 

because: 

J 1 

I r 

Footnotes and comments 

20. Signature of interviewer 21. Code 

28 
r-- - 

- 

~ 

1. (o) What is the name of the head of this household? (Enter name in first column) 

(b) What a& th e names of all other persons who live here? (List all persons who live .here.) 

(c) Do any (other) lodgers or roomers live here? 0 No 0 Yes (List) 

(d) Is there anyone else who lives here who 

is now temporarily in a hospital? 0 Yes (List) 

(e) Away on business? 0 Yes (List) 

(f) On a visit? 0 Yes (List) 

(g) Is there anyone else staying here now? 0 Yes (List) 

----------------i----------------~i---- ----m------w-----------, 

(h) Do any of the people in this household have a home elsewhere? 

0 No (leave on questionnaire) III Yes (apply h ousehold membership rules; if not a household member, delete) 

r 

2. How are you related to the head of the household? (Enter relationship to head, for example: head, wife, daughter, 

grandson, mother-in-law, partner, lodger, lodger’s wife, etc.) 

Last name-- <!) 

0 EA -----a----------a, 

First name and initial 

I 3 How old were you on your last birthday? (Check “EA” box in question 1 for all persons 18-79 years old) 

I 

Age 0 Under 

1 year 

4. Race (Check one box for each person) 

0 Ulhite 0 Negro 

0 Other 

I 5. Sex (Check one box for each person) - I 0 Male n Female I 

I If 17 years old or over, ask: I c Under 17 years I 

6. Are you now married, widowed, divorced, sepamted or never married? 

(Check one box for each person) 

If 17 years old or over, ask: 

7. (a) What were you doing most of the past 12 months - - 

n Under 17 years 

(For males): working, or doing something else? 

n Working 

(For females): working, keeping house, or doing something else? 0 Keeping house 

I If “Something else” checked, and person is 45 years old or over, ask: 

0 Something else 

----------------- 

I (b) Are you retired? I IYes c-10 I 

n Married ( Divorced 

0 Widowed m Separated 

u Never married 

I NOTE: Determine which adults are at.home and record this information. Beginning with question 8 you are to interview 

for himself or herself, each adult person who is at home. n At ho&? “~$$.tars 1 

8. Were you sick at any time LAST WEEK OR THE WEEK BEFORE? (That is, the 2-week period which ended n Yes 

last Sunday)? 

(a) What was the matter? 

(b) Anything else? I I 

Last week or the week 

you told me about)? 

before did you take any medicine or treatment for any condition (besides . . . which 

(a) For what conditions? 

0 Yes 

(b) Anything else? 

10. Last week or the week before did you have any accidents or injuries? 

(a) What were they? 

(b) Anything else? 

n Yes 

Ill. Did you ever have an (any other) accident or injury that was still bothering you last week or the week before? 

I (a) In what way did it bother you? 

(b) Anything else? 

0 Yes 

12. AT THE PRESENT TIME do you have any ailments or conditions that have lasted for a long time? 

(If “No”) Even though they don’t bother you all the time? 

(a) What are they? 

(b) Anything else? 

13. Has anyone in the family - you, your --, etc. - had any of these conditions DURING THE PAST 12 MONTHS? 

m Yes 

L_I Yes 

cl No 

m No 

(Read Card A, condition by condition; record any conditions mentioned in the column for the person) 

I 14. Does anyone in the family have any of these conditions? 

- I 

L_1 Yes 

(Read Card B, condition by condition; record any conditions mentioned in the column for the person) 

n No 

(0) Have you been in a hospital at any time DURING THE PAST 12 MONTHS? 

If “Yes,” 

0 Yes 

c 

El No 

-------_-____ 

(b) How many times were you in the hospital overnight or longer? 

16. If baby under one year listed as a household member, ask: 

(a) Was the baby born in a hospital or at home? 

No. of times 

1 (Check proper boxes for 

0 llospital 0 llome 

~-~----------_ 

I If “hospital” in q. lb(a) and 1 or more in q. 15(b), ask: both mother and child.) 

(b) Was this hospitalization included in the number you just gave me? I 

0 Yes :x: No 

I 

17. (a) During the past 12 months has onyone in the family been a patient in a nursing home or sanitarium? 

If “Yes,” ask: 

(b) Who was this? 

(c) How many times were you in a nursing home or sanitarium? t 

0 Yes CII No 

-----------__ 

No. of times 

R (For For persons 17 years old or over, show who responded for (or was present during the asking of) q. 8- 17. IResponded f or self-entirely i 

‘+8-17) o 

ff ;;;z;s responded for self, show whether entirely or partly. For persons under 17 show who responded IResponded for self-partly I 

r Cal.- was respondent ’ 

29 
Table I - ILLNESSES, MPAIRMENTS, AND INJURIES 

Ques- 

:ion 

NO. 

(b) 

Did you 

EVER 

at any 

time 

talk to 

a doctol 

about 

. . . ? 

cc> 

Ask for any entry in Ask only for: 

Col. (d- 1) or Col. (d- 2) Impairments and injuries 

that includes the words: And for. 

Ask only if 

6 years old 

or over and 

blindness, 

poor vision, 

or eye 

trouble of 

any kind. 

Can you 

see well 

enough 

to read 

ordinary 

newspaper 

print with 

glasses? 

(d-3) 

X 

0 Yes 

n No 

Cal. 

No. 

of 

person 

(a> 

An Impairment, 

or 

a Symptom, 

or 

came from question 11 or 14: 

What was the cause of. . .? 

What did the doctor say 

it was? - - did he give it 

a medical name? 

(b) If doctor not talked to: 

Record original entry and 

ask:(d- 2) - (d- 5) as 

required. 

Ask for all injuries during 

past 2 weeks: 

Abscesses Inflammation 

Aches 

Bleeding 

Neuralgia 

Neuritis 

Blood Clot Pains 

Boils Sores 

Cancer Soreness 

cyst Tumor 

Growth Ulcers . 

