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Department of

Agriculture

Economic

Research

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Rural Development

Research Report

Number 86

Health Status and

Use of Health Care

Services by the

Population

A Residential Comparison

Carolyn C. Rogers

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Health Status and Use of Health Care Services by the Older Population:

A Residential Comparison. By Carolyn C, Rogers, Agriculture and Rural Economy

Division, Economic Research Service, U.S. Department of Agriculture. Rural

Development Research Report No. 86.

Abstract

Although the majority of elderly persons are, and perceive themselves to be, in good

health, health status differs by residential location, with a higher proportion of

nonmetro elders reporting their health as fair or poor (35 percent) than metro elders

(29 percent). The nonmetro elderly are also more likely to have certain chronic

conditions, such as arthritis, that are clearly associated with poorer physical

functioning. Differences in elders* self-assessments of health and physical functioning

remain evident when other factors, such as age, race, social support networks, income,

and education are accounted for. The nonmetro elderly use less health care (compared

with metro residents) than is commensurate with their health status. This suggests that

there is a gap between the nonmetro elderly's need for care, based on then- poorer

health status and lower socioeconomic standing, and the availabihty of services to meet

this need. This report uses data from the 1984 Supplement on Aging to the National

Health Interview Survey to describe the nature and magnitude of differences in healüi

status and use of health care services by the older population, by place of residence.

Keywords: Elderly, older population, health status, health care services, metrononmetro residence

Acknowledgments

The author thanks David A. McGranahan, Paul Frenzen, and Linda L. Swanson

(Economic Research Service) for their critical review. Susan G. Cooley (Department

of Veterans Affairs) and Jane Takeuchi (American Association of Retired Persons)

provided constructive comments in reviewing the report. The author appreciates the

assistance of Kimberly R. McCray, Monique Ceruti, and Dominique N. Harris m

preparing the manuscript and tables for publication. Appreciation is also extended to

Teri Thrash (Economics Management Staff) for editorial assistance.

Washington, DC 20005-4788 September 1993
Contents

Page

Summary iii

Introduction 1

Previous Research 2

Health Status 2

Use of Health Care Services 3

Social Support Networks . 3

Current Study Design . 4

Source of Data 4

Definitions and Methods 4

Results by Residence and Selected Characteristics 6

Socioeconomic Characteristics of Persons Aged 60 Years and Older 6

Social Support Networks 6

Health Status of Persons Aged 60 and Older, by Residence 8

Use of Health Care Services, by Residence 12

Conclusions 15

References 16

List of Tables

1. Demographic and socioeconomic characteristics of the elderly,

by residence, 1984 19

2. Social support networks and use of community services by the elderly,

by residence, 1984 21

3. Summary measures of health status of the elderly, by age and residence, 1984 . 22

4. Functional status of the elderly, by residence, 1984 23

5. Proportion of the elderly reporting their health as fair or poor,

by residence and selected characteristics, 1984 24

6. Proportion of the elderly with one or more ADL and lADL difficulties,

by residence and selected characteristics, 1984 25

7. Use of health care and community services by the elderly, by age and

residence, 1984 26

8. Proportion of the elderly who used no formal health care services,

by residence and selected characteristics, 1984 27

9. Proportion of the elderly in fair or poor health who used no formal health

care services, by residence and selected characteristics, 1984 28

Appendix Tables

1. Social support networks and use of community services by tiie elderly,

by age and residence, 1984 29

2. Self-reported health status of tiie elderly, by age and residence, 1984 31

3. Disability among the elderly, by age and residence, 1984 32

4. Self-reported health status of the elderly, by residence and selected

characteristics, 1984 34

5. Functional status of the elderly, by residence and selected chamcteristics, 1984 . 37

6. Functional limitations of üie elderly, by residence and

selected characteristics, 1984 40

7. Use of health care services by the elderly, by age and residence, 1984 43

8. Use of formal healtii care services by üie elderly, by residence and

selected characteristics, 1984 46

9. Use of formal health care services by the elderly in fair or poor health,

by residence and selected characteristics, 1984 49
Summary

The majority of persons aged 60 years and older are, and perceive themselves to be, in

good health. But, health status differs by place of residence, with a higher proportion

of nonmetro elders reporting their health as fair or poor (35 percent) than metro elders

(29 percent). The nonmetro elderly are also more likely to have certain chronic

conditions, such as arthritis, that are clearly associated witli poorer physical

functioning. Differences in elders' self-assessments of health and physical functioning

remain evident by residence when other factors, such as age, race, social support

networks, income, and education are held constant.

This report uses data from the 1984 Supplement on Aging to the National Health

Interview Survey conducted by the National Center for Health Statistics. This data set

is the latest available and the most appropriate because it provides a large enough

sample size to study differences in the elderiy's health and other characteristics

separately by residence. The report describes the nature and magnitude of differences

in health status and use of health care services by the older population, by place of

residence.

Socioeconomic status, as measured by education and income, is important to the health

status of the elderiy, with higher socioeconomic status associated with better health.

This effect is magnified in nonmetro areas, where elderiy persons are generally less

educated and have lower incomes than the metro elderly. Social support networks are

strong in nonmetro areas, but not enough to overcome the effects of the nonmetro

elderiy's lower socioeconomic status.

The nonmetro elderly are less likely to use formal health care services, defined as

physician visits, hospital stays, and nursing home care, than are their metro

counterparts. The nonmetro elderiy's poorer health and lower socioeconomic status,

combined with lower use of services, suggests that a gap exists between the nonmetro

elderiy's need for care and the availability of services to meet this need.

Other findings of this study are as follows:

• 71 percent of metro elders reported their healtlii as good to excellent in 1984,

compared with 65 percent of nonmetro elders.

• 53 percent of nonmetro elders had arthritis, compared with 47 percent of metro

elders.

• Metro-noimietro differences in physical functioning diminish with age.

• Among the nonmetro elderiy, 40 percent with incomes of less than $20,000

reported their health as fair or poor in 1984, compared with 19 percent with

incomes of $20,000 or more.

• 82 percent of metro elderiy persons used fonnal health care services, while 79

percent of the nonmetro elderiy reported such use.

in
Health Status and Use of Health Care

Services by the Older Population:

A Residential Comparison

Carolyn C. Rogers*

Introduction

The U.S. population is aging, with concomitant changes

in the structure of the family and in health and social

services. In 1990, 42 million Americans were elderly, or

aged 60 and older, with 26 percent residing in

nonmetropolitan (nonmetro) areas. The population aged

60 and older increased 17 percent between 1980 and

1990, 19 percent in metropolitan (metro) areas and 12

percent in nonmetro areas.' The most rapidly growing

segment of the older population is the oldest old, or those

aged 75 and older. Between 1980 and 1990, the oldest

old in metro areas increased 33 percent, and their

nonmetro counterparts increased 30 percent. Older

persons are at greater risk of disability, and are more

substantial users of health, medical, and otiier services

than the general population. With an aging population,

the number of persons aged 60 and older with disabilities

is increasing, creating a greater need for medical,

rehabilitative, and social services.

Awareness of the special needs of the rural elderly has

increased, along with the increase in size and visibility of

the older population. The level and determinants of the

health status of the older population by residential

location have not received as much attention as have

variations in the healtii status of the elderiy by

demographic and socioeconomic characteristics. This

study focuses on the health status and use of health care

services by the nonmetro elderly living in the community,

compared with their counterparts in metro areas. The

survey data used in this report exclude the

institutionalized elderly, who represent 5 percent of the

older population. Tliirty-two percent of current nursing

home residents are nonmetro elderiy, and 39 percent of

*Carolyn C. Rogers is a Demographer with the Agriculture and Rural

Economy Division, Economic Research Service, U.S. Department of

Agriculture.

'Metro-óonmetro is used interchangeably with urban-rural in this

report Metro is defined as a county or counties consisting of a large

population nucleus of 50,000 or more inhabitants, together widi adjacent

communities that have a high degree of economic and social integration

with that nucleus. Nonmetro refers to counties outside a metro area.

nursing homes are located in nonmetro areas (National

Center for Health Statistics, 1989).^

The availability and accessibility of health care services is

critical for the quality of life for many older Americans.

The nonmetro elderly use health care services less than

the metro elderly, as recognized in a 1988 report by the

National Research Council The availability of health

care services often poses problems in low-density,

sparsely populated nonmetro conmiunities. Many of

these communities are both far from sophisticated

medical care, which is concentrated in metro centers, and

restricted in their ability to provide comprehensive

services in their own jurisdictions. An understanding of

tiie nature of the relationship between residential location

and health status is essential to the allocation of health

care and community resources and the planning of

appropriate health care services in rural areas.

Rural residence may have boüi positive and negative

effects on health. Because rural areas generally have

cleaner air, are less congested, and have a slower pace

than urban areas, one might expect better healtii for tiie

riiral aged. On the otiier hand, one can argue that tiie

lower incomes of tiie rural elderly, less adequate medical

services, and less adequate housing and transportation

would contribute to poorer health for the rural elderly.

The importance of research on residential differences in

healtii status and health service use is evident.

The increasing number of older persons, their greater risk

of disability, and tiieir greater use of health care services

have increased the need for a more complete

understanding of the nature and magnitude of differences

in health status and use of health care services by tiie

older population by place of residence. The aim of this

study is to better understand older Americans and how

their demographic and socioeconontic characteristics, as

well as tiieir social support networks, affect their health

^Nonmetro areas have a larger share of nursing home beds (6,599 beds

per 100,000 elderly residents) than metro areas (5,257 beds per

100,000).
and use of health care serviœs. The study focuses on

factors that differentiate the nonmetro elderly from the

elderly in central cities and suburban areas in terms of

health status, family structure and living arrangements,

social and community support, economic well-being, and

the use of health care services.

This report addresses the following issues:

• Do elderly persons residing in nonmetro areas differ

from their counterparts in central cities and suburban

areas with respect to health status? And, if so, what is

the magnitude of the difference?

• How do place of residence and demographic and

socioeconomic characteristics affect the health status of

the elderly?

• Do elderly persons residing in nonmetro areas use

health care services to a greater or lesser extent than

their counterparts in central cities and suburban areas?

• How do health status, demographic and socioeconomic

characteristics, and social support networks within

nonmetro areas, central cities, and suburban areas

affect use of health care services?

Previous Research

Several research studies have described residential

differences in the health status and use of health care

services by the older population. Other studies have

examined the effects of the elderly's social support

networks on their health status and subsequent use of

health care services. This section will highlight previous

research work that is relevant to the present analysis.

Health Status

The majority of research on the health status of the rural

or nonmetro elderly indicates that they have poorer health

and higher incidences of health problems than their urban

or metro counterparts (Coward and Lee, 1985; Krout,

1989; National Center for Health Statistics, 1984).

Several research studies have found that the rural elderly

have a greater number of health problems and more

severe disabilities than their urban counterparts, and that

more rural elderly persons retire for health reasons

(Coward and Lee, 1985; Davenport and Davenport, 1977;

Lassey, Lassey, Lee, and Lee, 1980; McCoy and Brown,

1978; and Palmore, 1983). Among the low-income

elderly, chronic disorders and impairments were found to

be more prevalent among rural than urban residents, even

when sex, age, and race were statistically controlled

(McCoy and Brown, 1978).

Some studies, however, have not found significant ruralurban differences in the health status of the elderly. A

detailed examination of national health statistics by the

Urban Institute found some differences based on

residence, although these differences were usually neither

large nor consistent. Place of residence (rural-urban) is

not associated in general with significant differences m

health status (Paringer, Bluck, Feder, and Holahan, 1979).

Looking at residential differences in self-assessed health,

Krout (1989) found no significant differences for

residence, but did find differences for race, household

income, education, and length of residence in the

community. More positive health assessments were

found for elderly persons who are white, better educated,

wealthier, and longer term residents of their communities.

The Urban Institute study is a useful starting point for the

present analysis. It is the most recent full-scale study that

examines the relationship between place of residence and

health status, altiiough the study, published in 1979, is

dated. A major problem with the study is that the authors

presented their results without evaluating the relative

merits of üie various measures used. Mortality rates

showed slight differences, but without a consistent pattern

by residence. Incidence of acute illness was found not to

vary significantly by place of residence. However,

among the low-income elderly in rural areas, the

prevalence of chronic conditions and activity limitations

was greater than among their counterparts in urban areas.

Based on bed disability days, the data suggested that the

elderly in rural areas may have had somewhat poorer

health status than those living in other parts of the

country. The relationship between health status and place

of residence varied, depending on the health status

measure being used in the analysis, and tiie authors

offered no interpretation of the different findings.

The Urban Institute study also found significant

differences based on self-assessments of health by place

of residence. Elderly persons in nonmetro areas were 25-

30 percent more likely to rate their health as fair or poor

than were their counterparts in metro areas, which

confinns residential variations found in other healüi status

measures. This finding appears to negate the authors'

conclusions of no significant residential differences, in

that self-assessed healtii status is one of tiie best

indicators of health. Self-reporting of health status by tiie

elderly correlates well with ratings by physicians and

survival rates, and is a useful survey instrument

(Ouslander and Beck, 1982).

Not all previous studies have clearly demonstrated that

residential location has an independent effect on health.

In light of these inconsistent findings, more systematic

research is needed to assess the nature of healtii status

differences by place of residence and to determine
whether rural residence in itself is a disadvantage. Ruralurban differences in health status may result from

intervening factors, such as lower income, exposure to

health risks, and poorer health care services. For

example, a nonmetro disadvantage in health status may be

associated with lower socioeconomic status (lower income

and educational levels) in nonmetro areas.

Use of Health Care Services

Signifícant differences exist in health care services for the

elderly by residence. Substantial evidence has indicated

that the range of services for elders living in small towns

and rural communities is narrower, that fewer service

alternatives are available, that rural health and human

services are less accessible and more costly to deliver

than in urban areas, and that fewer healüi care providers

exist in rural areas to offer particular services (Coward

and Rathbone-McCuan, 1985; Coward and Cutier, 1989;

Coward and Lee, 1985; Krout, 1986; Raüibone-McCuan,

1981; and Taietz and Müton, 1979).

The continuing inadequacies in the number and types of

facilities and services available in many rural

communities have been well documented (Coward and

Lee, 1985). In a study of rural and urban counties in

upstate New York, for example, urban counties had

significantiy more services available üian did rural

counties (Taietz and Milton, 1979). From a national

sample of area agencies on aging (AAA's), Nelson (1980)

found üiat rural AAA's were particularly weak in fiscal

and professional staff resources necessary to develop a

broad range of care. Rural service netwoiks also tended

to have the greatest deficiencies in the services most apt

to be needed by the severely disabled living in tiie

conmiunity. A large and signifícant rural disadvantage

existed in the availability of adult day-care services,

homemaker services, and foster care (Nelson, 1980). In

addition, Krout (1989) found a rural disadvantage in

health service availability and accessibility.

Rund areas have fewer health resources and services and

a lower ratio of doctors, nurses, pharmacists, and other

health care personnel to elderly residents than metro areas

have (Krout, 1986; Lassey and Lassey, 1985). The health

care facilities most needed by the elderly are hospitals,

nursing homes, and residential care homes. Although tiie

nursing home component of the long-term care network

serves only a small proportion of elders at any one point

in time (about 5 percent of the elderly population), it

consumes the largest proportion of public dollars spent on

tiie elderly (Coward and Cutier, 1989). The lower

physician-to-population ratio in rural areas suggests that

rural residents may visit doctors less frequentiy because

physicians are less accessible. Distance is also a major

factor in accessibility of services; rural residents face

longer travel and waiting times when they visit physicians

(Paringer, Bluck, Feder, and Holahan, 1979).

Social Support Networks

Social support (familial and nonfamilial) is usually

thought to be beneficial to health and longevity, and may

have a moderating effect on health status and the use of

formal healtii care services by the elderly. Married

persons use health care services less frequentiy, either

because they can substitute home health care (informal

care) for formal health care or because marriage confers

other benefits, such as improved health status, that also

might be characteristic of nonmarried people who live

with otiiers (Cafferata, 1987). A spouse is the most

important source of help in times of illness, especially for

men; adult children living inside the house, and to a

lesser extent siblings, are also important sources of help

during illness (Shanas, 1979). Proximity and contact with

friends and relatives are also important in assisting

elderly persons in a wide variety of personal care

activities and basic tasks of everyday living (Palmore,

1976; Stoller and Earl, 1983).

