Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies

Author(s): Ellen L. Idler and Yael Benyamini

Source: Journal of Health and Social Behavior, Vol. 38, No. 1 (Mar., 1997), pp. 21-37
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2955359
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 Self-RatedHealth and Mortality:A Reviewof Twenty-Seven
CommunityStudies*

ELLEN L. IDLER
YAEL BENYAMINI
Rutgers
University

Journal
of Healthand Social Behavior1997, Vol. 38 (March):21-37

We examine the growingnumberof studies of surveyrespondents'global

self-ratingsof health as predictorsof mortalityin longitudinalstudies of
representative
community samples.Twenty-seven studiesin U.S. and international
journals show impressively consistentfindings.Global self-ratedhealth is an
independentpredictorofmortality in nearlyall ofthestudies,despitetheinclusion
ofnumerous specifichealthstatusindicatorsand otherrelevantcovariatesknown
to predictmortality. We summarizeand reviewthesestudies,considervarious
interpretationswhichcould accountfor the association,and suggestseveral
approachesto thenextstageofresearchin thisfield.

The sociologicalstudyof mortality differ- longitudinalresearchhas flourishedin the

entialsemergedwiththebeginning of sociol- past 15 years. In thisrelativelyshorttime,
ogy,and thecontribution of social scienceto over two dozen studieshave been published
understanding mortality risksin populations in the U.S. and international literature
that
has continuedthroughout the twentieth cen- test the associationbetweensimple,global
tury.Socioeconomicstatusand measuresof health assessmentsand mortalityin the
socialnetworks andsupport arenowroutinely samplesused: Most finda significant, inde-
includedin mortality studies,along withthe pendentassociationthatpersistswhennumer-
traditional risk factorsof smoking,alcohol ous healthstatusindicators and otherrelevant
use, overweight, andtherespondents' disease covariatesare included.
historyand currenthealth status. Such There are several reasons for the rapid
assessmentsof healthstatusfrequently also appearanceof thesestudies.Althougha few
ask respondents to rate theiroverall health early studies(LaRue et al. 1979; Pfeiffer
withthe categoriesof excellent,good, fair, 1970; Singeret al. 1976) had suggestedsuch
and poor,or some variant.It is thesesimple an association,the firstclear demonstration
global assessmentsthatnow appearto have came with Mossey and Shapiro's 1982
mortality risksof theirown, independent of analysisof theManitobaLongitudinal Study,
othermedical, behavioral,or psychosocial whichshowedthatelderlyCanadians' self-
riskfactors. ratingsof healthwere betterpredictorsof
The study of self-ratings of health as seven-year survivalthantheirmedicalrecords
predictorsof mortality in population-basedor self-reports of medical conditions.This
was an appealingfinding forseveralreasons.
It emergedat a time when the field of
* Supportfor this paper came fromNational
psychosocialepidemiology was rapidlygain-
Instituteon AginggrantsAG11567 and AG03501 ingprestige, withthepublication oftheseries
and fromtheCenterforResearchon Healthand
of studieson social networksas determinants
Behavior,InstituteforHealth,HealthCare Policy,
and AgingResearch.Addresscorrespondence to:
of mortality that began with the Alameda
Ellen L. Idler,Ph.D., Institute
forHealth,Health County findings (Berkmanand Syme 1979;
Care Policy,and Aging Research,Rutgers,The House, Landis,and Umberson1988). At the
State Universityof New Jersey,30 College sametime,otherstudiesofhealthperceptions
Avenue, New Brunswick,NJ 08903; e-mail: and self-care wereexposingthebottomof the
idler@rci.rutgers.edu. "iceberg"of symptoms thatareunreported to
21

