Gender, educational and age differences in meanings that underlie global self-rated health

Comparison standards shape everyday judgments of low and high wellbeing in individuals with and without psychopathology: a diary-based investigation

People can easily rate and express their current levels of wellbeing, but the cognitive foundations for such judgments are poorly understood. We examined whether comparisons to varying standards underlie fluctuating wellbeing judgments within-person (i.e., throughout daily episodes) and between-person (i.e., high vs. low levels of psychopathology). Clinical and non-clinical participants recorded subjective affect for each distinct episode for one week. Participants briefly described current, best, and worst daily episodes, which we coded for presence and type of comparison standard (social, past temporal, criteria-based, counterfactual, prospective temporal, and dimensional). Participants also rated their engagement with these standards and the respective affective impact. During best episodes, participants reported more downward (vs. upward) comparisons that resulted in positive affective impact. In worst episodes, upward (vs. downward) comparisons were more frequent. In best and worst episodes, we most frequently identified past-temporal and criteria-based comparisons, respectively. The clinical group engaged more often with all potential standard types during worst daily episodes and was more negatively affected by comparative thoughts, amid consistently more negative affect levels across all episode types. Our data suggest that judgments of affect and wellbeing may indeed rely on comparative thinking, whereby certain standards may characterize states of negative affect and poor mental health.

Descriptive regression tree analysis of intersecting predictors of adult self-rated health: Does gender matter? A cross-sectional study of Canadian adults

BACKGROUND

While self-rated health (SRH) is a well-validated indicator, its alignment with objective health is inconsistent, particularly among women and older adults. This may reflect group-based differences in characteristics considered when rating health. Using a combination of SRH and satisfaction with health (SH) could capture lived realities for all, thus enabling a more accurate search for predictors of subjective health. With the combined measure of SRH and SH as the outcome we explore a range of characteristics that predict high SRH/SH compared with predictors of a low rating for either SRH or SH.

METHODS

Data were from the Canadian General Social Survey 2016 which includes participants 15 years of age and older. We performed classification and regression tree (CRT) analyses to identify the best combination of socioeconomic, behavioural, and mental health predictors of good SRH and health satisfaction.

RESULTS

Almost 85% of the population rated their health as good; however, 19% of those had low SH. Conversely, about 20% of those reporting poor SRH were, none-the-less, satisfied. CRT identified healthy eating, absence of a psychological disability, no work disability from long-term illness, and high resilience as the main predictors of good SRH/SH. Living with a spouse or children, higher social class and healthy behaviours also aligned with high scores in both self-perceived health measures. Sex was not a predictor.

CONCLUSIONS

Combining SRH and SH eliminated sex as a predictor of subjective health, and identified characteristics, particularly resilience, that align with high health and well-being and that are malleable.

Education and age trajectories of chronic conditions: Are tests of the cumulative advantage and disadvantage hypothesis biased by underreporting?

OBJECTIVE

This study examined the impact of underreporting on tests of the cumulative advantage and disadvantage hypothesis (CAD), which predicts age-related increases in health disparities between individuals with higher and lower education.

METHODS

Using the English Longitudinal Study of Ageing (ELSA), we identified underreporting by comparing self-reported hypertension and diabetes with biomedically measured hypertension (systolic blood pressure≥140 mm Hg and/or diastolic blood pressure≥90 mm Hg) and diabetes (fasting glucose level≥7 mmol/l and/or HbA1c≥6.5%). In a sample of 11,859 respondents aged 50 to 85 (54% women, 97% White), we assessed the associations between underreporting and the main analytic constructs in tests of the CAD (education, age, sex, and cohort).

RESULTS

The results showed that self-reported measures underestimated the prevalence of hypertension and diabetes. Underreporting showed weak to moderate associations with the main constructs in tests of the CAD, being more pronounced in individuals with lower education, in older age, in more recent cohorts, and among men. When correcting for underreporting using biomedical measures, the overall prevalence of hypertension and diabetes increased substantially, but education differences in age trajectories of both conditions remained similar.

