Original ResearchSelf-rated health and mortality: a follow-up study of a Spanish population
Introduction
Self-rated health (SRH) is commonly used in epidemiological research. This measure provides a complete overview of the health status of a population, allowing dynamic and continuous assessment to reflect judgements about the trajectory of health and not just the current level of health.1, 2 SRH has been described as a complex measure that joins multiple dimensions of health, and is used as a complementary indicator of objective measures.2 Moreover, SRH may be useful as a global screening tool to establish people's health status, adding a predictive value to the known risk factors. In a clinical context, SRH is a sensitive measure to complement specific measures, detects different clinical states, predicts functional impairment, and may be an indicator in risk assessments and clinical practice.3
In Europe, SRH has been included in many surveys and questionnaires to monitor health due to international recommendations (World Health Organization Europe and European Commission).4, 5, 6 Several transverse and longitudinal studies have shown the validity and reliability of this subjective measure as an overall health indicator, as it has been related to different objective measures such as functional capacity, morbidity, use of health services and mortality.3, 7, 8, 9
Although comparison of SRH between countries is very complex, some studies have found large differences in distribution.10, 11, 12, 13, 14, 15, 16 In Europe, a north–south gradient has been described, with individuals living in Scandinavian countries having healthier perceptions than individuals living in countries in southern Europe.11, 13, 15 Other differences have been identified between people of Eastern and Western Europe, being generally worse in former communist countries than in Western European countries.10 These disparities may be explained, in part, by the true state of health, but also by differences in the standard of health thresholds;13 the style of reporting; the variability across different cultures;3, 15, 16, 17 the wording, language and scale of response;18, 19 or even the version of the instrument used in the survey.20, 21, 22, 23, 24
In 2007, 34% of a European Community population (EU-25) reported poor SRH.16 The factors that best explained this result, in order of importance, included: chronic diseases, limitation of activity, increasing age, being outside the labour market (unemployed, retired or inactive), country of residence, low educational level, low income level and sex.16 Another study in 11 European countries described differences between the determinants of SRH in an elderly population, and reported that education, depression, chronic conditions, mobility difficulties, somatic symptoms and levels of physical activity were important components of SRH.15
Overall, between 1980 and 1990, poor SRH decreased in several European countries.12 However, in Spain, the percentage of people who reported poor SRH increased from 27.0% in 1993 to 30.2% in 2006 (24.9% in men and 35.0% in women).25
Moreover, the association of SRH with mortality has been established by several authors.7, 8, 17, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 This association is often weaker in women than in men.7, 17, 34 Regarding the ability of SRH to predict mortality, taking into account differences between socio-economic groups, several studies have found discrepant results, including stronger associations in subjects with high socio-economic status,30, 34, 37 stronger associations in subjects with low socio-economic status28, 33 and no association.32, 35
In Spain, although some studies have evaluated the association between SRH and mortality, they have all been conducted in populations over 60 years of age,37, 38, 39, 40 and have reported differing results.
Given the lack of studies in Spain to establish the association between SRH and mortality, the predictive role of SRH for mortality in the general population, and the discrepancies in the findings in elderly populations, the aims of this study were: to describe and analyse the associations of health status, socio-economic and demographic characteristics with SRH, and the associations between SRH and mortality by follow-up of a cohort of subjects representative of the general population.
Section snippets
Methods
This longitudinal study monitored a cohort of subjects who were part of the sample for the 2005 Health Interview Survey of the Valencian Community (HISVC). The questionnaire normally used in health surveys was used in this study. The variables included in the questionnaire dealt with lifestyle, sociodemographic characteristics, SRH, health status and the use of health services.
Details about the survey methodology (sample design, sample size, sampling procedure, consent, ethics, etc.) have been
Results
After four years of follow-up, there were 188 deaths (3.6%) among the 5275 individuals in the cohort [99 men (52.9%) and 89 women (47.1%)]. The frequencies and percentages of deaths at the end of the follow-up period, by sex and for the total population, for each of the categories of the explanatory variables are shown in Table 1. In both men and women, there were more deaths in individuals who reported poor SRH, older age, unemployment, primary or no education, self-perceived low income, born
Discussion
This article reports the results of the first longitudinal study on the associations and predictive role of SRH. This study is based on the follow-up of a general population of Spanish adults (age ≥21 years), through data from a health interview survey and mortality results obtained from the local mortality register. This study found that all the variables studied were significantly associated with SRH, both in men and women, except country of birth. Thus, according to the results, the
Ethical approval
Not required as this study used secondary data derived from a survey undertaken by the Office of Health Plan (Conselleria de Sanitat of the Valencian Autonomous Government) which is the highest authority on health statistics in this region. Ethical considerations were taken into account by this authority.
Funding
This study was supported, in part, by the Dirección General de Salud Pública (Conselleria de Sanitat of the Generalitat Valenciana). The funding source had no involvement in the process of
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