Infection Weakness 

What part of the body is affected 

Show detail for: 

Ear or eye - (one or both) 

Head - (Skull, scalp, face) 

Back - (Upper, middle, lower) 

Arm - (Shoulder, upper, elbow 

lower, wrest, hand; one 

or both) 

Leg - (Hip, upper, knee, lowe] 

ankle, foot; one or both) 

Cd- 5) 

*For an allergy or stroke’ 

ask: 

How does the allergy 

(stroke) affect you? 

(d-4 

What part of the body was 

hurt? 

What kind of injury was it? 

Anything el se? 

(d-1) (d-2) 

[ Yes 

El No 

X 

n Ye: 

n ~0 

X 

n Yes X 

n ~0 

0 Yes 

n ~0 

X X 

n Yes 

n ~0 

[Yes 

nN0 

X X 

0 Yes 

n ~0 

Dye.5 

cw 

X X 

0 Yes 

I No 

X 

( Yes 

X 

El No 

Table II - HOSPITALIZATlOr( DURING PAST 32 MONTHS 

When did 

. 

How 

:h”, ;z;er many 

w 

pital? 

nights 

were you 

in the 

(Month, hospital? 

year) 

(c) (d) 

MO: 

Yr: Nights 

MO: 

Yr: Nights 

MO. .- 

Yr: Nights 

What did they say at 

did they 

the hospital 

give it a me dical name? 

To the condition was -- Cal. Interviewer 

NO. 

Questron 

of No. 

z 

per- 

% 

son 

z 

8 .3 

cl 

(a) (b) 

H,;geyeny Will you How many Was this 

need to 

nights 

of these person 

-- ask Cols. -- nights still in 

were in (f) and were last the hosthe past (g)? week or pita1 on 

12 the week last 

months? before? Sunday 

night? 

(If “they” didn’t say, ask): 

What did the lost doctor you talked to say it was? 

(Entry 

Body” 

must show “Cause,” “Kind,” and “Part 

in same detail as required in Table I) 

of 

or DYes - j--J Yes 

Nights 

(NO $tE,, g No 

30 
-- 

Toble I - ILLNESSES, IMPAIRMENTS, AND INJURIES 

-.- 

How many 

of these 

-- days 

were you 

in bed all 

or most of 

the day? 

--- 

If 6 - 16 

years old 

ask: 

How many 

days did 

. . . keep 

you from 

school 

last week 

or the 

week 

before? 

(h) (8 

-Days 

or 

( None 

-Days -Days 

OK or 

! None 0 None 

LAST WEEK 

OR THE 

WEEK BEFORE did 

. . . cause you 

to cut down 

on your usual 

activities for 

as much as a 

day? 

- 

5 

r 

About 

how 

many 

days 

during 

the past 

12 

months, 

has . . . 

kept you 

in bed 

for all 

or most 

of the 

day? 

To 

interviewer: 

CONZk!lE . 

(k) is 

checked, 

or the 

condition 

is on 

Card A 

or is an 

impairment; 

otherwise, 

STOP 

If 1 or 

more day: 

in Col. 

(n) and 

Co1 (e) 

is checked, ask: 

How 

many of 

these 

days 

were 

during 

last 

week 

or the 

week 

before? 

1 

(aa) (4 

- Days 

0 gone 

-Day: 

or 

: 0 None 

l ’ ,,,, 

-Days 

or 

0 None 

-Days 

Or 

[ None 

-Days 

OK 

‘. n None 

. ._ Y”” 

-Days 

or 

m None 

-Days -Days 

or or 

” 0 None n None 

If 17 year: 

old or ove 

ask: 

LAST 

WEEK or 

the WEEK 

BEFORE, 

how many 

days did 

. . . keep 

you from 

work? 

[For 

Females 

add) 

not counting work 

around thf 

house? 

(9 

-Days 

or 

0 None 

How 

many 

days, 

includ. 

ing 

the 

Saturdays 

and 

Sundays? 

Days 

Did you first notice . . . 

(did it happen) during the 

east 3 months OR before 

ihat time? 

Ask after completing last 

condition for each person 

[f “Yes” 

in Col. 

:cr ): 

Which? 

(Enter 

X on 

line for 

each 

condition 

named) 

(r\ 

If ‘(1:’ 

“2” or tt 9, * 

4. ;p”,: 

Is this 

because 

of any 

of the 

conditions 

I 

ou 

ave 

told me 

about? 

(4) 

( Yes 

I No 

[ Yes 

0 No 

0 Yes 

0 No 

Please 

look at 

this card 

and read 

each 

statement 

Then tell 

me which 

statement 

ptyq:: 

term; of 

health. 

(Show 

Cards DG, as 

wroptiate) 

(P) 

Check one Did . . . start 

during the past 

2 weeks or 

before that time? 

(If during past 

2 weeks, ask): 

Which week, 

last week or 

the week 

before? 

During 

3 

mos. 

3efore 

3 

mos . 

[Go 

to 

Cal. 

b)) 

W (1) 

Check one 

0 Last week 

n Week before 

0 Before 2 wk: 

( Last week 

0 Week beSore 

n Before 2wks 

Days 

OK 

Days a None 

-Days -Days 

or or 

1 None m None 

-Days 

or 

g None 

L_1 Last week 

m Week before 

m Before 2 wks 

n Last week 

n Week before 

0 Before 2 wks 

-Days Days 

or Or 

7 None ( None 

Jays -Days 

or or 

n None n None 

Days 

0 Yes 

El No 

- Day5 

or 

0 None 

-Days 

or 

L_I None 

-Days 

or 

n None 

Days 

( LBst week 

m Week before 

a Before 2 wks 

[ Last week 

m Week before 

0 Before 2 wks 

0 Yes 

L_1’No 

0 Yes 

IIIPo 

Days 

Days 

-Days 

11 gone 

nays 

or 

L_I None 

Table II - HOSPITALIZATION DURING PAST 12 MONTHS 

Were any operations performed on To Interviewer 

you during this stay at the hospital? 