CONCLUSIONS

Underreporting affected conclusions about the prevalence of hypertension and diabetes, but it did not affect conclusions about the CAD hypothesis for either condition.

Women suffer but men die: survey data exploring whether this self-reported health paradox is real or an artefact of gender stereotypes

BACKGROUND

Despite consistently reporting poorer health, women universally outlive men. We examine whether gender differences in lived circumstances considered, and meaning attributed to SRH by women and men might explain this paradox.

METHODS

In an online survey 917 adults rated their health (SRH) and mental health (SRMH) and reflected upon what life experiences they considered in making their ratings. Descriptive findings were sex-disaggregated. The multiple experiences listed were then subject to factor analyses using principal components methods and orthogonal rotation.

RESULTS

Women reported poorer SRH and SRMH. They considered a wider range of circumstances, weighing all but self-confidence and behaviors as more important to SRH than did men. Two underlying components, psychosocial context and clinical status were identified overall. Physical health and pain were more important elements of men's clinical status and behaviors. Comparisons with others of the same age played a larger role in male psycho-social context. Two components also underpinned SRMH. These were clinical problems and psycho-social circumstances for which self-confidence was only important among men.

CONCLUSIONS

Women's and men's common interpretation of measures like SRH suggests that women's health disadvantage is neither artefactual nor determined by gendered meanings of measures and does not explain the paradox. SRH and SRMH captured social circumstances for all. Convergence of characteristics women and men consider as central to health is evidence of the dynamism of gender with evolving social norms. The remaining divergence speaks to persisting traditional male stereotypes.

Gender roles and selection mechanisms across contexts: a comparative analysis of the relationship between unemployment, self-perceived health and gender

Health literature shows that unemployment has a gendered effect on health. However, whether men or women are more affected and why remains unclear. We assume that unemployment harms women less than men because of two mechanisms: social roles theories and health selection. First, the availability and centrality in individuals' lives of roles other than employment may reduce the detrimental effect of unemployment for women. Second, the gendered impact of unemployment on health results from the different ways selection mechanisms operate across genders. Moreover, these two mechanisms may operate differently in different contexts - for example, across different gender regimes. We investigate this by pursuing a three-step comparative approach. The analysis relies on EU-SILC data covering Italy and Sweden for 2004 to 2015 and SOEP data for Germany (1995-2017) and applies correlated dynamic random-effects probit models. While we find weak support for the role of health selection in shaping the relations between unemployment, health, and gender, our empirical results are in line with the hypothesis of a larger gendered effect in older (vs younger) cohorts, western (vs eastern) Germany and Italy (vs. Sweden). Future empirical research needs to directly address the role of gender regimes in moderating such complex relationships.

Diverging ideas of health? Comparing the basis of health ratings across gender, age, and country

BACKGROUND

Self-rated health (SRH) is arguably the most widely used generic health measurement in survey research. However, SRH remains a black box for researchers. In our paper, we want to gain a better understanding of SRH by identifying its determinants, quantifying the contribution of different health domains to explain SRH, and by exploring the moderating role of gender, age groups, and the country of residence.

METHOD

Using data from 61,365 participants of the fifth wave (2013) of the Survey of Health, Ageing and Retirement in Europe (SHARE) living in fifteen European countries, we explain SRH via linear regression models. The independent variables are grouped into five health domains: functioning, diseases, pain, mental health, and behavior. Via dominance analysis, we focus on their individual contribution to explaining SRH and compare these contributions across gender, three age groups, and fifteen European countries.

RESULTS

Our model explains SRH rather well (R² = .51 for females/.48 for males) with functioning contributing most to the appraisal (.20/.18). Diseases were the second most relevant health dimension (.14/.16) followed by pain (.08/.07) and mental health (.07/.06). Health behavior (.02/.01) was less relevant for health ratings. This ranking held true for almost all countries with only little variance overall. A comparison of age groups indicated that the contribution of diseases and behavior to SRH decreased over the life-course while the contribution of functioning to R² increased.

