In our analyses, the addition of physical and psychosocial health variables attenuated, but did not eliminate, the association between race and SRH (i.e., Whites were still 3.7 times more likely than Blacks to report favorable SRH). When participants were compared at the same level of objective physical functioning, Whites were significantly more likely to report favorable SRH compared with Black elders after adjusting for differences in demographics, physical health, and psychosocial health. Even among those participants with the best performance scores across several physical domains, Whites were 5.5 times more likely to report favorable SRH than Black elders. These data are consistent with the hypothesis of greater health pessimism among Black elders. It also suggests that enduring self-concept might be the most accurate way to view SRH, whereby cultural differences exist in how health is interpreted and the extent to which individual factors influence SRH assessments.
Information gained from our analysis supports the notion that SRH taps into multiple dimensions of health (Idler & Benyamini, 1997
). The association between race and SRH persisted after adjusting for multiple health-related variables, suggesting that the factors which influence SRH are complex and not readily captured with standard subjective and objective measures. In the Cardiovascular Health Study of the Elderly, Schulz et al. (1994)
found that from an extensive list of 70 predictors, it was the health-related factors which participants were aware of that had the strongest association with SRH (e.g., prescription medications, known illnesses, etc.). Our work expands on this by demonstrating that objective physical function is also important to the SRH of older adults. The observation that multiple factors predict SRH supports previous literature, but the finding that racial differences exist at similar levels of functioning warrants further discussion.
Research suggests that definitions of what constitutes good (and poor) health differ across diverse populations because the meaning of “healthy” is often related to group referents and lifetime experiences (Damron-Rodriguez, Frank, Enriquez-Haass, & Reuben, 2005
; Krause & Jay, 1994
). In a study of 114 older adults with chronic illness, Blacks tended to focus more on the presence or absence of conditions, whereas Whites focused more on functioning (Silverman, Smola, & Musa, 2000
). Krause and Jay found that Whites used physical functioning as a frame of reference, whereas non-Whites (Black and Hispanic) might think more about health problems when interpreting SRH. Results from these studies support our finding of comparatively greater concordance between SRH and physical functioning among Whites (i.e., high functioning corresponded with higher SRH ratings among Whites but not Blacks). It is possible that in the current study, high levels of functioning were responsible for elevated SRH among Whites but did not influence ratings of health to the same extent among Black elders due to different definitions of health.
An alternate explanation is that factors not included in the current analyses might better explain SRH among Black elders. McMullen and Luborsky (2006)
recently suggested that Black older adults might be using more than biomedical and physical health criteria when defining health as a way to maintain health identity. Although our models of SRH included some psychosocial measures, these constructs were not exhaustive and tend to be less well-measured than standard physical health variables. The addition of a more diverse set of health and psychosocial variables might show a greater attenuation of the race difference than was observed in the current analyses.
The hypothesis of health pessimism among Black elders was explored in the current analysis in a way that has not been previously described. Prior studies have shown that racial differences in SRH persist after controlling for a number of demographic and health-related variables. However, none to our knowledge have examined the health pessimism hypothesis by using objective physical functioning as the standard on which physical health is gauged. Using objective indicators in research on health pessimism has implications for the development of screening instruments to identify older adults who are at risk for poor outcomes. Hong, Oddone, Dudley, and Bosworth (2005)
found that among older veterans with hypertension, health pessimists had less control over their blood pressure than elders in any other health congruence group (good health realists, poor health realists, or health optimists). If health pessimists are at heightened risk for poor health outcomes, future research could address whether health pessimism is a stable trait based on a history of poor health or whether health pessimism in older adulthood could be modified with targeted behavioral interventions.
The underlying reasons for racial group differences in health pessimism are not well understood. As previously suggested, these differences in health pessimism might be due to cultural or psychosocial variations in how individuals conceptualize the global construct of SRH. In our study, for example, self-reported pain was higher among White men compared with Black men, which might also suggest differences in how these groups view, interpret, and report physical symptoms. Another intriguing possibility which has some support in the social science literature is the idea that lifetime experiences have resulted in more negative health appraisals among Black individuals. In a sample of 1,106 Blacks and Whites age 18 years and older, interpersonal maltreatment (defined as perceived maltreatment from others in daily life) explained racial differences in health pessimism (Boardman, 2004
). It is possible, then, that perceived maltreatment might lead to elevated health pessimism among racial minority elders, although the data are currently unavailable to test this in the Health ABC cohort.
The present study has limitations which must be acknowledged. First, the data were cross-sectional, which limited our ability to understand the directionality of the relationships between variables. It is possible that health pessimism in the baseline Health ABC sample could lead to poor health outcomes and accelerated health decline over time. Although our results were consistent with the literature, generalizability may be limited because Health ABC participants were relatively high functioning at baseline. Also, factors which are unaccounted for in our analyses might be influencing SRH. Finally, although performance on the multidimensional PPB seems to be a strong measure of functioning, participants in future analyses should be equated on additional measures (e.g., grip strength, 400 m walk, etc.) to see if the health pessimism hypothesis holds across other dimensions of physical functioning.
Understanding SRH in minority populations could have important clinical and policy implications because of its widespread use and its predictive utility (Damron-Rodriguez et al., 2005
; Ferraro & Kelley-Moore, 2001
). SRH is not only strongly related to health but also provides information about well-being that is not explained by other measures. We demonstrated that racial differences in SRH did not coincide with differences in functioning nor were these differences explained by a variety of demographic, physical, and psychosocial factors. SRH is perhaps the most commonly used measure of global health in national surveillance surveys. For example, Healthy People 2010 uses SRH to measure health-related quality of life and describe overall health across a range of demographic characteristics. However, many of these surveys lack the data necessary for developing an in-depth understanding of racial variations in SRH. The current analysis makes a unique contribution by including objective physical functioning as one of these factors in a large and diverse sample of community-dwelling older adults.