Formal social support may be more important in the

absence of sources of informal support, such as a spouse,

children, other relatives, friends, and neighbors.

Measures of formal social support include participation in

formal organizations, religious participation, and

nonfamilial social relations. Living with others may

reduce the need for the use of formal health care services

(such as physician visits), independentiy of marital status,

because of tiie substitution of home care (family

members) for formal health care and/or the enhancement

of physical and mental health.

Several studies have supported the substitution effect,

where informal or family resources (presence of a spouse

or adult child who can care for an elderly person) are

substituted for formal health care resources. Using data

from the National Medical Care Expenditure Survey,

Cafferata (1987) found diat elderly persons living witii

otiiers were more likely to stay in bed, but less likely to

see a doctor, üian were persons who lived alone. Less

use of formal health care services was also found among

both married persons and nonmarried persons living witii

others (Greene, 1983). Another study confirmed tiie

importance of living arrangements, finding tiiat elderly

nonmarried individuals who lived with others had a lower

volume of physician visits than did married individuals

(Stoller and Earl, 1983).
Current Study Design

This study examines the importmice of residential location

on the health status and use of health care services by the

older population. The analysis is based on the 1984

Supplement on Aging (SOA), a special supplement to the

National Health Interview Survey (NHIS). The 1984

SOA is the most appropriate data set for this analysis

because it provides a large enough sample size to study

differences in the elderly's health and other characteristics

separately by residence-central city, suburban, and

nonmetro--and is the latest and richest source of data.

Source of Data

The NHIS is an annual household interview survey of the

civilian noninstitutional population of the United States

conducted by the National Center for Health Statistics

(NCHS). All interviews are conducted in person by

trained Bureau of the Census interviewers with a family

member most knowledgeable about the family's health.

The 1984 SOA obtained more detailed information about

the health status, social characteristics, and living

arrangements of persons 55 years of age and older who

were living in the community, with a total sample of

16,148 respondents. The interviews were conducted with

14,783 of the sample persons themselves, or 91.5 percent

of the entire SOA sample. The remaining 1,365

interviews were proxy respondents for people unable to

respond for themselves because of physical or mental

impairments, hospitalization, or other extended absence

from the household. Proxy respondents were ahnost

always a relative living in the same household and

knowledgeable about the sample person, usually a spouse,

sometimes a sibling or child.

The SOA produced an extensive cross-sectional data file

about persons 55 years of age and older. A broad

spectrum of topics related to health, social functioning,

and living arrangements of older persons living in the

community was covered. Information was included on

family structure, relationships, and living arrangements;

community and social support and use of community

services; occupation and retirement and sources of

retirement income; health conditions and impairments;

activities of daily living (ADL's), instrumental activities

of daily living (lADL's), and functional limitations;

prevalence of chronic conditions; nursing home stays; and

opinions about one's own health.

Because the SOA was a survey of the noninstitutional

population, some selection bias was present from

excluding the institutionalized elderly, especially those

aged 85 and older. To the extent that the institutionalized

elderiy have more functional limitations than their

noninstitutionalized counterparts, the prevalence of

limitations for the total elderly population are

underestimated in this report.

Definitions and Methods

The older population, or the elderly, in this report are

persons 60 years old and older. The older population is

commonly referred to as persons aged 65 and older;

however, 60 years and older is often used and is preferred

in this study due to sample size considerations. Data are

presented for the young old, ages 60 to 74 years, and the

oldest old, ages 75 and older, because the aging process

itself leads to a number of changes in an individual's

social and economic conditions, and because many health

problems and functional limitations do not become

evident until late in life. The older population is a

diverse group, and many differences among the elderly

are age related. In many cases, data are presented for the

entire age group, 60 years old and older, because either

the subgroup of the population is very small (such as

minority elders) or the event is relatively rare (such as the

percentage who had ever been a patient in a nursing

home). The SOA is the most appropriate data source for

this study because it provides a large enough sample size

to make numerous subgroup comparisons, such as

differences in health status by income level.

Place of residence is one of many factors that can affect

the health of the elderly. Research that focuses

exclusively on the rural elderly, and thereby fails to treat

residence as a variable, cannot go beyond the descriptive

level and is limited in terms of promoting an

understanding of the implications of residence for the

lives of the elderly. The dichotomy metro-nonmetro

conceals important differences within the residential

areas. This study expands the residential classification

into nonmetro, suburban, and central city.^

The social and economic diversity Üiat exists in sm^l

towns and rural communities has been well documented

(Coward and CuUer, 1988; Dillman and Hobbs, 1982).

Consequently, dichotomous residential comparisons

(rural-urban or metro-nonmetro) are limited, and an

analytical framework that reflects greater residential

variation would be preferable. Both size of place and

proximity (adjacency) to a metro area are important

variables to consider, however, such geographic detail is

available only from the decennial census of population.

*Tlie metro-nonmetro designation in the 1984 SOA is based on the

1970 decennial census area definition. This artificially inflates the

nonmetro population, as many nonmetro areas became metro in the

1980 decennial census.
Health stattis is traditionally conceptualized as the

presence or absence of disease. Defining health in tenns

of disease ignores a critical concept of the health of the

elderiy-functional status (Ouslander and Beck, 1982).

The hnpairment of functioning, in tenns of basic

activities of daily living (ADL's) and instrumental

activities of daily living (lADL's), has important

consequences for elderly individuals' abilities to cope

with disease and illness, as well as their need for healüi

care services. Hence, including some measure of

functional status in defining the health of the elderly is

critical. For a more complete assessment of health status,

this study examines several measures: self-reported health

assessments, functional limitations, and limitations in

abilities to perform basic ADL*s and lADL's.

Self-reporting of healÜi among the elderly correlates well

with both ratings by physicians and survival rates,

especially among those under age 85, and is therefore a

useful survey technique (Ouslander and Beck, 1982).

This report presents data on self-assessments of health

and reports on certain chronic conditions. Self-reporting

in personal interviews can provide useful estimates of the

prevalence of medical conditions and functional

disabilities in the elderly (Ford and others, 1988).

Activities of daily living, or ADL*s, are the basic tasks of

everyday life, including bathing or showering, dressing,

eating, transferring (getting in or out of a chair or bed),

walking, getting outside, and using or getting to a toilet.

When people are unable to perfonn these activities, they

need help either from other persons or via mechanical

aids or devices. With advancing age, the prevalence of

functional limitations tends to increase; a higher

proportion of persons have difficulty performing personal

care or home management activities as tiiey age Pawson,

Hendershot, and Fulton, 1987). ADL's, especially

measures of mobility such as walking and getting outside,

are key indicators of one's ability to live independenfly in

the community and are also significant predictors of

admission to nursing homes (Branch mid Jette, 1982), use

of paid home care (Soldo and Mantón, 1985), and use of

hospital and physician services (Wan and Odell, 1981).

ADL's do not measure the full range of activities

necessary for independent living in the conununity, and

instrumental activities of daily living (IADL's) were

developed to partially fill tiiis gap. IADL's include meal

preparation, shopping for personal items, managing

money, using the telephone, doing heavy housework, and

domg light housework. lADL disabilities capture those

activities that are more complex and less severe tiian

ADL difficulties.

A third measure of functional ability includes walking a

quarter of a mile, walking up 10 steps, standing for 2

hours, sitting for 2 hours, stooping, aouching, or

kneeling, reaching up overhead, reaching out as if to

shake hands, using fingers to grasp, lifting or carrying 25

pounds, and lifting or carrying 10 pounds. The

prevalence of functional limitations is an important

indicator of quality of life and of the need for health and

social services in an aging population.

Estimates of functional limitations in this report are

conservative estimates. Persons who did not perform

certain activities for reasons unrelated to healtii, such as

men who did not cook because tiieir wives did so, and

those who did not respond were included in the base

populations (but not the numerators) of the proportions of

persons having difficulty with each activity. The

proportions of persons experiencing difficulty would have

been higher had the analysis been restricted to individuals

who routinely performed each activity (that is, to

individuals at risk of health-related problems in

performing ADL's and lADL's). Because some of the

individuals in these two categories may have had

unreported problems performing ADL's or IADL's, the

extent of functional disability is thus slightiy understated.

Krout (1989) developed an index of health dependency

that included the following measures: 12 or more

physician contacts over the last 12 montiis, 31 or more

days of hospitalization, being restricted at home for 1

month or more, overnight or longer admission to a

nursing home, having received nursing services at home,

having received homemaker services, having meals

delivered at home, use of a walker, and use of a

wheelchair. Elderly respondents identified as having used

none of the services were categorized as self-sufficient,

those using only one as slightiy dependent, and those who

had used two or more as care dependent. Krout

attributed tiae lower health dependency found in nonmetro

areas to tiie lesser availability of health and medical

services in nonmetro areas. Although his measure can be

criticized for confounding health status with health

service availability and use, it is instructive for

constructing a measure of the use of health services.

This study incorporates Krout's health dependency

measure into an index of health care service use. Health

care services can be meaningfully divided into informal

and formal health care services. Informal care consists of

care provided by family, friends, and neighbors. Formal

care consists of physician visits, hospital stays, and

nursing home stays. The elderly were characterized as

eitiîer using no formal care services or by tiie extent of

their use of these services. Those categorized as having

some or moderate use of formal care are persons who

either had 1-11 doctor visits in the past year, hospital

stays of 1-30 days in the past year, or no nursing home

stays. High use was defined as 12 or more doctor visits
within the past year, 31 or more days of hospitalization,

or nursing home stays for one or more nights.

Contingency table analysis is used to uncover the

bivariate relationship between residential location and

health status and use of health services, taking into

account the effects of demographic and socioeconomic

factors."* Controls are introduced to determine whether

the relationship between residence and health conditions

of the elderly is affected by demographic and

socioeconomic characteristics. Many previous studies of

health differences by residence are based on small

surveys of local areas or bivariate analyses of national

data, without tests for statistical significance or controls

for the effects of socioeconomic status. Advantages of

this study are its use of a national data set (SOA), tests

for statistical significance, more than one measure of

health status, and controls to determine the effects of

residential location on health status and the use of health

care services.

Results by Residence and Selected

Characteristics

The following sections of the report show residential

differences among older persons in tenns of their

socioeconomic characteristics, social support networks,

health status, and use of health care services.

Socioeconomic Characteristics of Persons Aged 60

Years and Older

Socioeconomic status differs by residential location. The

nonmetro elderly tend to be less educated and financially

worse off than their metro counterparts. The lower

socioeconomic status of the nomnetro elderly has

important implications for their health and use of health

care services.

Although different from the younger population in many

social, economic, and health characteristics, the elderly

are not a homogeneous group. There are considerable

differences among persons aged 60 and older in marital

status and living arrangements, social support networks,

educational and income levels, residential location, and

geographical region (table 1). One usually expects these

factors to be related to health status and the need for

medical care. While the elderly differ in many

demographic and social characteristics, this study focuses

on socioeconomic differentials, because such differences

have a large impact on the health of the elderly.

*A11 differences in the text are significant at the 95-percent level of

confidence.

The nonmetro elderly are more likely to own their own

home; however, their overall socioeconomic status, as

measured by income and education, is lower than that of

the metro elderly. Nonmetro elders tend to be less

educated and to have lower incomes and fewer sources of

retirement income (table 1). Fifty-three percent of

nonmetro elders had less than a high school education,

compared with 49 percent in central cities and 42 percent

in the suburbs (fig. 1). In addition, nonmetro elders were

worse off financially than their metro counterparts,

especially those in suburban areas. Seventy-five percent

of nonmetro elders aged 60 and older had incomes less

than $20,000, compared with 69 percent of those in

central cities and 56 percent in the suburbs (fig. 2). Not

unexpectedly, more elderly persons were below the

poverty level in nonmetro areas than in metro areas.

Social Support Networks

The social support networks of the nonmetro elderly are

about as strong as those of their suburban counterparts.

Suburban and nonmetro elders are more likely to have

someone who could provide needed care; they are also

less likely to live alone than their central city

counterparts. Social support is usually beneficial to

health and may also have a moderating effect on the

elderly's use of fonnal healüi care services.

Social support comes from a variety of sources. Living

arrangements, availability of potential caregivers, contacts

with friends, neighbors, and relatives, involvement in

social activities, and use of community services are all

measures of social support networks. By most measures,

nonmetro and suburban elders fare better than central city

elders. Nearly two-thirds of both nonmetro and suburban

elders lived with their spouses in 1984, compared with

only 52 percent of central city elders (table 2). Elderly

persons living with their spouses are expected to be

healthier than those who live alone or with other relatives

or nonrelatives. A higher proportion of central city elders

lived alone (32 percent) in 1984, compared with those in

nonmetro areas (27 percent) and the suburbs (24 percent).

Elderiy persons living alone are more likely to experience

health problems and greater poverty (Commonwealth

Fund Commission on Elderly People Living Alone,

1987). Suburban elders have more frequent contact with

friends and neighbors than either nonmetro or central city

elders, and about the same amount of contact with

relatives as nonmetro elders (table 2).

The presence of someone who could provide unpaid care

for an older person indicates the possibility of social

support. Spouses and children are potential sources of

such support for elderly persons. Both nonmetro and

suburban elders are more likely to have living adult

children who could provide care than are central city
Figure 1

Educational attainment of the eiderly, by residence^

Central city

Nonmetro

Suburb

"• Elderly defined as aged 60 years and older.

Figure 2

Income and poverty status of the elderly, by residence^

Percent

ou

69.1

56.4

75.0

60

40

20 19.8

15.1

n

i. \ 1 1

1 1

Income under $20,000

Hil Central city

"• Elderly defined as aged 60 years and older.

Suburb

Below poverty

I I Nonmetro
elders (table 1), Residential differences are found for

elderly persons having someone available to care for

them for a i^riod of a week (table 2). In 1984, suburban

elders aged 60 years and older were more likely to have a

household relative available to care for them (60 percent)

than were nonmeiro elders (56 percent) or central city

elders (51 percent). When age is taken into account, a

smaller proportion of the oldest old have a household

relative who could provide care. In 1984, 46 percent of

suburban elders aged 75 and older had a household

relative who could care for them, as did 42 percent of

nonmetro elders and 40 percent of central city elders

(app. table 1). The elderly aged 60 and older in central

cities were more likely to have no one to care for them

(12 percent) than either suburban or nonmetro elders (9

percent) (table 2),

The presence or absence of family caregivers may affect

an individual's use of a variety of social services in the

conununity. These services include eating meals in a

senior center and using a senior center, special

transportation for the elderly, homemaker services, adult

day care, and visiting nurse services. Regardless of

residence, 81 percent of the elderly aged 60 and older

never used community services in 1984 (table 2).

Nonmetro elders were somewhat more likely to use two

or more services (10 percent) than were their meti"o

counterparts (nearly 8 percent).

The most frequently used services were senior centers (13

percent) and eating me^s in a senior center (7 percent).

Nonmetro and suburban elders were both slighüy more

likely to use a senior center (13 to 14 percent) than were

the elderly in cenü'al cities (11 percent). More nonmetro

elders aged 60 and older took tlieir meals in senior

centers (10 percent) than did either suburban (5 percent)

or central city (6 forcent) elders. The data showed that

there is a greater need for community meals in nonmetro

areas, as reflected by lower socioeconomic status, and

that nonmetro residents seem to have this need better met

than their metro counterparts.

The basic difference in social support networks by age is

that the younger group (ages 60-74) is more likely to

have a household relative who could provide care if

needed, and that the oldest old, as expected, participate to

a greater extent in coimnunity services. For example, 29

percent of nonmetro elderly aged 75 and older used one

or more coimnunity services in 1984, compared with 15

percent of persons aged 60-74 (app. table 1). Among the

oldest old, nearly 14 percent of nonmetro elders ate meals

in a senior center, compared with 8 percent of

suburbanites and 7 percent of city elders.

Health Status of Persons Aged 60 and Older, by

Residence

Do elderly persons residing in nonmetro areas have better

or worse health than elders in central cities and suburban

areas? Differences in self-assessed health and various

measures of physical functioning show that suburban

elders are in better health than either nonmetro or central

city elders. A larger share of the nonmetro elderly have

functional limitations and certain chronic conditions (such

as arthritis) than do their metro counterparts. Residential

differences in health status remain evident even when

other factors-age, race, social support networks, income,

and education-are held constant. Nonmetro elders tend

to be less educated and financially worse off than metro

elders, and their lower socioeconomic status is clearly

associated with poorer health.