CONCLUSION

Our paper demonstrates that SRH is largely based on diverse health information with functioning and diseases being most important. However, there is still room for idiosyncrasies or even bias.

To what extent do socioeconomic inequalities in SRH reflect inequalities in burden of disease? The HELIUS study

BACKGROUND

Self-rated health (SRH), an attractive measure for health monitoring, shows persistent inequalities with regard to socioeconomic status (SES). However, knowledge on the extent to which inequalities in SRH reflect inequalities in disease burden is lacking.

METHODS

Data come from the multi-ethnic HEalthy LIfe in an Urban Setting study (Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish or Moroccan origin, N = 19 379, aged 18-70). SES was defined by educational and occupational level. Disease burden was operationalized as chronic diseases, physical and mental functioning (measured with SF-12) and depressive symptoms (measured with PHQ-9). We applied logistic regression analyses and reported average marginal effects (AME).

RESULTS

Dutch origin participants with low educational or low occupational level had higher probabilities of reporting fair/poor SRH, compared to the highest levels (AME = 0.20 95% CI: 0.13;0.27; and 0.12 (0.09;0.15), respectively). Associations were attenuated after adjusting for all disease burden indicators, to AME = 0.03 (0.01;0.04) and AME = 0.02 (-0.00;0.04). In all the non-Dutch origin groups, a larger part of the inequalities remained after adjustment.

CONCLUSION

Socioeconomic inequalities in SRH are for a large part explained by higher disease burden in lower socioeconomic groups, but less so in those with non-Dutch origin. Future research should examine if our conclusions also hold for trend data on inequalities in SRH.

Does the single-item self-rated health measure the same thing across different wordings? Construct validity study

Purpose

The self-rated health (SRH) item is frequently used in health surveys but variations of its form (wording, response options) may hinder comparisons between versions over time or across surveys. The objectives were to determine (a) whether three SRH forms are equivalent, (b) the form with the best construct validity and (c) the best coding scheme to maximize equivalence across forms.

Methods

We used data from 58,023 respondents of the Swiss Health Survey. Three SRH forms were used. Response options varied across forms and we explored four coding schemes (two considering SRH as continuous, two as dichotomous). Construct validity of the SRH was assessed using 34 health predictors to estimate the explained variance.

Results

Distributions of response options were similar across SRH forms, except for the “good” and “very good” options (“good” in form 1: 58.6%, form 2: 65.0% and form 3: 44.1%). Explained variances differed across SRH forms, with form 3 providing the best overall explained variance, regardless of coding schemes. The linear coding scheme maximised the equivalence across SRH forms.

Conclusion

The three SRH forms were not equivalent in terms of construct validity. Studies examining the evolution of SRH over time with surveys using different forms should use the linear coding scheme to maximise equivalence between SRH forms.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02533-2) contains supplementary material, which is available to authorized users.

Age Effects of Frames of Reference in Self-reports of Health, Well-being, Fatigue and Pain

RATIONALE

Self-reports of health and well-being are central for population monitoring, so it is paramount that they are measured accurately. The goal of this study was to examine the impact of age on the use of the comparison standards or frames of reference (FoRs) in self-reports of health, life-satisfaction, fatigue, and pain, and to determine if the age-health outcome associations were affected by age differences in FoRs.

METHODS

Respondents (n = 2000) selected from the U.S. general population self-rated their life-satisfaction and health outcomes. Following this, they were asked to indicate if they used any comparisons (FoRs) when making their rating and the direction of these comparisons (upward, lateral or downward). Analyses examined (a) whether age groups differed in the type and direction of FoRs, and (b) whether age patterns in health, life-satisfaction, fatigue, and pain were altered when FoRs were statistically controlled.

