Académique Documents
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2, 200–208
q The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cki102
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Perceived Health
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Background: The single-item measure on self-assessed health has been widely used, as it presents
researchers with a summary of an individual’s general state of health. A qualitative study was initiated to
find out which particular aspects are included in health self-assessments; which aspects do people
consider when answering the question ‘How is your health in general?’. Subgroup differences were
studied with respect to gender, age, health status and health assessment. Methods: Qualitative study
with stratification by background characteristic, health status and health assessment (n ¼ 40). Results:
Almost 80% of the participants referred to one or more physical aspects (chronic illness, physical
problems, medical treatment, age-related complaints, prognosis, bodily mechanics, and resilience).
However, when assessing their health, participants also include aspects that go beyond the physical
dimension of health. In total, 80 percent of the participants—whether or not in addition to physical
aspects—referred to other health dimensions. Besides physical aspects, participants considered the
extent to which they are able to perform (functional dimension 228%), the extent to which they
adapted to, or their attitude towards an existing illness (coping dimension 228%), and simply the way
they feel (wellbeing dimension 220%). In this study, health behaviour or lifestyle factors (behavioural
dimension 23%) proved to be relatively unimportant in health selfassessments. Conclusions Self-
assessed health proved to be a multidimensional concept. For most part, subgroup differences in self-
assessed health could be attributed to experience with ill health: being relatively inexperienced with
health problems versus having a history of health problems.
Keywords: qualitative study, selfassessed health, stratified sample, subgroup differences
...........................................................................................
he single question ‘How is your health in general?’ is a crude aspects.5 – 9 Additionally, some studies found that aspects such
T and simple measure that has been widely used, as it presents as health comparison,5 health transcendence, externally focused,
researchers with a summary of an individual’s general state of non-reflective,6 social role activities, and social relationships9
health. It is presumed that in self-assessed health numerous were included in health self-assessments. Only two of these
aspects of health are combined within the perceptual framework qualitative studies attempted to include equal numbers of
of the individual respondent.1 – 3 This measure proved to be a participants of different sociodemographic backgrounds.5,7 The
powerful predictor for mortality; poor self-assessed health other studies included convenience samples predominantly
increases the mortality risk, even when other (more objective) consisting of women, elderly, highly educated participants6,8,9
indicators of health status have been controlled for.4 or participants with health problems.8 However, health
Many studies have been conducted to find out which standards may vary among different subgroups, and probably
particular aspects are included in health self-assessments. In depend very much upon gender,6 age5,10 and experience with
quantitative studies the relationship between a priori defined health problems.10 Therefore, it is difficult to decide whether the
health measures and self-assessed health has been analysed. In findings in these studies reflect general health conceptions, or
these studies, however, a significant proportion of variance in are determined by the most prevalent subgroup. It would be
relevant to know whether participants from different subgroups
self-assessed health remains unexplained. This suggests that
consider entirely different aspects when assessing their health,
when assessing their health, participants may include health
but with the exception of Krause and Jay’s study,5 qualitative
aspects that have not been routinely included in quantitative
studies on self-assessed health rarely examined subgroup
analyses. Therefore, some researchers have used a qualitative
differences.
approach to identify the remaining and unknown aspects of We initiated a qualitative study on self-assessed health in a
self-assessed health. Briefly summarizing, selfassessed health sample that has been stratified on background characteristics,
seems mainly to be associated with physical health problems, health status, and health assessment. The present paper focuses
functional capacities, health behaviour, and psychological on the aspects that people consider when answering the
question ‘How is your health in general? Is it very good, good,
....................................................... fair, sometimes good and sometimes poor, or poor?’. We believe
1 Department of Public Health, Erasmus University Rotterdam, The that health assessments follow an individual process of ordering
Netherlands and weighing different health aspects. Therefore, we asked
2 Department of Medical Psychology and Psychotherapy, Erasmus participants what went through their minds when answering the
University Rotterdam, The Netherlands
Correspondence: I.M.A. Joung, Department of Public Health, Erasmus
question on self-assessed health. The analysis was guided by the
MC, University Medical Center Rotterdam, P.O. Box 1738, 3000 DR following research questions: Which aspects do participants
Rotterdam, The Netherlands, tel. +31 10 4087714, fax +31 10 4089449, consider when answering the question on self-assessed health?
e-mail: i.joung@erasmusmc.nl Do participants with different background characteristics (age
and gender), and participants with different health status (with Table 1 Distribution of stratification variables in study
and without current chronic conditions) consider the same or population
different aspects when assessing their health? Do participants
with good and less-than-good self-assessed health consider the Stratification variables Categories N
same or different aspects when assessing their health? Gender Women 20
.................................................. .
Men 20
.................................................. .