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22 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
and untreatedby the medical care system study,were identified throughcitationsand
(Verbruggeand Ascione 1987). Together, monitoring of leadingjournals.This search
these researchdirectionsseemed to under- located 27 such studiespublishedby mid-
scorethevalidity oflayperspectives on health 1996.
and the usefulnessof holisticdefinitions of
health,as in theWorldHealthOrganization's
"complete state of physical, mental, and REVIEW OF THE STUDIES
social well-being."GeorgeKaplan wrotein
1983 thatpoor perceivedhealthmay be "a Interviewer:Is it hardforyou to compare
commonfeature"whichlinksvariousadverse yourown healthwiththatof otherpeople
psychosocialstatessuch as social isolation, of yourown age, wouldyou say it is . . .
negative life events, depression,and job Respondent(85-year-oldwoman): Well
stress (Kaplan and Camacho 1983:292), mostof themare dead, aren'tthey?(Jylha
suggesting thatself-ratings of healthheldthe 1994:988)
key to understanding other psychosocial Table 1 summarizesthe characteristics of
influenceson health.Thus, self-ratings pro- thesestudies.Theyare presented chronologi-
vide a simple, direct,and global way of cally (alphabetically withinyear)and identi-
capturing perceptions of healthusingcriteria fiedby theirnationalorigin,samplesize, age
that are as broad and inclusive as the range, follow-upperiod, wordingof the
responding individualchoosesto makethem. question,typeof otherhealthstatusmeasures
There is another,morepragmaticreason considered,other covariates,and findings
fortheoutburst of thesestudies,and thatis regardingthe independenteffectof self-
the appealingnatureof the questionitself. ratings ofhealthon mortality or survivaltime.
Virtually all of thestudiesthathave appeared These studieshave come fromall overthe
since 1982 have been secondaryanalysesof world-Sweden, Lithuania, Israel, Great
datacollectedearlierforsomeotherpurpose. Britain,the Netherlands,France, Poland,
Global self-ratings of healthwereincludedin Hong Kong, Japan,Australia,Canada, and
so manypopulation-level studiesbecausethey the UnitedStates.Follow-upperiodsranged
are simultaneously economicalmeasuresof from2 to 7 yearsin 20 of thestudies,from9
healthstatusas wellas conversational waysto to 13 yearsin 6 studies,and 28 yearsin one
openthetopicofhealthstatuswhenitis to be study.Excludingthe last study(Deeg et al.
coveredin theinterview in moredetail.Many 1989), in whichonly1 percentof thealready
researchers, readingthe earlystudies,must elderlysamplesurvivedfor28 years,survival
haverealizedthattheycouldquicklyreplicate ratesrangedfrom32 to 95 percent,with22
andevenimproveupontheanalysiswiththeir studiesreporting over70 percentsurvival.In
own alreadycollecteddata. some studies, the outcome is treatedas
The purposeofthisreviewis to collectand survivaltime;in othersit is a binaryvariable
appraisethepublishedstudiesof self-ratingsformortality. In eithercase, and in bothshort
of health and of mortality. We limit our and long follow-upperiods,the predictive
reviewto studies(1) publishedin English,(2) effectof self-ratings is the rule, with few
of representative community(not patient) exceptions.
samplesfollowedprospectively, and(3) which The questionelicitingtheself-ratingdiffers
provideestimatesof theeffectof self-ratingsfrom study to study. In some cases the
of healthon mortality or survivaltime,after questionasks respondents to comparetheir
covariatesfor (at least) health status and healthto thatof otherstheirage, presumably
sociodemographic factorsare includedin the askingthemto dismissaging-related condi-
analysis. Studies were identifiedfor the tions; in othersthe global natureof the
reviewby searchingMedlineforthefollow- questionis underscored withthe phrase"in
ing keywords: self-assessedhealth, self- general" or "all in all." In still others
ratingsof health, self-ratedhealth, self- respondents are instructedto ratetheirhealth
assessmentsof health, perceived health, "at thepresenttime."The consistency of the
self-perceptions of health,subjectivehealth, effectsseems to show thatthe conceptof
self-evaluatedhealth, self-evaluationsof self-rated healthstatusis relativelyinsensitive
health, global health, and self-reportedto the semanticvariationsin the questions
health.A numberof otherarticles,in which elicitingit. It is possible thatcomparisons
self-ratingsofhealthwerenotthefocusofthe withsociallysimilarothersare implicitin the

