Perhaps the most striking finding from this study is the similarities in the health-related correlates of SRH reported in Table
. Individuals with more medical conditions, functional limitations or poor mental health gave poorer ratings in all countries and these factors accounted to some degree for the cross-national differences in raw SRH scores. However, some country level differences remained after accounting for these individual health correlations, and the respondents’ country provided a context within which some correlates carried different levels of influence.
Seeking explanations for these cross-national differences requires consideration of complex historical, economic and cultural factors that potentially influence individuals’ health and health perceptions. These wider influences potentially extend beyond those located at the individual level (e.g. educational background) and extend to national (e.g. health service availability), cultural (e.g. gender expectations) and cohort (e.g. experiences of war and economic depression) levels. Further, these various factors are likely to interact. For example, older Japanese and Korean men may share a cultural acceptance of cigarette smoking, but their childhood and young adult experiences (in oppressor and oppressed nations respectively) differ both from each other and from ascendent cohorts now at younger ages. Similarly, whether or not one is married is an individual level indicator, but its impact may depend upon cultural and economic circumstances that vary at the societal level.
Cross-national differences in self-rated health
When considering the raw ratings, older Koreans rated their health as very much poorer than those in the three other countries. They were also more likely to report poor mental health and, further, the associations of mental health and functional disability with SRH were somewhat larger in Korea than other countries. The inclusion of social and health variables, along with their interactions, left Korean ratings differing only from those provided by the more highly rated Australian sample, suggesting that for Korean elders poor SRH largely reflects poorer objective health and its greater impact. Several factors might combine to explain these findings, although without access to relevant data to test these ideas, interpretation of the findings remains speculative. Firstly, this cohort of older Koreans may be uniquely vulnerable to poor health, and especially poor mental health, possibly as a result of their early life experiences. During the first half of the twentieth century, Korea suffered a particularly troubled history, with the greatest pressures on the population falling during the period 1935–1945 [41
]. Most of our respondents were children or teenagers for all or part of this decade, with the youngest having been born in 1941; such difficult circumstances early in life could have had a lasting effect on their mental health and the way they perceive their lives. Such an effect could be specific to Koreans of this cohort. Future research should attempt to separate age from cohort effects in Korea, preferably through cross-sequential analyses or by examining a later cohort (e.g. those 45 to 64
years) who would have not experienced the same levels of deprivation early in life. This could clarify the relative importance of the historical influence discussed above as well as the economic factors associated with ageing and retirement considered below.
Secondly, although the four countries studied here are currently considered to have very high levels of human development [42
], the present economic circumstances of older people in these countries may not be equivalent. It is possible that the very rapid and later social improvements in Korea, which contrast with earlier improvements in population level economic well-being in the other countries, may not have benefited older people as much as younger people [43
]. A related factor may be emergent tensions in filial expectations and supports. Traditional Korean family exchange has been ordered by the principles of Confucian philosophy, within which Hyo
, the duty of children to care for their parents, is a core value [44
]. The proportion of elderly Koreans living with their children was, however, considerably reduced by the end of the twentieth century [45
]. At the time of our survey more Koreans (approximately 30%) remained in the labor force after 65
years of age than in Western countries, suggesting that they may not be receiving either the filial or public support that they might have expected [46
Labor force participation is also high among men above the retirement age in Japan, notwithstanding the mature social security system that has provided better retirement income: previous studies have suggested that continuing to work serves social and psychological benefits for Japanese men [47
]. Older Koreans, however, have had less access to retirement income and their jobs are more likely to be casual, low-skilled and poorly paid compared to younger workers [46
]. Such conditions may further contribute to their poor mental health as they may continue to work out of economic necessity more than choice. Self reports of poor health by Korean elders appear to be largely accounted for by objective differences in their reported physical and mental health, and the ways in which those health conditions impact upon them, suggesting that they are a cohort in need of further study and potentially additional support. This picture of poor health in Korea is especially pronounced for women, suggesting that gender inequalities should also be a focus of further study.
After accounting for differences in social and health status, and the ways in which these factors operate differently in different countries, the remaining cross-national differences in level of SRH indicate that, ceteris paribus,
older Australians provided more optimistic assessments of their health than older adults in the other countries. Systematic differences in preference for extreme versus central responding in Western versus Asian countries do not appear to account for this finding. The data in Table
suggest that preference for the extreme negative response option may be characteristic specifically of the Korean sample, although past research has hypothesized a central
tendency underlying some Asian response patterns. Table
further shows that any extreme responding preference was in fact confined to women; Korean men used the good, fair and poor responses in approximately equal proportions. An extreme negative response set may partially account for our findings, but it is important to note that it is confined to Korean women, and is not amenable to any broader gender or cultural explanation. It seems likely that explanations may lie in contextual influences that are specific to countries and/or cohorts rather than in crude distinctions between Western and East Asian ways of thinking or responding. It is also notable that Australian ratings differ significantly from those in the USA, notwithstanding many social and cultural similarities. Future studies should include indicators of access to health care, for example provision of public health care and health insurance subsidies: the better access in Australia than the USA in both these respects may be important for individual perceptions of health.
The changing position of Japan in the ranking, after taking personal factors into account, is partly consistent with Lee and Shinkai’s (2003) findings – in our raw data mean SRH was also healthiest in Japan. After accounting for all other variables, Japan’s position was not reversed with respect to Korea, as it was in Lee and Shinkai’s study, but it became significantly worse than Australia and was no longer better than Korea. This suggests that the original ratings of better health in Japan were reported because the Japanese elders were indeed somewhat healthier, with the lowest reports of chronic illness and disability, so their ‘advantage’ in SRH was a real one and apparent differences were reduced once health indicators were was taken into account.
