Brian Altonen, MPH, MS

Introduction

When analyzing the preventive and therapeutic health measures taken by members of the “older population” (defined as 55+ yo for this study) , there are two types of medical expenses that need to be considered with regard to how much personal income is invested in the health care practice.    First,  there are the necessary expenses that  an individual must engage in as he/she gets older.  The most basic of these pertain to dietary changes, such as the cost of modifying a diet from a normal calories-complex carbohydrate-protein-fats-fiber relationship to one that results in the reduction of calories, in particular regarding complex carbohydrates and fat, in exchange for a reduced calories diet with higher fiber, little change in protein content percentages, and a higher percent of simple carbohydrates provided in the form of increase fruit and vegetable consumption.  The result of this change in theory is the improvement in long term quality-of-life [QOL] matters and a reduction in long-term disease and poor health related outcomes.  

There is this direct relationship that exists in people in relation to their long-term occupation defined monthly income related earnings following retirements and the availability of money that can be utilized in the form of luxury expenses, which is the utilization of available unused finances to the purchase of luxury items thought to improve long-term health potentials.  These luxury items related to health include the cost of over-the-counter products not covered by insurance such as the expenses provided for purposes of exercise and sports or recreation activities considered to be good for the health, the expenses related to high cost nutriceuticals claimed to help prolong or improve upon age-related changes in personal performances, and the expense of dietary additions, changes or substitutes purchased with the goal of improving upon one’s health through diet-related methods common to the regular and allied health medical literature.

One’s ability to engage in these finance related activities is dependent upon his/her income source and cost of living expenses.  Some people received barely enough to cover the overhead required for making it from one month to the next, whereas others receive monthly amounts that once the major bills are paid result in additional money that can be utilized at the individual’s personal discretion. 

The following are the four types of categories expected based on simple boolean logic.  The expectation of this study is to be able to classify all of the individuals into one of these categories based on spending behaviors.

• Low Required-Low Luxury
• Low Required-High Luxury
• High Required-Low Luxury
• High Required-High Luxury

An expected gaussian distribution of costs is expected for all of the individuals involved in this study when combined onto a single plot, with Required expenditures expected to be greater than Luxury Expenditures, and the distributions of points for these two expenses equally distributed around the overall geometric centroid for these two sets of values (Average Required-Average Luxury).   

Another way to interpret this data is to look at the difference between the two costs, beginning with the assumption that one cost is going to be greater than the other as a given parameter.  For example, since this is a study of personal health maintenance activities, the expectations are that individual will spend the bulk of their Out-of-Pocket expenses on making surely they obtain the items required for good health maintenance such as physician-recommended home test kit supplies, preventive OTC prescription products,  preventive health recreational activities (sports or fitness center participation), OTC supplements considered to be beneficial to health, the necessary food product considered to be best choice with regard to the maintenance of safe or health food consumption behaviors and any related nutritional product changes recommended for the individual such as no alcohol consumption or minimal fast food consumption.  If we then decide upon a percentage allowance for luxury out-of-pocket expense uses that allow for self-perceived quality of life improvement, at the expense of minimizing long-term health advantages, we can measure such luxury items as alcohol consumption beyond a pre-set standard, tobacco use in any way, shape or form, recreational drug use, unhealthy food consumption, and non-preventive recreational expenses as examples.

When we review a large population of people and produce a graph illustrating the gaussian realtionship between these two measures and their changes or differences, we can then use this graph to model population change based upon this initial starting point or graph.  To achieve this, we look at  a similar set of numbers reviewed over time, and determine what types of differences exist.  An individual with a well-defined behavior will demonstrate recurring behaviors of the same form or class, such as a high required-high luxury expense individual maintaining that  habit over time or a low required-low luxury expense individual maintaining the same habit.  The two remaining possible outcomes, individuals demonstrating a fluctuation between high and low expenses for required and luxury expenses in an unpredictable manner, represent individuals in need of modification of health behaviors and stabilization of the kinds of health of unhealthy practices they tend to engage in.  By stabilizing these behavioral patterns we are then able to modify the behaviors in the right fashion so as to improve health status, resulting in expense habits that demonstrate an individual spending more in required health care or health-promoting  expenses and less in luxury, non-health promoting expenses.

Methodologies for Measuring OTC Expenses

Survey Tool

To measure OTC expenses, a survey tool was developed and then handed out as a part of a 5-part series provided as part of an accredited education program.  This accredited education program was sponsored by a nationally recognized agency responsible for developing and administering programs to several locations across the United States from New York to Oregon.  The population this program targeted was 55 years of age and older.   This age group was targeted due to the assumption that increased engagement in these continuing education programs also often represented a students desire to learn about new options that are available for health maintenance, often with the goal of engaging in the activities taught at these classes in the near future.  To determine whether or not these individuals were willing to become engaged in such activities, this survey included the following groups of questions:

• Questions pertaining to standard demographic data (age, gender, ethnicity, hisp v. non-hisp., income range, career or work history, current employment status, etc.)
• A series of questions related to activities engaged in typically assumed to be related to some sort of physical well-being process such as jogging, walking, swimming, dancing, hiking, etc.
• A series of questions related to dietary practices and activities
• A series of questions related to programs that require some sort of social interaction such as dancing, attending groups meetings, attending special interest group activities, etc.
• A series of questions related to religious and religious-like behaviors and practices
• Detailed questions about particular nutritional and “healthy diet” related knowledge base and practices at home
• Detailed questions about the uses of OTC supplements
• Detailed essay/short answer responses related to the request for a listing of the types of OTC products they current have in their home or medical chest
• Short answer responses related to the general classes of medicines they are taking, based on a listing of chronic diseases included with the survey

This rather lengthy survey was submitted as a homework assignment to be handed in at the beginning of the next class held 7 days later.