Measures of Health Status

There are various aspects to health, and many measures

can be used to assess the health of the elderly (table 3).

Self-reported health status is one of the best measures of

health, and corresponds closely with objective measures

of health, such as physical exams and physician ratings.

Difficulty in performing ADL's and lADL's is also an

infonnative measure of health and is associated with

living independently in the community. The various

other measures of health in table 3 support the finding

that suburban elders are in better health than their

nonmetro and central city counterparts.

Self-reported health status for persons aged 60 and older

is lower for nonmetfo elders than for their metro

counterparts. Thirty-five percent of nonmetro elders

reported their health as fair or poor in 1984, compared

with 32 percent for elders in central cities and 27 percent

in suburban areas (table 3 and app. table 2). Although

residential differences in self-assessments of health are

less pronounced among the elderly aged 75 and older, the

same residential pattern is evident: a larger share of

nonmetro elders reported their health as fair or poor than

did their metro counterparts.

One measure of functional ability is performance of

ADL's. Most elderly persons aged 60 and older living in

the community have no difficulties performing personal

care activities, also known as ADL's. Seventy-eight

percent of both nonmetro and central city elders reported

no difficulty with activities of daily living in 1984,

compared with 82 percent of the suburban elderly (table

4). Suburban eiders tended to report a lower number of

ADL difficulties than did their counterparts in other areas.
Ten percent of suburban elders reported two or more

ADL difficulties, compared with about 12 percent each of

nonmetro eiders and central city elders. Elderly persons

are more likely to have problems with walking than with

any other personal care activity; 18 percent of nonmetro

elders had difficulty walking, compared with 15 percent

in metro areas.

A second measure of physical functioning, instrumental

activities of daily living, also shows that suburban elders

aged 60 and older reported fewer lADL difficulties than

their counterparts in central cities or nonmetro areas

reported (table 4). Twenty-six percent of nonmetro elders

had one or more lADL difficulties, compared with 23

percent of metro elders. Elderly persons most frequently

have difficulty performing heavy housework; 22 percent

of nonmetro elders had difficulty performing this IADL.

Combining both ADL and lADL measures shows that

nonmetro elders are less likely to be free of difficulties in

performing these activities. Thirty-two percent of

nonmetro elders reported difficulty with both ADL's or

lADL's, compared with 30 percent of central city elders

and 26 percent of suburban elders (table 3).

A third measure of physical functioning, which includes

activities such as walking a quarter of a mile and lifting

or carrying 10 pounds, also shows that the nonmetro

elderly were more likely to report having limitations than

were their metro counterparts, with 58 percent of

nonmetro elders reporting one or more functional

Ihnitations (table 4). This compares with 53 percent of

central city elders and 48 percent of suburban elders who

had one or more functional limitations (tables 3 and 4).

The activities most frequently reported as difficult are

walking a quarter of a mile (26 percent), walking up 10

steps without rest (22 percent), standing for 2 hours (31

percent), stooping, crouching, or kneeling (36 percent),

and lifting or carrying 10 pounds (36 percent). With the

exception of lifting and carrying activities, nonmetro

elders were more likely to report difficulty with these

functional activities than were metro elders. For

example, 29 percent of nonmetro elders had difficulty

walking a quarter of a mile, compared with 27 percent in

cities and 23 percent in the suburbs.^

Common chronic conditions of the elderly include

arthritis, hypertension (high blood pressure),

cataracts, heart disease, varicose veins, diabetes, cancer,

osteoporosis (especially hip fracture), and stroke

(Guralnick and others, 1989). Forty-nine percent of

persons aged 60 and older reported having arthritis, with

^Data from unpublished tabulations from the NHIS Supplement on

Aging.

nonmetro elders being more likely to report having

arthritis or rheumatism (53 percent) than were metro

elders (47 percent) (table 3). Nonmetro elders were also

more likely to have hypertension (44 forcent) than their

counterparts in central cities (42 percent) and suburban

areas (39 percent). Higher proportions of the oldest old

have arthritis and hypertension than do their younger

counterparts (table 3).

Arthritis and hypertension are prevalent among the elderly

and affect their self-assessments of health. Persons with

arthritis are more likely to report their health as fair or

poor. For example, 44 percent of nonmetro elders with

arthritis reported fair or poor health in 1984, compared

with 24 percent of their counterparts without arthritis

(app. table 4). Among suburban elders, 35 percent of

those with arthritis and 20 percent without reported their

health as fair or poor. A similar pattern is found for the

effect of hypertension on reported he^th status; elderly

persons without hypertension more frequently report their

health as excellent or very good than do their counterparts

with hypertension.

Arthritis and hypertension affect the elderly's ability to

perform the various activities of daily living, and higher

proportions of those with one or more activity limitations

have arthritis or hypertension. A much better level of

physical functioning is found among elders without

arthritis. Nearly 23 percent of nonmetro elders with

arthritis reported having difficulty with at least one ADL

and lADL in 1984, compared with only 8 percent of

elders without arthritis (app. table 5). Elderly persons

with arthritis commonly have difficulty with the ADL's

of walking, getting out, and transferring. The most

frequently reported lADL difficulty for elders with

arthritis is heavy housework. The same relationship is

found for elderly persons with and without hypertension.

The effect of having arthritis or hypertension is magnified

for the nonmetro elderly, who have a higher prevalence

of these chronic conditions than do their metro

counterparts. Wide residential differences are apparent in

self-reported health status and physical functioning, with

suburban elders faring better than either nonmetro or

central city elders.

Restricted activity and bed disability days indicate

disability, and may subsequently lead to doctor visits or

the use of other formal health care services. Only 13

percent of elders aged 60 and older were restricted in

activity over a 2-week period, and about 7 percent were

restricted to bed in the 2 weeks prior to the interview

(table 3 and app. table 3). While proportions of the

youngest old and the oldest old who have either restiicted

activity or bed disability days do not differ significantly,

a greater share of persons aged 75 and older were
restricted for a longer time in the 2-week period (app.

table 3). Elderly persons who are restricted in activity or

confined to bed can also be expected to depend more

heavily on formal health care services.

A higher proportion of elderly persons in poorer healththose who either reported difficulties with ADL's and

lADL's, or reported their health as fair or poor—reported

having both restricted activity and bed disability days.

About 28 percent of those in poorer health had restricted

activity days in 1984, and nearly 20 percent were

restricted for 6-14 days over a 2-week period (app. table

3). Nine to ten percent of elders in poorer health

reported 6-14 bed disability days in the past 2 weeks,

compared with only 3 percent of all persons aged 60 and

older. Nonmetro elders with ADL-IADL difficulties are

somewhat less likely to be confined to bed than are their

metro counterparts; about 14 percent of nonmetro elders

with one or more ADL-IADL difficulties were confined

to bed in the past 2 weeks, compared with about 17

percent of their metro counterparts.

The best measures of the health status of the elderiy are

self-reported health and performance difficulties with

ADL*s and lADL's. Respondent-assessed health is one

of the most informative measures of health; it is

associated with mortality, life satisfaction, and objective

measures of health status, such as physical exams and

physician ratings. Performance of ADL's and lADL's

are also telling measures of health; they are key

indicators of the ability to live independently in the

conununity, the use of paid home health care, the use of

both hospital and physician services, and admission to

nursing homes.

Self-assessments of health are closely correlated with

performance of ADL's and lADL's; those who have

difficulty performing ADL's and IADL's are more likely

to report their health as fair or poor. Among the elderiy

who report difficulty perfonning ADL's and IADL's, 69

percent assessed their health as fair or poor, only 11

percent assessed their health as excellent or very good,

and 20 percent as good.

Controlling for Selected Characteristics

How do the demographic and socioeconomic

characteristics of the elderly affect their health status?

The relationship between residence and health status was

controlled by demographic characteristics, social support

networks, and socioeconomic status. Age and race are

two of the most important demographic characteristics

affecting the elderly's health. Two indicators of social

support networks include the type of living arrangements

of the elderly and the availability of potential caregivers.

Education and income are measures of socioeconomic

status. Income was selected over poverty status because

the elderly with high or low income are more evenly

distributed than are the elderly above and below poverty.

Demographic Characteristics. Age makes a difference

in self-assessments of health (table 5 and app. table 4).

Elderly persons aged 75 and older report their health to

be excellent or very good less fi-equently than do elders

aged 60-74. The oldest old are somewhat more likely to

report their health as fair or poor than are the youngest

old, which is consistent with the greater prevalence of

activity limitations and functional disabilities among

elders aged 75 and older.

With advancing age, physical functioning usually declines

and the prevalence of ADL-IADL difficulties increases

(table 6 and app. table 5). For example, only 12 percent

of nonmetro elders aged 60-74 had difficulties with one

or more ADL's and lADL's in 1984, compared with 26

percent of the nonmetro elderly aged 75 and older.

Dawson, Hendershot, and Fulton (1987) also found that

the proportion of elderly persons experiencing difficulty

with personal care activities (ADL's) increased with age.

Residential differences in performance of ADL's-IADL's

are not significant for elders aged 75 and older. With

advancing age, residential location seems to diminish in

importance as a factor affecting physical functioning.

Minority elders report lower self-assessments and more

activity limitations, and appear to be in poorer health.

Both black and Hispanic elders are more likely to report

their health as fair or poor than their white and nonHispanic counterparts (table 5 and app. table 4). For

example, 61 percent of black nonmetro elders reported

fair or poor health in 1984, compared with 33 percent of

their white counterparts. The poorer self-assessments of

health by the black elderly may also partly reflect their

lower socioeconomic status. A greater proportion of

nonmetro elders, regardless of race or ethnicity, report

their health as fair or poor than do their metro

counterparts. In addition, 23 percent of nonmetro black

elders had both ADL and lADL difficulties, compared

with 15 percent of their white counterparts (table 6 and

app. table 5).

Women can expect to live longer than men, but are older

women in better or worse health than older men? A

larger proportion of women aged 60 and older have

activity limitations than do their male counterparts (app.

table 5). This gender difference may partly reflect the

fact that elderly women are older, on average, than

elderly men. When all elders aged 60-74 and 75 and

older are examined separately, however, gender

differences remain. For example, among nonmetro

women aged 60-74 in 1984, 13 percent had difficulty

with both ADL's and IADL's, compared with 9 percent

10
of their male counteqjarts. Among nomnetro women

aged 75 and older, where the age effect was greatest, 32

percent had both ADL and lADL difficulties, compared

with 18 percent of the nonmetro men aged 75 and older.

Social Support Networks. Stronger social support

networks are associated with better health status. Elderly

persons who either live with their spouses or live alone

are healthier than those who live with other relatives or

nonrelatives. About 33 percent of nonmetro elders who

lived alone or with their spouses reported their health as

fair or poor in 1984, compared with 44 percent of

nonmetro elders who lived with other relatives or

nonrelatives (table 5). The elderly who live with their

spouses also have fewer ADL-IADL difficulties. For

example, 12 percent of nonmetro elders who lived with

their spouses had ADL-IADL difficulties, compared with

20 percent of those who lived alone, and 28 percent of

those who lived with others (table 6). It was expected,

however, that elders living alone would fare worse than

those living with others. Perhaps the elderly living with

others do so because of their poor health and the need for

assistance.

Having someone who can provide care appears to benefit

health status. Lower proportions of the elderly report

their health as fair or poor when they have someone

(either a relative or nonrelative) available as a potential

care-giver* (table 5). Elderly persons who have no one to

provide care have poorer self-assessments of health.

Elderly persons with no one available to provide care are

also more likely to experience difficulties performing

ADL's and IADL*s. Among nonmetro elders in 1984, 24

percent who had no one to provide care had difficulties

with both ADL's and lADL's, compared with 18 percent

of elders with a nonrelative care-giver, 17 percent of

those with a nonresident relative care-giver, and only 13

percent of those with a relative in residence available to

provide care (table 6). The elderly in central cities are

more likely to have no one to care for them üian are tiie

elderly in other areas, and their poorer health may reflect

weaker social support networks. Having a household

relative available to provide care appears to enable tiie

elderly to take better care of their health.

Marriage confers health benefits to elderly persons in that

one's spouse is the most important source of help in

periods of iltaess. Married elderly persons living with

their spouses are less likely to have difficulties with

ADL-IADL's than are their unmarried counterparts.

^This could be a relative or a Donrelatlve, either in the household or

not, who could be counted on when needed to provide assistance to tlie

elderly person.

Widowed, divorced, or separated persons fare worse in

their ability to perform the various activities of daily

living (app. tables 5 and 6). Divorced and separated

persons have been found to be more likely to suffer from

acute medical conditions and to have greater short-term

disability Üian are persons in other marital statuses;

formerly married persons appear to have the most chronic

health problems (Verbrugge, 1979). Older persons living

with their spouse and those who have a resident relative

as a potential care-giver have tiie fewest functional

limitations. Having no one as a potential care-giver is the

most disadvantaged position.

Socioeconomic Status. Socioeconomic status is

important for all measures of health, with important

implications for the use of health care services by the

elderly. Socioeconomic status plays a part in perceptions

of health, witii higher socioeconomic status associated

with better healüi. Wide differences in healüi status are

found among tiie elderly by income level, witii a higher

proportion of low-income elderly (earning less than

$20,000) reporting fair or poor healüi than tiieir

counterparts witii incomes of $20,000 or more (table 5).

For example, 40 percent of nonmetro elders with incomes

of less than $20,000 reported their health as fair or poor

in 1984, compared with 19 percent of their counterparts

witii incomes of $20,000 or more. Residential differences

witiiin income group are still evident, as noimietro elders

are more likely to report poorer healtii than are tiieir

metro counterparts. The income effect on self-assessed

healtii is magnified for tiie nonmetro elderly, due to tiieir

lower financial standing. Among the low-income elderly,

a greater proportion reside in nonmetro areas than in

either suburban areas or central cities.

Higher income is also associated with fewer ADL-IADL

difficulties (table 6). Only 8 percent of nonmetro elders

witii incomes of $20,000 or more had ADL-IADL

difficulties in 1984, compared with 19 percent of their

counterparts witii incomes of less than $20,000. In

addition, 57 percent of the nonmetro elderly with incomes

of $20,000 or more had no functional limitations,

compared with 37 percent of tiie low-mcome nonmetro

elderly (app. table 6). Because a larger proportion of

nonmetro elders have incomes of less than $20,000 than

do tiieir metro counterparts, tiie strong income effect on

healtii status makes low income an important factor in the

healtii of the nonmetro elderly.

Educational attainment also reflects one's socioecononüc

status. Higher education is also associated with fewer

elders reporting fair or poor healtii. In 1984,18 percent

of nonmetro elders who had completed 1 or more years

of college reported fair or poor health, compared with 24

percent of nonmetro elders who had completed 4 years of

high school, and 46 percent who had not completed high

11
school (table 5). Residential differences are apparent

within educational categories. The effect of educational

attainment on health status is especially significant for the

nonmetro elderly, as Üiey are more likely to be less

educated than their metro counterparts. Among those

with less than a high school education, a greater

proportion reside in nonmetro areas than in either

suburban areas or central cities.

The elderly with less than a high school education are

more likely to have functional limitations than are their

counterparts with higher education. About 20 percent of

nonmeü-o elders witii less tiian a high school education

had one or more ADL-IADL difficulties in 1984,

compared with only 10-12 percent of their better educated

counterparts (table 6). A higher proportion of the elderly

with at least 4 years of high school have no functional

limitations, compared with those who had not completed

high school (app. table 6). High school completion

appears to be the decisive factor, with only slight

improvements in physical functioning for those who had

completed some college.

Older persons who are employed tend to be those who

are able to work, and are in relatively good health.

Employed elders perceive tiieir health as excellent or very

good more frequently than do their unemployed

counteiparts and those not in the labor force (app. table

4). This coincides with the finding that elderly persons

who perceive themselves to be completely retired had

poorer health assessments. A more positive outlook is

probably associated with keeping active later in life. In

addition, employed elderly persons are less likely than

unemployed elderly persons to have difficulties in

activities of daily living, probably due to the retirement of

elderly disabled persons. Large differences in functional

status by employment and retirement status may reflect

the fact that many elders retire due to poor health.