Cross-national differences in the correlates of self-rated health
Cross-national differences notwithstanding, we wish to re-iterate that the health-related correlates of SRH were found to be similar across countries; those with more medical conditions, functional limitations or poor mental health gave poorer ratings. Our findings, in conjunction with the majority of past studies, support a conclusion that health-related correlates of SRH are found universally. Although cross-national differences in SRH were initially large, they were much reduced when these health-related factors, along with social factors and the differing contextual effects of these, were taken into accounted.
Potentially important differences in impact were observed for some social and behavioral variables, for example poorer SRH was associated with being a current smoker only in Australia and USA. In these countries cigarette smoking has declined significantly and they are now well into Stage IV of the ‘smoking epidemic’, where smokers are in a minority and smoking is regarded as socially abnormal and a major health risk [48
]. In Japan and South Korea however, smoking rates are still much higher, especially among males and adults younger than those surveyed here. Health-related behaviors such as smoking may influence perceptions of health (independently of their indirect effect through their actual health impact) via the messages that are current in the individual’s social climate. This could have the paradoxical effect of producing poorer health ratings among older smokers in nations where health promotion is more effective and risk behaviors are less prevalent.
A recent review has suggested that there is little health inequality associated with socioeconomic disadvantage in Japan, and that the longevity of Japanese elders is associated with a range of factors specific to Japanese culture [49
]. We also found that none of the socioeconomic indicators were significant correlates of SRH in Japan. Data from the same NUJLSOA survey have also shown that educational attainment was unrelated to a more objective health indicator, functional disability [50
]. These authors proposed that education may not be necessary to maintain good health in Japan, since access to health care is universal. These findings reinforce our contention that the impact of individual level indicators is moderated by national factors. Such complex effects can be revealed by cross-national research such as ours, complemented by examining possible changes after major economic or policy change [19
]. It is perhaps worth noting that the beneficial effect of education, although significant, was also smaller in Australia than the remaining two countries; this may also be explained by a strong system of universal health care.
Although none of the other correlates of SRH showed an interaction with gender, we found differences in the effect of gender between nations. After taking differences in socioeconomic factors and health indicators into account, women were more optimistic in the USA (consistent with Grol-Prokopczyk and colleagues’ (2011) finding using a vignette approach) and more pessimistic in Korea than their male counterparts, while in Australia and Japan no gender difference was observed. This contrasts with the pattern in the raw data (Table
) which showed poorer SRH among women in all countries. In Australia and Japan this gender difference in ratings disappeared after accounting for differences in indicators of health status (diagnoses, physical limitation and depressive symptoms), suggesting that the observed gender differences in SRH reflect gender differences in health in these countries. In the USA the difference was actually reversed in multivariate analysis, with women’s ratings being more positive than men’s after accounting for illness burden. Only in Korea did women report their health more negatively than men after accounting for their (also higher) health burden. Our data highlight the fact that gender is a social construction that resides within a wider culture, and which is a stronger correlate in some countries than others. Future researchers should remain aware that the effects of both gender and education may be specific to the sample under investigation.
Our study is based on large and representative samples, and our selection of countries allows us to draw valuable inferences about the meaning of SRH responses. However, the process of making cross-national comparisons based on secondary data also has limitations. Firstly, there is inherent difficulty in establishing whether the Korean and Japanese surveys convey exactly the same meaning to respondents as the English questionnaires. While translations were undertaken with great care, we should remain aware that some constructs may have different meanings in different languages and cultures. In particular the response scale for the SRH question in the Japanese survey was worded somewhat differently which may have affected the distribution of responses in this country.
Secondly, several of the surveys employed complex sampling strategies, so the use of sampling weights may have been preferred. Weights were not, however, available for the Australian data so this approach could not be taken. Simulations have demonstrated that the use of population weights is, in any case, of dubious value for regression analyses such as those reported here, although our estimates of the levels of self-reported health may be affected [52
Thirdly, we are mindful of particular limitations associated with our mental health variable – mental health is clearly an important determinant of SRH, but our indicators may be too variable to draw firm conclusions about how this effect varies between countries. We also note that the CES-D is primarily a depression measure. Some studies of older Holocaust survivors (e.g. Sharon et al., 2009) have found elevated anxiety but not depression; anxiety among survivors of other traumatic war-time experiences may also influence SRH and is not accounted for in our data.
Fourthly, we were limited by the lack of a more contemporaneous socioeconomic indicator; especially for older persons educational attainment may have been superseded by employment-related advantages or disadvantages, and may be less relevant for older people in societies undergoing rapid socioeconomic development. As discussed above, current financial stress may be an important factor in driving both mental health and SRH; a variable assessing income would be valuable to explore this idea further. More broadly, better measures of social class position are needed for examining social determinants of health in older people [53
Fifthly, we are aware that survivor effects, both from birth and within the longitudinal waves of a study, may differ between the cohorts that we have used. The potential importance of survival effects can be illustrated by the fact that, even in the relatively advantaged cohort of Australians, only 75% of their birth cohort would have survived to age 65
years at the time of the survey [54
]. Our decision to constrain the dates of the surveys to a single decade, in order to match the respondent’s historical cohort, has also resulted in the use of data collected in later waves in some surveys than others. Only the Korean data used responses to a wave one survey so it remains a possibility that respondents in other countries have been subject to a greater degree of selection since recruitment than the Korean sample.
Finally, because we were interested in self-rated health, we only used data from older adults who were sufficiently well (physically, emotionally and cognitively) to participate in the surveys themselves; our findings may not generalize to the very sick and institutionalized elderly. In light of our speculation that historical effects may be important for these samples, we also recommend caution in generalizing our findings to younger cohorts.