RESULTS

Compared to middle-aged and older people, younger respondents were more likely to compare themselves with other people when self-rating their health and life-satisfaction. They were also more likely to use a hypothetical situation when evaluating their pain and fatigue. Younger participants used lateral comparisons less often and downward comparisons more often than middle-aged and older participants. When these age differences in FoRs were statistically controlled, the observed age patterns in self-reported health outcomes were somewhat reduced.

CONCLUSIONS

The results show that people of different ages use different FoRs when self-reporting their life-satisfaction and health outcomes.

Health Measurement and Health Inequality Over the Life Course: A Comparison of Self-rated Health, SF-12, and Grip Strength

The cumulative (dis)advantage hypothesis predicts education differences in health to increase with age. All previous tests of this hypothesis were based on self-reported health measures. Recent research has suggested that self-reported health measures may not adequately capture differences in key analytical constructs, including education, age, cohort, and gender. In this study, I tested the cumulative (dis)advantage hypothesis using a self-reported subjective measure (self-rated health), a self-reported semi-objective measure (PCS based on SF-12), and an objective measure (grip strength) of general physical health. Hierarchical linear models applied to five waves of panel data (SOEP, 2006-2014, N = 3,635 individuals aged 25 to 83, comprising N = 9,869 person-years) showed large differences between health measures. Among men, education differences in both self-reported measures of health widened substantially with age, consistent with the cumulative (dis)advantage hypothesis. For grip strength, education differences were small and changed little with age, inconsistent with the hypothesis. Among women, education differences in both self-reported measures of health remained stable over the life course, but they widened substantially when measured by grip strength. I conclude that evidence on the cumulative (dis)advantage hypothesis is sensitive to the choice of a health measure.

Depression Fully Mediates the Effect of Multimorbidity on Self-Rated Health for Economically Disadvantaged African American Men but Not Women

Background. Although chronic medical conditions (CMCs), depression, and self-rated health (SRH) are associated, their associations may depend on race, ethnicity, gender, and their intersections. In predominantly White samples, SRH is shown to better reflect the risk of mortality and multimorbidity for men than it is for women, which suggests that poor SRH among women may be caused not only by CMCs, but also by conditions like depression and social relations-a phenomenon known as "the sponge hypothesis." However, little is known about gender differences in the links between multimorbidity, depression, and SRH among African Americans (AAs). Objective. To study whether depression differently mediates the association between multimorbidity and SRH for economically disadvantaged AA men and women. Methods. This survey was conducted in South Los Angeles between 2015 to 2018. A total number of 740 AA older adults (age ≥ 55 years) were enrolled in this study, of which 266 were AA men and 474 were AA women. The independent variable was the number of CMCs. The dependent variable was SRH. Age and socioeconomic status (educational attainment and marital status) were covariates. Depression was the mediator. Gender was the moderator. Structural Equation Modeling (SEM) was used to analyze the data. Results. In the pooled sample that included both genders, depression partially mediated the effect of multimorbidity on SRH. In gender specific models, depression fully mediated the effects of multimorbidity on SRH for AA men but not AA women. For AA women but not AA men, social isolation was associated with depression. Conclusion. Gender differences exist in the role of depression as an underlying mechanism behind the effect of multimorbidity on the SRH of economically disadvantaged AA older adults. For AA men, depression may be the reason people with multimorbidity report worse SRH. For AA women, depression is only one of the many reasons individuals with multiple CMCs report poor SRH. Prevention of depression may differently influence the SRH of low-income AA men and women with multimorbidity.

Is the single self-rated health item reliable in India? A construct validity study

Introduction

In high-income countries, the self-rated health (SRH) item is used in health surveys to capture the population’s general health because of its simplicity and satisfactory validity and reliability. Despite scepticism about its use in low-income and middle-income countries, India implemented the SRH item in many of its demographic and population health surveys, but evidence of its validity is lacking. The objective was to assess the construct validity of the SRH item in India.