Whar is the name and address of the hospital you were in? ‘Carry this condition through Table I, 

if it does not appear there 

If “Yes,” (Enter name, city and State; if city not known, enter county) 

AN? 

’ ii 

(a) What was the name of the 

1 or more nighgin Col. (f), 

3 

operation? 

condition is on Card A, or is an C 

impairment 2 

(b) Any other operations? 

------------------** 

Will you need to fill Table I? cl 

(i) -(i) (xx) 

111 yes El No 

-----------------_-_--------- r3 yes [No 1 

l-7 Yes El No 

-------------_______--------- [1 Yes 010 2 

0 Yes El No 

-------------------_--~~~~--~ j El Yes ~No 3 

. 

31 
If 17 years old or over, ask: 

18. (a) What is the highest grade you attended in school? 

(Circle highest grade attended or check “None”) 

(b) Did you finish the -- grade (year)? 

If Male and 17 years old or over, ask: 

19. (a) Did you ever serve in the Armed Farces of the United States? If “Yes,” ask: 

0 Under 17 year: 

Elem: 12345678 

High: 1 2 3 4 

College : 12 3 4 5+ 

0 None 

------ -------- 

u Yes u No 

0 Fem. or und. 17 yrs. 

0 Yes 0 No ------a------- 

(b) Are you now in the Armed Forces, not counting the reserves? (If “Yes, ” delete this person from questionnaire)-+ m Yes 0 No 

(c) Was any of your service’during a war or was it peace-time only? ------m------M 

0 War fl PeaceIf “War,” ask: time only 

(d) During which war did you serve? 

-ti &-;- - - - -Exorean 

If “Peace-time” only, ask: 0 Other 

------v-----v- 

(e) Was any of your service between June 27, 1950, and January 31, 19551 

Ask for all persons 17 years old or over: 

20. (a) Did you work at any time last week or the week before? 

If “No,” ask 20(b) and (c). 

(b) Even though you did not work last week or the week before do you have a iob or business? 

0 Yes 0 No 

0 Yes 

0 Under 17 year: 

0 No 

-------------- 

0 Yes 0 No 

-------------- 

(c) Were you looking for work,,or on layoff from a iob? 0 Yes 0 No 

21. If “Yes,” in question 20(a), (b), or (c), ask: Name of employer: 

/ (a) For whom did you work? ------------aIndustry: 

If “Yes” in q. 20(c); (b) What kind of business or industry was this? 

q. 21(a) - (e) applies 

~c--a-io~~- - - - - - - - - 

to the person’s (c) What kind of work were you doing? 

------------em 

last full-time 

civilian job. (d) Class of worker (Fill from information above; or, if not clear, ask): 0 Private-paid 0 Gov’t 

Ask only for persons 20 years old or over: 

UovJn n Non-paic 

------------a- 

(e) Have you been a --, or doing this kind of work for the post three years? 0 Under 20 year: 

0 Yes 0 No 

22. Which of these income groups represents your total family income for the past 12 months, that is, your’s, your-- -‘s Group 

etc? (Show Card H.) Include income from all sources, such as wages, salaries, rents from property, pensions, help 

from relatives, etc. 

s 

.Ask only fot sample persons not at home at time of interview: Time/day 

What ! s. the best time. to find - - - at--home? 

TO BE FILLED BY INTERVIEWER AFTER INTERVIEWING SAMPLE PERSON(S) -- NOT TO BE ASKED OF RESPONDENTS 

Section I 

(a) Did anyone ask one or more questions about the health examination? [Yes ~NO If “Yes,” (b) What were the questions? 

Section 2 

Please write in below your suggestions for overcoming problems during follow-up visits. 0 No problems observed 

I 

32 
r r.-.. ACK CiNl -..w. Y nF -. -- SAMPLE . . . . . -- PERSON&\ . - -w-w.. \-, 

Name Name 

Enter name and column number of sample person (from question 1). Column number Column number 

23. Would you say your own health, in general, is excellent, 

1 0 Excellent 2 l--J Good 1 0 Excellent 2 n ‘Good 

good, fair, or poor? 

3 0 Fair 4 /J Poor 3 0 Fair 4 j-J Poor 

5 0 DK 5[DK 

10 Very important 10 Very important 

24. How important do you think it is for people to have a regular check-up., . 

very important, fairly important, or hardly important at all? 

2 0 Fairly important 2 0 Fairly important 

3 0 Hardly important 3 a Hardly important 

4uDK 4[DK 

25. (a) Do you have a doctor you usually go to? 10 Yes 2 0 No 1 m Yes 2mNo 

If “Yes ,” 

(b) What is his name and address? 

!6. How long has it been since you last talked to any doctor about yourself? Mos. or.-. Yrs. .-Mos. or -Yrs, 

0 Less than 1 mo. 0 Never 0 Less than 1 mo. [1 Never 

!7. Do you get check-ups from a doctor AS OFTEN as once every two years? 10 Yes 2uNo 10 Yes 2 0 No 

28. (a) Do you have a dentist you usually go to? 10 Yes 2 0 No 10 Yes 2oNo 

If “Yes,” 

(b) What is his name and address? 

29. How long has it been since you last saw a dentist about yourself? - Mos. or p Yrs. -Mos. or- Yrs, 

0 Less than 1 mo. 0 Never 1_1 Less than 1 mo. 0 Never 

SO. Do you go to a dentist AS OFTEN as once every year? 10 Yes 2aNo 10 Yes 2 0 No 

#l. (a) Have you heard or read anything recently about the National Health 1 Yes 

Survey and the special health examinations being given in this area? 

x 

(Shof !$!izJ 

If “Yes,” 3 NHS newspaper 

1 x ;; news~~;ck!p::J 

(b) In a newspaper or magazine? On TV? Radio? From somebody 

4 0 Other newspaper 4 L_1 Other newspaper 

telling you about it? (check elf that apply) 

5 0 TV programs 5 0 TV programs 

G 0 Radio programs 6 0 Radio programs 

If “newspaper,” 

(c) Which newspaper? 