Age Younger (40 2 ) 14
.................................................. .
Data and methods Older (60+) 26
.................................................. .
Socio-economic status Low education 19
Study population .................................................. .
Our study population consists of participants of the GLOBE High education 21
.................................................. .
study, a longitudinal study designed to describe and explain Health status No current illness 20
sociodemographic inequalities in health in the Netherlands. .................................................. .
Design and objective of the GLOBEstudy have been described in Copd or back complaints 20
.................................................. .
detail elsewhere.11 At baseline in 1991, participants comprised a Self-assessed health Gooda 26
cohort of non-institutionalized men and women with Dutch (during interview)
nationality, 15 – 74 years of age, who were living in the city of .................................................. .
Eindhoven or surrounding municipalities. In 1997, a subgroup Less-than-good 14
of respondents to the baseline interview were approached to a: Includes category ‘very good’ (n ¼ 1).
participate in a follow-up study. For our qualitative study, we
drew a stratified sample from the respondents to the 1997 Interview analysis
follow-up. The interviews took place in 1998. We started with analysing the verbatim text of the interviews. In
The variables for stratification have been chosen because of each interview, we condensed the answers given to the single-
their supposed relationship with self-assessed health: gender, item measure on self-assessed health and the reasons for this
age, socioeconomic status, and health status. In order to obtain health assessment. Parts of the text representing the same theme
maximum contrast, we included men and women, younger than were summarised with a single phrase, hereby paraphrasing the
40 years of age and older than 60 years of age, with the highest participant. In this way, each interview could be condensed into
level of education (university degree) and with the lowest level personal themes. Next, we categorized the personal themes of all
of education (primary or lower vocational education), with a participants into a smaller number of recurrent themes, which
chronic illness (COPD/asthma or chronic back complaints) and we will refer to as health aspects. Finally, on categorization of
without a current illness. Furthermore, we stratified on the most these health aspects, five conceptually meaningful health
recent available (i.e. 1997) health assessment and thus included dimensions emerged (see Appendix 1 for a flow chart of the
participants with (very) good, as well as participants with less- coding process). For development of the overall categorization
than-good self-assessed health (stratification table is available scheme, and for the data analysis that followed, QSR NUD*IST
on request). software,12 were used.
To ensure reliability in coding and analysing the interviews
Non-response and changes in health assessments four researchers (JS, JB, IJ and HB) independently read and
In each stratum, participants were randomly selected. It was, coded eight of the interviews. The results were compared and
however, not possible to select participants in all strata, due to discussed to come to a reliable method for analysing the
various reasons. First, some strata did not exist in the interviews. Next, the principal investigator (JS) read and coded
population from which we drew our study sample. Second, all interviews, and designed the final categorization scheme.
the number of possible participants that fitted a particular Finally, one of the other researchers (IJ) independently applied
profile (i.e. stratum) could be very low. When these participants the categorization scheme (on the level of health dimensions) to
all refused to participate in our study, there were no other eight of the interviews. We then calculated Cohen’s Kappa, a
eligible participants we could approach. Third, some partici- measure of interrater reliability, and the level of agreement was
pants changed their health assessment during the 1998 semi- shown to be good (k ¼ 0.69).13
structured interview compared to the followup data (1997) on This paper presents the overall frequency distribution of the
which we based our initial selection of respondents. All in all, we different dimensions and health aspects, as well as the
were able to select participants for 74% of the existing strata. distribution of health dimensions by gender, age, health status,
From May till December 1998, we approached 63 people by and health assessment. Chi-square analyses are used to examine
mail and telephone. Fourteen persons were unwilling to whether referring to a particular dimension varies significantly
participate in the study, we were unable to get into contact for different subgroups.
with six persons, and three persons were unavailable during the
study period, although willing to participate. Thus, we
interviewed 40 participants, a response of 63%. The distribution Results
of the different stratification variables can be seen in table 1.
Which health aspects are taken into consideration?
Semi-structured interview The final categorization scheme consists of 17 health aspects,
All participants were interviewed in their homes by the principal categorized into five health dimensions. The frequencies with
investigator (JS). The semi-structured interviews, lasting which the different health dimensions and health aspects were
approximately 35 minutes, were tape recorded and transcribed mentioned are shown in table 2. In Appendix 2 the description
verbatim. Following a brief introduction the interviewees were of the health dimensions and health aspects are given and
presented with the core question ‘How is your health in general? illustrated with quotations. (1) We considered physical
Is it very good, good, fair, sometimes good and sometimes poor, references, i.e. any reference to disease, illness, medical
or poor?’, and were then asked to explain their particular treatments, or other ‘bodily’-oriented theme to be an aspect
response. of the physical dimension. (2) Any reference to general
Table 2 Frequency of health dimensions and health aspects health dimensions. In total, 40 participants made 62 references
to health dimension, thus on average participants mentioned
Health dimensions N (% of total) 1.55 health dimensions.
