Self-reported health as a cultural health determinant in Arab and Jewish Israelis: MABAT—National Health and Nutrition Survey 1999–2001
Introduction
Subjective health (SH) is commonly used in epidemiological studies and in health-related questionnaires as a proxy measure of health and as a measure of self-evaluation of health. The term can be defined as the individual's personal evaluation of his/her overall health. SH represents an overall summary of different aspects of one's health. It differs from other health measures in that the individual is asked to integrate all dimensions of health without specific reference to its different components, such as physical, mental, social or functional health, and without being prompted in one direction or another (Tissue, 1972; Brook et al., 1979; Liang, 1986; Jylha, 1994).
The process by which respondents construct their judgment is affected by the different dimensions of health and is processed in various ways depending on the individual's characteristics and his/her health (Krause & Jay, 1994; Borawski, Kinney, & Kahana, 1996; Manderbacka, 1998; Benyamini & Idler, 1999; Benyamini, Leventhal, & Leventhal, 2003; Tessler & Mechanic, 1978; Feinberg, Loftus, & Tanur, 1985). Personal characteristics may include age (SH decreases with age), socioeconomic factors such as income, occupation and education, where lower status corresponds to lower SH (Baron-Epel & Kaplan, 2001b; Borg & Kristensen, 2000). Social factors such as marital status influence SH too, for example, unmarried men have lower levels of SH (Bobak, Pikhart, Hertzman, Rose, & Marmot, 1998). Culture, values and beliefs may also play a role in the evaluation of SH (Wiseman, 1999). Knowledge, information, and perceptions of the individual has about many factors, such as physical illness or diseases, mental health, general feeling, pain, disabilities, tiredness, medications, medical treatments, social factors, health behaviors, and others, may play a role in the self-evaluation of health.
Generally, there seem to be three different issues influencing the evaluation of SH: the objective measures of health, the cultural surrounding in which the individual lives, and the comparisons the individual makes to judge SH.
Research interests in SH have grown considerably since follow-up studies found that SH predicts a number of future health outcomes. This contributed to the validity of the measure as representing health in general. The most important outcome is survival or mortality, and much research in the last few decades has been directed that way. Idler and Benyamini (1997) reviewed 27 studies looking at the predictive value of mortality by SH, and concluded that SH is an independent predictor of mortality after adjusting for various measures associated with survival. These studies were performed in many countries, mainly in the developed world. SH was found to predict survival in an older Jewish population in Israel too (Baron-Epel, Shemy, & Carmel, 2004). However, no information regarding the Arab population in Israel is available. SH has been found to predict other health-related variables less dramatically than mortality. In follow-up studies, poor SH predicted functional limitations, disability, receiving disability pension, morbidity, hip fracture, recovery from illness, future physician rating of health, and institutionalization in the elderly (Kaplan, Strawbridge, Camacho, & Cohen, 1993; Idler & Kasl, 1995; Idler, Russell, & Davis, 2000; Guttman, Strark, Donald, & Beattie, 2001; Mansson & Merlo, 2001; Shadbolt, 1997; Ferraro, Farmer, & Wybraniec, 1997). SH was also a predictor of long-term use of health services, including visiting a general practitioner and community nurse, home help support, hospitalization, and increased medication use (Idler & Benyamini, 1997; Bath, 1999; Angel & Gronfein, 1988; Idler, 1993; Miilunpalo, Vuori, Oja, Pasanen & Urponen, 1997).
In follow-up studies, poor SH predicted high levels of distress (low mental health); together with the fact that distress adds to low SH, these findings point to a downward spiral reaction. Distress itself may cause poor SH, which over time leads to still poorer SH (Farmer & Ferraro, 1997).
This line of research led to the assumption that SH can serve as a useful tool for identifying individuals at risk for subsequent health problems that may be preventable. However, this should be taken in the context of the community's culture. Wiseman (1999) reported that while Aboriginal Australians suffer a clear health disadvantage relative to their non-indigenous counterparts, a similar proportion of indigenous and non-indigenous Australians reported fair or poor health. Therefore, SH may not provide an accurate picture of the level of morbidity and mortality in certain populations. Appels, Bosma, Grabauskas, Gostautas, and Sturmans (1996) compared Dutch and Lithuanian men and found that Dutch men reported higher levels of SH. In both cohorts, SH was associated with mortality; however, there was no discussion to the reasons for the differences in levels of SH in the two population.
In Israel, two distinct ethnic groups dwell, each with its own culture, language, and religion. The two ethnic groups have different levels of health knowledge and attitudes. They mostly live in separate communities. Most of the research on the measure of SH has been performed on the Jewish population (Baron-Epel & Kaplan, 2001a; Kaplan & Baron-Epel, 2003; Baron-Epel et al., 2004; Carmel, Lapidot, Mutran, & Shemy, 1996; Carmel, 2001). However, this measure is used also in studies of the minority Arab population, but its validity in that community is not clear.
Objective measures of health available in Israel present a picture of poorer health in the Arab population and also lower socioeconomic levels (Israel Center for Disease Control, 2004). Therefore, we expected to find lower levels of SH in the Arab population group compared to the Jewish population.
The aim of the study was to identify differences between Arabs and Jews regarding their subjective evaluation of health and to measure the association of SH, self-reported diseases, and socioeconomic factors in the two populations.
Section snippets
Methods
The MABAT survey of 1999–2001 was the first stage of an ongoing process of monitoring the health and nutrition status of the population in Israel. The study population was based on a random sample from the population registry and a sample of neighbors of the people in the random sample. Eligibility required that the participant had been in Israel at least for 1 year prior to the interview and was not in long-term care or living in an institution. Due to logistic problems the Bedouin population
Sample characteristics
The age distribution of the Arab respondents was younger than the Jewish respondents. More Arabs reported being religious and more Jews reported being secular. Jews reported more years of education. These characteristics correspond to the general characteristics of the Arab and Jewish Israeli population. More Arabs reported having diabetes. More Jews reported having high levels of lipids and high blood pressure, and more Jewish women reported having cancer. Arabs were also found to weigh more
Subjective health vs. objective health
Our results suggest that more Arab men and younger Arab women report high levels of SH than corresponding Jewish population groups. Demographic, socioeconomic, and health variables measured in this study did not explain the higher SH of the Arab population. However, there may be additional factors not available in this study. In fact, life expectancy of Jewish Israelis, in general, is higher than that of Arab Israelis. Life expectancy in 2001 was 77.7 years for Jewish Israeli men and 74.5 years
Conclusions
This study emphasizes the need to regard self-reported health or SH in the context of culture, especially when comparing societies. It is not possible to correlate objective measures of health with SH in the same way in different populations and cultures. Health care workers should not take for granted that those reporting good subjective health are healthy, mainly within the Arab population. This is especially relevant for the health care workers that treat more than one population group with
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