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SELF-RATED HEALTH AND MORTALITY 23
TABLE 1. CommunityStudiesReportingAssociationBetweenSelf-RatedHealth and Mortality
AdjustedOR'
OtherHealthStatus Comparedto Best
Study - Sample Item
Self-Rating Variables OtherCovariates (95% CI)

Mosseyand Shapiro ManitobaLongitudinal Foryourage, in general, ManitobaHealthServices Sociodemographics 1971-1973

1982 Studyon Aging,Canada wouldyou say your data: Lifesatisfaction Poor2.9 (1.8, 4.7)
N=3,128 healthis: ICDA-8 diagnoses Fair2.0 (1.5, 2.8)
Ages 65 + Excellent,Good, Fair, physicianvisits Good 2.8 (1.2, 3.2)
1971-1977 Poor,Bad hospitalization 1974-1977
72.0% survived of conditions
Self-reports Poor2.8 (1.9, 3.9)
Fair2.0 (1.2, 3.2)
Good 1.4 (1.2, 1.6)

Kaplanand Camacho AlamedaCounty, All in all, wouldyou say of:

Self-reports Sociodemographics Poor3.6 (1.8, 2.1)
1983 California yourhealthis: disability
functional Healthpractices
N=6,928 Excellent,Good, Fair, chronicconditions Social networks
Ages 16-94 Poor symptoms Psychological
1965-1974 energylevel functioning
89.7% survived
and
Krzyzanowski Cracow,Poland (exactwordingn.a.) Forcedexpiratoryvolume% Sociodemographics Males
Wysocki N=3,047 Fairor better,Poor Body mass index Smoking Poor2.6 (1.6, 4.3)b
1986 Ages 19-70 of:
Self-reports
1968-1981 heartdisease
83.6% survived symptoms
respiratory

Jaggerand Clarke Leicester,England Do you thinkyour of:

Self-reports Sociodemographics Poor2.1 (1.5, 3.0)
1988 N= 1,203 healthis . . foryour physicaldisability Fair 1.3 (1.0, 1.7)
Ages 75 + age: incontinence
1981-1985 Good, Fair,Poor Cognitivefunction
67.8% survived medications
Prescription

Kaplan,Barell,and Lusky KiryatOno, Israel Do youconsider of:

Self-reports Sociodemographics Verysick 2.1 (n.a.)
1988 N= 1,078 yourselfa . . . person: chronicconditions Sick 2.1 (n.a.)
Ages 65 + Healthy,Fairlyhealthy, disability
functional
1978-1983 Sick, Verysick medications
72.2% survived
Deeg et al. Netherlands health
(Self-perceived MD performed examination Sociodemographics
1989 N= 2,645 decline): Biomedicaldata Familyhistory
Ages 65 + Yes, No Memorytest Social networks
1955-1983 (exactwordingn.a.) of:
Self-reports Lifesatisfaction
1% survived disability
functional
symptoms
healthcareuse
medicationuse

Grandet al. Ruralareas, Generalhealthrating of:

Self-reports Sociodemographics
1990 southwest France fromverygood to very morbidity Lack of projectsfor
N=645 bad (5 points). disability future
Ages 60 + Healthcomparedto healthcareutilization Feelingof
1982-1986 otherelderly(exact hospitalization uselessness
83% survived wordingn.a.) medication use Physicalexercise

Idlerand Angel NHEFS, U.S. Wouldyou say your Physicianobserved: Sociodemographics All Males
1990 N=6,440 healthin generalis: ICDA-8 diagnoses, Healthpractices Poor 1.5 (1 1, 2.2)
Ages 25-74 Excellent,Verygood, weightedby severity Males 45-64
1971-1984 Good, Fair,Poor Poor2.8 (1.5, 5.3)
72% survived Fair2.2 (1.2, 4.1)
Good 1.9 (1.0, 3 7)

Idler,Kasl, and Lemke New Haven, CT: How wouldyou of:

Self-reports Sociodemographics CT Males
1990 Connecticut rateyourhealthat the chronicconditions Healthpractices Poor5.3 (1.9, 14.7)
N=2,812 presenttime: functional
disability Fair 3.2 (1.4, 7.2)
Ages 65+ Excellent,Good, Fair, painsymptoms Good 2.5 (1.1, 5.8)
1982-1986 Poor,Bad Interviewer-measuredblood CT Females
77.8% survived pressure Poor3.0 (1.3, 6.9)
Iowa: Comparedto Interviewer-observed Fair2.6 (1.3, 5.4)
Iowa County,Iowa otherpeopleyourage medications
prescription Good 2.3 (I 1, 4.6)
N= 3,097 wouldyousay thatyour Iowa Males
Ages 65+ generalhealthis: Poor4.8 (2.2, 10.6)
1982-1986 Excellent,Good, Fair, Fair2.3 (1.3, 4.0)
85.9% survived Poor,Verypoor Iowa Females
Poor3.2 (1.5, 6.7)

Ho HongKong How is yourhealth, of:

Self-reports SociodemographicsWorse2.0 (1.3, 3.3)
1991 N = 1,054 comparedwithothers twoweeks
symptions-last Healthpractices
Ages 70 + yourage: year Social networks
chronicconditions-last
1985-1987 Better,Same, Worse functional
disability Social support
91.5% survived Interviewer-measuredheight, Bradburn Affect
weight,bloodpressure BalanceScale

Idlerand Kasl New Haven, How wouldyou rate of:

Self-reports Sociodemographics Males
1991 Connecticut yourhealthat the chronicconditions Healthpractices Poor6.7 (2 0, 22.7)
N=2,812 presenttime: disability
functional Externalresources Fair4.1 (1.7, 10.1)
Ages 65 + Excellent,Good, Fair, painsymptoms resources Good 3.2 (1.2, 8.1)
Internal
1982-1986 Poor,Bad Interviewer-measuredblood Females
77.8% survived pressure Poor3.1 (1.3, 7.2)
Interviewer-observed Fair2.8 (1.4, 5.8)
medications
prescription Good 2.4 (1 2, 4.8)

(continued)