When self-assessments of health and functional status are

examined separately for the younger old, ages 60-74, and

the oldest old, ages 75 and older, tiie same basic

relationships between demographic and socioeconomic

characteristics and healtii status are apparent.^ Residential

differences in healtii status are smaller in magnitude for

the oldest old tiian for younger elderly persons. The

suburban advantage in healtii status seems to diminish

somewhat for the oldest old. Poorer health is found

among women, minorities, those with fewer sources of

social support, and retired persons. Better healtii is found

among the elderly living with their spouses. Higher

socioeconomic status, measured by education and income

^Unpublished tabulations by the author from tlie NHIS Supplement on

Aging.

levels, is strongly associated with more positive selfassessments of health and fewer functional limitations.

Residential differences, though smaller than those of

education or income, are still evident. And because

nonmetro elders have lower socioeconomic status than

their metro counterparts, tiie effect on healtii status is

more pronounced for the nonmetro elderly.

Role of Residential Location

The effects of residential location on health status are

twofold. First, differences in self-assessed health and

various measures of physical functioning are found by

residential location. Surburban elders are more

advantaged tiian tiieir counterparts in nonmetro areas and

central cities, with nonmetro elders performing the worst

on measures of functional ability. Second, residential

location affects healtii status indirectiy, in tiiat nonmetro

elders are more likely to have those characteristics

associated with poorer health. Nonmetro elders are more

likely to be less educated and financially worse off tiian

tiiieir meü"o counterparts, and lower socioeconomic status

is strongly associated with poor healtii, as measured either

by self-assessments or functional limitations. Nonmetfo

elders are also more likely to have certain chronic

conditions (for example, arthritis and hypertension),

which have a strong effect on health status and tiie ability

to perfonn various activities of daily Hving. In addition,

the more recent metro residents appear to be in poorer

health than those who have resided in metro areas over a

greater length of time. Although the survey data cannot

distinguish recent metro residents who have changed

residence witiiin metro areas from those who have moved

from nonmetro areas, some nonmetro residents may have

moved to metro areas to be closer to relatives and/or

health services.

Use of Health Care Services, by Residence

Do elderly persons residing in nonmetro areas use health

care services to a greater or lesser extent than their

counterparts in central cities and suburban areas? The

nonmetro elderly are less likely to use fonnal health care

services, such as physicians, hospitals, and nursing

homes, than are their metro counterparts. The data on

use of heaJtii services suggest tiiat these services may be

more accessible to those in metro areas. Among tiie

elderly in fair or poor healtii, lower proportions of

nonmetro elders use health services, and a smaller share

use such services at a high level.

Health Care and Community Services Used

The network of health care services available in small

towns and rural areas is more limited tiian that available

in urban areas (Coward and Cutier, 1988). Formal healtii

12
care is comprised of doctor visits, hospital stays, and

nursing home stays. Use of formal health care services

differs by residence, with nonmetro elders aged 60 and

older less likely to have seen a doctor in the past year

than were metro elderly persons aged 60 and older (table

7). For example, 21 percent of nonmetro elders had not

seen a doctor in the past year, compared with 19 percent

of the metro elderly (app. table 7). Nonmetro elders are

about as likely to have been hospitalized or to have ever

been in a nursing home as are their metro counterparts.

This study constructed a measure of formal health care

service use by combining doctor visits, hospital stays, and

nursing home stays. The elderly are classified as using

no health care services, a moderate level of health care

services, and a high level of such services. Moderate use

is defined as either 1-11 doctor visits or hospital stays of

1-30 days in the past year, and no nursing home stays.

High or extensive use of fonnal care is defined as either

12 or more doctor visits, hospital stays of 31 or more

days, or any nursing home stays. In 1984, 81 percent of

the elderly aged 60 and older used some type of formal

health service: 79 percent in nonmetro areas, 81 percent

in cities, and 83 percent in the suburbs (table 7). Central

city elders were more likely to report high or extensive

use of services (nearly 18 percent) than their suburban

and nonmetro counterparts (about 14 percent each). This

may reflect both poorer health and weaker social support

networks among the elderly in cities.

Use of health care services is greater for those in poorer

health and the oldest old. Elderly persons in poorer

health are more likely to have seen a doctor, stayed in a

hospital, and been a patient in a nursing home in the past

year (table 7). For example, 30 percent of nonmetro

elders 60 years old and older in fair or poor health had

been hospitalized in the past year, compared with 18

percent of all nonmetro elders the same age. The oldest

old are also more likely to have been hospitalized than

are their younger counterparts. Sixteen percent of

nonmetro persons 60-74 years old had stayed in a

hospital, compared with 25 percent of their older

counterparts. Nonmetro elders aged 75 and older are

slightly more likely to have been hospitalized in the past

year than are their metro counterparts.

Use of health care services by the older population

generally indicates the overall number of persons needing

care. It is also important to examine the use of health

care services by those in poorer health to determine

whether they are receiving medical care proportionate to

their needs. Since one's health status reflects the need

for health care, the relationship between health service

use and residential location will subsequently be

examined for those in poorer health. Those in poorer

health are defined as those who report theh* health as fair

or poor. Virtually identical results are obtained when

self-assessed health and difficulties performing ADL's

and IADL*s are used to define the subset of the elderly

most in need of health care. When health status is taken

into account, inequities in the use of health care services

by residential location and other characteristics become

apparent.

While fewer nonmetro elders use formal health care

services than do either central city or suburban elders,

residential location does not affect overall use of

community services. About 19 percent of elderly persons

aged 60 and older used one or more conununity service

(table 7). The availability of services in the community

is undoubtedly a factor in use, and actual use reflects

both availability and level of participation by local

residents.

Controlling for Selected Characteristics

Basic demographic characteristics, social support

networks, and socioeconomic characteristics are expected

to influence the use of health care services. Tables 8 and

9 show the effects of these control variables on health

care service use.

Demographic Characteristics. Greater use of formal

health care services occurs with advancing age. The

oldest old tend to use some type of health care service

and to use services more extensively than the younger

elderly. For example, nearly 22 percent of nonmetro

elders aged 60-74 did not use formal health care services

in 1984, compared with 18 percent of nonmetro elders

aged 75 and older. Among the nonmetro elderly, 18

percent of the oldest old used formal health care to a

great extent, compared with 12 percent of the younger

group (app. table 8).

Are elderly persons in poorer health using health care

services proportionate to their needs? A higher

proportion of the elderly in poorer health use health care

services, compared with all older persons. Among

nonmetro elders aged 75 and older, 32 percent in poorer

health and 18 percent of all persons the same age'were

high users of formal health care services in 1984 (app.

tables 8 and 9). Among those in poorer health, the oldest

old are somewhat more likely to use health care services,

and to use such services extensively, than are their

younger counterparts. For example, 32 percent of

nonmetro elders aged 75 and older m poor health used

health care services extensively, compared with 24

percent of their younger counteiparts (app. table 9).

Use of health care services does not differ significantly

by race; however, black elders tend to use such services

more extensively than do white elders. About 20 percent

13
of nonmetro black elders aged 60 and older used health

care services to a great extent in 1984, compared with 13

percent of their white counterparts (app. table 8). This

reflects the lower self-assessments of health and physical

functioning of elderly blacks. Black elders in fair or poor

health are also more likely to be high users of health care

^rvices than are comparable white elders (app. table 9).

Social Support Networks. Married persons who live

with their spouse are slightly less likely to use health care

services than are persons who live alone (table 8 and app.

table 8). Married older persons seem to substitute

informal health care at home for formal health care

services. High use of health c^e services is greater

among the elderly who live alone or with others-relatives

or nonrelatives. Among the nonmetro elderly, 11 percent

of those living with their spouse used health care services

extensively in 1984, compared with 17 percent of elders

living alone, and 18 percent of those living with others

(app. table 8).

Strong social support networks may provide elders with

many informal care-givers and may lead to less frequent

use of formal health care services. Elderly persons who

had a household relative who could provide care were

slightly less likely to use health care services than were

those without someone to provide care (table 8), Among

the noiunetro elderly, 22 percent who had a household

relative as a potential care-giver used no formal health

care, compared with 20 percent of those with no one to

provide care. Only 12 percent of nonmetro elders with a

household relative as potential care-giver were high users

of formal health care services, compared with 18 percent

of their counterparts with no care-giver (app. table 8),

reflecting the positive role of strong social support

networks. Residential differences in services use are

evident, with a greater share of the central city elderly

extensively using fonnal health care services. Older

persons with strong social support networks seem to

substitute home unpaid health care for formal health care

services. Among the elderly in fair or poor health, the

strength of social support networks does not affect service

use in a consistent maimer (app. table 9).

Socioeconomic Status. Socioeconomic status, measured

by income and education level, affects the health of the

elderly, with higher socioeconomic status associated with

better health. How is the use of health services affected

by socioeconomic status? The elderly with higher

socic^conomic status have less need for health care

services; on the other hand, they can better afford to pay

for such services. Higher income is associated with

greater use of health care services (table 8). The lowincome elderly in nonmetro areas were somewhat less

likely to use formal health care services (79 percent) in

1984 than were their counterparts with incomes of

$20,000 or more (81 percent). The low-mcome elderly

also tend to use formal health care services more

extensively than the high-income elderly. Among the

nonmetro elderly, 15 percent of low-income elders used

formal health care services extensively, compared with 10

percent of high-income elders (app. table 8). Higher

income is also associated with higher use of he^th care

services among those in fair or poor health (app. table 9).

The fact that elders with lower socioeconomic status tend

to be in poorer health, on average, implies that a large

unmet need for services exists among this group.

Central city elders place greater demands on health

services than do their suburban and nonmetro

counterparts. Among the low-income elderly, 19 percent

in central cities were high users of formal health care

services in 1984, compared with 16 percent in the

suburbs and 15 percent in nonmetro areas. In

comparison, 15 percent of central city elders with

incomes of $20,000 or more used formal health care

extensively, compared with 12 percent in the suburbs mû

10 percent in nonmetro areas. Because elders with lower

socioeconomic status also have poorer health, their

overall use of health services reflects a gap between need

for care and use of services. This has a greater effect in

nonmetro areas because the nonmetro elderly have lower

socioeconomic status, on average, thai do their metro

counterparts. Both residential location and socioeconomic

status clearly affect health care service use.

Higher educational attainment is related to higher use of

health care services among the elderly, in the same

manner as higher income level. Eighteen percent of

nonmetro elders with at least 1 year of college used no

formal health care services, compared with 21 percent of

their less-educated counterparts (table 8). The lesseducated also tend to have poorer health status, which

implies that a gap exists in the need for health care and

the use of such services. This gap may be more critical

in nonmetro areas, as nonmetro elders are, on average,

less educated than their metro counterparts.

Because employed elders are generally in better health

than their unemployed counterparts and those not in the

labor force, do they use health care services less

frequently? Employed elders are less likely to use health

care services at all, and when they do, they are less likely

than their nonworking counterparts to use such services

extensively. Only 6 percent of employed nonmetro elders

were high users of health care services in 1984, compared

with 15 percent of their counterparts not in the labor

force (app. table 8). Differences in use of services by

residence were apparent, with 20 percent of central city

elders not in the labor force being high users, compared

with 16 percent of suburban elders and 15 percent of

nonmetro elders.

14
Elderly persons with arthritis or hypertension also tend to

have functional limitations, and hence are more likely to

need regular physician and other health care services. In

1984,16 percent of nonmetro elders with arthritis did not

use formal health care services, compared with 26 percent

of nonmetro elders without arthritis (app. table 8),

Elderiy persons with arthritis or hypertension not only use

health care services more often, but also use these

services more extensively. Residential differences are

evident, with the metro elderly using services more than

their nonmetro counterparts, and central city elders

placing the heaviest demands on health care services.

Role of Residential Location

Residential differences in the use of formal health care

services are apparent, with higher use by elders in metro

areas. The SOA data on use of health care services

suggests that these services may be more accessible to

elders in metro areas. A lower physician-to-population

ratío in rural areas suggests that rural elders may visit

doctors less frequently because they are less accessible.

Use of health care services by length of residence in an

area differs by metro-nonmetro residence. Elderly

persons residing in nonmetro areas for a shorter time

period used health care services less than longer tenn

residents.^ On the other hand, greater use of health care

services is found among more recent residents of metro

areas. This suggests that the more recent residents of

nonmetro areas may be both younger and healthier, and

that nonmetro elders in poorer health may relocate to

metro areas to obtain needed medical care.

Greater use of formal health care services is an indicator

of poorer health. Among the elderly in fair or poor

health, a marked increase is seen in both elders who use

health care services and those who use health care

services extensively. Residential differences persist, with

lower proportions of nonmetro elders in poorer health

using health care services and a smaller share using such

services at a high level, compared with their metro

countCTparts. This pattern of residential use is fairly

consistent for all variables in table 9 and app. table 9.

Nonmetro elders may move to metro areas to obtain

medical and health care services, as reflected in

differences in high use of health services by length of

residence (app. table 9). Among elderly persons in fair

or poor health who had lived at their current residence for

less Ihan 1 year, a higher proportion of those in metro

areas are high users of formal health care services than

are elders residing m nonmetro areas.

'Unpublished tabulations by the author from the NHIS Supplement on

Aging,

Conclusions

The majority of elderly persons are, and perceive

themselves to be, in good health. National survey data

show that suburban elders rate their health better than

their counterparts in cities and nonmetro areas, and also

report fewer ADL, lADL, and functional limitations than

do either nonmetro or central city elders. The health

status of nonmetro elders and city elders is comparable

on these measures. The nonmetro elderly are more likely

to have certain chronic conditions, such as arthritis, than

are their metro counterparts, and the presence of such

chronic conditions is clearly associated with poorer

physical functioning. Difficulty in performing personal

care and home management activities, known as activities

of daily living (ADL's) and instrumental activities of

daily living (lADL's), may indicate some loss in the

quality of life, but does not necessarily indicate a present

or imminent need for health care and social services.

Residential differences in self-assessments of health and

physical functioning are still evident when other factorsage, race, social support networks, income, and

education-are held constant. Socioeconomic status, as

measured by education and income, and residential

location both affect the health of the elderiy, with higher

socioeconomic status associated with better health. This

has a greater effect on the nonmetro elderly, as they are,

on average, less educated and financially worse off than

their metro counterparts. Social support networks among

nonmetro elderly persons may ameliorate their poorer

health to some extent, but not enough to overcome the

effects of their lower socioeconomic status.

Health care services are expected to be less available to

nonmetro elders, and the lower use of such services by

the nonmeti"o elderiy implies that this is indeed the case.

The nonmetro elderly are less likely to use formal health

care services-physician visits, hospital stays, and nursing

home care-than their metro counterparts. These

residential differences are still apparent when controls for

demographic and socioeconomic characteristics are

introduced. Central city elders tend to use health care

services to a greater extent than do either norunetro or

suburban elders. When health status is controlled,

residential differences in the use of health care services

are evident. The nonmetro elderly use fewer health care

services, compared with metro residents, than is

conunensurate with their health status. This suggests a

gap between the nonmetro elderly's need for care, based

on their poorer health status and lower socioeconomic

standing, and the availability of services to meet this

need. Lower socioeconomic groups may be

disadvantaged with respect to access to health care, and

new strategies are needed to increase the use of health

care by such groups.

15
The ability or inability of the elderly to obtain help with

difficult personal care activities is an important factor in

determining which individuals are able to remain in the

community and which must enter nursing homes or other

institutions for needed care and assistance. A substantial

and growing number of the elderly have, or are at risk of

developing, chronic conditions that impair their ability to

function independently. This has important implications

for long-term care and Federal spending, as well as for

effective local planning for health care and other services.

Health and social services need to be designed to provide

better and more effective care for this population. An

increasing number of private long-term care insurance

policies and proposed public long-term care insurance

programs rely on ADL measures to determine if an

individual qualifies for benefits. Residential differences

in functional limitations as well as access to and

availability of services need to be considered in planning

for services in particular areas.

