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1.  Contributors to self-reported health in a racially and ethnically diverse population: focus on Hispanics 
Annals of epidemiology  2012;23(1):19-24.
To understand if Hispanics report health differently than other racial/ethnic groups after controlling for demographics and risk factors for poor health.
The sample (n=5,502) included 3,201 women, 1,767 black, 1,859 white and 1,876 Hispanic subjects from the Boston Area Community Health Survey, a population-based survey of English and Spanish-speaking residents of Boston, Massachusetts, United States, age 30–79 in 2002–05. Multiple logistic regression was used to examine the association between race/ethnicity (including interview language for Hispanics) and fair/poor self-reported health (F/P SRH) adjusting for gender, age, socioeconomic status (SES), depression, nativity, and comorbidities.
Compared to whites, Hispanics interviewed in Spanish were seven times as likely to report F/P SRH (Odds Ratio = 7.7, 95% confidence interval 4.9, 12.2) after adjusting for potential confounders and Hispanics interviewed in English were twice as likely. In analyses stratified by depression and nativity, we observed stronger associations with Hispanic ethnicity in immigrants and non-depressed individuals interviewed in Spanish.
Increased odds of F/P SRH persisted in the Hispanic group even when accounting for interview language and controlling for SES, age, depression, and nativity, with language of interview mitigating the association. These findings have methodologic implications for epidemiologists using SRH across diverse populations.
PMCID: PMC3519959  PMID: 23149066
Hispanic Americans; self-reported; health status; comorbidity
2.  Measuring the need for medical care in an ethnically diverse population. 
Health Services Research  1996;31(5):551-571.
OBJECTIVE: To examine measures of need for health care and their relationship to utilization of health services in different racial and ethnic groups in California. DATA SOURCE: Telephone interviews obtained by random-digit dialing and conducted between April 1993 and July 1993 in California, with 7,264 adults (ages 18-64): 601 African Americans, 246 Asians, 917 Latinos interviewed in English; 1,045 Latinos interviewed in Spanish; and 4,437 non-Latino whites. STUDY DESIGN: A cross-sectional survey was conducted from a stratified, probability telephone sample. DATA COLLECTION: Interviews collected self-reported indicators of need for health care: self-rated health, activity limitation, major chronic conditions, need for ongoing treatment, bed days, and prescription medication. The outcome was self-reported number of physician visits in the previous three months. PRINCIPAL FINDINGS: Compared to whites, one or more of the other ethnic groups varied significantly (p < .05) on each of the six need-for-care measures after adjustment for health insurance, age, sex, and income. Latinos interviewed in Spanish reported lower percentages and means on five of the need measures but the highest percentage with fair or poor health (32 percent versus 7 percent in whites). Models regressing each need measure on the number of outpatient visits found significant interactions of ethnic group with need compared to whites. After adjustment for insurance and demographics, the estimated mean number of visits in those with the indicator of need was consistently lower in Latinos interviewed in Spanish, but the differences among the other ethnic groups varied depending on the measure used. CONCLUSION: No single valid estimate of the relationship between need for health care and outpatient visits was found for any of the six indicators across ethnic groups. Applying need adjustment to the use of health care services without regard for ethnic variability may lead to biased conclusions about utilization.
PMCID: PMC1070141  PMID: 8943990
3.  Determinants of Self-Rated Health in a Representative Sample of a Rural Population: A Cross-Sectional Study in Greece 
Self-rated health (SRH) is a health measure related to future health, mortality, healthcare services utilization and quality of life. Various sociodemographic, health and lifestyle determinants of SRH have been identified in different populations. The aim of this study is to extend SRH literature in the Greek population. This is a cross-sectional study conducted in rural communities between 2001 and 2003. Interviews eliciting basic demographic, health-related and lifestyle information (smoking, physical activity, diet, quality of sleep and religiosity) were conducted. The sample consisted of 1,519 participants, representative of the rural population of Tripoli. Multinomial regression analysis was conducted to identify putative SRH determinants. Among the 1,519 participants, 489 (32.2%), 790 (52%) and 237 (15.6%) rated their health as “very good”, “good” and “poor” respectively. Female gender, older age, lower level of education and impaired health were all associated with worse SRH, accounting for 16.6% of SRH variance. Regular exercise, healthier diet, better sleep quality and better adherence to religious habits were related with better health ratings, after adjusting for sociodemographic and health-related factors. BMI and smoking did not reach significance while exercise and physical activity exhibited significant correlations but not consistently across SRH categories. Our results support previous findings indicating that people following a more proactive lifestyle pattern tend to rate their health better. The role of stress-related neuroendocrinologic mechanisms on SRH and health in general is also discussed.
PMCID: PMC3367289  PMID: 22690175
self-rated health; determinants; lifestyle; sleep; religiosity; cross-sectional
4.  Language Bias and Self-Rated Health Status among the Latino Population: Evidence of the Influence of Translation in a Wording Experiment 
A growing body of research seeks to understand how language bias in survey research impacts our abilities to make generalizations in the study of racial and ethnic disparities. This research uses a wording experiment to assess self-rated health among a representative study of the Latino population (n=1,200). Our analysis shows that by manipulating only the translation of the category fair health into Spanish we are able to directly test the hypothesis that the translation of fair to regular in Spanish suppresses Latino self-rated health. We find convincing evidence through the use of logistic and multinomial logistic regressions that respondents provided with the term regular report poorer health when compared to those who were given the alternative translation of mas o menos. We also find that this translation effect is driven solely by a movement of respondents to choose fair rather than good health, which can in fact explain lower than expected health status rates in studies looking to explore differences between Latinos and non-Latinos. This research informs the study of racial and ethnic disparities, providing a detailed explanation for mixed findings in the Latino health disparities literature.
PMCID: PMC4823170  PMID: 26439110
health disparities; self-reported health; language bias; Latino populations; survey research
5.  Are Latinos Less Satisfied with Communication by Health Care Providers? 
To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white).
A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale.
We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this “very poor,”“poor,” or “fair”; p < .01); (2) answers to their questions (27% vs 16% vs 12%; p < .01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p < .01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p < .01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p < .01).