7 0 Somebody telling 7 0 Somebody telling 

12, How important do you think it is for people to cooperate on surveys such 

1 0 Very important 1 1_1 Very important 

as this.. . very important, fairly important, or hardly important at all? 

2 0 Fairly important 2 0 Fairly important 

3 0 Hardly important 3 0 Hardly important 

4uDK 4mDK 

B3. As you might expect, the Public Health Service cannot learn all they need 

to know about health in the nation just by asking questions. For some 

things they need actual measurements and tests obtained in a health 

1 0 Certainly come 1 [ Certainly come 

2 0 Probably come 2 1_1 Probably come 

examination. 

(a) How do you think most people will feel about helping in this way-- 

3 0 Probably not come 3 0 Probably not come 

will they certain Iy come, probably come or probably not come for such 

4oDK 4nDK 

a health examination? 

i4. Throughout the United States, the Public Health Service is giving a 

Preferred times : Preferred times: 

health examination to a sample of adults and you are in this sample. For 

your community, a special examination center has been set up at 

and the examinations will be given from ,~ 

through 0 Appointment made. .- 0 Appointment made: .- 

. No. No. 

The examination is not painful or embarrassing in any way and free 

transportation to and from the center will be provided. From our past Date Date 

experience we know that most people ore glad to come for the examination. Appointment times are available during morning, afternoon and Time Time 

evening hours. 

(a) We would like to.make an appointment for yo.u -- 

which time would be most convenient for you 

to come? 

(Specify any problems mentioned (Specify any problema mentioned 

about coming) about comfng) 

0 Appointment not made 0 Appointment not made 

(Specify reaeon for no appointment) (Specify reaeon for no appointment) 

15. Present medical authorization for signature 

u Signed 0 Refused 0 Signed 

0 Not asked to sign 0 Not asked 

0 Refused 

to sign 

. 

33 
I 

’ 

19. (a) Did you ever serve in the Armed Forces of the United States? If “Yes,” ask: I u rem. or una. 11 yrs. 

[1 Yes 0 No -----a-------- i 

APPENDIX VI 

LEAFLET GIVEN EXAMINEE WHEN APPOINTMENT IS MADE 

YOU 

AND THE 

HEALTH 

EXAMINATION 

SURVEY 

Why you? 

If you have been asked to come to our examining center, you are one member of a very important group of 

people who, taken all together, make up a representative 

sample of the people of the United States, From this sample will come important scientific information on the 

health of the entire United States, You will be the representative of thousands of others who are just like you-- 

the same age, same schooling, and most important of all, 

the same level of health. However, the fact that there are 

thousands of other people whom you represent does not 

mean that there is anyone who can take your place, The 

scientific sampling method has led us to YOU, If you are 

not there to represent those thousands, their part in the 

health picture is missing and the picture may be misleading, 

What to expect: 

The health examination which you will receive is 

very thorough in some respects, but is not a complete 

examination. For example, no internal examinations will 

be done. All of our staff--the receptionist, the physician, 

the nurse, the dentist, the technician--will do everything 

to make your visit to the examining center a pleasant experience. 

After this, the nurse will be with you during the rest 

of the examination, explaining each step. She shows you 

to an examining room, asks you to undress to the waist 

and put on a white gown. 

After you meet thedoctor, he reads over your medical history and asks a few questions about it. He examines your eyes and ears, takes your blood pressure several times, and makes a complete examination of your 

heart by listening to the sounds it makes. 

After you meet the dentist, he checks over your teeth 

and mouth. He also gives you an eye test--if you have 

eyeglasses, please be sure to bring them with you, because we need to test your vision both with and without 

glasses. 

In. another part of the examination the nurse makes 

a record of the impulses of your heart with an electrocardiograph (EKG&for this test you lie down, relax, and 

even go to sleep if you wish. But youcan’t sleep long because this test takes a very short time. Some simple 

body measurements, such as arm and chest size, shoulder width, etc., will also be done. 

Other parts of the examination include: a hearing 

test; x-rays of your chest, hands and feet; height and 

weight; .blood and urine specimens. 

After you have dressed, you are invited to enjoy refreshments while you give us your opinion and reactions 

to the health examination, Knowing what you think about 

it helps us to improve and to make the examination even 

more comfortable and convenient, 

THE U. S. NATIONAL HEALTH SURVEY 

U.S. DEPARTMENT OF 

HEALTH, -EDUCATION, AND WELFARE 

Public Health Service 

Washington 25, O.C. 

U.S. NATIONAL .HEAlTH SURV=Y 

HES-4 

9-59 

At the start, you meet the receptionist who will ask 

if you would like the findings of the examination sent to 

your own physician and dentist. This is so that your own 

doctor can tell youabout the results. Then the receptionist gives you a sweet, lemon-flavored soft drink, After 

that, she helps you fill out a questionnaire that contains 

the kinds of questions your doctor asks when he gets 

your medical history. 

34 
C-3 o0 

+I 

: 

3 

-3 z 

I+- 

?iT 7 

w 

0 

S 

- 

4 

S 

-. 

FiF 

D 

w 

-. 

rt- 

- 

- 

A. 

S 

cn 

I-+ 

D 

- 

-. 

r+ 

i-+ 

c 

- 

- 

-9 

FJ 

I+- 

CJ 

-1 

-. 

I-+- 

+ 

G 

- 
17. a. Have you ever been bothered by 

physical work or exercising? 

If YES b. How often? 

c. Does it bother you 

18. a. Have you ever been bothered by 

shortness of breath when doing 

pE5-l pi5-l /-q 

Almost everytime (Lessoften 

quite a bit just a little 1 

shortness of breath when you were not 

doing physical work or exercising? 

If YES b. How often? 

c. Does it bother you 

1 YES1 

19. a. Have you ever been bothered by shortness of breath when you are 

excited 

If YES 

or upset about something? 