Activities Expenses Diary

Students were required to keep a diary of their costs related to health maintenance purchases, events and activities.  The kinds of data to be monitored included the following types of purchases which they felt could be related to health maintenance activities:

• food costs
• standard vitamin product costs
• unique, uncommon or atypical nutritional supplement costs (not purchased for daily consumption but for occasional or non-cyclical use for less than 4 months or less than 6 times per year)
• costs for memberships and activities related to that membership. 

Since this latter expenditure is usually spent once per year, information is provided related to types of activities engaged in–support group meetings, attending lectures with topics on health, healthy lunch program participation, morning yoga, exercise equipment use, aerobics or some other form of sports activity training and participation, sports and other recreational activities (like handball, tennis, squash, dancing, etc.)  number of visits, per date, with costs defined as being paid either on a per visit, per month, per half year, or per year basis; if these activities are part of another membership for a larger group, provide the cost for membership with that group and the percent of group activities per week, month or year that are related to this particular health maintenance activity.

Students were also asked to keep in their diary all receipts pertaining to transportation costs and/or all receipts pertaining to gasoline consumption.  For each gasoline receipt, the odometer reading was supposed to be entered.  The first odometer reading to be entered into their diary should be the current reading before they travel home at the end of the course.  For this activity a small pocket-book was provided in which these notes were to be taken.  These books measured 5.5″ x 8.5″ approximately, and contained at least 50 folded pages and a manila pocket glued inside the back cover, in which receipts were to be kept.   All receipts were to be dated, and if possible a note made of their type of use–for example, ‘gas purchased at food store’, ‘gas purchased for visit to doctor’s office,’ ‘gas following a trip to the zoo’, ‘gas related to yesterday’s activities related to church, field trip, shopping, family visit . . . etc.’  

At the end of this activity or program, the individual is asked to determine if these costs represent typical monthly or quarterly behaviors.   If not, the participant is asked to estimate what portion of the activities performed during other season or months are not well represented–such as –‘half as much as my winter activities for December to March’, ‘winter travel months triple due to need for public transportation’, ‘allergy costs double in summer due to season’, ‘exercise twice as often during the warmer (or cooler) months’, etc.

Unhealthy Activities and Expenses

A second much shorter booklet is provided about 2o pages in length in which specific questions are to be answered.  These questions are provided in the front of the book, and are stapled or pasted to every fifth or sixth page of the book, always beginning on the right page, for review by the student. 

On a regular basis (daily, biweekly or weekly), the participant is to make special entries into this book that represent inner reflections into his/her awareness of his/her health and unhealthy activities, in order to determine which of these can be changed.  Each individual is asked to regular review the diary for the past day’s events and then reflect upon these activities as the pages are read for the days to be covered.  These reviews should be performed on a fairly regular basis such as every Friday or Saturday night or Sunday afternoon.  The participant should  try to document any activities he/she may have engaged in that counter the health prevention activities detailed by these activities.  For each of these entries, the following topics have to be considered and then an entry made for each of these topic reviews. 

These entries are to be entered in such a way that they are immediately recognizable, such as my providing each with a title with date of entry in ALL CAPITAL LETTERS UNDERLINED (i.e. SATURDAY, JUNE 1, YEAR), or highlighted using a highlighted tool, or underlined with a color pen or pencil.  These retrospective notes were to end with the following questions:

• Which activities did I perform that counter the benefits of my health promotion activities?
• Which of these activities did I engage in because of these activities?
• Which of these activities do I hope to change in the next year?
• Which of these activities do I hope to change in the next 6 months?
• Which of these activities do I think I can change in the next 6 weeks?

The activities to be considered for each and every one of these section entries as follows (if possible, include scalar method, asking the participant to rank levels of engagement from 1- 5):

• Alcoholic beverage consumption (aside from physician’s recommendation)
• Smoking history
• Skipped or forgotten prescription drug use history
• Poor food purchase activities and/or poor dietary practices (bad food choice, too much fast food, etc.)
• Limited or lack of OTC supplements use when these are recommended by a physician, nurse or other care giver (i.e. poor calcium use on a daily basis, poor aspiring half-dose consumption per day, lack of regular blood pressure or blood sugar screenings, etc.)
• Poor rest and relaxation activities and behaviors
• Poor exercise related health prevention activities
• Poor participation in socially active events (including church)

The following barriers to each of the above have to be linked to the above notes, by using the following question at the end of each section entered:

I did not participate in or purchase the item due to:

• Cost
• Lack of a group or program that provides such an activity
• Lack of membership with a group or program that provides these activities
• Lack of adequate income to cover the expense of this object (list objects if possible)
• Lack of desire or enthusiasm needed for regular engagement
• Lack of availability of product or activity
• Warning from associates or friends again use (if physician or care giver is against, ity is assumed these products are not purchased)
• Other

Then, the individual should:

1. Star any of these that have been changed since the last entry.
2. Check each of one of the above that he/she hopes to change and in what length of time (for example, by an entry like 1 week, 1 month, 3 months, 6 months, 1 year, 2 years, etc.)