This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.
PMCID: PMC1496614  PMID: 10417598
Hispanic; Latino, satisfaction, communication; quality of care
6.  Determinants of self-rated health in an Irish deprived suburban population – a cross sectional face-to-face household survey 
BMC Public Health  2016;16:767.
Self-rated health (SRH) is amongst the most frequently assessed health perceptions in epidemiological research. While there is a growing understanding of the role of SRH, a paradigm model has yet to be widely accepted with recent studies concluding that further work is required in determining whether there are important predictors of SRH yet to be highlighted. The aim of this paper is to determine what health and non-health related factors were associated with SRH in a suburban deprived population in Dublin, Ireland.
A cross sectional face-to-face household survey was conducted. Sampling consisted of random cluster sampling in 13 electoral divisions, with a sampling frame of 420 houses. Demographic information relating to the primary carer was collected. Health status of the primary carer was measured through SRH. Household level data included the presence or absence of persons with a chronic disease, persons who smoked, persons with a disability and healthcare utilisation of general practitioner and hospital level services. A logistic regression model was utilised in the analysis whereby the odds of primary carers with poor SRH were compared to the odds of carers with good SRH taking health and non-health related factors into account.
Of the 420 households invited to participate a total of 343 were interviewed (81.6 % response rate). Nearly half of the primary carers indicated their health as being ‘good’ (n = 158/342; 46.2 %).
Adjusting for the effects of other factors, the odds of primary carers with second level education were increased for having poor SRH in comparison to the odds of those with third level education (OR 3.96, 95 % CI (1.44, 11.63)). The odds of primary carers who were renting from the Council were increased for having poor SRH compared to the odds for those who owned their own property (OR 3.09, 95 % CI (1.31, 7.62)). The odds of primary carers that were unemployed (OR 3.91, 95 % CI 1.56, 10.25)) or retired, ill or unable to work (OR 4.06, 95 % CI (1.49, 11.61)) were higher for having poor SRH than the odds of those in employment. If any resident of the household had a chronic illness then the odds of the primary carer were increased for having poor SRH compared to the odds for a primary carer in a household where no resident had a chronic illness (OR 4.78, 95 % CI (2.09, 11.64)). If any resident of the household used the local hospital, the odds of the primary carer were increased for having poor SRH compared to the odds for the primary carer in a household where no resident used the local hospital (OR 2.01, 95 % CI (1.00, 4.14)).
SRH is affected by both health and non-health related factors. SRH is an easy to administer question that can identify vulnerable people who are at risk of poor health.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-3442-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4982417  PMID: 27515433
Self-rated health; Predictor; Community; Deprivation; Education; Employment; Chronic illness; Hospital use
7.  Long-Term Biological and Behavioural Impact of an Adolescent Sexual Health Intervention in Tanzania: Follow-up Survey of the Community-Based MEMA kwa Vijana Trial 
PLoS Medicine  2010;7(6):e1000287.
David Ross and colleagues conduct a follow-up survey of the community-based MEMA kwa Vijana (“Good things for young people”) trial in rural Tanzania to assess the long-term behavioral and biological impact of an adolescent sexual health intervention.
The ability of specific behaviour-change interventions to reduce HIV infection in young people remains questionable. Since January 1999, an adolescent sexual and reproductive health (SRH) intervention has been implemented in ten randomly chosen intervention communities in rural Tanzania, within a community randomised trial (see below; NCT00248469). The intervention consisted of teacher-led, peer-assisted in-school education, youth-friendly health services, community activities, and youth condom promotion and distribution. Process evaluation in 1999–2002 showed high intervention quality and coverage. A 2001/2 intervention impact evaluation showed no impact on the primary outcomes of HIV seroincidence and herpes simplex virus type 2 (HSV-2) seroprevalence but found substantial improvements in SRH knowledge, reported attitudes, and some reported sexual behaviours. It was postulated that the impact on “upstream” knowledge, attitude, and reported behaviour outcomes seen at the 3-year follow-up would, in the longer term, lead to a reduction in HIV and HSV-2 infection rates and other biological outcomes. A further impact evaluation survey in 2007/8 (∼9 years post-intervention) tested this hypothesis.
Methods and Findings
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 young people aged 15–30 y who had attended trial schools during the first phase of the MEMA kwa Vijana intervention trial (1999–2002). Prevalences of the primary outcomes HIV and HSV-2 were 1.8% and 25.9% in males and 4.0% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV (males adjusted prevalence ratio [aPR] 0.91, 95%CI 0.50–1.65; females aPR 1.07, 95%CI 0.68–1.67) or HSV-2 (males aPR 0.94, 95%CI 0.77–1.15; females aPR 0.96, 95%CI 0.87–1.06). The intervention was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime (aPR 0.87, 95%CI 0.78–0.97) and an increase in reported condom use at last sex with a non-regular partner among females (aPR 1.34, 95%CI 1.07–1.69). There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study population was likely to have been, on average, at lower risk of HIV and other sexually transmitted infections compared to other rural populations, as only youth who had reached year five of primary school were eligible.
SRH knowledge can be improved and retained long-term, but this intervention had only a limited effect on reported behaviour and no significant effect on HIV/STI prevalence. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
Trial Registration NCT00248469
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, about 2.5 million people become infected with the human immunodeficiency virus (HIV), the virus that causes AIDS. HIV is most often spread through unprotected sex with an infected partner, so individuals can reduce their risk of HIV infection by abstaining from sex, by delaying first sex, by having few partners, and by always using a condom. And, because nearly half of new HIV infections occur among youths (15- to 24-year-olds), programs targeted at adolescents that encourage these protective behaviors could have a substantial impact on the HIV epidemic. One such program is the MEMA kwa Vijana (“Good things for young people”) program in rural Tanzania. This program includes in-school sexual and reproductive health (SRH) education for pupils in their last three years of primary education (12- to 15-year-olds) that provides them with the knowledge and skills needed to delay sexual debut and to reduce sexual risk taking. Between 1999 and 2002, the program was trialed in ten randomly chosen rural communities in the Mwanza Region of Tanzania; ten similar communities that did not receive the intervention acted as controls. Since 2004, the program has been scaled up to cover more communities.