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18
Table l»Demographic and socioeconomic characteristics of the elderly, by residence, 1984^

Characteristics

Residence

U.S. total Metro Nonmetro

Central

Total city Suburb

Thousands

37,256 23,793 10,089

Percent

13,704 13,463

29.0 30.1 29.3 30.7 27.1

43.7 43.6 43.6 43.5 44.0

22.1 21.4 21.8 21.0 23.5

5.1 5.0 5.3 4.7 5.3

42.8 42.2 39.9 43.9 43.8

57.2 57.8 60.1 56.1 56.2

91.4 90.2 82.0 96.3 93.3

8,6 9.8 18.0 3.7 6.7

3.1 3.9 5.2 3.0 1.7

96.9 96.1 94.8 97.0 98.3

Number of elders

Demographic:

Age:

60-64 years

65-74 years

75-84 years

85 years and older

Gender:

Male

Female

Race:^

White

Black

Ethnicity:^

Hispanic

Non-Hispanic

Marital status:

Married

Widowed, divorced,

or separated

Never married

Number of living children:

None

1 child

2-4 children

5 or more children

Region:

Northeast

Midwest

South

West

60.9 59.7 53.6 64.1 63.2

34.7 35.5 40.0 32.2 33.2

4.4 4.9 6.4 3.7 3.7

11.9 12.6 15.4 10.5 10.7

17.4 18.2 19.9 17.0 16.0

54.4 55.5 51.4 58.5 52.6

16.3 13.7 13.3 14.0 20.7

23.2 28.0 25.5 29.9 14.6

25.4 24.5 24.8 24.4 26.9

33.7 26.9 30.9 24.0 45.8

17.7 20.6 18.9 21.8 12.7

See Continued- footnotes at end of table.

19
Table 1-Demographic and socioeconomic characteristics of the elderiy, by residence, 1984^--Continued

Residence

U.S. total Metro Nonmetro

Central

Characteristics Total city Suburb

Percent

Length of time at residence (years):

Less than 1 5.1 5.1 4.6 5.5 5.0

1-10 31.3 29.7 29.3 30.1 34.1

11-20 23.2 24.2 24.7 23.8 21.3

At least 21 40.4 40.9 41.5 40.6 39.6

Socioeconomic:

Education:

Less than high school 47.8 44.8 49.3 41.6 53.2

High school, 4 years 31.6 32.8 30.8 34.3 29.4

College, 1 or more years 20.6 22.4 19.9 24.2 17.4

Employment status in past 2 weeks:

Employed 21.2 22.2 20.8 23.3 19.3

Unemployed LI LI 1.2 1.0 1.0

Not in labor force 77.8 76.6 78.0 75.6 79.7

Income:

Less than $20,000 66.6 61.8 69.1 56.4 75.0

$20,000 or more 33.4 38.2 30.9 43.6 25.0

Poverty status:

Below poverty 14.3 11.2 15.1 8.3 19.8

Above poverty 85.7 88.8 84.9 91.7 80.2

Tenure:

Home owned 79.1 76.3 68.4 82.2 84.2

Rented 18.3 22.0 30.2 16.0 11.8

Rent free 2.5 1.7 1.4 1.9 4.1

Retirement status:

Completely retired

Living in a retirement

community

Retired due to health''

Now receiving retirement

income

68.3

80.6

68.0

79.2

69.5

79.0

66.8

79.4

68.9

3.7 3.7 3.3 4.0 3.6

25.7 23.7 25.7 22.2 29.0

83.0

Number of retirement

income sources:^

1

2-6

65.6 63.1 64.7 61.9 70.0

34.2 36.7 35,2 37.8 29.9

^Elderly defined as aged 60 years and older.

^Excludes other races.

^Persons of Hispanic origin may be of any race.

"^Excludes those who are not retired or who never worked,

^Excludes those with no retirement income.

20
Table 2—Social support networks and use of community services by the elderly, by residence, 1984^

Characteristics

Residence

U.S. total Metro

Total

Central

city Suburb

Nonmetro

Number of elders 37,256 23,793

Thousands

10,089

Percent

^Elderly defined as aged 60 years and older.

^Excludes never-married elders, elders with no child(ren), and elders with children at home.

13,704 13,463

Living arrangements:

Live alone 27.2 27.4 32.0 24.0 26.8

With spouse 59.6 58.5 52.4 62.9 61.7

With other relative

or nonrelative 13.2 14.1 15.6 13.1 11.5

Social activities:

See children:^ 2.6 2.6 3.3 2.2 2.6

Less than once a year 94.0 94.0 93.7 94,1 94.0

1-12 times a year .2 .2 .1 .3 .2

13 or more times a year

In past 2 weeks:

Saw friends/neighbors 70.9 71.3 68.4 73.5 70.2

Saw relatives 78.7 77.9 74.9 80.0 80.1

Went to church 51.8 51.2 50.7 51.5 52.9

Social support:

Someone to provide care for

a few weeks:

No one 10.0 10.6 12.0 9.5 9.1

Household relative 56.1 56.1 50.8 60,0 56.0

Relative not in household 26.6 25.4 27.5 23.8 28.7

Nonrelative 5.1 5.6 6.9 4.6 4.3

Don't know or refused 2.2 2.4 2.8 2.1 1.9

Number of community

services used:

None 81.4 81.7 81.4 81.8 81.0

1 9.9 10.6 10.3 10.8 8.6

2 or more 8.7 7.7 8.3 7.3 10.4

Percent using selected

community services:

Senior center 12.7 12.2 11.3 12.9 13.5

Special transportation

for elderly 3.6 3.5 4.0 3.1 3.7

Meals taken in senior

center 7.1 5.7 6.2 5.3 9.6

21
Table 3-Summary measures of health status of the elderly, by age and residence, 1984^

Residence

Characteristics

U.S.

total

Metro

Total

Central

city Suburb

Nonmetro

Elderly aged 60 years and older:

In fair or poor health^

With ADL-IADL difficulties^

With 1 or more limitations'*

With arthritis

With hypertension

Restricted activity days^

Bed disability days^

Elderly aged 60-74 years:

In fair or poor health

With ADL-IADL difficulties

With 1 or more limitations

With arthritis

With hypertension

Restricted activity days

Bed disability days

Elderly aged 75 years and older:

In fair or poor health

With ADL-IADL difficulties

With 1 or more limitations

With arthritis

With hypertension

Restricted activity days

Bed disability days

Percent

30.9 28.8 31,5 26.8 34.7

29.2 27.8 30.2 26.0 31.8

52.9 50.2 52.8 48.3 57.6

49.0 46.8 47.1 46.6 53.0

4L8 40.4 42.0 39.2 44.4

12.8 12.8 13.6 12.2 12.8

6.8 7.0 7.4 6.7 6.3

29.9 27.5 31.0 24.9 34.4

23.8 22.3 25.1 20.3 26.4

48.0 45.2 47,8 43.3 53.2

47.3 44.7 44.9 44.5 52.1

40.5 39.1 40.9 37.8 42.9

12.2 12.2 13.0 11.7 12.2

6.2 6.5 7.1 6.0 5.7

33.6 32.5 33.0 32.0 35.5

43.9 43.1 43.8 42.7 45.2

66.4 64.9 67.2 63.1 68.9

53.7 52.8 53.1 52.6 55.2

45.4 43.9 45.0 42.9 48.0

14.4 14.4 15.3 13.6 14.4

8.2 8.5 8,1 8.8 7.9

^Elderly defined as aged 60 years and older.

^From self-reported assessments of health.

Includes those who report difficulty performing either personal eare or home management activities.

Includes those with difficulty in one or more functional activities.

^Restricted activity days and bed disability days refer to the past 2-week period.

22
Table 4--Fuiictional status of the elderly, by residence, 1984^

Residence

U.S. total Metro Nonmetro

Central

Characteristics Total city Suburb

Thousands

Number of elders 37,256 23,793 10,089

Percent

13,704 13,463

ADL dimculties:^

Number:

None 79.5 80.3 78.3 81.7 78.2

One 8.3 7.7 8.2 7.4 9.2

Two or more 1L7 11.2 12.5 10.3 12.4

Unknown .6 .8 1.0 .6 .3

Have difficulty:

Bathing or showering 8.3 8.3 8.7 8.1 8.4

Walking 16.3 15.3 17.2 14.0 18.0

lADL difficulties:^

Number:

None 75.4 76.4 74.0 78.1 73.7

One or more 24.0 22.9 24.9 21.3 25.9

Unknown .6 .8 1.0 .6 .4

Have difficulty:

Shopping for personal items 9.4 9.5 11.0 8.3 9.3

Doing heavy housework 21.3 20.7 22.7 19.3 22.4

ADL-IADL combined:

No ADL or lADL

difficulties 70.8 72.2 69.8 74.0 68.2

No ADL difficulties,

l+L\DUs 9.2 8.7 9.3 8.2 10.2

1+ADUs, no lADL

difficulties 5.1 4.7 5.0 4.6 5.8

1+difficulties, both

ADL and LADL 14.9 14.4 15.9 13.2 15.8

Number of functional limitations:"^

None 46.8 49.4 46.7 51.5 42.2

One or more 52.9 50.2 52.8 48.3 57.6

One 12.6 12.1 11.8 12.3 13.6

2-3 14.6 14.1 14.3 13.9 15.5

4-10 25.7 24.0 26.7 22.1 28.6

Don't know .3 .4 .5 ,3 .2

^Elderly defined as aged 60 years and older.

^Activities of daily living (ADLs) include bathing or showering, dressing, eating, transferring (getting in or out of a bed or chair),

walking, getting outside, and using or getting to a toilet.

^Instrumental activities of daily living (lADL's) include preparing own meals, shopping for personal items, managing money, using

the telephone, and doing heavy and light housework.

"^Functional limitations refer to difficulty in the following 10 activities: walking a quarter of a mile, walking up 10 steps without rest,

standing for 2 hours, sitting for 2 hours, stooping, crouching, or kneeling, reaching up overhead, reaching out as if to shake hands,

using fmgers to grasp, lifting or carrying 25 pounds, and lifting or carrying 10 pounds.

23
Table 5--Proportion of the elderly reporting their health as fair or poor, by residence and selected

characteristics, 1984^

Characteristics Central city

Residence

Suburb Nonmetro

Demographic:

Age:

60-74 years

75 years and older

31.0

33.0

Percent

24.9

32.0

34.4

35.5

Race:^

White

Black

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

Someone to provide care:^

No one

Household relative

Relative not in household

Nonrelative

Socioeconomic:

Income:

Less than $20,000

$20,000 or more

28.7

45.1

30.0

29.9

40.2

38.7

30.5

31.0

29.8

35.9

22.0

26.0

48.0

24.1

26.0

35.2

34.9

25.8

26.2

25.2

32.9

19.3

32.7

61.0

32.8

33.9

43.8

38.8

33,0

36.5

35.7

40.4

19.0

Education:

Less than high school

High school, 4 years

College, 1 or more years

39.7

25.1

20.1

36.2

21.5

18.4

45.7

24.2

18.1

^Elderly defined as aged 60 years and older.

Excludes other races.

^Includes anyone (relative or nonrelative) who could be a potential care-giver.
Table 6--Proportion of the elderly with one or more ADL and lADL difficulties, by residence and selected

characteristics, 1984^

Characteristics Central city

Residence

Suburb Nonmetro

Demographic:

Age:

60-74 years

75 years and older

12.4

25.4

Percent

9.3

24.6

11.5

26.4

Race:^

White

Black

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

Someone to provide care:^

No one

Household relative

Relative not in household

Nonrelative

Socioeconomic:

Income:

Less than $20,000

$20,000 or more

15.9

16.8

19.6

11.2

24.5

24.9

13.1

15.5

22.3

18.0

11.0

12.9

21.5

14.6

9.9

26.9

24.3

11.3

12.7

17.2

16.5

9.4

15.2

23.3

20.3

11.5

28.4

24.0

13,3

17.1

17.8

18.5

7.9

Education:

Less than high school

High school, 4 years

College, 1 or more years

19.9

12.0

11.6

18.2

9.9

9.2

19.8

10.3

11.5

^Elderly defined as aged 60 years and older.

^Excludes other races.

^Includes anyone (relative or nonrelative) who could be a potential care-giver.

25
Table T-Use of health care and community services by the elderly, by age and residence, 1984*^

Residence

Characteristics

U.S. total Metro

Total

Central

city Suburb

Nonmetro

Persons aged 60 years and olden

Used formal health services^

Any doctor visits

Any hospital days

Ever in nursing home

High formal service use^

Used 1 or more community services^

Persons aged 60 years and older in fair

or poor health:

Used formal health services

Any doctor visits

Any hospital days

Ever in nursing home

High formal service use

Persons aged 60-74 years:

Used formal health services

Any doctor visits

Any hospital days

Ever in nursing home

High formal service use

Used 1 or more community services

Persons aged 75 years and older:

Used formal health services

Any doctor visits

Any hospital days

Ever in nursing home

High formal service use

Used 1 or more community services

Percent

81.1 82.1 80.8 83.0 79.4

80.5 81.4 80.0 82.4 78.8

17.7 17.2 16.7 17.6 18.4

1.5 1.5 1.7 1.3 1.5

14.7 15.4 17.5 13.9 13.5

18.6 18.3 18.6 18.2 19.0

89.7 90.5 90.1 90.8

89.0 89.7 89.4 89.9

30.4 30.7 29.7 31.7

3.0 3.1 3.0 3.3

29.2 31.2 33.0 29.7

79.8 80.7 79.5 81.6

79.3 80.1 78.8 81.1

15.6 15,4 15.4 15.4

.7 .8 .9 ,7

13.2 14.0 16.1 12.5

15.0 15.1 15.3 14.9

84.5 85.9 84.5 87.0

83.7 85.0 83.4 86.3

23.2 22.4 20.5 23.9

3.6 3.6 4.0 3.2

18.7 19.4 21.3 17.9

28.0 27.4 27.2 27.6

88.7

87.9

29.8

2.8

26.2

78.2

77.7

15,9

.6

11.9

14.9

82.3

81.5

24.6

3.7

17.6

29.0

Elderly defined as aged 60 years and older.

Use of formal services is defined as either 1-11 doctor visits or hospital stays of 1-30 days in the past year, and no nursing

home stays. High use of formal care was determined if the individual had either 12 or more doctor visits, had been hospitalized

for 31 or more days, or had ever been in a nursing home.

Community services consist of using a senior center, special transportation for the elderly, meals in a senior center,

homemaker services, adult day care, and visiting nurse services.
Table 8--Proportion of the elderly who used no formal health care services, by residence and selected

characteristics, 1984^

Residence

Characteristics Central city Suburb Nonmetro

Percent

Demographic:

Age:

60-74 years

75 years and older

Race:^

White

Black

20.5

15.5

19.5

18.0

18.4

13.0

17.1

16.2

21.8

17.7

20.6

21.9

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

Someone to provide care:^

No one

Household relative

Relative not in household

Nonrelative

17.0

20.4

19.4

18.2

21.2

17.2

15.2

15.8

17.8

15.6

14.3

17.6

16.7

16.1

19.0

21.1

22.0

20.0

22.3

17.4

21.2

Socioeconomic:

Income:

Less than $20,000

$20,000 or more

18.4

19.9

17.2

16.5

20.9

19.2

Education:

Less than high school

High school, 4 years

College, 1 or more years

19.7

20.0

15.8

17.0

17.3

16.7

^Elderly defined as aged 60 years and older.

Excludes other races.

^Includes anyone (relative or nonrelative) who could be a potential care-giver.

20.8

21.3

18.0

27
Table 9"Proportion of the elderly in fair or poor health who used no formal health care services, by

residence and selected characteristics, 1984^

Residence

Characteristics Central city Suburb Nonmetro

Percent

Demographic:

Age:

60-74 years

75 years and older

Race:^

White

Black

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

Someone to provide care:^

No one

Household relative

Relative not in household

Nonrelative

10.0

9.5

10.4

8.8

8.5

11.2

8.6

11.4

10.9

8.9

3.2

10.8

5.7

9.1

113

7.3

11.0

5.5

7,5

10.0

8.2

7.4

11.6

10.8

11.2

13.0

9.8

11.9

11.6

14.2

13.0

7.8

6.5

Socioecononiic:

Income:

Less than $20,000

$20,000 or more

9.0

10.2

10.3

6.1

11.5

10.7

Education:

Less than high school

High school, 4 years

College, 1 or more years

10.3

8.9

6.6

10.3

7.9

8.1

12.6

9.6

3.2

^Elderly defined as aged 60 years and older.