Health aspects (n)
Table 3 Frequency of different health dimensions, by gender, age, health status and health assessment
Gender
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Women (20) 15 (75) 3 (15) 6 (30) 4 (20) 1 (5) 1.5 t-test
n.s.a
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Men (20) 16 (80) 8 (40) 5 (25) 4 (20) 0 (0) 1.7
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Age
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
40 2 (14) 7 (50) 2 (14) 3 (21) 7 (50) 0 (0) 1.4 t-test
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
60+ (26) 24 (92) 9 (35) 8 (31) 1 (4) 1 (4) 1.7 p ,0.10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Health status
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
No current illness (20) 15 (75) 6 (30) 0 (0) 6 (30) 1 (5) 1.4 t-test
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Chronically ill (20) 16 (80) 5 (25) 11 (55) 2 (10) 0 (0) 1.7 p ,0.10
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Health assessment
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Goodb (26) 19 (73) 5 (19) 6 (23) 7 (27) 0 (0) 1.4
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Fair (6) 5 (83) 2 (33) 1 (17) 1 (17) 1 (17) 1.7 Anova
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
c
Sometimes poor (5) 4 (80) 2 (40) 3 (60) 0 (0) 0 (0) 1.8 p ,0.05
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Poor (3) 3 (100) 2 (67) 1 (33) 0 (0) 0 (0) 2.0
a: n.s. Not significant
b: Includes category ‘Very good’ (n ¼ 1)
c: In full: ‘Sometimes good and sometimes poor’
Table 4 Overview of the main dimensions (in italics) of five qualitative studies on selfassessed health
This paper Krause and Jay (5) Borawski-Clark et al. (6) Manderbacka (7) Idler et al. (9)
on self-assessed health are quite similar with respect to the become statistically significant. This does not imply that the
health aspects that have been drawn from the interviews. remaining non-significant subgroup differences of 20 to 25% we
Second, some studies only included those aspects in the identified should be discarded as irrelevant, as these may very
analysis which participants mentioned first (single-reference well be real differences. When these findings were to be repeated
studies), other studies included all aspects which participants in a larger study population, these subgroup differences would
mentioned (multiple-reference studies). Due to both the be statistically significant. Therefore, we included these smaller
multiple-reference / single-reference disparity and the differen- and non-significant subgroup differences in our interpretation
tial categorization of health aspects over these dimensions it is of the findings regarding subgroup differences.
quite difficult to compare studies with respect to the average
number of health dimensions referred to by participants (e.g. an
average of 1.55 dimensions in our study, 1.39 dimensions in a Categorization scheme
singlereferences study by Krause and Jay5 and 1.19 dimensions As noted earlier the physical health dimension was very
in a multiple-reference study by Borawski-Clark.6 dominant. On the other hand, virtually no reference was
Third, even in our small-scale study we were able to identify made to mental health. Only one responder did mention
some statistically significant subgroup differences. In this small mental health, stating that for her own health assessment a
study population, it required a difference of over 30% points to balance in physical and mental health was important.
Although several psychological mechanisms were mentioned pants in less-than-good health seem to experience more physical
(e.g. categorized within the the coping dimension) or positive and functional health problems than participants in better
health was stressed (e.g. feeling good in the wellbeing health—as reflected in the larger number of health dimensions
dimension), none of the respondents made reference to they refer to—which they also present as being more severe. On
mental health as such, nor to specific mental diseases or the basis of these interviews we cannot determine whether the
complaints, such as depression or anxiety. This is all the more participants in less-than-good health truly suffer from more
remarkable since mental health problems are among the most severe problems than participants in better health, or that for
prevalent diseases in the Netherlands and among the diseases some reason these participants are less capable of coping with
with the largest consequences for quality of life.14 However, health problems.