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 24 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
TABLE 1. (continued)
AdjustedOR'
OtherHealthStatus Comparedto Best
Study Sample Item
Self-Rating Variables OtherCovariates (95% CI)
Rakowski,Mor,and LSOA, U.S. Wouldyou say your Self-reports
of: Sociodemographics 1.4 (1.1, 1.7)
Hiris N= 1,252 (healthy) healthin generalis: functional
disability Social networks
1991 Ages 70 + Excellent,Verygood, hipfracture
1984-1986 Good, Fair,Poor heightand weight
92.5% survived
Wannamethee
and BRHS, GreatBritain How wouldyou Self-reports
of: Social class Withdiagnosis
Shaper N= 7,725 (males) describeyourhealth majorchronicconditions Healthpractices Fair/Poor
1.5 (1.1, 2.0)
1991 Ages 40-59 statusat present: regularmedicaltreatment
1983-1987 Excellent,Good, Fair, chestpain
95.1% survived Poor breathlessness
weight/height
Parker,Thorslund, Tierp,Sweden (exactwordingn.a.) Nurseevaluationsof: Sociodemographics
and Nordstrbm N=421 Veryhealthy,Fairly somaticstatus Lifesatisfaction
1992 Ages 75 + Somewhat
healthy, mentalstatus Social networks
1986-1990 sick,Verysick dementia
75-84: 74% survived of:
Self-reports
85 +: 57% survived ADL/IADL
symptoms
Thomaset al. Bronx,New York (exactwordingn.a.) of:
Self-reports SociodemographicsFair/poor
2.0 (1.3, 3.1)
1992 N= 1,855 Excellent/good, problemsin dailyliving Use of services
Ages 65 + Fair/poor sensoryimpairments
1984-1987 use of psychotropic
meds
92.9-94.7% survived seriouschronicillness
sleep problems
.Shahtahmasebi,
Davies, NorthWales (exactwordingn.a.) of:
Self-reports Sociodemographics Poor2.4 (n.a.)
and Wenger N= 534 Excellent/good,All health-limited
activities PGC MoraleScale Fair2.0 (n.a.)
1992 Ages 65+ rightforage, Fair,Poor MD/RNvisit Social support All right1.5 (n.a.)
1979-1987 homehelp
50.1% survived OARS score
WolinskyandJohnson LSOA, U.S. Wouldyou say your of:
Self-reports Sociodemographics Males
1992 N = 4,503 healthin generalis: functional
disability Healthattitudes Poor 1.7 (n.a.)
Ages 70 + Excellent,Verygood, chronicconditions Social supports Females
1984-1988 Good, Fair,Poor Poor2.2 (n.a.)
76.4% survived Fair 1.9 (n.a.)
Chipperfield Manitoba,Canada How wouldyourate of:'
Self-reports Sociodemographics Well
1993 N=4,303 yourhealthcomparedto chronicconditions Mentalhealth Poorer2.5 (1.2, 5.2)
Ages 65 + othersyourage: functional
disability problems To
1971-1983 Excellent(1)-Poor (5) Life satisfaction I0.9)c
32% survived Ill
Better0.5 (0.3, 0.8)c
Pijls, Feskens,and Zutphen,Netherlands We wouldliketo Physicianobserved: Sociodemographics Not healthy5.4
Kromhout N=783 knowwhatyouthink physicalexamination Healthpractices (2.7, 11.0)
1993 Ages 65-85 aboutyourhealth. bloodpressure Moderately 2.4
1985-1990 Please checkwhat serumcholesterol (1.5, 3.8)
77.0% survived fitsbestin of:
Self-reports
yourcase. Do you chronicconditions
feel:Healthy,Rather cardiovascular
symptoms
healthy,Moderatelyhealthy,medications
Not healthy familyhistoryof disease
Rakowskiet al. LSOA, U.S. Wouldyou say your of:
Self-reports Sociodemographics Poor 1.8 (1.3, 2.4)
1993 N=5,630 healthin generalis: functional
ability Social support Fair 1.5 (1.2, 1.9)
Ages 70 + Excellent,Verygood, chronicconditions Activity compared
1984-1990 Good, Fair,Poor weight/height to age peers
72% survived
Wolinskyet al. LSOA, U.S. Wouldyou say your of:
Self-reports Sociodemographics
1993 N=3,646 healthin generalis: functionalability Social support
Ages 70 + Excellent,Verygood, chronicconditions Healthworries
1986-1988 Good, Fair,Poor Healthcareutilization Controloverhealth
89% survived Changesin functional
ability1984-1986
McCallum,Shadbolt, Sydney,Australia Wouldyou say your of:
Self-reports Sociodemographics Females
and Wang N= 1,050 overallhealthis: seriousillness/accident Country of origin Fair2.4 (1.1, 5.2)
1994 Ages 60+ Excellent,Good, Fair, functionalability PGC MoraleScale Good 3.2 (1.5, 6.7)
1981-1988 Poor Social support
78.0% survived
Schoenfeld
et al. MacArthur EPESE, U.S. How wouldyou rate of:
Self-reports Sociodemographics Morehealthy
1994 N = 1,192 yourhealthat the chronicconditions Healthpractices Poor/bad 93.5
Ages 70-79 presenttime?Would functional
ability (35.2, 248.3)
1988-1991 you say it is: hospitalizations Fair20.6
95.0% survived Excellent,Good, Fair, Cognitivefunction (10.7, 39.5)
Poor,Bad Good 4.5
(3.3, 6.3)
Sugisawa,Liang,and Liu Japan (exactwordingn.a.) of:
Self-reports Sociodemographics 37% reductionin
1994 N = 2,200 Excellent,Verygood, chronicdiseases Healthpractices foreach
mortality
Ages 60 + Good, Fair,Poor functional
disability in scale
increment
1987-1990
92.7% survived
Wolinsky,
Callahan, LSOA, U.S. Wouldyou say your of:
Self-reports Sociodemographics Poor 1.9 (n.a.)
and Johnson N= 6,504 healthin generalis: chronicconditions Healthworries Fair 1.6 (n.a.)
1994 Ages 70+ Excellent,Verygood, functional
disability Social support Good 1.3 (n.a.)
1984-1990 Good, Fair,Poor
71.1% survived
(continued)