Analysis

At the end of the program, the notebooks and miscellaneous materials are collected and then catalogued for use in a Qualitative Activities Review.  Costs are tabulated and summarized, wtih a special column used to include notes made by the patient on the related document or paper item, a column for later cross-referencing this information with the diary as part of the analytic process, a column for coding this information, and a column for special notes the reviewed wished to add, including dates of the review, dates of reflection, notes on each of these, etc.  This data may be placed into an excel spreadsheet, access database, or specific program format design for later text review and note-taking such as Atlas.ti or the like.

The research has to define his/her methodology in the following steps or along the following kind of research path:

Grounded Theory, basing your theory on either or both of the following processes:

• Open Coding Evaluation process (code as you review, and recode and re-review based on topics as they begin to surface)
• Closed Coding Evaluation process (start with a strict coding process and expectation, but later retain the right to return to the document and recode based on findings)

Engage in an evaluation process based upon your own goals with this research, documenting these as well in whatever research notes you take as part of this research process.

Types of questions and research projects that can be developed due to a review of these documents, and afterwards undergo added subsequent reviews using this research process:

1. Participants with a potential for hypertension or obesity or heart disease are identified, and their dietary and OTC products utilization are evaluated in order to determine if those with a known specific cardiovascular or chronic disease condition versus those who without perform similar practices–for one group this practice is considered to be preventative and palliative, for the other it is assumed to be mostly preventive
2. Participants with a smoking or alcohol consumption history are defined and evaluated for dietary practices and OTC products use as these relate to their amount of activity and levels of engagement in the prevention process (the level of engagement is defined based on readiness to change, as per their response to when they hope to change or eliminate the bad habit)
3. A review of the types of patients willing versus unwilling to engage in activity-related preventive activities such as exercise programs, sports activities, etc.
4. A review of types and percentages of patients that engage in social group related activities, such as attending meetings, daily activities, hiking groups, dancing classes or events, churches, etc.
5. A review of age-gender related differences for diet, social, activity, and other preventive activities and engagement on poor health maintenance practices, i.e. a comparison of 55-60, 60+ responses for matched participants.

Reviewing Expenses

The following recommendations are provided on how to engage in this activity:

• Expense-related data requires that costs be analyzed in a fairly generic, non-discrete manner.  
• All expenses for which information is provided should be evaluated as Required versus Luxury, with Required defined based on medical history inferred by response to other parts of the survey (i.e a categorical organ systems-related check box series of questions on chronic diseases, or an open-ended response question on listing these diseases and the medication histories, data which is then recoded).  
• Luxury expenses are those incurred due to the purchase of OTC preventive medications and the cost for participation in all health promoting activities. 
• Specific questions in the original survey may need to be added and followed up in order to determine the true cost for required out-of-pocket expenditures incurred by each patient.  These questions would require a listing of medication names or types and estimated costs per month for each individual drug, or all drugs collectively. 
• Only Out-of-Pocket Expenses are to be requested; in other words, if a patient has a prescription for a drug that normally costs $1000/month, and has an out-of-pocket requiring a $135 payment for a refill, then the expense evaluated is $135, not $1000.

The best way to evaluate the expenses attached to someone’s preventive/palliative self-generated activities is through the use of a log equation for evaluating costs.  If expenses accounted for vary from <$10 for some of the research categories to >$1000 for the most expensive categories, then the log10 equivalent to expenses should be evaluated, otherwise, apply natural Log values to the expense equations for interpretation.  The differences between two groups of logExpense may then be evaluated and compared for statistical comparison of the data sets selected for review.  For example, LogExpense for risk behavior can be compared with LogExpense for healthy behaviors.  This would be done if the patient were asked to include in the diary questions related to the amount of  money spent on cigarettes per week, or an estimate of such derived from the estimated number of packs smoked per week, per day, etc.    Likewise, the logExpense for amount of money spent on alcoholic beverages, or amounts of unhealthy foods purchased versus healthy foods could be evaluated (these specific questions would also have to be  required for the expenses diary to then be of use).  In general, the amount of activities one engaged in relative to health can be measured by reviewing the expenses related to travel that are incurred, such as gas expenses, monthly or daily bus tickets that had to be purchased, and costs for taxis to the zoo or shared driving expenses for group-related events.

The advantages of using log values is that logs can produce results that are more likely to form a straight line.  This enables a more specific relationship to be displayed on the graphs or charts that are produced.  This relationship is usually very noticeable on the graph or chart.