this finding is in agreement with the findings from other
qualitative studies.5 – 7,9 Probably, mental health is not The role of coping
consciously taken into account by responders when assessing Besides prior or current experience with physical or functional
their health. health problems, coping with these problems seems to be
important for one’s health assessment. It is inherent to our
Differences with respect to background characteristics coding process that only explicit statements referring to
and health status adapting to illness, attitude towards illness, or comparison
We found that men refer to functional aspects more were considered to be referring to aspects of coping. However, if
frequently than women, although this result is only marginally we look more close at the data, we find that there are other,
significant. In Western societies men are normally the more implicit, references which could be considered as a way of
breadwinner and thus responsible for the main source of coping with health complaints, i.e. referrence to age-related
income. This may be the reason that men, more than women, complaints or functioning. It seems as if participants who
have incorporated the functional definition of health as ‘being consider age-related physical complaints or functional decline
able to perform the necessary duties’.15,16 We also observed to be normal, are less bothered by them. And although not all
clear and some significant age-differences in our studygroup. participants mentioning age-related (‘normal’) complaints or
Participants in the 60+ age group referred to physical and age-related functioning assessed their health as good, it may be
functional aspects almost twice as much as younger just the reason why they did not assess their health more
participants. In contrast, half of the younger participants poorly.17
mentioned aspects of wellbeing, whereas this aspect is
mentioned only incidentally by elderly participants. Although
the distribution of participants with and without a current Conclusions
illness is equal in both age groups, elderly participants more
We have shown that that self-assessed health is a multi-
frequently mention a history of illness. Elderly participants
dimensional concept. Over the years several qualitative studies
probably incorporate these prior episodes of (physical or
on self-assessed health have produced comparable results, even
functional) ill-health in their health assessments. Furthermore,
though these studies differed with respect to the subgroups they
we found some differences between participants with and
included and the methodology they applied. The consistency of
without a current illness. Aspects of coping are typically
the findings suggests that we have actually taken a step nearer to
mentioned by participants with a chronic illness. On the other
identifying which particular aspects are involved in health
hand, aspects of wellbeing are typical aspects of participants
assessments.
with no current illness. Some (predominantly younger)
participants are relatively inexperienced with (coping with)
physical, functional or age-related health problems. Conse-
quently, these participants do not incorporate these health Acknowledgements
dimensions in their health assessments, but simply rely on the The authors would like to thank Dr Ir E. J. de Min for providing
way they feel. Other (predominantly elderly) participants are the software for calculating kappa coefficients, and Dr H. van de
more experienced with episodes of ill-health. Yet, for these Mheen for participation during the early stages of the research
participants it is not so much the presence of (physical, project. We would also like to thank Ms K. Gribling for her
functional or agerelated) health problems but the extent to careful translation of the excerpts from the interviews. The
which they are capable of coping with these problems which GLOBE-study is supported by the Dutch Ministry of Public
determines their eventual health assessment. The importance Health, Welfare and Sports, and the Netherlands Health
of experience with health problems and the ability to cope Research and Development Council (ZON).
with them is also reflected in the finding that elderly and
chronically ill participants include more health dimensions in
their health assessments than do younger participants and
those with no current illness. Key points
Differences between participants with good and less- † In this qualitative study we studied which particular
aspects are included in self-assessed health.
than-good health assessment
† Self-assessed health proved to be a multidimensional
There are some differences between participants in good and concept, including primarily physical, functional,
participants in less-than-good health, though not statistically coping and wellbeing aspects.
significant. Again, these differences may be the result of some † Health behaviour or lifestyle factors proved to be
participants having experienced less health problems than relatively unimportant in health self-assessments.
others. For participants in good health two lines of reasoning † Subgroup differences in self-assessed health could
can be distinguished. Participants with no current illness or primarily be attributed to prior experience with ill-
other health problems reason: ‘I am not bothered by any health.
physical or functional health problem, I am feeling good’, † The consistancy of these findings with other qualitative
participants with (a history of) chronic illness or other (e.g. age- studies suggest that we have identified the key
related) health complaints reason: ‘I am not bothered by dimensions of self-assessed health.
physical or functional complaints, I cope with them’. Partici-
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Yes, I feel good, I’m never tired and uh especially during the past If you’re ill and out of sorts, you can forget it, you just feel
few years, sure. (…) Yes, physically healthy? I guess, if you’re not rotten. If you have a psychological problem you feel just as
tired (…) I feel fit, not tired, so I feel healthy. Woman, 40 2 , low rotten even though physically, there’s nothing wrong. But you’re
ses, no current illness, ‘good’ not completely healthy if you’ve got a problem with either. (…)
Feeling good: reference to general feelings without any Healthy is when you have no infections of any kind. I guess
objective justification, simply referring to ‘feeling good’ that’s part of it. And that there’s no blackness messing up your
Yes, I feel good, I feel absolutely great. For me, health is ‘feeling mind.(…) I mean, you don’t have flu, mentally you’re okay.
good’. And I do. That’s how simple it is. (…) Oh, that’s, I guess, not And it’s like ‘everything’s good, I’m doing fine. Woman, 40 2 ,
feeling bad. Man, 40 2 , high ses, chronic back complaints, high ses, chronic back complaints, ‘fair’
‘good’ BEHAVIOUR
Body/mind equilibrium: reference to the (im)balance of Eating healthy food: mentioning eating well (all from our
physical and mental problems own garden) and not eating sweets