Why Was This Study Done?
Although the quality and coverage of the MEMA kwa Vijana program was good, a 2001/2002 evaluation found no evidence that the intervention had reduced the incidence of HIV (the proportion of the young people in the trial who became HIV positive during the follow-up period) or the prevalence (the proportion of the young people in the trial who were HIV positive at the end of the follow-up period) of herpes simplex virus 2 (HSV-2, another sexually transmitted virus). However, the evaluation found improvements in SRH knowledge, in reported sexual attitudes, and in some reported sexual behaviors. Evaluations of other HIV prevention programs in other developing countries have also failed to provide strong evidence that such programs decrease the risk of HIV infection or other biological outcomes such as the frequency of other sexually transmitted infections or pregnancies, even when SRH knowledge improves. One possibility is that it takes some time for improved SRH knowledge to be reflected in true changes in sexual behavior and in HIV prevalence. In this follow-up study, therefore, researchers investigate the long-term impact of the MEMA kwa Vijana program on HIV and HSV-2 prevalence and ask whether the improvement in knowledge, reported attitudes and sexual risk behaviours seen at the 3-year follow up has persisted.
What Did the Researchers Do and Find?
In 2007/8, the researchers surveyed nearly 14,000 young people who had attended the trial schools between 1999 and 2002. Each participant had their HIV and HSV-2 status determined and answered questions (for example, “can HIV be caught by sexual intercourse (making love) with someone,” and “if a girl accepts a gift from a boy, must she agree to have sexual intercourse (make love) with him?”) to provide three composite sexual knowledge scores and one composite attitude score. 1.8% of the male and 4.0% of the female participants were HIV positive; 25.9% and 41.4% of the male and female participants, respectively, were HSV-2 positive. The prevalences were similar among the young people whose trial communities had been randomly allocated to receive the MEMA kwa Vijana Program and those whose communities had not received it, indicating that the MEMA kwa Vijana intervention program had not reduced the risk of HIV or HSV-2. The intervention program was associated, however, with a reduction in the proportion of men reporting more than four sexual partners in their lifetime and with an increase in reported condom use at last sex with a non-regular partner among women. Finally, although the intervention had still increased SRH knowledge, it now had had no impact on reported attitudes to sexual risk, reported pregnancies, or other reported risky sexual behaviors beyond what might have happened due to chance.
What Do These Findings Mean?
These findings indicate that, in the MEMA kwa Vijana trial, SRH knowledge improved and that this improved knowledge was retained for many years. Disappointingly, however, this intervention program had only a limited effect on reported sexual behaviors and no effect on HIV and HSV-2 prevalence at the 9-year follow-up. Although these findings may not be generalizable to other adolescent populations, they suggest that intervention programs that target only adolescents might not be particularly effective. Young people might find it hard to put their improved skills and knowledge into action when challenged, for example, by widespread community attitudes such as acceptance of older male–younger female relationships. Thus, the researchers suggest that the integration of youth HIV prevention programs within risk reduction programs that tackle sexual norms and expectations in all age groups might be a more successful approach and should be evaluated.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Rachel Jewkes
More information about the MEMA kwa Vijana program is available at their Web site
Information is available from the Programme for Research and Capacity Building in Sexual and Reproductive Health and HIV in Developing Countries on recent and ongoing research on HIV infection and other STIs
Information is available from the World Health Organization on HIV and on the health of young people
Information on HIV is available from UNAIDS
Information on HIV in children and adolescents is available from UNICEF
Information on HIV prevention interventions in the education sector is available from UNESCO
Information on HIV infection and AIDS is available from the US National Institute of Allergy and Infectious Diseases
The US Centers for Disease Control and Prevention provide information on HIV/AIDS and on HIV/AIDS among youth (in English and Spanish)
HIV InSitehas comprehensive information on all aspects of HIV/AIDS, including links to information on the prevention of HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS prevention and AIDS and sex education (in English and Spanish)
PMCID: PMC2882431  PMID: 20543994
8.  Question context and priming meaning of health: effect on differences in self-rated health between Hispanics and non-Hispanic Whites 
American journal of public health  2013;104(1):179-185.
Despite little empirical evidence, the current data collection practice recommends placing self-rated health (SRH) before specific health-related questions (hence, without a health context) to remove potential context effects. This paper examined the implications of this design on measurement comparability between Hispanics and non-Hispanics.
This study used two methodologically comparable surveys conducted in English and Spanish that asked SRH in different contexts: before and after specific health questions. Focusing on the elderly, we compared the influence of question contexts on SRH between Hispanics and non-Hispanics and between Spanish and English speakers.
Results showed that the question context influenced SRH reports of Spanish speakers (and Hispanics) drastically but not of English speakers (and non-Hispanics). Specifically, on SRH within a health context, Hispanics reported more positive health, decreasing the gap with non-Hispanic Whites by two thirds, and the measurement utility of SRH was improved through more consistent mortality prediction across ethnic/linguistic groups.
Contrary to the current recommendation, asking SRH within a health context enhanced measurement utility. Studies using SRH may result in erroneous conclusions when not considering its question context.
PMCID: PMC3910022  PMID: 23678900
9.  Self-rated health and ethnicity: focus on indigenous populations 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18538.
Self-rated health (SRH) is a commonly used measure in surveys to assess general health status or health-related quality of life. Differences have been detected in how different ethnic groups and nationalities interpret the SRH measure and assess their health. This review summarizes the research conducted on SRH within and between ethnic groups, with a focus on indigenous groups.
Study design and methods
A search of published academic literature on SRH and ethnicity, including a comprehensive review of all relevant indigenous research, was conducted using PubMed and summarized.
A wide variety of research on SRH within ethnic groups has been undertaken. SRH typically serves as an outcome measure. Minority respondents generally rated their health worse than the dominant population. Numerous culturally-specific determinants of SRH have been identified. Cross-national and cross-ethnicity comparisons of the associations of SRH have been conducted to assess the validity of SRH. While SRH is a valid measure within a variety of ethnicities, differences in how SRH is assessed by ethnicities have been detected. Research in indigenous groups remains generally under-represented in the SRH literature.