Methods

Data for 4492 men and 4736 women from the Indian sample of the World Health Survey (2003) were used. Overall, 43 health status indicators were grouped into health dimensions (physical, mental and functional health, chronic diseases, health behaviours) and the SRH item was regressed on these indicators by using sex-stratified multivariable linear regressions, adjusted with demographic and socioeconomic variables.

Results

Respondents (participation rate 95.6%; mean age 38.9 years) rated their health as very good (21.8%), good (36.4%), moderate (26.6%), bad (13.2%) or very bad (2.0%). Among men, the adjusted explained SRH variance by health dimensions ranged between 18% and 41% (physical 33%, mental 32%, functional health 41%, chronic diseases 23%, health behaviours 18%). In multivariable models, the overall explained variance increased to 45%. The 43 health status indicators were associated with SRH and their effect sizes were in the expected direction. Among women, results were similar (overall explained variance 48%).

Conclusion

The SRH item has satisfactory construct validity and may be used to monitor health status in demographic and population health surveys of India.

Do conceptualisations of health differ across social strata? A concept mapping study among lay people

OBJECTIVES

The legitimacy of policies that aim at tackling socioeconomic inequalities in health can be challenged if they do not reflect the conceptualisations of health that are valued in all strata. Therefore, this study analyses how different socioeconomic groups formulate their own answers regarding: what does health mean to you?

DESIGN

Concept mapping procedures were performed in three groups that differ in educational level. All procedures followed exactly the same design.

SETTING

Area of the city of Utrecht, the Netherlands.

PARTICIPANTS

Lay persons with a lower, intermediate and higher educational level (±15/group).

RESULTS

The concept maps for the three groups consisted of nine, eight and seven clusters each, respectively. Four clusters occurred in all groups: absence of disease/disabilities, health-related behaviours, social life, attitude towards life. The content of some of these differed between groups, for example, behaviours were interpreted as having opportunities to behave healthily in the lower education group, and in terms of their impact on health in the higher education group. Other clusters appeared to be specific for particular groups, such as autonomy (intermediate/higher education group). Finally, ranking ranged from a higher ranking of the positively formulated aspects in the higher education group (eg, lust for life) to that of the negatively formulated aspects in the lower education group (eg, having no chronic disease).

CONCLUSION

Our results provide indications to suggest that people in lower socioeconomic groups are more likely to show a conceptualisation of health that refers to (1) the absence of health threats (vs positive aspects), (2) a person within his/her circumstances (vs quality of own body/mind), (3) the value of functional (vs hedonistic) notions and (4) an accepting (vs active) attitude towards life.

Validity of Self-Rated Memory Among Middle-Aged and Older Chinese Adults: Results From the China Health and Retirement Longitudinal Study (CHARLS)

Memory self-ratings are often used in primary care practice and social surveys due to its relative ease of administration. Yet their usefulness to accurately measure individuals' memory-related cognitive function is largely unknown. This article assesses the construct validity of self-rated memory for measuring memory-related cognitive function among middle-aged and older adults (45+ years) in China using a national sample (N = 13,690) from the China Health and Retirement Longitudinal Study. We first compare self-rated memory with a number of well-established memory tests and then investigate the role of sociodemographic factors in determining self-reports conditional on memory test performance. We find that self-rated memory is only weakly correlated with memory test performance and yields low sensitivity and specificity in detecting individuals with relatively poor memory test performance. We also find evidence for substantial differential item functioning across sociodemographic groups. Our results, therefore, caution against the use of simple self-rated memory measures for memory assessments in primary care or survey research.