^Excludes other races.

^Includes anyone (relative or nonrelative) who could be a potential care-giver.
Appendix table l-Social support networks and use of community services by the elderly, by

age and residence, 1984^

Residence

U.S. total Metro

Characteristics

Total Central

city

Suburb

Nonmetro

Thotisands

Elderly aged 60-74 years:

Number 27,110 17,533 7,353

Percent

10,179 9,578

Living arrangements:

Live alone 22.0 22.8 nj& 19.2 20.5

With spouse 67.2 65.7 58.6 70.8 69.9

With other relative

or nonrelative 10.8 11.5 13.5 10.0 9.6

Social activities:

See children-^

Less than once a year 2.6 2.6 3.2 2.1 2.6

1-12 times a year 94.2 94.4 94.0 94.6 93.9

13 or more times a year .1 .2 .1 .3 .2

In past 2 weeksSaw friends/neighbors 72.7 73.3 70.4 75.4 71.6

Saw relatives 79.9 79.1 76.3 81.1 81.3

Went to church 53.3 52.8 52.7 52.9 54.3

Social support:

Someone to provide care for

a few weeksNo one 8.2 9.0 10.3 8.1 6.8

Household relative 61.0 60.8 55.1 64.9 61.5

Relative not in household 24.1 23.1 25.8 21.1 26.1

Nonrelative 4.6 5.1 6.5 4.1 3.7

Don't know or refused 2.0 2.1 2.4 1.9 1.8

Number of community services used:

None 85.0 84.9 84.7 85.1 85.1

1 8.2 9.0 8.5 9.3 6.8

2 or more 6.8 6.1 6.9 5.5 8.1

Percent using selected

community services:

Senior center

Special transportation

for elderly

Meals taken in senior center

11.3

2.5

6.1

11.1

2.5

5.0

10.2

3.2

5.9

11.8

2.0

4.4

11.7

2.4

8.0

See footnotes at end of table. Continued29
Appendix table l-Social support networks and use of community services by the elderly, by

age and residence, 1984^»Continued

Characteristics

Residence

U.S. total Metro Nonmetro

Total Central

city

Suburb

Thousands

10,145 6,260 2,736

Percent

3,524 3,885

41.0 40.3 43.3 37.9 42.3

39.5 38.2 35.7 40.2 41.5

Elderly aged 75 years and olden

Number

Living arrangements:

Live alone

With spouse

With other relative

or nonrelative

Social activities:

See children--^

Less than once a year

1-12 times a year

13 or more times a year

In past 2 weeksSaw friends/neighbors

Saw relatives

Went to church

Social support:

Someone to provide care for

a few weeksNo one

Household relative

Relative not in household

Nonrelative

Don't know or refused

Number of community services used:

None

1

2 or more

Percent using selected

community services:

Senior center

Special transportation

for elderly

Meals taken in senior center

19.5

16.3

6.4

9.9

21.5

15.3

6.2

7.6

21.0

14.4

6.0

7.1

21.9

14.9 15.0 16.5 13.8

42.8 43.0 39.5 45.8

33.1 31.9 32.1 31.7

6.5 7.0 8.0 6.2

2.8 3.2 3.9 2.6

72.0 72.6 72.8 72.4

14.3 15.1 15.0 15.1

13.7 12.3 12.2 12.4

16.0

6.3

8.0

16.2

2.7 2.8 3.3 2.5 2.4

93.4 92.7 92.7 92.7 94.4

.2 .3 0 .4 .2

66.1 65.7 62.9 67.9 66.7

75.5 74.4 71.3 76.9 77.3

47.8 46.7 45.4 47.8 49.4

14.7

42.4

35.0

5.7

2.2

7L0

13.0

16.0

17.9

6.9

13.6

elderly defined as aged 60 years and older.

^Excludes never-married elders, elders with no child(ren), and elders with children at home.
Appendix table 2"SeIf-reporte€l health status of the elderly, by age and residence, 1984^

Residence

Unite U.S. total Metro

Central

Nonmetro

Characteristics Total city Suburb

Elderly aged W years and older.

Number Thousands 37,107 23,702 10,037 13,665 13,405

Health status:

Excellent or very good Percent 38.0 39.5 37.4 41.0 35.3

Good do. 31.1 31.8 31.1 32.3 29.9

Fair or poor do. 30.9 28.8 31.5 26.8 34.7

Elderiy aged 60-74 years:

Number Thousands 27,021 17,480 7,326 10,154 9,542

Health status:

Excellent or very good Percent 38.9 40.3 37.7 42.3 36.3

Good do. 31.2 32.2 31.4 32.8 29.3

Fair or poor do. 29.9 27.5 31.0 24.9 34.4

Elderiy aged 75 years and older:

Number Thousands 10,086 6,223 2,711 3,512 3,863

Health status:

Excellent or very good Percent 35.5 37.0 36.8 37.2 33.1

Good do. 30.9 30.5 30.2 30.8 31.4

Fair or poor do. 33.6 32.5 33.0 32.0 35.5

^Elderly defined as aged 60 years and older.

31
Appendix table 3--Disability among the elderly, by age and residence, 1984^

Residence

U.S. total Metro Nonmetro

Characteristics Units Total

Central

city Suburb

Elderly aged 60 years and older:

Number Thousands 37,256 23,793 10,089 13,704 13,463

Restricted activity days in past 2 weeks:

None

1-5

6-14

Percent

do.

do.

87.2

4.8

8.0

87.2

4.6

8.2

86.4

4.7

8.9

87.8

4.5

7.6

87.2

5.1

7.7

Bed disability days in past 2 weeks:

None

1-5

6-14

Percent

do.

do.

93.2

3.3

3.4

93.0

3.5

3.5

92.6

3.5

3.9

93.3

3.5

3.2

93.7

3.0

3.3

Having 1 or more ADL or

lADL difficulties:

Number Thousands 10,823 6,555 3,011 3,544 4,268

Restricted activity days in past 2 weeksNone

1-5

6-14

Percent

do.

do.

71.6

S.6

19.8

70.7

8.3

21.0

69.4

9.0

21.7

71.8

7.7

20.4

72.9

9.0

18.1

Bed disability days in past 2 weeksNone

1-5

6-14

Percent

do.

do.

83.8

6.4

9.9

82.5

6.9

10.6

82.4

7.4

10.2

82.6

6.4

11.0

85.7

5.6

8.7

Reporting health as fair or poor:

Number Thousands 11,478 6,820 3,162 3,657 4,658

Restricted activity days in past 2 weeks ~

None

1-5

6-14

Percent

do.

do.

72.8

8.2

19.0

71.2

8.1

20.7

70.9

8,6

20.5

71.5

7.7

20.8

75.2

8.4

16.4

Bed disability days in past 2 weeksNone

1-5

6-14 days

Percent

do.

do.

84.4

6.7

8.9

82.7

7.4

9.9

82.2

7.7

10.1

83.1

7.1

9.8

86.8

5.7

7.5

See footnote at end of table. Continued32
Appendix table 3-Dísability among the elderly, by age and residence, 1984^»Continued

Residence

U.S. total Metro Nonmetro

Central

Characteristics Units Total city Suburb

Elderly aged 60-74 years:

Number Thousands 27,110 17,533 7,353 10,179 9,578

Restricted activity days in past 2 weeks:

None Percent 87.8 87.8 87.0 88.3 87.8

1-5 do. 5.1 4.9 4.9 4.9 5.4

6-14 do. 7.1 7.3 8.1 6.8 6.8

Bed disability days in past 2 weeks:

None Percent 93.8 93.5 92.9 94.0 94.3

1-5 do. 3.4 3.7 3.6 3.7 3.0

6-14 do. 2.8 2.8 3.5 2.3 2.7

Elderly aged 75 years and olden

Number Thousands 10,145 6,260 2,736 3,524 3,885

Restricted activity days in past 2 weeks:

None Percent 85.6 85.6 84.7 86.4 85.6

1-5 do. 4.1 3.9 4.4 3.5 4.4

6-14 do. 10.3 10.5 11.0 10.2 10.0

Bed disability days in past 2 weeks:

None Percent 91.8 91.5 91.9 91.2 92.1

1-5 do. 3.0 3.0 3.2 2.9 3.0

6-14 do. 5.2 5.5 5.0 5.9 4.9

'Elderly defined as aged 60 years and older.

33
Appendix table 4-Self-reported health status af the elderly, by residence and selected characteristics, 1984^

Excellent or veiy good Good Fair or poor

Characteristics

of

elders

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

Th/niJi/ind.K

Demographic:

Age:

60-74 years

75 years and older 10,086

37.7

36.8

42.3

37.2

36.3

33.1

31.4

30.2

32.8

30.8

29.3

31.4

31.0

33.0

24.9

32.0

34.4

35.5

Gender:

Male

Female

15,898

21,209

38.4

36.8

41.5

40.5

36.1

34.7

3L1

31.0

31.5

32.9

28.3

31.2

30.5

32.2

27.0

26.6

35.6

34.1

Race:^

White

Black

33,502

3,167

39.3

28.7

41.5

28.2

36.5

20.9

32.0

26.2

32.6

23.8

30.8

18.1

28.7

45.1

26.0

48.0

32.7

61.0

Ethnicity:^

Hispanic

Non-Hispanic

1,155

35,825

26.4

38.0

30.0

41.4

20.1

35.7

28.9

31.2

38.3

32.1

35.5

29.8

44.6

30.8

31.7

26.6

44.4

34.6

Marital status:

Married

Widowed, divorced.

77,579 36.9 40.2 35.4 33.3 33.5 30.6 29.8 263 34.0

or separated

Never married

12,798

1,635

37.7

39.1

41.3

46.1

35.6

31.3

28.4

29,7

303

303

28.1

34J

33.9

313

28.4

23.6

363

34.2

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

10,072

22,160

42.3

36.7

43.8

40.4

39.0

35.2

27.7

33.4

32.1

33.6

28.2

30.9

30.0

29.9

24.1

26.0

32.8

33.9

or nonrelative 4,875 29.9 38.4 27.5 29.9 26.4 28.6 40.2 35.2 43.8

See footnotes at end of table. Continued-
Appendix table 4-Self-reported health status of the elderly, by residence and selected characteristics, I984^--Continued

Number

of

Excellent or very good Good Fair or poor

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

TTí/íIJXíWUJK _ P^WV^ftt

Someone to provide care:^

•-'—rcrmíu—

No one 3,719 34.7 31.6 32.6 26.6 33.5 28.6 38.7 34.9 38.8

Household relative 20,827 36.9 41.9 36.6 32.6 32.3 30.4 30.5 25.8 33.0

Relative not in household 9,867 37.9 42.4 32.4 3L1 31.4 3L1 31.0 26.2 36.5

Nonrelative 1,8% 41.7 42.9 40.6 28.5 31.9 23.8 29.8 25.2 35.7

Socioeconomic:

Education:

Less than high school 17,518 29.6 31.2 25.7 30.7 32.6 28.5 39.7 36.2 45.7

High school, 4 years 11,598 41.8 44.3 43.3 33.0 34.1 32.5 25.1 21.5 24.2

College, 1 or more years 7,562 51.0 52.9 51.7 28.9 28.7 30.1 20.1 18.4 18.1

Employment status in

past 2 weeks:

Employed 7,860 55.2 57.6 49.9 28.8 29.6 29.5 16.1 12.8 20.7

Unemployed 399 58.2 37.8 35.3 27.7 36.7 41.4 14.0 25.5 23.4

Not in labor force 28,848 32.4 35.9 31.8 31.7 33.1 29.9 35.9 3L1 38.3

Income:

Less than $20,000 23,487 32,7 34.1 30.7 31.4 33.0 28.9 35.9 32.9 40.4

$20,000 or more 11,832 48.1 49.3 48.4 30.0 31.4 32.7 22.0 19.3 19.0

Poverty status:

Below poverty 4,477 26.3 27.4 23.9 26.2 29.2 22.7 47.5 43.4 53,3

Above poverty 26,840 39.3 41.9 37.5 32.0 32.6 31.4 28.6 25.5 31.2

Retirement status:^

Completely retired 25,347 32.6 35.8 32.0 31.6 32.9 29.5 35.8 31.3 38.6

Partly retired 3,076 44.1 51.8 40.6 32.9 31.0 31.3 23.0 17.1 28.1

Not retired 7,071 52.8 54.8 48.8 29.1 30.8 30.4 18.2 14.4 20.8

See footnotes at end of table. ContinuedwLn
Appendix table 4-Self-reported health status of the elderly, by residence and selected characteristics, 1984^"Continued

Number

of

Excellent or very good Good Fair or poor

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thniisiíinílv —_P/^/»4»M/_ -

Residential:

J. /(C/MJlU#tM.> —X cfCc/li—

Region: 8,599 36.8 41.7 38.9 34.0 33.7 34.1 29.2 24.6 27.0

Northeast 9,426 34.9 38.6 35.4 333 34.8 32.9 31.8 26.5 31.8

Midwest 12,500 36.6 39.9 32.6 26.9 28.7 26.0 36.5 31.4 41.4

South 6,582 42.9 43.7 40.9 31.0 31.4 33.0 26.1 24.9 26.1

West

Length of residence:

Less than 1 year 1,871 38.0 37.8 35.1 23.0 37.2 24.4 39.0 25.0 40.5

1-10 years 11,559 31.6 39.3 36.8 31.3 31.2 29.0 37.1 29.5 34.2

11-20 years 8,523 40.8 39.9 34.6 27.2 31.5 29.5 32.0 28.6 35.9

At least 21 years 14,889 39.3 43.1 34.6 34.1 33.1 31.6 26.6 23.8 33.8

Selected medical conditions:

Hypertension:

Has 15,517 27.0 30.4 27.2 32.3 34.8 30.0 40.8 34.8 42.8

Does not have 21,235 45.1 47.8 42.0 30.5 30.7 29.8 24.4 21.5 28.2

Arthritis:

Has 18,179 28.3 31.5 27.5 30.5 33.8 28.6 41.2 34.7 43.9

Does not have 18,270 45.7 49.7 44.3 31.9 30.8 31.6 22.4 19.5 24,1

Elderly defined as aged 60 years and older.

'^Excludes other races.

^Persons of Hispanic origin may be of any race.

''includes anyone (relative or nonrelative) who could be a potential care-giver.