0. How often? Almost everytime 

C. Does it bother you 

I YES 

I Less often I 

I I 

just a little 

30. a. Have you ever waked up at night because you were short of 

breath? 

If YES b. How often? 

c. Does it bother you 

1 Every few nights 1 

quite a bit 

1 Less often ] 

1 just a little ] 

21. a. In the past few years, have you ever had any pain, discomfort, 

or tightness in your chest? p-j p5-l p-1 

IF YES, please answer questions b through j below. 

b. How often? 

c. Does it bother you 

) Less often 1 

. 1 

1 just a little 1 

d. Where does it bother you? 

j 

(Check every place it bothers you.) 

Front pz-] IRight pTGiq pi?TxG-ieft 

Somewhere else 1 State where 

e. Does it usually stay in one place ] piizT%q~~ 

f. HOVV long does the pain usually last? 

Just a few minutes Few minutes to an hour More than an hour 

q. Does it usually come I When you take a lot of exercise I or 

when you are quiet or 

is there. no difference 

h. Does it usually come when you are upset or 

doesn't this make any difference 

j. Do you take any pills or medicine for it? 

36 
22. a. In the past few years, have you ever had any *pa 

or trouble in or around your heart? 

IF YES, please answer questions b through j below. 

b. How often? Every few days 

c. Does it bother you [quite a bit 1 

1, discomfort, 

d. Where does it bother you? (Check every place it bothers you.) 

[] -piq p7EjKxq [Middle1 [Leftside] 

Somewhere else State where 

e. Does it usually stay in one place 1 piFGiiJF] 

f. Hoti long does the pain usually last? 4 

Just a few minutes Few minutes to an hour More than an hour 

q. Does it usually come When you take a lot of exercise 

1 when you are quiet1 or 

1 is there, no difference 1 

h. Does it usually come when you are upset or 

doesn't this make any difference 

j. Do you take any pills or medicine for it? 

23. a. Sometimes, our hearts "act funny" (odd) like missing a beat, 

or beating real fast, or seem to turn over. Have you ever 

noticed your heart do anything like that? pF5-l [-iqll?] 

If YES b. How often? Every few days 

c. Does it bother you 

24. a. Have you ever been bothered by your heart beating 

If YES b. How often? Every few days 

c. Does this bother you [quite-l 

hard? El YES 

(Less] 

I iust a little I 

25. ai. Are your ankles ever swollen at bedtime'? 

If YES b. Is the swelling gone by morning? 

26. a. When you walk, do you have pains or cramps in your legs? p5-] [NOI p-1 

If YES b. How often? Every few days 1 (1 

c. Does it bother you just a little 

65. a. Has a doctor ever told you that you have hardening of the 

arteries? pqK] 

If YES b. Have you had this condition in the past 12 months? [YESIp]pl 

37 
66. a. Have you ever had any reason tcthink you may have high blood 

pressure? pE-jp5-p-l 

If YES or ? b. Did a doctor tell you it was high blood 

pressure? rYqTiii1 

If YES 

67.a. Have you eve 

trouble? 

If YES or ? 

c. How long ago did you first start having it? 

(lyearl 11-51 lover 5 years 1 

d. Have you had it in the past 12 months? [--YE-j )I pJ 

e. Do you take any pills or medicine for it? pq p-j I?) 

f. Give name of the medicine 

r had any reason to think you may have heart 

pqpiqpj 

b. Did a doctor tell you that you had heart 

trouble? 

If YES, what did he call it? 

, 

c. How long ago did you first start having it? 

Ilyearl -1-5 1 over 5 years 1 

. 

d. Have you had it in the past 12 months? pE-J piiq ri 

e. Do you take any pills or medicine for it? p-j piq Fi 

If YES f. Give name of the medicine 

B. Arthritis and Rheumatism 

27. a. Have you ever had morning stiffness, or weakness 

get up? 

If YES b. How often? pzizq 

c. Does it bother you lquitel 

when you 

I YES 

[ Less often1 

just a little 

28. a. How about swelling of the joints? Have you noticed anything 

like that? 

If YES b. How often? 

c. Does it bother you 

29. a. How about pain in the joints? 

that? 

If YES b. How often? 

c. Does it bother you 

I YES 

, 

Every few days 

Have you noticed anything like 

I YES 

Every few days 

[quite ' 

pixzoften 

piz77q 

j0. a. How about tenderness of the joints? Have you noticed anything 

like that? I YES 

If YES b. How often? Every few days 

c. Does it bother you 

38 
61. a. Have you ever had any reason to think you may have rheuqxtism 

or arthritis? p-1 piq ITI 

If YES or ? b. Did a doctor tell you it was rheumatism or I 

arthritis? pE-jpi-1 

c. How long ago did you first start having it? 

d. Have you had it in the past 12 months? 

e. Do you take any pills or medicine for it? pq%j p-j 

62. a. Has a doctor ever said you '-lad rheumatic fever (inflammatory 

rheumatism) p-j pi5-j 

If YES b. Have you had it in the past 12 months? (YESp--jpJ 

c. Are you taking any pills or medicine for it? 

If YES d. What is it? 

64. Has a doctor ever said you had gout? 

C. Qiabetes 

6% Have you had any recent increase in being thirsty 

(drink a lot of water)? 

70. Have you had any recent increase in urination 

(pass a lot of water)? 

71. am Have you lost any weight recently (without trying to)? 

IF YES: 

b. How much weight have you lost? *- lbs. 

c. Over what period of time have you lost this weight? 

72. a. Has any of your relatives ever had diabetes? pq piq (?I 

IF YES: 

b. Please give relationship of this person or these persons 

to you.: 

39 
aAPPENDIX VIII 

NOTES ON STATI’STICAL DESIGN 

,Outhe of Design Development 

This outline is restricted primarily to the more exclusively statistical aspects of the designing, and within 

that confine to a severely abstracted account. 