Gender and the structure of self-rated health across the adult life span

Despite the widespread use of self-rated health (SRH) in population health studies, the meaning of this holistic health judgment remains an open question. Gender differences in health, an issue of utmost importance in population research and policy, are often measured with SRH; the comparisons could be biased if men and women differ in how they form their health judgment. The aim of this study is to examine whether men and women differ in how health inputs predict their health rating across the adult life span. We use the 2002-2015 National Health Interview Survey data from US-born respondents aged 25-84. Ordered logistic models of SRH as a function of 24 health measures including medical conditions and symptoms, mental health, functioning, health care utilization, and health behaviors, all interacted with gender, test how the measures influence health ratings and the extent to which these influences differ by gender. Using a Bayesian approach, we then compare how closely a select health measure (K6 score) corresponds to SRH levels among men and women. We find little systematic gender difference in the structure of SRH: men and women use wide-ranging health-related frames of reference in a similar way when making health judgments, with some exceptions: mid-life and older men weigh physical functioning deficits and negative health behaviors more heavily than women. Women report worse SRH than men on average but this only holds through mid-adulthood and is reversed at older ages; moreover, the female disadvantage disappears when differences in socio-economic and health covariates are considered. Our findings suggest that the meaning of SRH is similar for women and men. Both groups use a broad range of health-related information in forming their health judgment. This conclusion strengthens the validity of SRH in measuring gender differences in health.

Are Single-Item Global Ratings Useful for Assessing Health Status?

The research performance of the single-item self-rating In general, would you say your health is: excellent, very good, good, fair, or poor? was evaluated relative to the SF-36 General Health Scale that contains this item, using data for a sample of psychiatric outpatients who had co-occurring chronic physical conditions (N = 177). The scale was more robust than the single-item in cross-sectional validity tests and for predicting 2-year outcomes, but the single-item had stronger discriminant validity as a measure of physical health, especially in post-baseline analyses. Single-item and scale were both sensitive enough to detect change in perceived health over 2 years and a conditional experimental effect on health self-perceptions in a randomized trial. These findings demonstrate that a global single-item can be as valid, reliable, and sensitive as a multi-item scale for longitudinal research purposes, even if the scale performs better in cross-sectional surveys or as a screening measure.

Are Single-Item Global Ratings Useful for Assessing Health Status?

The research performance of the single-item self-rating In general, would you say your health is: excellent, very good, good, fair, or poor? was evaluated relative to the SF-36 General Health Scale that contains this item, using data for a sample of psychiatric outpatients who had co-occurring chronic physical conditions (N = 177). The scale was more robust than the single-item in cross-sectional validity tests and for predicting 2-year outcomes, but the single-item had stronger discriminant validity as a measure of physical health, especially in post-baseline analyses. Single-item and scale were both sensitive enough to detect change in perceived health over 2 years and a conditional experimental effect on health self-perceptions in a randomized trial. These findings demonstrate that a global single-item can be as valid, reliable, and sensitive as a multi-item scale for longitudinal research purposes, even if the scale performs better in cross-sectional surveys or as a screening measure.

Is self-rated health still sensitive for changes in disease and functioning among nonagenarians?

OBJECTIVES

With age, there is an increasing gap between relatively stable levels of self-rated health (SRH) and actual health status. This study investigates longitudinal changes in SRH and examines its sensitivity to changes in chronic conditions and functioning among people aged 90 and older.

METHODS

In the Vitality 90+ Study, questionnaires were sent to all people aged 90 years and older living in Tampere, Finland. Included were respondents who provided data on the 2001 measurement and at least one follow-up measurement in 2003, 2007, or 2010 (N = 334). Generalized Estimating Equations analyses examined longitudinal change in SRH and the predictive value of number of chronic conditions and a functioning score based on 5 activities.

RESULTS

Within 2 years, most people (56.3%) had unchanged SRH, but declined SRH (22.3%) was associated with worse baseline functioning and declined functioning. Clear declines in SRH after 6 and 9 years were associated with increased chronic conditions (odds ratio [OR] = 1.23) and decreased functioning (OR = 1.28). The impact of chronic conditions and functioning was smaller among institutionalized people (chronic conditions OR = 0.90; functioning OR = 1.18) than among people living independently (chronic conditions OR = 1.30; functioning OR = 1.44).

DISCUSSION

SRH among nonagenarians was sensitive to changes in the number of chronic conditions and functioning although more pronounced on the longer than on the shorter term.