These results suggest that different ethnic groups and nationalities vary in SRH evaluations, interpretation of the SRH measure, and referents employed in rating health. To effectively assess and redress health disparities and establish culturally-relevant and effective health interventions, a greater understanding of SRH is required, particularly among indigenous groups, in which little research has been conducted.
PMCID: PMC3417472  PMID: 22663937
self-rated health (SRH); ethnicity; indigenous health; health measures; surveys
10.  Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care 
Health Services Research  2003;38(3):789-808.
Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language.
Data Sources
Data were derived from the National CAHPS ® Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000.
Data Collection
The CAHPS® data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent.
Study Design
Data were analyzed using linear regression models. The dependent variables were CAHPS ® 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health.
Principal Findings
Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities.
This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.
PMCID: PMC1360917  PMID: 12822913
Race/ethnicity; consumer assessments; CAHPS®; patient experiences; patient reports and ratings
11.  Predictors of Self-rated Health Status Among Texas Residents 
Preventing Chronic Disease  2005;2(4):A12.
The purpose of this study was to investigate the predictors of self-rated health status for Texas adults using the current 2003 Behavioral Risk Factor Surveillance System data. Self-rated health is generally accepted as a valid measure of health status in population studies, and understanding its correlates may help public health professionals prioritize health-promotion and disease-prevention interventions.
The two research questions addressed by this study involved the predictors of self-rated health: 1) "Do demographic characteristics, health care coverage, leisure-time physical activity, and body mass index predict self-rated health status for Texas residents aged 18 to 64 years?" and 2) "Does choice of interview language (English vs Spanish) predict self-rated health status for Texas residents of Hispanic ethnicity aged 18 to 64 years?" Key analysis variables were identified, and descriptive statistics were used to describe the major variables and determine whether the number of respondents for each variable was sufficient for analysis. Multivariate regression analysis was used to assess the variables.
Multiple logistic regression analysis (controlling for diabetes and arthritis) of the self-rated health predictors indicated that older age, lack of health care coverage, lack of a college education, being Hispanic, having a lower income, obesity, and not exercising explained 19.4% of the variance of fair and poor self-rated health. The interview language (English or Spanish), age, sex, education, income, obesity, health insurance coverage, and physical activity (controlling for chronic illness) explained 22.8% of the variance in fair and poor self-rated health for Hispanic respondents.
The results of this study suggest that a college education, a lower body mass index, non-Hispanic ethnicity, and participation in physical activity are associated with good, very good, or excellent self-rated health status. The finding that the interview language significantly predicted fair and poor self-rated health substantiates previous research and emphasizes the importance of culturally sensitive approaches to health care services.
PMCID: PMC1435709  PMID: 16164816
12.  Relation between Overweight/Obesity and Self-Rated Health Among Adolescents in Germany. Do Socio-Economic Status and Type of School Have an Impact on That Relation? 
This study investigates the relation between overweight/obesity and self-rated health (SRH), and whether this relation varies by social factors. Data was taken from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS, baseline 2003‒2006). For the definition of overweight and obesity, body mass index was calculated based on standardized height and weight measurements. SRH of adolescents (n = 6813, 11‒17 years) was raised with the question: “How would you describe your health in general?” The response categories were “very good”, “good”, “fair”, “poor”, and “very poor”. We dichotomized these responses into: “very good/good” vs. “fair/poor/very poor”. Socio-economic status (SES) in the family of origin and adolescents’ school type were analyzed as modifying factors. Prevalence and age-adjusted odds ratios with 95% confidence intervals were calculated by binary logistic regression models. We found that overweight and obese boys and obese girls reported fair to very poor SRH more often than their normal weight peers, and that these differences were more apparent in early than late adolescence. In addition, the relation between obesity and SRH was similarly strong in all sub-groups, but there was seldom a relation between overweight and SRH. In summary, the results show that obesity is linked to poor SRH regardless of SES and school type, while the relation between overweight and SRH varies by social factors among adolescents.
PMCID: PMC4344724  PMID: 25690000
overweight and obesity; self-rated health (SRH); socio-economic status (SES); type of school; social inequalities; adolescence; KiGGS; health survey; Germany
13.  Self-ratings of Health and Change in Walking Speed Over 2 Years: Results From the Caregiver-Study of Osteoporotic Fractures 
American Journal of Epidemiology  2011;173(8):882-889.
Although poorer self-rated health (SRH) is associated with increased mortality, less is known about its impact on functioning. This study evaluated whether poorer SRH was associated with decline in walking speed and whether caregiving, often considered an indicator of chronic stress, modified this relation. The sample included 891 older US women from the Caregiver-Study of Osteoporotic Fractures. SRH was assessed at the baseline Caregiver-Study of Osteoporotic Fractures interview, conducted in 1999–2001, and was categorized as fair/poor or excellent/good. Rapid walking speed over 2, 3, or 6 m was measured at baseline and 2 annual follow-up interviews. Respondents with fair/poor SRH walked significantly slower at baseline than those with excellent/good health (mean = 0.8 (standard deviation, 0.3) vs. 1.0 (standard deviation, 0.3) m/second, P < 0.001). In adjusted linear mixed models of percentage change in walking speed, respondents with fair/poor SRH experienced a greater decline in walking speed than those with excellent/good SRH (−5.66% vs. −0.60%, P = 0.01). Caregivers with fair/poor SRH declined more than noncaregivers (−9.26% vs. −4.09%). High-intensity caregivers had the largest decline (−12.88%), whereas low-intensity caregivers in excellent/good SRH had no decline (2.61%). In summary, poorer SRH was associated with decline in walking speed in older women, and the stress of caregiving may have exacerbated its impact.
PMCID: PMC3105256  PMID: 21354990
aged; caregivers; gait; health; self report; walking
14.  Recruiting Ethnically Diverse General Internal Medicine Patients for a Telephone Survey on Physician-Patient Communication 
Limited evidence exists on the effectiveness of recruitment methods among diverse populations.