As already noted in this report, a survey design is 

the product of an iterative process in which, in sucT 

cessive steps, a closer and closer match is attempted 

among objectives, feasible operating procedures, budget, other resources, and idealized mathematical models, 

In the Health Examination Survey, this process began in 

the summer of 1957 with review of earlier experience 

of others in related matters, with .many staff discussions of problems and possibilities, and with theinitiation of several exploratory and developmental projects. 

These latter projects were to be carried out mostly by 

research contractors, and were intended to shed more 

light on specific examining and measurement techniques 

and on methods of securing favorable response to the 

offer of a clinical examination. Soon there began the 

specifications and procurement of needed equipment. 

By the fall of 1958, the general pattern of the Survey was emerging. It had been decided that the examinations would be conducted in mobile caravans, and 

would, for the first cycle, cover the adult, civilian, noninstitutional population, The general content of the 

examination itself was chosen. It seemed desirable that 

the regular HIS data be obtained for all prospective 

examinees prior to the examination. This step would be 

taken for two reasons: first, it was to be the fundamental sampling procedure, and second, it would provide data which might clarify the relationship between 

the Health Interview Survey and the Health Examination 

Survey. 

Now a streamlined statistical model was developed. 

It contemplated a three-stage sampling process, with 

the first of these stages subdivided into parts, so that 

four levels of units were recognized: Primary Sampling 

Units, locations (of examining places within PSU’s), 

clusters (of households), and persons. To convert the 

purely algebraic model to operational indicators, it 

was necessary to implement the mathematical analysis 

with estimates of likely values of a good many parameters. 

Estimation of needed parameters in a new kind of 

undertaking is always difficult, For this part of the job, 

it included determinations of total budget, overhead 

costs, unit costs for scores of activities, population 

variances for quite a variety of groups of persons, and 

target tolerances for typical end products. The estimates were made. Experience in pretests and data 

from the Health Interview Survey played an important 

role here. 

40 

The formal solution for this first model yielded a 

plan with 38 PSI-J’s, 1,347 clusters of households, and 

5,538 examinees. The scheme envisaged an average of 

about 4 examinees per cluster, 36 clusters per PSU, 

and 146 examinees per PSU. The first results also 

pointed to one location per PSU in areas with low density of population, two locations in medium-density 

areas, and three locations in high-density areas, As 

planning work proceeded, there were many revisionsof 

the estimated parameters, but the final design is very 

similar to the initial model. 

Of technical interest. was the conclusion that the 

l’optimum is broad” for the circumstances of this survey. More specifically, it was decided that there was 

not a great difference in expected precision or cost for 

a design of 30 PSU’s with 200 examinees per PSU, and 

one of 50 PSU’s with about 120 examinees per PSU. 

Some of the scheduling and operating problems, however, would be rather diff&ent for these two situations. 

Many questions remained to be settled before the 

design was complete. Some of these were decided on 

the basis of administrative or supervisory judgment. 

But wherever possible, data from the three pretests 

were utilized in conjunction with principles of securing 

either minimum variance, or minimum cost. Among 

the decisions which have a distinct effect on the design 

are these: 

1. 

2. 

3. 

4. 

5. 

6. 

7. 

80 

9. 

10. 

Making the design essentially self-weighting. 

Introduction of the three subsamples or rounds. 

Use of four or five interviewers at each stand. 

Assignment of examinees alternately to each of 

two nurse-physician teams. 

Selection of an average of one person per household from four households in a segment, rather 

than two persons from each of two households 

in ,a segment. (Both schemes were tested.) 

Insistence that there be close to 150 examinees 

at each location. This step was taken with some 

loss from unequal sampling fractions, but for 

the reasons indicated in another section of this 

report. 

Deletion of a procedure for taking the examination into the home of the sample person who 

would not come to the caravan center. 

Decision to adopt but very limited use of auxiliary medical data for nonrespondents, as distinct 

from other possible courses of using such data 

wherever they might be found. 

Introduction of multiple reading of X-ray and 

EKG charts. 

Pretest tabulation of such readings as height and 

weight, in order to improve coding and recording 

instructions. 
11 . Establishing an itinerary which is geared subjectively to hoped-for maximum response, and 

moderate travel cost, rather than random sequencing. This meant, for example, examining 

all West Coast locations consecutively, avoiding 

northern Wisconsin in midwinter, and avoiding 

New York City in vacation-prevalent July and 

August. In addition, budget shortages at one 

point in time led to a rerouting which was somewhat less desirable than the original choice had 

been. This rerouting also has delayed the completion of Round I by approximately six months. 

Definition of Universe 

The universe to be covered by theHealthExamination Survey is the “civilian, noninstitutional, population 

of the United States.” But every word in this title needs 

more careful definition in the conduct of the Survey. 

The operational definition covers many pages of field 

manuals. Prominent characteristics are the following: 

The United States is restricted for cost reasons 

alone to the mainland, excluding Alaska and Hawaii. 

The time period is considered the “average over the 

three-year period ending late in 1962.” Noninstitutional 

is defined by exclusion through an extensive list of 

types of places. In particular, among the out-of-scope 

places are correctional institutions, resident hospitals 

and nursing-care homes, and homes for the needy. 

Civilian personnel resident at a miltary base are included. 

There is a variety of special cases about which 

there may be difference of opinion as to whether they 

should or should not be within scope. Among these, for 

example, are American Indians living on reservations. 

It was decided that they should be included. There are 

several classes of cases for which inclusion or exclusion is largely a matter of semantics (and associated 

estimation procedures). These arise from the fact that 

the nature of the examining process is such that it is 

restricted to the physically available ambulatory population. For any other person, the choice is to consider 

him out-of-scope, or nonrespondent. Examples of such 

persons are: people who die between the time they are 

selected for the sample and the time they are scheduled 

for examination; persons who are in hospitals, or otherwise physically unable to go or be taken to the caravan 

center; persons in jail (local jails are not considered 

institutions); crews of vessels and other persons who 

are not at their place of residence at any timeat which 

the HES examining team is available in their community. 