^Excludes those who never worked.
Appendix table 5-Functional status of the elderly, by residence and selected characteristics, 1984^

Characteristics

Number

of

elders

No ADL-IADL difficulties

No ADL difficulties,

1 or more lADL difficulties

1 or more ADL difficulties,

no lADL difficulties

1 or more difficulties with

both ADL*s and lADL's

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

Demographk:

Age:

60-74 years

75 years and older

Genden

Male

Female

Race:^

White

Black

Ethnicity:^

Hispanic

Non-Hispanic

Thomands

26,956

10,060

74.9

56.2

79.7

57.3

15,839

21,176

78.5

64.1

80.3

69.0

33,413

3,164

71.3

63.0

74.6

58.4

1,154

35,734

61.6

70.3

72.4

74.1

73.6

54.8

74.1

63.5

69.1

57.3

64.1

68.3

8.4 6.8

11.5 12.4

5.1 5.0

12.0 10.7

83 8.0

13.9 14.3

9.8 12.1

9.2 8.1

-Percent9.5

12.0

6.8

12.9

10.0

12.6

15.3

10.1

4.3 4.2

6.8 5.7

5.7 6.1

4.4 3.4

4.6 4.5

6.3 5.7

5.4 2.9

4.9 4.6

5.3

6.9

7.3

4.6

5.7

6.9

5.7

5.7

12.4 9.3

25.4 24.6

10.6 8.6

19.5 16,8

15.9 12.9

16.8 21.5

23.1 12.6

15.5 13.2

11.5

26.4

11.7

19.0

15.2

23.3

14.9

15.9

Marital status:

Married

Widowed, divorced,

or separated

Never married

Social support:

Living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

22,494

12,799

1,623

10,058

22,074

4,884

76.1

61.8

67.1

65.3

76.4

57.2

79.1

63.7

73.3

70.0

79.4

55.1

73.5

58.5

64.3

61.0

73.8

54.9

7.9

11.7

5.8

9.8

7.8

12.9

6.5

11.5

9.5

10.7

6.3

12.7

9.0

12.6

10.8

12.7

8.8

12.1

4.6

5.1

6.7

5.3

4.6

5.4

4.3

5.2

3.5

4.8

4.3

5.3

6.0

5.1

8.9

5.9

6.0

4.7

11.4

21.3

20.3

19.6

11.2

24.5

10.1

19.5

13.7

14.6

9.9

26.9

11.6

23.8

16,0

20.3

11.5

28.4

See footnotes at end of table. Continued"
00

Appendix table 5*-Fuiictional status of the elderly, by residence and selected characteristics, 1984*--Continued

No ADL difficulties. 1 or more ADL difficulties, 1 or more difficulties with

Number

of

No ADL-L\DL difficulties 1 or more lADL difficulties

Central Suburb Nonmetro

no lADL difficulties both ADL's, and \ADVs

Central Suburb Nonmetro Central Suburb Nonmetro Central Suburb Nonmetro

Characteristics elders city city city city

Thousmtds u^^.^*

Someone to provide care:^

„ ^ Ç,,,ucr«————

No one 3,739 57.0 59.7 54.2 11.3 11.2 15.7 6.8 4.8 6.1 24.9 24.3 24.0

Household relative 20,880 73.8 76.9 72.6 8.1 7.2 8.1 5.1 4.6 6.0 13.1 11.3 13.3

Relative not in household 9,897 68.9 73.9 65.7 11.3 9.2 11.8 4.3 4.2 5.3 15.5 12.7 17.1

Nonrelative 1,906 67.3 67.6 63.1 6.6 10.1 12.7 3.7 5.1 6.3 22.3 17.2 17.8

Socioeconomic:

Education:

Less than high school 17,512 63.0 66.3 60.7 11.0 9.8 12.5 6.1 5.7 7.0 19.9 18.2 19.8

High school, 4 years 11,572 75.3 78.6 77.0 8.1 7.6 7.5 4.6 3.8 5.2 12.0 9.9 10,3

College, 1 or more years 7,505 78.8 80.9 77.5 6.9 6.3 7.9 2.7 3.6 3.1 11.6 9.2 11.5

Employment status in past 2

weeks: 7,823 90.6 91.0 88.3 4.3 3.1 4.9 2.3 2.7 4.3 2.8 3.2 2,5

Employed 394 91.4 83.0 69.8 5.4 5.9 6.9 0 3.2 5.4 3,2 7.9 17.9

Unemployed 28,798 64.0 68.6 63.3 10.6 9.8 11.5 5.7 5.2 6.2 19.6 16.4 19.0

Not in labor force

Income:

Less than $20,000 23,464 65.8 68.2 63.2 10.3 9.9 11.7 5.9 5.4 6.6 18.0 16.5 18.5

$20,000 or more 11,804 79.3 80.8 81.9 6.7 6,1 6.4 3.0 3.7 3.8 11.0 9.4 7.9

Poverty status:

Below poverty 4,489 54.5 55.0 50.7 12.7 13.6 15.3 6.9 7.7 7.7 25.9 23.7 26.3

Above poverty 26,818 73.3 75.5 72.0 8.3 8.0 9.3 4.6 4.3 5.6 13.7 12.3 13.1

Retirement status:^

Completely retired 25,330 63.7 68.5 62.5 10.6 9.8 11.9 5.9 5.3 6.2 19.7 16.3 19,4

Partly retired 3,070 83.8 86.5 80.9 6.6 4.7 5.4 2.9 2.9 5.8 6.7 5.9 7.9

Not retired 7,076 88.3 89.9 87.2 4.8 4.0 5.1 2.2 2.3 4.4 4.7 3.9 3,3

See footnotes at end of table. Continued"
Appendix table 5«FuiictionaI status of the elderiy, by residence and selected characteristics, 1984^--Continued

No ADL difficulties, 1 or more ADL difficulties. 1 or more difficulties with

Number

of

No ADL-IADL difficulties 1 or more lADL difficulties no lADL difficulties both ADL's, and L\DL's

Central Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

ThnusuFtdx

Residential:

M. rtV(4iJI4rH4a9 ^,

tr vc.ru

Region:

Northeast 8,567 71.1 76.3 71.7 8.7 7.3 7.6 4.8 3.7 5.6 15.4 12.7 15.0

Midwest 9,397 70.6 75.5 69.6 8.2 7.8 9.5 5.4 4.1 5.9 15.8 12.7 15.0

South 12,498 64.6 68.2 64.4 12.1 9.7 11.9 5.6 6.5 6.1 17.7 15.6 17.6

West 6,553 75.7 75.5 74.8 6.9 8.3 8.5 3.5 4.2 4.9 13.9 12.0 11.8

Length of residence:

Less than 1 year 1,869 65.1 70.6 69.1 11.3 7.7 7.1 5.6 6.3 6.5 18.1 15.4 17.2

1-10 years 11,504 62.6 68.9 68.5 11.8 9.5 11.2 6.1 5.9 5.3 19.5 15.7 15.0

11-20 years 8,524 71.2 75.1 68.4 9.0 9.3 9.7 4.8 3.3 7.0 15.0 12.2 14.9

At least 21 years 14,890 74.5 77.6 67.7 7.4 6.6 10.0 4.2 4.0 5.6 13.9 11.7 16.7

Hypertension:

Has 15,550 60.2 67.1 60.5 12.1 9.9 11.9 6.4 5.2 6.7 21.3 17.8 20.9

Does not have 21,244 77.1 78.5 74.5 7.2 7.1 8.8 3.9 4.1 5,1 11.9 10.3 11.7

Arthritis:

Has 18,220 57.7 62.7 57.4 12.3 11.2 12.2 6,6 6.7 7.8 23.4 19.5 22.5

Does not have 18,272 80.7 84.5 81.0 6.7 5.4 7.6 3.4 2.6 3.4 9.2 7.5 8.0

Elderly defined ^s aged 60 years and older.

^Excludes other races.

^Persons of Hispanic origin may be of any race.

"^Includes anyone (relative or nonrelative) who could be a potential care-giver.

^Excludes those who never worked.

so
è

Appendix table 6-Functional limitations of the elderly, by residence and selected characteristics, 1984^

Number

of

No functional limitations One to three limitations Four or more limitations

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thnus!íin/ív —/ng/*C^/t/—-

Demographic:

JL lHJl40UJf4A,ü

Age:

60-74 years 27,034 52.2 56.7 46.8 24.9 25.8 29.0 22.9 17.5 24.2

75 years and older 10,115 32.8 36.9 31,1 29.9 27.4 29.4 37.3 35.7 39.5

Gender:

Male \5m^ 56.3 60.3 49.0 24.8 23.1 27.4 18.9 16.6 23.6

Female 21,264 40.7 44.8 37.0 27.2 28.6 30.4 32,0 26.6 32.6

Race:^

White 33,543 48.2 52.1 43.1 26.2 26.4 29.4 25.6 21.5 27.5

Black 3,168 40.4 36.5 32.1 27.1 24.3 25.3 32.6 39.3 42.5

Ethnicity:^

Hispanic 1,163 38.1 46.1 42.2 27.8 30.8 17.0 34.1 23.1 40.8

Non-Hispanic 35,854 47.4 51.8 42.3 26.2 26.1 29.2 26.4 22.1 28.5

Marital status:

Married 22,568 53.6 57.3 46.5 25.2 24.4 30.0 21.3 18.3 23.6

Widowed, divorced,

or separated 12,847 37.3 40.2 33.1 28.2 29.5 28.6 34.5 30.3 38.3

Never married 1,636 51.5 49.5 51.6 23.8 30.2 18.8 24.7 20.3 29.6

Social support:

Living arrangements:

Live alone 10,099 39.7 44.3 34.9 28.9 30.5 29.9 31.4 25.2 35.2

Live with spouse 22,148 53.7 57.6 46.6 25.2 24.4 30.0 21.1 18.0 23.3

Live with other relative

or nonrelative 4,902 39.1 35.8 36.2 24.4 27.2 22.0 36.5 37.0 41.9

See footnotes at end of table. Continued"
Appendix ^--Functional limitations of the elderly, by residence and selected characteristics, 1984^-Continued

Number

of

No functional limitations One to three limitations Four or more limitations

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thnjusnn/is: — J^amtvtt^

Someone to provide care:^

JL 1KJt^^VUUAH '-rciLtírU•—

No one 3,739 35.3 34.8 30.3 25.7 28.8 29.0 39.0 36.5 40.7

Household relative 20,876 52.0 56.1 47.0 25.3 24.1 28.7 22.7 19.7 24.3

Relative not in household 9,900 43.5 48.5 37.8 28.3 29.2 30.0 28.2 22.3 32.1

Nonrelative 1,906 44.4 46.4 39.8 27.6 30.9 26.9 28.0 22.6 33.3

Socioeconomic:

Education:

Less than high school 17,574 39.4 41.0 34.9 26.7 29.0 29.3 33.9 30.0 35.8

High school, 4 years 11,595 54.0 56.8 48.8 25.5 25.5 30.9 20.5 17.7 20.2

College, 1 or more years 7,551 55.0 62.5 54.6 27.0 23.0 25.4 18.1 14.5 20.0

Employment status in

past 2 weeks:

Employed 7,838 70.4 71.3 64.9 21.3 22.0 25.7 8.4 6.6 9.4

Unemployed 399 56.0 64.3 51.4 34.9 19.5 24.1 9.2 16.2 24.4

Not in labor force 28,912 40.6 45.4 36.7 27.5 27.6 29.9 32.0 27.1 33.3

Income:

Less than $20,000 23,553 41.2 43.2 36.8 27.6 29.5 30.1 31.2 27.3 33.1

$20,000 or more 11,809 59.5 61.8 57.1 23.3 22.2 26.9 17.1 16.0 16.0

Poverty status:

Below poverty 4,500 29.1 28.4 28.1 27.2 29.2 26.4 43.8 42.4 45.6

Above poverty 26,869 49.9 53.1 44.7 26.4 26.5 30.5 23.7 20.4 24.9

Retirement status:^

Completely retired 25,429 40.4 45.4 35.9 27.5 27.5 30.3 32.1 27.1 33.7

Partly retired 3,082 56.3 61.8 51.8 27.4 26.1 31.8 16.3 12.1 16.4

Not retired 7,087 69.2 70.1 64.3 20.9 22.4 23.6 9.9 7.5 12.1

See footnotes at end of table. Continued-
6

Appendix 6-Functional limitations of the elderly, by residence and selected characteristics, 1984^-Continued

Number

of

No functional limitations One to three limitations Four or more limitations

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thousands —^PercentResidential:

Region:

Northeast 8,614 52.0 56.5 49.7 24.0 275 28,3 24.0 21.0 22.1

Midwest 9,433 44.3 50.7 44.0 29.5 27.8 28.3 26.2 21.5 27.7

South 12,524 41.7 46.8 38.0 27.3 26.1 29.4 31.0 27.0 32.5

West 6,578 52.1 51.1 45.4 23.5 29.6 30.4 24.4 19.3 24.2

Length of residence:

Less than 1 year 1,873 43,7 50.1 41.3 26.7 23.5 28.9 29.7 26.5 29.9

1-10 years 11,573 40.3 45.9 42.0 26.9 27.2 29.8 32.8 26.8 28.2

11-20 years 8,553 49.1 5L1 42.8 22.9 29.0 28.4 27.9 19.9 28.8

At least 21 years 14,918 50.5 56.3 42.3 27.8 24.2 29.0 21.7 19.5 28.7

Selected medical conditions:

Hypertension:

Has 15,581 35.3 42.5 32.2 27.5 28.6 31.2 37.2 29.0 36.6

Does not have 21,300 55.8 57.6 50.5 25.3 24.6 27.4 18.8 17.8 22.1

Arthritis:

Has 18,266 28.4 33.5 26.1 32.1 32.7 33.0 39.5 33.8 40.9

Does not have 18,306 63.7 68.2 61.2 21.2 20.1 24.4 15.2 11.6 14.4

Elderly defined as aged 60 years and older.

^Excludes other races.

^Persons of Hispanic origin may be of any race.

"•includes anyone (relative or nonrelative) who could be a potential care-giver.

^Excludes those who never worked.
Appendix table 7--Use of health care services by the elderly, by age and residence, 1984^

Residence

U.S. total Metro Nonmetro

Total Central Suburb

Characteristics Units city

Elderly aged 60 years and older:

Number Thousands 37,256 23,793 10,089 13,704 13,463

Doctor visits in past 12 months:

None Percent 19.5 18.6 20.0 17.6 21.2

Ml do. 67.8 68.0 64.8 70.3 67.4

12 or more do. 12.7 13.4 15.2 12.1 11.4

Short stay in hospital in past

12 months:

None Percent 82.3 82.8 83.3 82.4 81.6

1-30 days do. 16.2 15.8 15.3 16.1 17.0

31 or more days do. 1.5 1.5 1.4 1.5 1.4

Ever resident/patient in nursing home:

Yes Percent 1.5 1.5 1.7 1.3 1.5

No do. 97.5 97.3 96.7 97.8 97.9

Unknown do. .9 1.1 1.6 .8 .6

Use of formal health care services:

No use Percent 18.9 17.9 19.2 17.0 20.6

Moderate use do. 66.4 66.7 63.3 69.1 65.9

High use do. 14.7 15.4 17.5 13.9 13.5

Having 1 or more ADL or lADL

dtffîculties:

Number Thousands 10,823 6,555 3,011 3,544 4,268

Doctor visits in past 12 monthsNone Percent 10.5 9.5 8.4 10.4 12.1

Ml do. 63.6 62.8 61.4 64.0 64.9

12 or more do. 25.8 27.7 30.2 25.6 23.0

Short stay in hospital in past

12 monthS"

None Percent 68.7 69.0 69.1 68.9 68.3

1-30 days do. 27.4 27.0 27.3 26.7 28.1

12 or more days do. 3.9 4.0 3.6 4.4 3.6

Ever resident/patient in nursing homeYes Percera 4.3 4.4 4.1 4.6 4.1

No do. 95.3 95.1 95,3 95.0 95.4

Unknown do. .5 .5 .5 .4 .5

Use of formal health care servicesNo use Percent 9.6 8.5 7.7 9.3 11.2

Moderate use do. 59.4 58.7 57.3 59.9 60.6

High use do. 31.0 32.7 35,0 30.8 28.2

See fcxrtnole at end of table. Continued43
Appendix table 7--Use of health care services by the elderly, by age and residence, 1984^"Continued

Residence

U.S. total Metro Nonmetro

Total Central Suburb

Characteristics UniU city

Reporting their health as fair or poor:

Number Thousands 11,478 6,820 3,162 3,657 4,658

Doctor visits in past 12 monthsNone Percent 11.0 10.3 10.6 10.1 12.1

1-11 do. 63.8 62.5 60.4 64.3 65.6

12 or more do. 25.2 27.2 29.0 25.6 22.3

Short stay in hospital in past

12 monthS"

None Percent 69.6 69.3 70.3 68.3 70.2

1-30 days do. 26.8 26.9 26.3 27.4 26.6

31 or more days do. 3.6 3.9 3.4 4.3 3.2

Ever resident/patient in nursing homeYes Percent 3.0 3.1 3.0 3.3 2.8

No do. 96.1 95.6 95.4 95.8 96.7

Unknown do. .9 1.2 1.6 .9 .5

Use of formal health care servicesNo use Percent 10.3 9.5 9.9 9.2 11.3

Moderate use do. 60.6 59.3 57.1 61.1 62.4

High use do. 29.2 31.2 33.0 29.7 26.2

Elderly aged 60-74 years:

Number Thousands 27,110 17,533 7,353 10,179 9,578

Doctor visits in past 12 months:

None Percent 20.7 19.9 21.2 18.9 ?,?.3

1-11 do. 67.2 67.4 64.1 69.7 67.0

12 or more do. 12.0 12.8 14.7 11.4 10.7

Short stay in hospital in past

12 months:

None Percent 84.4 84.6 84.6 84.6 84.1

1-30 days do 14.4 14.2 14.1 14.3 14.8

31 or more days do. 1.2 1.2 1.2 1.2 1.1

Ever resident/patient in nursing home:

Yes Percent .7 .8 .9 .7 .6

No do. 98.4 98.2 97.7 98.6 98.9

Unknown do. .8 1.0 1.4 .7 .5

Use of formal health care services:

No use Percent 20.2 19.3 20.5 18.4 21.8

Moderate use do. 66.6 66.7 63.4 69.1 66.3

High use do. 13.2 14.0 16.1 12.5 11.9

See footnote at end of table. Continued44
Appendix table 7--Use of health care services by the elderly, by age and residence, I984^"Continued

Residence

U.S. total Metro Nonmetro

Total Central Suburb

Characteristics Units city

Elderly aged 75 years and older

Number TJiousands 10,145 6,260 2,736 3,524 3,885

Dcx;tor visits in past 12 months:

None Percent 16.3 15.0 16.6 13.7 18.5

1-11 visits do. 69.2 69.7 66.6 72.1 68.3

12 or more visits do. 14.5 15.3 16.8 14.2 13.2

Short-stay hospital episode days in past

12 months:

None Percent 76.8 77.6 79.5 76.1 75.4

1-30 days do. 21.0 20.1 18.4 21.4 22.5

31 or more days do. 2.2 2.3 2.1 2.5 2.1

Ever resident/patient in nursing home:

Yes Percent 3.6 3.6 4.0 3.2 3.7

No do. 95.1 94.9 94.1 95.6 95.5

Unknown do. 1.2 1.5 1.9 1.2 .7

Use of formal health care services:

No use Percent 15.5 14.1 15.5 13.0 17.7

Moderate use do. 65.8 66.5 63.2 69.1 64.7

High use do. 18.7 19.4 21.3 17.9 17.6

^Elderly defined as aged 60 years and older.

