What is self-rated health and why does it predict mortality? Towards a unified conceptual model☆
Introduction
Hardly any other measure of health is more widely used and more poorly understood than self-rated health (or self-assessed health, or self-perceived health). It is based on asking individuals to evaluate their health status on a four- or five-point scale, or to compare their health status with that of age peers. This simple question has been one of the most frequently employed health indicators in sociological health research since the 1950s (Garrity et al., 1978, Maddox, 1962, Suchman et al., 1958). In epidemiological and medical research it began to gain currency when Singer, Garfinkel, Cohen, and Srole (1976) and then Mossey and Shapiro (1982) and Kaplan and Camacho (1983) demonstrated its association with mortality. It is frequently used by economists as well (Crossley and Kennedy, 2002, Juerges, 2007). Data on self-rated health are collected in major national and international surveys, such as the World Value Survey and European Value Survey (Inglehart et al., 2003, Mansyur et al., 2008), the National Health and Nutrition Examination Survey in the US and the SHARE in Europe. It is included in the SF-36 survey instrument (Ware & Gandek, 1998) and recommended as a standard part of health surveys (Robine et al., 2003, World Health Organization, Statistics Netherlands, 1996). It has also been recommended as a tool for disease risk screening (May, Lawlor, Brindle, Patel, & Ebrahim, 2006) and clinical trials (Fayers & Sprangers, 2002).
The exact wordings and response options of self-rated health questions vary. In the question that is most widely used in the US, responses are set out on a scale from excellent through very good, good and fair to poor, while the options recommended by WHO (1996) and the EURO-REVES 2 group (Robine et al., 2003) are very good, good, fair, bad and very bad; there is also a version that uses the options very good, fairly good, average, fairly bad, and bad (Heikkinen et al., 1983, Jylhä et al., 1998). Although the levels and distributions are not directly comparable between the measures, they represent parallel assessments of the same phenomenon, and show basically concordant answers (Juerges et al., 2007, Jürges et al., 2008). In addition to these global questions, a comparative measure is sometimes used (“How would you assess your health status in comparison with other people of your age that you know? Is it better, the same or worse?”). The main focus in this paper is on global self-rated health, although most of what will be said also applies to the comparative version. Where appropriate, the differences in the behavior of these versions are pointed out.
In 1958, Edward A. Suchman, Bernard S. Phillips and Gordon F. Streib concluded that “self-ratings of health measure something different than physician's ratings – what we have called ‘perceived’ or ‘subjective’ health as opposed to ‘actual’ or ‘objective’ health – but that depending upon one's hypothesis such a self-rating may or may not be valid”. Since then, the relationship of self-rated health to different individual and environmental characteristics has been explored in several hundred studies, and its associations with mortality have been the focus of concern in around one hundred. Several researchers, most notably Ellen Idler (Idler, 1979, Idler and Benyamini, 1997, Idler and Kasl, 1991, Idler et al., 2004) but also others (Benyamini et al., 1999, Ferraro, 1980, Ferraro and Kelley-Moore, 2001, Knäuper and Turner, 2003, Tissue, 1972) have shed light on the unique characteristics of the self-rated health measure and its role in predicting mortality. Nevertheless, studies repeatedly highlight our deficient and fragmentary understanding of the nature of this indicator: it is just not clear what exactly self-rated health measures and why it has such a strong and constant association with mortality.
The motivation for this paper comes from the conviction, based on many years of work around this theme (Jylhä, 1994, Jylhä et al., 1998, Jylhä et al., 1986, Jylhä et al., 2006, Leinonen et al., 2001), that our difficulties in understanding self-rated health stem not so much from a lack of empirical information as from conceptual and theoretical vagueness and poor integration of knowledge. Self-rated health, an individual and subjective conception that is related to the strongest biological indicator, death, constitutes a cross-road between the social world and psychological experiences on the one hand, and the biological world, on the other. Most empirical studies on self-rated health come from the epidemiological tradition that focuses on the statistical associations of variables rather than on the processes from which the variables emerge. There is an obvious need for more comprehensive approaches.
The purpose of this paper is to bring together the cognitive perspective and the epidemiological perspective to self-rated health into a common conceptual framework. The proposed model helps us understand the individual process of health assessment, its biological basis and its social and cultural contexts and, ultimately, the association of self-rated health with mortality. It can also help researchers from different backgrounds interpret their empirical findings and generate new research.
The paper has three parts. First, I discuss the notion of self-rated health and suggest a model that describes the process of evaluation in which self-ratings are produced. The starting point is to acknowledge that self-rated health originates in an active cognitive process and cannot be properly understood without understanding this process. The purpose is to clarify the nature of the different types of information that people have about their health and the way in which they use this information in their self-ratings. Second, based on this model, I proceed to examine the relationship of self-rated health with death. Here, new research at the interface of cognitive neuroscience, neurobiology and immunology is discussed to develop hypotheses on the pathways that mediate information on bodily status to individual consciousness. Third, I discuss some of the advantages and limitations of self-rated health as a measure of health in research and clinical practice. Finally, I suggest some directions for future research. Throughout, the new thoughts and hypotheses are developed and validated against earlier research findings.
Section snippets
The process of health assessment
Self-rated health differs from most indicators of health in that its origins lie in an active cognitive process that is not guided by formal, agreed rules or definitions. It can be understood as “…a summary statement about the way in which numerous aspects of health, both subjective and objective, are combined within the perceptual framework of the individual respondent” (Tissue, 1972, p. 93). What, then, are the relevant aspects, how are they combined, and in what sort of framework?
By
Why does self-rated health predict mortality?
Studies on the association of self-rated health with mortality have been earlier reviewed by Benyamini and Idler, 1999, DeSalvo et al., 2006 and Idler and Benyamini (1997); these reviews cover the work done before 2003. A Medline search conducted in January 2008 for the period from 2003 to 2007 yielded an additional 32 population studies, although some of them share the same data. The latest findings repeat, confirm and expand on the findings of earlier studies, but the basic message remains
Use of the self-rated health variable in research and clinical practice
It is time now to ask what can be said about the use of self-rated health in research, clinical practice and health policy, and about the validity of the measure. What did the early pioneers mean when they said that “….depending upon one's hypothesis such a self-rating may or may not be valid” (Suchman et al., 1958, p. 232)?
In his discussion about the validity of health assessments, Hyland (1993) emphasizes that validity should not be understood as an abstract term but established with
Next step towards a better understanding of self-rated health
This paper suggests that (1) self-ratings of health are produced in a cognitive process that is inherently subjective and contextual, and (2) the basis of self-rated health lies in the biological and physiological state of the individual organism, and this explains its association with mortality. The paper has also proposed a conceptual model that can help understand how these two seemingly contradictory claims could both be true. In their seminal paper, Idler and Benyamini (1997) argued that
Acknowledgements
The research was supported by grants from the Academy of Finland and by the Signe and Ane Gyllenberg Foundation. Main part of the work was done while MJ was a Senior Researcher at the University of Tampere Centre for Advanced Study.
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I wish to thank my anonymous reviewers for their excellent comments and suggestions; David Kivinen for his help with the English language; and Raili Salmelin, PhD, for her assistance with preparing the figure.