On Basic Estimation Technique 

Not so long ago estimates of population parameters 

were limited to inflation of sample data by the reciprocal of the sampling fraction. A wider rangeof possibilities exists today. This greater latitude is largely a 

function of the. doctrine of making maximum use of all 

relevant information. The newer methods include such 

processes as ratio estimation-which will be used in 

the HES summary routine-and regression, difference, 

and poststratification techniques. Data from Round I will 

be used to explore the applicability of some of these 

processes. Of particular interest is possible use of the 

extensive HIS data (some 360,000 persons) in conjunction with the HES raw data. 

th Consider the situation within the a- age-sex category. Assume that the HES interview sample (6,300 

total persons) shows pa1 as the estimated relative number of persons with a characteristic which is correlated with the x-characteristic. As an illustration, say 

pgI, is the estimated proportion from the HESinterview 

of persons with one or more chronic conditions in the 

arthritis or cardiovascular groups, and Z’$ is a preliminary estimated relative number of persons inthose 

groups with a positive cardiovascular examination statistical diagnosis. Similarly pa2 is the HES-interview 

estimate of the proportion of persons without the indicated condition and Z” ’ is the examination estimate of 

82 

the relative number in this latter group with the cardiovascular diagnosis. 

There are from the Health Interview Survey (360,000 

persons) estimates paI and pi2 which correspond, r,espectively, to pal and p”2 , and which have smaller 

sampling variance, It may be, then, that 

X" 

a = y; c pai ““I 

i 

X If 1 

a = y;! c pai ““i’ 

i 

would be, where both y” and a 

of total number of persons 

yi t ar 

in the 

X 

t1 t 

a = ygl’ c pai X’a’i 

i 

is a better estimate than 

‘e sample 

a% class . Note 

estim ates 

that 

is exactlv the estimate 

which would have been obtained if all interview data had 

been disregarded. 

Whether an estimate of the form x” will be utilized a 

or the “preliminary” estimate xa ’ , will be determined 

from analysis of data from Round I. 

Within PSU Sampling Variations 

The typical procedure for selection of examinees 

within a PSU has been described previously in this report. It was stated that the detailed procedure varies 

somewhat from one place to another, Two of the variations, used in several places, are described briefly 

here. 

In the later stands of the cycle, use is made of data 

which have become available from. the 1960 Population 

Census. In order to reduce costs, the principal part of 

the sample is drawn from the address registers which 

were established as a part of the Census-taking process. These list samples are then supplemented with 

samples of new construction-obtained from building 

permit files- in order to cover addresses which were 

not in existence at the time of the Census. For the major part of the list sample, “Super-segments” of 20 

adjacent addresses are drawn, and then subsampled to 

produce the standard HES subsegment of an expected 

four households. 

For very large metropolitan areas, even with two 

or more locations of the examining caravan, it is quite 

difficult and costly to persuade sample persons from 

41 
all parts of the area to come to the examining center. 

For such areas, an additional subsampling stage has 

been introduced. This. has been termed the “satellite” 

system. It is illustrated in the stylized figure 1. The 

metropolitan area is divided into seven subareas: a cen- 

. < tral city, and six radial arms. The final sample area 

consists of the central city, and two of the six satellite 

areas, the latter being drawn randomly and withinsampled more heavily so that they represent the total 

satellite territory. Two locations of the caravans are 

used, at places appropriate for travel to and from the 

chosen subareas-in figure 1, say, at points A and B, if 

satellite areas II and V are drawn into the sample. 

Figure 7. Locations A and 6 for a major metropolitan area in which the sampie areas are the Central City and subareas I1 and V of the six satellite 

territories. 

The Master Control Card 

With the complex survey design, and many variable 

factors associated, with the undertaking, it is necessary 

to know rather precisely the status of every sample 

person, For this purpose, and for ultimate use in instructing the electronic computer for data processing, 

a master control card is established for each sample 

person. Through the common tie of examinee number 

(which is assigned to each sample person, whether 

examined or not), information on the control card can 

be integrated with any other data which pertain to that 

examinee. 

The master control card contains the following 

items: a set of eight basic design weights which account for all stages of sample selection and variations 

in the central design; a set of four estimation weights 

which reflect relevant interview data and population 

controls; a single one-digit summary weight for use in 

experimental and preliminary punchcard procedures; 

the examinee number; stand number (PSU); segment 

number; superstratum number (geography and population density); first-stage type (certainty or noncertainty); round number; second-stage selection code (satellite status); location code (within PSU); age; sex; and 

examination status (showing whether examined; if not, 

why; and if auxiliary data obtained, source of data), 

Illustration of Selection of a Stand 

The illustration is for the selection of one of the 

stands in the E-cell matrix which represents “Other 

SMSA’s in the South,” and more specifically that.one of 

the 42.strata described as “southern SMSA% with less 

than 141,000 population in 1950 plus 6 larger southern 

SMSA’s with similar characteristics.” 

Table I. Data for selection or a stand 

(small southern SMSA’s) 

Substratum 

in 500 area design 

1,. Orlando, Fla. 

2. Baton Rouge, La. 

3. Montgomery, Ala. 

4. Lubbock, Tex. 

Wichita Falls, Tex. 

5. Durham, N.C. 

Winston-Salem, N.C. 

6. Jackson, Miss. 

7. Gadsden, Ala. 

Lexington, Ky. 

8. Roanoke, Va. 

9. Greenville, S.C. 

10. Waco, Tex. 

Galveston, Tex. 

Il. Savannah, Ga. 

12. Asheville, N.C. 

Raleigh, N.C. 

13. Augusta, Ga. 

14. Mobile, Ala. 

15. Amarillo, Tex. 

Laredo, Tex. 

San Angelo, Tex. 