Describe response rates by recruitment stage, ethnic-language group, and type of initial contact letter (for African-American and Latino patients).
Tracking of response status by recruitment stage and ethnic-language group and a randomized trial of ethnically tailored initial letters nested within a cross-sectional telephone survey on physician-patient communication.
Adult general medicine patients with ≥1 visit during the preceding year, stratified by 4 categories: African-American (N= 1,400), English-speaking Latino (N= 894), Spanish-speaking Latino (N= 965), and non-Latino white (N= 1,400).
Ethnically tailored initial letters referred to shortages of African-American (or Latino) physicians and the need to learn about the experiences of African-American (or Latino) patients communicating with physicians. Of 2,482 patients contacted, eligible, and able to participate (identified eligibles), 69.9% completed the survey. Thirty-nine percent of the sampling frame was unable to be contacted, with losses higher among non-Latino whites (46.5%) and African Americans (44.2%) than among English-speaking (32.3%) and Spanish-speaking Latinos (25.1%). For identified eligibles, response rates were highest among Spanish-speaking Latinos (75.2%), lowest for non-Latino whites (66.4%), and intermediate for African Americans (69.7%) and English-speaking Latinos (68.1%). There were no differences in overall response rates between patients receiving ethnically tailored letters (72.2%) and those receiving general letters (70.0%).
Household contact and individual response rates differed by ethnic-language group, highlighting the importance of tracking losses by stage and subpopulation. Careful attention to recruitment yielded acceptable response rates among all groups.
PMCID: PMC1490122  PMID: 15963168
recruitment; telephone survey; African Americans; Latinos; physician-patient communication
15.  Is regular drinking in later life an indicator of good health? Evidence from the English Longitudinal Study of Ageing 
Older people who drink have been shown to have better health than those who do not. This might suggest that moderate drinking is beneficial for health, or, as considered here, that older people modify their drinking as their health deteriorates. The relationship between how often older adults drink and their health is considered for two heath states: self-rated health (SRH) and depressive symptoms.
Data were analysed from the English Longitudinal Study of Ageing (ELSA), a prospective cohort study of older adults, using multilevel ordered logit analysis. The analysis involved 4741 participants present at wave 0, (1998/1999 and 2001), wave 4 (2008/2009) and wave 5 (2010/2011). The outcome measure was frequency of drinking in last year recorded at all three time points.
Older adults with fair/poor SRH at the onset of the study drank less frequently compared with adults with good SRH (p<0.05). Drinking frequency declined over time for all health statuses, though respondents with both continual fair/poor SRH and declining SRH experienced a sharper reduction in the frequency of their drinking over time compared with older adults who remained in good SRH or whose health improved. The findings were similar for depression, though the association between depressive symptoms and drinking frequency at the baseline was not significant after adjusting for confounding variables.
The frequency of older adults’ drinking responds to changes in health status and drinking frequency in later life may be an indicator, rather than a cause, of health status.
PMCID: PMC4975801  PMID: 26797821
16.  Language and Regional Differences in Evaluations of Medicare Managed Care by Hispanics 
Health Services Research  2008;43(2):552-568.
This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country.
Data Sources
CAHPS 3.0 Medicare managed care survey data collected in 2002.
Study Design
The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health.
Data Collection/Extraction Methods
The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish.
Principal Findings
Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care.
Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.
PMCID: PMC2442381  PMID: 18370967
CAHPS; patient experiences; Medicare managed care; Hispanics; language; ethnic disparities; geographic variations
17.  Self ratings of health predict functional outcome and recurrence free survival after stroke 
Study objective: To measure stroke victims' self rated health (SRH) status and SRH transition, and to compare how the two are prospectively associated with disability and recurrence free survival.
Design: Prospective case registry study with face to face follow up interviews at three months, one, two, and three years. Ascertained were SRH status and SRH transition using single question assessments, Barthel Index (BI), Frenchay Activities Index (FAI), and Mini Mental State Examination (MMSE).
Setting: A multiethnic inner city population of 234 533.
Participants: Patients surviving the initial three months after a first in a lifetime stroke in 1995 to 1998.
Results: Of 690 stroke survivors 561 (81.3%) could complete the self report items. Answers to the item on SRH status did not vary significantly between the four follow up interviews. However, responses to the item on SRH transition changed significantly during follow up with three months ratings being more negative than all subsequent ratings. SRH transition, but not SRH status, showed a prospective association with long term outcome in multivariate analyses controlling for the BI, FAI, and MMSE. Compared with all other patients, patients reporting "Much worse health" at three months were more likely to be disabled ( = BI<20) at one year (OR 6.29, 95% CI 2.26 to 17.52) and their combined risk of stroke recurrence and death was increased over five years (HR 1.72, 95% CI 1.25 to 2.38).
Conclusions: Items on SRH should be used with caution in populations with high rates of disability and language problems, as many participants are unable to complete them. SRH transition may be a better predictor of disability and recurrence free survival after major medical events than SRH status.
PMCID: PMC1732360  PMID: 14652262
18.  Health Characteristics and Health Behaviors of African American Adults According to Self-rated Health Status 
Ethnicity & disease  2014;24(1):97-103.
Although African Americans report poorer self-rated health (SRH) than Whites, few studies have explored what factors are associated with SRH in this population. Our study described the health characteristics and health behaviors of a sample of adult church members according to SRH status.
74 African Methodist Episcopal churches in South Carolina.
1077 church members (99% African American).
Main Outcome Measures
Self-reported physical activity, fruit and vegetable consumption, fat- and fiber-behaviors, perceived stress, and presence of chronic health conditions, objectively measured body mass index (BMI), waist circumference, and blood pressure. Health-related characteristics and health behaviors across SRH categories were calculated. Analysis of covariance examined relationships between SRH and the presence of chronic diseases, the total number of chronic diseases, health-related variables, and health behaviors.
The health characteristics and health behaviors of participants worsened with declining SRH. The percentage of participants with each individual chronic health condition increased, as did the total number of chronic health conditions, as SRH declined. A higher BMI, a greater waist circumference, and higher perceived stress were associated with poorer SRH. Participants with lower physical activity and poorer fat- and fiber-behaviors also had poorer SRH. Fruit and vegetable consumption was not associated with SRH.