45
4^0\

Appendix table 8-Use of formal health care services by the elderly, by residence and selected characteristics, 1984^

Number

of

None used Moderate use High use

Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thousands ——-Percent"

Demographic:

Age:

60-74 years 26,830 20.5 18.4 21.8 63.4 69.1 66,3 16.1 12.5 11.9

75 years and older 10,007 15.5 13.0 17.7 63.2 69.1 64.7 21.3 17.9 17.6

Gender:

Male 15,750 23.2 19.4 22.5 61.2 68.4 64.8 15.6 12.1 12.8

Female 21,087 16.5 15.2 19.2 64,8 69.6 66.7 18.7 15.2 14.1

Race:^

White 33,268 19.5 17.1 20.6 63.9 69.4 66.4 16.6 13,5 13.1

Black 3,139 18.0 16.2 21.9 60.4 63.6 58.2 21.6 20.3 19.9

Ethnicity:^

Hispanic 1,152 20.9 17.9 17.1 49.2 64.4 67.1 29.9 17.7 15.8

Non-Hispanic 35,564 19.1 17.1 20.6 64.1 69.3 65.9 16.8 13.6 13.5

Marital status:

Married 22,388 20.3 17.9 21.2 64.7 69.8 67.4 15.0 12.4 11.3

Widowed, divorced,

or separated 12,736 17.6 14.7 18.3 61.7 68.1 64.4 20.7 17.1 17.3

Never married 1,621 19.0 23.0 30.1 62.3 64.9 52,6 18.8 12,1 17.3

Social support:

Living arrangements:

Live alone 10,014 17.0 15.8 19,0 63.4 68.6 64.3 19.6 15.6 16.7

Live with spouse 21,977 20.4 17.8 21,1 64.7 70,0 67.6 14.9 12.2 11.3

Live Avith other relative

or nonrelative 4,846 19.4 15.6 22.0 58.6 65.8 60.1 22.0 18.6 17.9

See footnotes at end of table. Continued-
Appendix table 8-Use of formal health care services by the elderly, by residence and selected characteristics^ 1984^»Continued

Number

None used Moderate use Hií5h use

of Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

'¡'itiynK/m/fv --"iCrccnt"

Someone to provide care:^

M. rli/t*Ot4rK*o

No one 3,723 18.2 14.3 20.0 59,0 66.0 62.3 22.8 19.7 17.7

Household relative 20,783 21.2 17.6 22.3 63.2 69.2 65.6 15.6 13.1 12.2

Relative not in household 9,864 17.2 16.7 17.4 65.9 70.4 68.0 17.0 12.8 14.5

Nonrelative 1,891 15.2 16.1 21.2 62.8 68.6 64.0 22.0 15.3 14.8

Socioeconomic:

Education:

Less than high school 17,404 19.7 17.0 20.8 59.4 67.2 64.5 21.0 15.8 14.7

High school, 4 years 11,536 20.0 17.3 21.3 66.4 70.3 67.1 13.6 12.4 11.7

College, 1 or more years 7,479 15.8 16.7 18.0 69.4 70.5 69.0 14.8 12.8 13.0

Employment status in

past 2 weeks:

Employed 7,794 25.6 22.9 27.4 65.8 69.4 66.5 8.6 7.7 6.1

Unemployed 397 30.6 20.9 15.7 62.4 67.5 70,3 7.0 11.6 14.0

Not in labor force 28,646 17.3 15.2 19.0 62.7 69.0 65.7 20.0 15.8 15.3

Income:

Less than $20,000 23,352 18.4 17.2 20,9 62.8 67.1 64.3 18.8 15.6 14.7

$20,000 or more 11,751 19.9 16.5 19.2 65.2 71.7 70.7 14.9 11.9 10.0

Poverty status:

Below poverty 4,461 21.0 18.1 21.9 54.0 63.3 58.4 25.0 18.6 19.8

Above poverty 26,715 18.6 16.5 20.3 65.7 70.1 67.5 15.7 13.4 12.2

Residential:

Region:

Northeast 8,537 20.6 17.8 21.3 60.2 68.1 65.3 19.1 14.1 13.4

Midwest 9,355 21.2 18.0 20,2 64.0 69.7 65.9 14.8 12.3 13.9

South 12,413 17.7 14.7 19.8 65,6 72.4 67.1 16.7 12.9 13.1

West 6,532 16.9 17,5 23.7 63.0 66.1 62.1 20.0 16.4 14.2

See fcxjtnotes at end of table. Continued-

^
00

Appendix table 8-Use of formal health care services by the elderly, by residence and selected characteristics, 1984^--Continued

Characteristics

Number

of

elders

None used Moderate use High use

Central Central Central

city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thousands "Percent--

Length of residence:

Less than 1 year

1-10 years

11-20 years

At least 21 years

Selected medical conditions:

Hypertension:

Has

Does not have

Arthritis:

Has

Does not have

1,856

11,457

8,493

14,811

15,471

21,139

18,117

18,185

17.9

19.6

17.9

19.7

7.9

27.4

12.0

25.7

15.2

16.7

16.1

18.2

7.6

23.1

12.3

21.2

25.0

21,6

18.5

20.3

10.4

28.9

15.5

26,4

61.0

59.3

64.3

65.7

69.8

58.8

65.6

61.3

69.5

67.8

70.5

69.2

74.8

65.4

69.8

68.6

60.2

64.4

68.6

66.6

71.7

61.2

66.3

65.6

21.0

21.1

17.8

14.6

22.3

13.8

22.4

13.1

15.4

15.5

13.4

12.7

17.6

11.5

17,9

10.2

14.8

14.1

12.9

13.1

17.9

9.9

18.2

7.9

^Elderly defined as aged 60 years and older.

^Excludes other races.

^Persons of Hispanic origin may be of any race.

'^Includes anyone (relative or nonrelative) who could be a potential care-giver.
Appendix table 9"Use of formal health care services by the elderly in fair or poor health, by residence and selected characteristics, 1984^

Characteristics

Demographic:

Age:

60-74 years

75 years and older

Gender:

Male

Female

Race:^

White

Black

Ethnicity:^

Hispanic

Non-Hispanic

Marital status:

Married

Widowed, divorced,

or separated

Never married

Social support:

living arrangements:

Live alone

Live with spouse

Live with other relative

or nonrelative

Number

of

elders

None used

Thousands

8,003

3,338

4,881

6,461

9,639

1,560

457

10,839

6,695

4,155

481

2,890

6,546

1,905

Central

city

10.0

9.5

12.9

8.0

10.4

8.8

9.1

10.0

11.2

8.6

Suburb Nonmetro

10.8

5.7

11.9

7.1

9.1

11.3

15.9

9.0

10.9

5.5

11.6

10.8

12.2

10.6

11.2

13.0

12.3

11.2

11.9

Moderate use High use

Central

city Suburb Nonmetro

Central

city Suburb Nonmetro

•Percent'

57.1

56.9

58.6

56.1

56.6

58.5

41.6

58.2

59.2

61.1

61.2

60.8

61.4

61.6

59.8

50.3

61.5

63.4

64.8

56.9

63.6

61.5

62.6

59.1

64.5

62.4

65.5

8.2 5.7 9.9 55.2 56.5 57.5

11.2 14.0 14.2 52.7 64.3 57.7

8.5 7.3 9.8 55.8 55.7 58.2

11.2 11.0 11.9 58.9 633 65.6

11.6 54.4 59.9 56.6

32.8

33.6

28.5

35.9

33.0

32.7

49.3

31.8

29.7

36.6

36.1

35.7

29.8

37.0

28.1 23.6

33.1 32.4

27.3 24.1

31.6 27.9

29.3 26.2

28.9 27.9

33.8 23.2

29.5 26.4

25.7 22.5

See footnotes at end of table.

37.8 32.6

21.7 28.1

37.0 32.0

25.7 22.4

34.6 31.8

Continuedê
O

Appendix table 9-.üse of formal health care services by the elderly in fair or poor health, by residence and selected characteristics, 1984^-

Continued

Number

None used Moderate use High use

of Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thousands _— —Percent- -_„__—_>„_

Someone to provide care:^

No one 1,383 11.4 7.5 14.2 50.3 57.5 55.7 38.3 35.0 30.1

Household relative 6,110 10.9 10.0 13.0 58.6 60.7 62.4 30.5 29.4 24.6

Relative not in household 3,092 8.9 8.2 7,8 59.9 65.2 64.0 3L1 26.5 28.2

Nonrelative 564 3.2 7.4 6.5 54.0 63.2 71.5 42.8 29.4 22.1

Socioeconomic:

Education:

Less than high school 7,084 10.3 10.3 12.6 553 61.2 62.8 34.4 28.5 24.6

High school, 4 years 2,690 8.9 7.9 9.6 60.5 64.3 62.3 30.6 27.8 28.0

College, 1 or more years 1,407 6.6 8.1 3.2 59.7 55.2 62.8 33.8 36.7 34.0

Employment status in

past 2 weeks:

Employed 1,270 10.1 18.2 19.9 69.1 65.2 70.2 20.8 16.6 9.8

Unemployed S5 (B) (B) (B) (B) (B) (B) (B) (B) (B)

Not in labor force 9,986 9.8 8.0 10.3 555 60.5 61.4 34.6 31.4 28.3

Income:

Less than $20,000 8,541 9.0 10.3 11.5 56.9 59.7 62.3 34.0 30.0 26.2

$20,000 or more 2,336 10.2 6.1 10.7 58.1 63.9 63.8 31.6 30.0 25.5

Poverty status:

Below poverty 2,185 7.4 11.8 12.3 50.7 54.5 57.8 41.9 33.7 29.9

Above poverty 7,531 9.8 8.5 11.4 59.7 62.5 64.2 30.5 29.0 24.4

See footnotes at end of table Continued-
Appendix table 9»Use of formal health care services by the elderly in fair or poor health, by residence and selected characteristics, 1984^-

Continued

Numl)er

None used Moderate use Hiehuse

of Central Central Central

Characteristics elders city Suburb Nonmetro city Suburb Nonmetro city Suburb Nonmetro

Thousands —PercentResidential:

Region:

Northeast 2,753 11.9 8.2 10.4 52.2 59.2 56.8 35.9 32.7 32.7

Midwest 2,791 11.7 8.2 10.0 58.3 65.6 61.4 30.0 26.2 28.5

South 4,628 7.8 10.3 11.8 62.2 65.0 65.2 29.9 24.7 23.0

West 1,669 8.7 10.4 13.5 50.7 53.1 56.1 40.6 365 30.5

Length of residence:

Less than 1 year 628 2.4 7.9 10.2 59.1 60.4 62.1 38.6 31.7 27.7

1-10 years 3,810 9.6 7.7 12.5 53.5 58.3 60.6 37.0 34.0 26.9

11-20 years 2,693 8.5 10.0 9.8 56.7 61.8 63.8 34.9 28.2 26.4

At least 21 years 4,137 12.3 10.3 11.4 60.4 63.6 63.4 27.3 26.2 25.2

Selected medical conditions:

Hypertension:

Has 6,072 5.2 5.0 7.1 59.4 63.8 62.9 35.4 31.2 30.0

Does not have 5,178 15.0 13.5 16,4 55.1 58.3 6il 30.0 28.2 21.5

Arthritis:

Has 7,205 7.6 8.1 10.3 56.8 59.8 60.6 35.6 32.1 29.2

Does not have 3,950 13.4 10.3 13.9 57.5 63.9 66.6 29.1 25.8 19.5

(B) Base too small to show percentages.

^Elderly defined as aged 60 years and older.

^Excludes other races.

^Persons of Hispanic origin may be of any race.

^Includes anyone (relative or nonrelative) who could be a potential care-giver.

Ui
U.S. Department of Agriculture

Economic Research Service

SUMMARY OF REPORT

Family Support Act's Likely Effect on Rural

Poverty Outlined in New Report Numbens, April 1993

Contact: Robert A. Hoppe (202)219-0807

The Family Support Act will help some rural poor

escape from welfare rolls, but it is not a cure for

poverty or welfare, according to a new USDA

report The new report, The Family Support Act: Will

It Work In Rural Areas?, from USDA's Economic Research Service, examines the potential effectiveness of

the Family Support Act (FSA) of 1988 in rural areas.

The Family Support Act's emphasis on education and

training will help the rural poor become self-supporting.

However, the act is targeted largely at poor families

headed by women and, thus, will not reach all of the

poor. In addition, certain conditions specific to rural

areas, such as lack of services and jobs and geographically scattered sen/ices, could hinder success.

The FSA is major welfare reform legislation that

focuses on the Aid to Families with Dependent Children

(AFDC) program, which is targeted largely at femaleheaded families. Goals of the FSA are to encourage

work by AFDC parents through the Job Opportunities

and Basic Skills Training (JOBS) program and to encourage responsibility of absent parents for their offspring

through stricter enforcement of child-support provisions.

The act could eventually reduce welfare dependency

and costs to the Government. Most of the provisions

have already taken effect, but it is still too early to gauge

how successful the FSA will be.

The poor population in female-headed families is

large and growing in rural areas. About 30 percent of

the rural poor now live in female-headed families This

means, however, that the FSA will not reach the

remaining 70 percent of the rural poor. Furthermore, the

FSA will not equally affect all poor, female-headed

families.

Success of the act depends on success of State and

local officials at implementing it. They differ greatly in

their ability to take advantage of the FSA. Some of the

most serious obstacles to success of the act are related

to characteristics of rural areas themselves: the lack of

services and jobs. Rural areas have fewer services

than urban areas and more geographically dispersed

services. And, the lack of jobs may mean that rural

labor markets have difficulty absorbing graduates of the

JOBS program.

A related problem is the southern concentration of

nonmetro poor in female-headed families. The Southern States in particular may have problems meeting

matching requirements necessary to fund the sen/ices

required by the act.

The act does have features favorable to rural areas.

Extending Aid to Families with Dependent ChildrenUnemployed Parent (AFDC-UP) to all States is helpful

to the rural poor, who tend to live in States that did not

previously have the program. The number of rural poor

meeting the eligibility criteria for the new program is

relatively small, however. The act also provides funding

to encourage States to provide transportation and child

care for JOBS participants. The act's emphasis on

education and training should also help some rural

AFDC parents with low skills, training, and education

levels escape poverty and welfare dependency. And,

the work orientation of the act should fit the work ethic of

rural people, both the poor and the nonpoor.

To Order This Report...

The information presented here is excerpted from

The Family Support Act: Will It Work In Rural

Areas?, RDRR-83, by Robert A. Hoppe. The cost is

$15,00.

To order, dial 1-800-999-6779 (toll free m the

United States and Canada) and ask tor the report by

title.

Please add 25 percent to foreign addresses

{including Canada). Charge to VISA or MasterCard.

Or send a check (made payable to ERS-NASS) to:

ERS-NASS

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