16. Corpus Christi,Tex. 

17. Shreveport, La. 

18. Macon, Ga. 

Stratum total-- 

Substratum 

population 

in millions 

in 1950 

114 114 

156 156 

138 138 

199 101 

246 101 

141 

192 

133 133 

167 167 

241 129 

151 151 

258 123 

162 162 

228 228 

201 

164 164 

174 174 

134 134 

3,199 

500 area 

sample 

PSU 

1950 

POPU- lation 

141 

94 

87 

Table I exhibits pertinent information. This stratum had 3,199,OOO population in 1950. Some of the 18 

substrata contain more than one PSU, but each substratum was represented in the SOO-area design by a single 

PSU; namely the one for which 1950population is shown 

in the right-hand column of the table. Controlled selection had determined earlier that in the 42-area design 

42 
this stratum was to be represented by either a Florida Each of these areas had first been picked with 

or a Georgia PSU. Consequently the Florida and probability proportionate to size (PPS) to represent its 

Georgia PSU*s (of the 500 area sample) were listed stratum; a single choice was made among the four, 

along with cumulative population: 

PSU Stratum 1950 

popu lat ion 

Orlando, Fla. 114 

Savannah, Ga. 151 

Augusta, Ga. 162 

Macon, Ga ,, 134 

Cumulative 

population 

114 

265 

427 

561 

again with PPS, so that the total process is a selection 

with PPS. The random number in this instancewas 119, 

and thus selected Savannah, Georgia, to represent the 

stratum of 25 PSU’s. The reciprocal of over-allprobability of selection of Savannah is 3,199,000/151,000, or 

21.19. It should be noted in this process that the population weight ascribed to the PSU’s among which selection 

is made is that of the stratum (in the 500 area design) 

from which it came, and not just the population of the 

selected PSU. 

*U.S. GOVERNMENT PRINTING OFFICE : 1965 0 - 775-521 

43 
REPORTS FROM THE NATIONAL CENTER FOR HEALTH STATISTICS 

Public Health Service Publication No. 1000 

Series 1. Programs and collection procedures 

NO. 1. Origin, Program, and Operation of the U.S. National Health Survey. 35 cents. 

No. 2. Health Survey Frocedure: Concepts, Questionnaire Development, and Definitions in the Health Interview Survey. 45 cents. 

No. 3. Development and hlaintenance of a National Inventory of Hospitals and Institutions. 25 cents. 

No. 4. Plan and Initial Program of the Health Examination Surv*cy. 

Series 

No. 

No. 

No. 

No. 

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NO. 

No. 

No. 

No. 

No. 

2. Data evaluation and methods research 

1. Comparison of Two-Vision Testing Devices. 30 cents. 

2. Measurement of Personal Health Expenditures. 45 cents. 

3. The One-Hour Glucose Tolerance Test. 30 cents. 

4. Comparison of Two hlethods of Constructing Abridged Life Tables. 15 cents. 

5. 4n Index of Health: Mathematical Models. 

6. Reporting of Hospitalization in the Health Interview Survey. 

7. Health Interview Responses Compared With Medical Records. 

8. Comparison of Hospitalization Reporting in Three Survey Procedures. 

9. Cooperation in Health Examination Surveys. 

10. Hospital Utilization in the Last Year of Life. 

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No. 1. The Change in Mortality Trend in the United States. 35 cents. 

No. 2. Recent Mortality Trends in Chile. 30 cents. 

Series 4. Documents and committee reports 

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Series 10. Data From the Health Interview Survey 

No. 1. 

No. 2. 

No. 3. 

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No. 5. 

No. 6. 

No. 7. 

No. 8. 

No. 9. 

No. 10. 

No. 11. 

NO . 12. 

No. ‘13. 

No. 14. 

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No. 16. 

No. 17. 

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Family Income in Relation to Selected Health Characteristics, IJnited States. 40 cents. 

Length of Convalescence After Surgery, United States, July 1960-June 1961. 35 cents. 

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Current Estimates From the Health Interview Survey, United States, July 1962-June 1963. 35 cents. 

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Acute Conditions, Incidence and ,4ssociated Disability, United States, July 1962-June 1963. 45 cents. 

Health Insurance Coverage, United States, July 1962-June 1963. 35 cents. 

Bed Disability Among the Chronically Limited, LJnited States, July 1957-June 1961. 45 cents. 

Current Estimates From the Health Interview Survey, United States, July 196%June 1964. 40 cents. 

Illness, Disability, and Hospitalization Among Veterans, United States, July 1957-June 1961. 35 cents. 

Acute Conditions, Incidence and Associated Disability, IJnited States, July 1963-June 1964. 40 cents. 

Health Insurance, Type of Insuring Organization and Multiple Coverage, United States, July 1962-June 1963. 35 cents. 

Chronic Conditions and Activity Limitations, United States, July 1961-June 1963. 35 cents. 

Series 11. Data From the Health Examination Survey 

No. 1. 

No. 2. 

No. 3. 

No. 4. 

No. 5. 

No. 6. 

No. 7. 

No. 8. 

No. 9. 

Cycle I of the Health Examination Survey: Sample and Response, United States, 1960-1962. 30 cents. 

Glucose Tolerance of .4dults, United States, 1960-1962. 25 cents. 

Binocular Visual Acuity of Adults, United States, 1960-1962. 25 cents. 

Blood Pressure of Adults, by Age and Sex, United States, 1960-1962. 35 cents. 

Blood Pressure of Adults, by Race and Region, United States, 1960-1962. 25 cents. 

Heart Disease in Adults, United States, 1960-1962. 35 cents. 

Selected Dental Findings in Adults, United States, 1960-1962. 30 cents. 

Weight, Height, and Selected Body Dimensions of Adults, United States, 1960-1962. 

Findings on the Serologic Test for Syphilis in .4dults, IJnited States, 1960-1962. 

Series 12. Data From the Health Records Survey 

No reports to date. 

Series 20. Data on mortality 

No reports to date. 

Series 21. Data on natality, marriage, and divorce 

No. 1. Natality Statistics :!nalysis, United States, 1962. 45 cents. 

No. 2. Demographic Characteristics of Persons Married Bctvvccn January 1955 and June 1958, United States. 35 cents. 

Series 22. Data from the program of sample surveys related to vital records. 

No reports to date.