A better understanding of what health-related variables and health behaviors contribute to SRH may inform future interventions, as researchers and practitioners can target and effectively change the most salient factors. Fortunately, a majority of the factors are modifiable and can be prevented or reversed with changes in lifestyle.
PMCID: PMC4230694  PMID: 24620455
Self-rated Health; Health Behaviors; Chronic Health Conditions; African Americans
19.  Self-rated health among Greenlandic Inuit and Norwegian Sami adolescents: associated risk and protective correlates 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.19793.
Self-rated health (SRH) and associated risk and protective correlates were investigated among two indigenous adolescent populations, Greenlandic Inuit and Norwegian Sami.
Cross-sectional data were collected from “Well-being among Youth in Greenland” (WBYG) and “The Norwegian Arctic Adolescent Health Study” (NAAHS), conducted during 2003–2005 and comprising 10th and 11th graders, 378 Inuit and 350 Sami.
SRH was assessed by one single item, using a 4-point and 5-point scale for NAAHS and WBYG, respectively. Logistic regressions were performed separately for each indigenous group using a dichotomous measure with “very good” (NAAHS) and “very good/good” (WBYG) as reference categories. We simultaneously controlled for various socio-demographics, risk correlates (drinking, smoking, violence and suicidal behaviour) and protective correlates (physical activity, well-being in school, number of close friends and adolescent–parent relationship).
A majority of both Inuit (62%) and Sami (89%) youth reported “good” or “very good” SRH. The proportion of “poor/fair/not so good” SRH was three times higher among Inuit than Sami (38% vs. 11%, p≤0.001). Significantly more Inuit females than males reported “poor/fair” SRH (44% vs. 29%, p≤0.05), while no gender differences occurred among Sami (12% vs. 9%, p≤0.08). In both indigenous groups, suicidal thoughts (risk) and physical activity (protective) were associated with poor and good SRH, respectively.
In accordance with other studies of indigenous adolescents, suicidal thoughts were strongly associated with poorer SRH among Sami and Inuit. The Inuit–Sami differences in SRH could partly be due to higher “risk” and lower “protective” correlates among Inuit than Sami. The positive impact of physical activity on SRH needs to be targeted in future intervention programs.
PMCID: PMC3567202  PMID: 23396865
adolescents; Arctic; indigenous; Inuit; protective factors; risk factors; Sami; self-rated health (SRH); suicidal behaviours
20.  Measuring Disparities: Bias in the SF-36v2 among Spanish-speaking Medical Patients 
Medical care  2011;49(5):480-488.
Many national surveys have found substantial differences in self-reported overall health (SROH) between Spanish-speaking Hispanics and other racial/ethnic groups. However, because cultural and language differences may create measurement bias, it is unclear whether observed differences in SROH reflect true differences in health.
This study uses a cross-sectional survey to investigate psychometric properties of the SF-36v2 for subjects across four racial/ethnic and language groups. Multi-group latent variable modeling was used to test increasingly stringent criteria for measurement equivalence.
Our sample (N = 1281) included 383 non-Hispanic whites, 368 non-Hispanic blacks, 206 Hispanics interviewed in English and 324 Hispanics interviewed in Spanish recruited from outpatient medical clinics in two large urban areas.
We found weak factorial invariance across the four groups. However, there was no strong factorial invariance. The overall fit of the model was substantially worse (change in CFI > .02, RMSEA change > .003) after requiring equal intercepts across all groups. Further comparisons established that the equality constraints on the intercepts for Spanish-speaking Hispanics were responsible for the decrement to model fit.
Observed differences between SF-36v2 scores for Spanish speaking Hispanics are systematically biased relative to the other three groups. The lack of strong invariance suggests the need for caution when comparing SF-36v2 mean scores of Spanish-speaking Hispanics with those of other groups. However, measurement equivalence testing for this study supports correlational or multivariate latent variable analyses of SF-36v2 responses across all four subgroups, since these analyses require only weak factorial invariance.
PMCID: PMC3078179  PMID: 21430580
disparities; measurement self-reported health; race/ethnicity; SF-36v2
21.  Television viewing by young Latino children: Evidence of heterogeneity 
To determine if hours of daily television viewed by varying age groups of young children with Latina mothers differs by maternal language preference (English/Spanish) and to compare these differences to young children with non-Latina white mothers.
Cross-sectional analysis of data collected in 2000 from the National Survey of Early Childhood Health.
Nationally representative sample.
1,347 mothers of children 4-35 months.
Main Exposure
Subgroups of self-reported maternal race/ethnicity (non-Latina white (white), Latina) and within Latinas, stratification by maternal language preference (English/Spanish).
Outcome Measure
Hours of daily television viewed by the child.
Bivariate analyses showed children of English- versus Spanish-speaking Latinas watch more daily television (1.88 versus 1.31 hours,p<0.01). Multivariable regression analyses stratified by age revealed differences by age group. Among 4-11 month olds, children of English- and Spanish-speaking Latinas watch similar amounts of television. However, among children 12-23 and 24-35 months, children of English-speaking Latinas watched more television than children of Spanish-speaking Latinas (IRR=1.61,CI=1.17-2.22; IRR=1.66,CI=1.10-2.51, respectively). Compared to children of white mothers, children of both Latina subgroups watched similar amounts among the 4-11 month olds. However, among 12-23 month olds, children of English-speaking Latinas watched more compared to children of white mothers (IRR=1.57,CI=1.18-2.11). Among 24-35 month olds, children of English-speaking Latinas watched similar amounts compared to children of white mothers, but children of Spanish-speaking Latinas watched less (IRR=0.69,CI=0.50-0.95).
Television viewing amounts among young children with Latina mothers vary by child age and maternal language preference supporting the need to explore sociocultural factors that influence viewing in Latino children.
