Characterizing self-rated health during a period of changing health status☆
Introduction
The use of a ‘self-rated health’ (SRH) question in population and clinical health surveys has become common (Finnegan et al., 2005, Jylha et al., 1998, Lorraine et al., 2005, Menec and Chipperfield, 2001, Shadbolt, 1997). Historically, most SRH research has focused on its predictive significance for health outcomes, including social-psychological well-being (Hillen et al., 2000, Mulsant et al., 1997), morbidity (Dominick et al., 2002, Idler and Kasl, 1991), health care utilization (Kennedy et al., 2001, Menec and Chipperfield, 2001) and mortality (Benyamini and Idler, 1999, Idler and Benyamini, 1997). Findings have predominantly been as expected; poorer self-perceived health is associated with poorer health outcomes.
A cumulative assessment of the literature suggests that the health-related correlates of SRH correspond with three global health dimensions. The majority of work examining potential predictors of SRH have focused on the dimension of physical health. Studies have shown SRH to be closely related to the experience of physical symptoms, including occurrences of pain (Mantyselka et al., 2003, Perruccio et al., 2005, Reyes-Gibby et al., 2002), functional limitations and disability (Hoeymans et al., 1999, Leinonen et al., 2001, Perruccio et al., 2005), and fatigue and weakness (Kaplan and Baron-Epel, 2003, Stewart et al., 2008). The majority of the work has focused on fair/poor SRH or worsening SRH and findings have been fairly consistent – poorer SRH is associated with greater disease severity and symptom burden.
The second health dimension is mental well-being. The predominant indicators for this dimension have included depression and depressive symptoms (Han, 2002, Mulsant et al., 1997, Schnittker, 2005), anxiety and associated symptoms (Cockerham et al., 1988, Kroenke, 2003, Stewart et al., 2008), psychological distress (Cockerham et al., 1988, Goldman et al., 2004, Larsson et al., 2002), and mastery or control, particularly among individuals with chronic conditions (Cott et al., 1999, Nguyen et al., 2008, Schulz and Decker, 1985). The label mental well-being is used deliberately since not all classifications within these studies are clinical diagnoses. Once again, findings have been fairly consistent, that poorer SRH is associated with a greater likelihood of depressive symptoms and worse scores on a variety of anxiety and distress scales. Greater levels of perceived mastery and control have been found to be associated with better SRH.
Finally, the third dimension is social health. Evidence suggests that a significant component of SRH is related to social functioning, including the extent of social engagement, participation in social activities, and the availability of social supports, networks and resources (Cagney et al., 2005, Hillen et al., 2000, Pilpel et al., 1988, Zunzunegui et al., 2004).
While the associations identified above have been relatively consistent, studies have found that between 30% and 80% of people with at least one chronic condition(s) or with chronic symptoms report good or better health (Cott et al., 1999, Mantyselka et al., 2003, Perruccio et al., 2005, Reyes-Gibby et al., 2002). In patients who survived hospitalization for stroke, myocardial infarction, or hip fracture, Wilcox et al. (Wilcox, Kasl, & Idler, 1996) reported that in the six months following hospitalization, health perceptions did not universally decline after the illness. In examining the congruence–incongruence between observed health problems and SRH, Chipperfield (Chipperfield, 1993) reported that while the majority of elders provided subjective health ratings that were congruent with their reports of diseases or health problems, incongruence was found in nearly 20% of cases. This incongruence between SRH and physical health suggests SRH reflects more than just physical health. A study by Unden and Elofsson (Unden & Elofsson, 2001) found a correlation of 0.45, with agreement in about 60% of cases, between SRH and physicians’ assessment of physical health based on physical examinations. Whereas factors representing physical health explained most of the variance in physicians’ ratings of patients’ health, psychosocial health factors explained most of the variance in patients’ SRH.
Following from a review of the social psychology literature around expressions of ‘self’ in social contexts (Banaji & Prentice, 1994), Bailis and colleagues (Bailis, Segall, & Chipperfield, 2003) recently suggested the potential utility of a process theory, raised in the review, for understanding self-conceptions of health. They put forward two interpretations of SRH, labeling one a spontaneous assessment of overall health and the other as an enduring self-concept. For the former, SRH is viewed as a feedback system, a response to one’s current state of well-being or illness. This view sees SRH as a responsive, health status measure. For the latter, SRH is viewed as determined by an individual’s inherent perceptions of their own health, particularly as either a healthy or unhealthy person. In this case, SRH represents the self-concept of health and is relatively stable over time, independent of observed changes in health status.
Given the level of importance that has been attributed to SRH and its potential to predict health outcomes, an accurate characterization of SRH (i.e. identifying potential constituent components) is critical, particularly if it can aid in identifying individuals on different trajectories of health changes and, in turn, improve the development of targeted interventions, for instance. Further, an enhanced interpretation of SRH sets a strong foundation for an appropriate and necessary examination of the external validity of SRH across groups defined by a variety of factors such as cultural background, health conditions, and age groups.