PMCID: PMC2828343  PMID: 20124147
22.  The impact of area residential property values on self-rated health: A cross-sectional comparative study of Seattle and Paris 
This study analyzed the impact of area residential property values, an objective measure of socioeconomic status (SES), on self-rated health (SRH) in Seattle, Washington and Paris, France. This study brings forth a valuable comparison of SRH between cities that have contrasting urban forms, population compositions, residential segregation, food systems and transportation modes. The SOS (Seattle Obesity Study) was based on a representative sample of 1394 adult residents of Seattle and King County in the United States. The RECORD Study (Residential Environment and Coronary Heart Disease) was based on 7131 adult residents of Paris and its suburbs in France. Socio-demographics, SRH and body weights were obtained from telephone surveys (SOS) and in-person interviews (RECORD). All home addresses were geocoded using ArcGIS 9.3.1 (ESRI, Redlands, CA). Residential property values were obtained from tax records (Seattle) and from real estate sales (Paris). Binary logistic regression models were used to test the associations among demographic and SES variables and SRH. Higher area property values significantly associated with better SRH, adjusting for age, gender, individual education, incomes, and BMI. The associations were significant for both cities. A one-unit increase in body mass index (BMI) was more detrimental to SRH in Seattle than in Paris. In both cities, higher area residential property values were related to a significantly lower obesity risk and better SRH. Ranked residential property values can be useful for health and weight studies, including those involving social inequalities and cross-country comparisons.
•We studied the impact of area property values on health in Seattle and Paris.•Higher area property values associated with better SRH in both cities•Ranked area property values can be useful for health and weight studies.•BMI was more detrimental to SRH in Seattle than in Paris.
PMCID: PMC4929065  PMID: 27413663
Socioeconomic status; Health disparities; Adult population; BMI
23.  Early Emergence of Ethnic Differences in Type 2 Diabetes Precursors in the UK: The Child Heart and Health Study in England (CHASE Study) 
PLoS Medicine  2010;7(4):e1000263.
Peter Whincup and colleagues carry out a cross-sectional study examining ethnic differences in precursors of of type 2 diabetes among children aged 9–10 living in three UK cities.
Adults of South Asian origin living in the United Kingdom have high risks of type 2 diabetes and central obesity; raised circulating insulin, triglyceride, and C-reactive protein concentrations; and low HDL-cholesterol when compared with white Europeans. Adults of African-Caribbean origin living in the UK have smaller increases in type 2 diabetes risk, raised circulating insulin and HDL-cholesterol, and low triglyceride and C-reactive protein concentrations. We examined whether corresponding ethnic differences were apparent in childhood.
Methods and Findings
We performed a cross-sectional survey of 4,796 children aged 9–10 y in three UK cities who had anthropometric measurements (68% response) and provided blood samples (58% response); ethnicity was based on parental definition. In age-adjusted comparisons with white Europeans (n = 1,153), South Asian children (n = 1,306) had higher glycated haemoglobin (HbA1c) (% difference: 2.1, 95% CI 1.6 to 2.7), fasting insulin (% difference 30.0, 95% CI 23.4 to 36.9), triglyceride (% difference 12.9, 95% CI 9.4 to 16.5), and C-reactive protein (% difference 43.3, 95% CI 28.6 to 59.7), and lower HDL-cholesterol (% difference −2.9, 95% CI −4.5 to −1.3). Higher adiposity levels among South Asians (based on skinfolds and bioimpedance) did not account for these patterns. Black African-Caribbean children (n = 1,215) had higher levels of HbA1c, insulin, and C-reactive protein than white Europeans, though the ethnic differences were not as marked as in South Asians. Black African-Caribbean children had higher HDL-cholesterol and lower triglyceride levels than white Europeans; adiposity markers were not increased.
Ethnic differences in type 2 diabetes precursors, mostly following adult patterns, are apparent in UK children in the first decade. Some key determinants operate before adult life and may provide scope for early prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, nearly 250 million people have diabetes, and the number of people affected by this chronic disease is increasing rapidly. Diabetes is characterized by dangerous amounts of sugar (glucose) in the blood. Blood sugar levels are normally controlled by insulin, a hormone that the pancreas releases when blood sugar levels rise after eating (digestion of food produces glucose). In people with type 2 diabetes (the most common type of diabetes), blood sugar control fails because the fat and muscle cells that usually respond to insulin by removing sugar from the blood become less responsive to insulin (insulin resistant). Type 2 diabetes can be controlled with diet and exercise, and with drugs that help the pancreas make more insulin or that make cells more sensitive to insulin. Long-term complications of diabetes include kidney failure, blindness, nerve damage, and an increased risk of developing cardiovascular problems, including heart disease and stroke.
Why Was This Study Done?
South Asians and African-Caribbeans living in Western countries tend to have higher rates of type 2 diabetes than host populations. South Asian adults living in the UK, for example, have a 3-fold higher risk of developing type 2 diabetes than white Europeans. They also have higher fasting blood levels of glucose, insulin and triglycerides (a type of fat), higher blood levels of “glycated hemoglobin” (HbA1c; an indicator of average of blood-sugar levels over time), more body fat (increased adiposity), raised levels of a molecule called C-reactive protein, and lower levels of HDL-cholesterol (another type of fat) than white Europeans. Most of these “diabetes precursors” (risk factors) are also seen in black African-Caribbean adults living in the UK except that individuals in this ethnic group often have raised HDL-cholesterol levels and low triglyceride levels. Ethnic differences in type 2 diabetes precursors are also present in adolescents, but the extent to which they are present in childhood remains unclear. Knowing this information could have implications for diabetes prevention. In this population-based study, therefore, the researchers investigate patterns of diabetes precursors in 9- to 10-year-old UK children of white European, South Asian, and black African-Caribbean origin.
What Did the Researchers Do and Find?
The researchers enrolled nearly 5,000 children (including 1,153 white European, 1,306 South Asian and 1,215 black African-Caribbean children) from primary schools with high prevalences of ethnic minority pupils in London, Birmingham, and Leicester in the Child Heart and Health study in England (CHASE). They measured and weighed more than two-thirds of the enrolled children and determined their adiposity. They also took blood samples for measurement of diabetes precursors from nearly two-thirds of the children. The recorded ethnicity of each child was based on parental definition. The researchers' analysis of these data showed that, compared with white Europeans, South Asian children had higher levels of HbA1c, insulin, triglycerides, and C-reactive protein but lower HDL-cholesterol levels. In addition, they had higher adiposity levels than the white European children, but this did not account for the observed differences in the other diabetes precursors. Black African-Caribbean children also had higher levels of HbA1c, insulin, and C-reactive protein than white European children, although the differences were smaller than those between South Asians and white Europeans. Similar to black African-Caribbean adults, however, children of this ethnic origin had higher HDL-cholesterol and lower triglyceride levels than white Europeans.
What Do These Findings Mean?
These findings indicate that ethnic differences in diabetes precursors are already present in apparently healthy children before they are 10 years old. Furthermore, most of the ethnic differences in diabetes precursors seen among the children follow the pattern seen in adults. Although these findings need confirming in more children, they suggest that the ethnic differences in type 2 diabetes susceptibility first described in immigrants to the UK are persisting in UK-born South Asian and black African-Caribbean children. Most importantly, these findings suggest that some of the factors thought to be responsible for ethnic differences in type 2 diabetes—for example, varying levels of physical activity and dietary differences—are operating well before adult life. Interventions that target these factors early could, therefore, offer good opportunities for diabetes prevention in high-risk ethnic groups, provided such interventions are carefully tailored to the needs of these groups.
Additional Information
Please access these Web sites via the online version of this summary at
The International Diabetes Federation provides information about all aspects of diabetes (in English, French and Spanish)
The US National Diabetes Information Clearinghouse provides detailed information about diabetes for patients, health-care professionals and the general public, including information on diabetes in specific US populations (in English and Spanish)
The UK National Health Service also provides information for patients and carers about type 2 diabetes (in several languages)
MedlinePlus provides links to further resources and advice about diabetes (in English and Spanish)
The US Agency for Healthcare Research and Quality has a fact sheet on diabetes disparities among racial and ethnic minorities
PMCID: PMC2857652  PMID: 20421924
24.  Longitudinal Associations between Self-Rated Health and Performance-Based Physical Function in a Population-Based Cohort of Older Adults 
PLoS ONE  2014;9(11):e111761.
Although self-rated health (SRH) and performance-based physical function (PPF) are both strong predictors of mortality, little research has investigated the relationships between them. The objective of this study was to evaluate longitudinal, bi-directional associations between SRH and PPF.
We evaluated longitudinal associations between SRH and PPF in 3,610 adults aged 65–89 followed for an average of 4.8 (standard deviation [SD]: 4.4) years between 1994 and July 2011 in the Adult Changes in Thought study, a population-based cohort in the Seattle area. SRH was assessed with a single-item question in the ACT study. Participants were asked at each evaluation to rate their health as “excellent”, “very good”, “good”, “fair”, or “poor” in response to the question “In general, how would you rate your health at this time”. PPF scores (ranging from 0–16, with higher indicating better performance) included walking speed, chair rises, grip strength, and balance.
At the baseline visit, participants averaged 74.5 (SD: 5.8) years of age and 2,115 (58.6%) were female. In multivariable linear mixed models, PPF declined with age, with more rapid decreases associated with very good, good, and fair (vs. excellent) baseline SRH. Adjusted annual change in PPF was −0.17 points (95% confidence interval [CI]: −0.19, −0.15) for individuals with excellent baseline SRH and −0.21 points (95% CI: −0.22, −0.19) for participants with fair SRH. In multivariable generalized linear mixed models, lower baseline PPF quartiles were associated with lower odds of excellent/very good/good SRH at age 75, however, differences between baseline PPF quartiles diminished with age.
These results suggest that less than excellent SRH predicts decline in physical functioning, however, poor physical functioning may not predict change in SRH in a reciprocal fashion. SRH provides a simple assessment tool for identifying individuals at increased risk for decline in physical function.
PMCID: PMC4218810  PMID: 25365288
25.  The association of neighbourhood and individual social capital with consistent self-rated health: a longitudinal study in Brazilian pregnant and postpartum women 
Social conditions, social relationships and neighbourhood environment, the components of social capital, are important determinants of health. The objective of this study was to investigate the association of neighbourhood and individual social capital with consistent self-rated health in women between the first trimester of pregnancy and six months postpartum.
A multilevel cohort study in 34 neighbourhoods was performed on 685 Brazilian women recruited at antenatal units in two cities in the State of Rio de Janeiro, Brazil. Self-rated health (SRH) was assessed in the 1st trimester of pregnancy (baseline) and six months after childbirth (follow-up). The participants were divided into two groups: 1. Good SRH – good SRH at baseline and follow-up, and, 2. Poor SRH – poor SRH at baseline and follow-up. Exploratory variables collected at baseline included neighbourhood social capital (neighbourhood-level variable), individual social capital (social support and social networks), demographic and socioeconomic characteristics, health-related behaviours and self-reported diseases. A hierarchical binomial multilevel analysis was performed to test the association between neighbourhood and individual social capital and SRH, adjusted for covariates.
The Good SRH group reported higher scores of social support and social networks than the Poor SRH group. Although low neighbourhood social capital was associated with poor SRH in crude analysis, the association was not significant when individual socio-demographic variables were included in the model. In the final model, women reporting poor SRH both at baseline and follow-up had lower levels of social support (positive social interaction) [OR 0.82 (95% CI: 0.73-0.90)] and a lower likelihood of friendship social networks [OR 0.61 (95% CI: 0.37-0.99)] than the Good SRH group. The characteristics that remained associated with poor SRH were low level of schooling, Black and Brown ethnicity, more children, urinary infection and water plumbing outside the house.
Low individual social capital during pregnancy, considered here as social support and social network, was independently associated with poor SRH in women whereas neighbourhood social capital did not affect women’s SRH during pregnancy and the months thereafter. From pregnancy and up to six months postpartum, the effect of individual social capital explained better the consistency of SRH over time than neighbourhood social capital.
PMCID: PMC3556498  PMID: 23324161
Women’s health; Self-rated health; Dental public health; Social capital; Social network; Social support; multilevel analysis

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