Bailis et al. (Bailis et al., 2003) sought to test the two distinctions of SRH. Their study examined SRH and health status over two time points, 2 years apart, using a general population-based health survey (ages 18+ years, n = 7505). Health status was captured as physical (sum of chronic conditions, sum of restrictions in 6 activities, presence/absence of disability days in previous 2 weeks, and a Health Utilities Index score) and mental health (summed distress and depression inventories) symptoms, a social support score, leisure physical activity, smoking, and body mass index. Their findings pointed towards SRH as being both static and dynamic, although predominantly static.
Similarly, a second study (Boardman, 2006) tested these distinctions in a general population sample of adolescents (n = 13,511) over two time points, 1 year apart, and captured health status as six individual health problems and psychological symptoms. While these authors also concluded that both distinctions appear reasonable, SRH remained relatively static in this adolescent sample.
For both studies, it is reasonable to expect that a substantial proportion of a general population sample would undergo little to no change in health status over a relatively short period. The adult-based study did not report the proportion of individuals who did or did not undergo change in health status over the two years, but did indicate that more than half the sample reported no change in SRH over the two years. In the adolescent-focused study, between 50% and 60% of the sample reported no change in physical or mental health status over the 1 year timeframe and just over 50% reported no change in SRH.
There is reasonable difficulty in distinguishing between the interpretations of SRH when the samples against which these interpretations are being evaluated are relatively stable with respect to health status. That is, it is difficult to determine whether the stability of SRH in a relatively unchanging population is a function of an enduring self-concept or a reflection of stability in health status.
The overall objective of the current study was to determine whether the distinct interpretations of SRH could be identified and characterized in a group of individuals undergoing health status changes. This longitudinal study followed a clinical sample of patients aged 18+ years undergoing primary total joint replacement (TJR) surgery for hip or knee osteoarthritis. TJR is well established as an effective intervention for reducing pain, improving function, and enhancing the quality of life in patients with osteoarthritis of the hip and knee (Jones et al., 2005). As a result of this procedure, we can confidently predict that there will be improvement that takes place over a relatively short period of time. The specific objectives were to determine, over six months of recovery from total joint replacement, 1. The predictive significance of physical health, mental well-being and social health for SRH; and 2. To assess the distinct interpretations of SRH by determining A) The relative stability of SRH over the period of change in health status and B) Whether SRH is responsive to changes in the health dimensions.
Section snippets
Study setting and patient sample
Individuals undergoing primary unilateral TJR for hip or knee osteoarthritis (449: 215 and 234 patients, respectively) were consecutively recruited from four Toronto, Canada hospitals from April 2006 to March 2007. Individuals were eligible if they were 18+ years of age and able to read and comprehend English. Individuals having replacement surgery for other than OA, a hemi-arthroplasty, or revision-arthroplasty were ineligible.
The study was approved by the Research Ethics Board of the
Analyses
Descriptive statistics were computed and the proportions not reporting changes in SRH and health status were examined. For ease of comparison, all health measure scores (except SRH and comorbidity counts) were transformed to a 0–100 scale; higher scores indicate worse health/more difficulty.
Structural equation modeling (SEM) was used for all model analyses using Mplus 3.13 (Muthen & Muthen, 2005).
Results
Sixty percent of the sample was female and near equal proportions of hip and knee surgeries were represented (47.9% and 52.1%, respectively). The mean age of the sample was 63.5 years (range: 31, 88) and the majority reported post-secondary education (72%). Pre-surgery, 13.5% reported “excellent” SRH, 36% and 37% reported “very good” and “good”, respectively, and 13.7% “fair” or “poor” SRH.
Pre-surgical health measure scores are presented in Table 1. The mean scores for pain and limitations in
Discussion
Despite its frequent use in health and medical research, little is known about the nature of SRH, and it was not until recently that a conceptual interpretation of SRH was proposed. This study assessed the tenability of the recently proposed distinctions of SRH as a spontaneous assessment of overall health or as an enduring self-concept (Bailis et al., 2003) in a clinical sample and more fully characterized the relationships linking health dimensions to SRH.
Two previous studies sought to test
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2014, Social Science and MedicineCitation Excerpt :The results that SRH is highly persistent through the 11-year observation, supplement these findings, suggesting that the concept of health formed early in life also remains into adult life. Together with previous studies of adults and elderly showing considerable stability in SRH, despite other age-related health decline (Bailis et al., 2003; Perruccio et al., 2010), our results, supports the enduring self-concept view assuming that SRH is a relatively stable construct, through the life course (Bailis et al., 2003). In view of the existing knowledge linking SRH to important medical outcomes (Miilunpalo et al., 1997; Haddock et al., 2006), the stability of SRH found in the present study, suggest that SRH formed early in life may be an important determinant for long-term health.
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AV Perruccio was funded by a Canadian Institutes of Health Research Canada Graduate Scholarships - Doctoral Award.