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 SELF-RATED HEALTH AND MORTALITY 25
TABLE 1. (continued)
AdjustedOR'
OtherHealthStatus Comparedto Best
Study Sample Item
Self-Rating Variables OtherCovariates (95% CI)
Appelset al. Kaunas,Lithuania Whatdo youthinkof Physicianobservation
of: Sociodemographics Kaunas
1996 Rotterdam, Netherlands yourown health CHD Healthpractices Poor 1.6 (1.0, 2.6)
N = 2,452 (Kaunas) conditioncomparedto bloodpressure Rotterdam
N=3,365 (Rotterdam) thatof othermenof cholesterol Poor 1.6 (1.2, 2.1)
Ages 45-60 (males) yourage: glucosetolerance
1972-1982 Better,Same, Worse weight/height
Kaunas: 83% survived
Rotterdam: 90% survived
Borawski,Kinney,and Florida Do youconsider of:
Self-reports Sociodemographics Sick/Verysick6.6
Kahana N=885 yourself
to be: chronicconditions Healthpractices (n.a.)
1996 Ages 72 + Veryhealthy,Fairly medications Fairlyhealthy2.9
1989-1992 healthy,
Sick, Verysick pain (n.a.)
91.1% survived shortnessof breath
weight/height
parentallongevity

Note: n.a., notavailable.

aShows ORs significant atp < .05 only,emptycell meansno OR less thanp = .05.
b95% CI calculatedforthistablefrompublished data.
cComparedto pooresthealth.

cognitiveprocessthatproducestheseratings whichwereincludedin almostall studiesare

(Feinberg,Loftus,and Tanur 1985); if so, prescriptionmedication use; health care
directing therespondent's attention thisway utilization,includingphysicianvisits and
wouldthenbe redundant, whichit appearsto hospitalizations;intervieweror physician/
be. In anycase, thewordingof thequestion nurse-performed measurementssuch as
in Englishis a minordifference compared height,weight,blood pressure,ventilatory
withthe manylanguagesthe interviews are function, glucosetolerance,and serumcho-
conducted in,andhereagaintherobustness of lesterol;and symptom and pain self-reports.
the conceptappears to overridetranslation Five studies of elderly samples included
difficulties. measuresof memoryor cognitivefunction.
All of the studiesin Table 1 adjustedfor Twelve studiesincludedhealthpracticerisk
age and either controlledfor gender or factorssuch as past smokingand alcohol
analyzed data separatelyfor males and consumption, exercise,or level of activity.
females.Most of themcontrolledforsocio- Threestudiesincludedself-reports of family
economic statusin some way, usually by historyof disease or parental longevity.
entering educationand/orincomelevel. Five Beyondthesemeasuresof sociodemographic
ofthe27 studieshada fullrangeofadultages andhealthstatus,18 studiesincludemeasures
or a sampleof nonelderly people. of social networksor support or more
Variablesmeasuringhealthstatusin other subjectivemeasuresof life satisfactionor
thanglobal ways are criticalto theanalyses; distress.
self-ratingsof healthwouldnotbe interesting We maketwoobservations aboutthislarge
to researchersas predictorsof mortality setof healthstatusindicators andriskfactors.
unlesstheyappearto add something beyond First,we eliminatedsome studiesfromthis
theknownmortality risks.Mostofthestudies reviewwhichhad self-ratings but few other
in Table 1 includedsomemeasuresofchronic measuresof healthstatus.As a consequence,
conditions:Five studiesused physicianor manyof thesestudiesare exemplary fortheir
nurseexaminations, one had extensivedata modelingof mortality riskfactors,and all are
frommedicalrecords,and theremaining 21 strongin this area; indeed, in manycases
studies relied on self-reports of chronic healthstatusmeasurement was the explicit
conditions.Most of the self-report studies purpose of the research. Second, many
includedonly 6 to 10 of the most serious studiesreportonlythehealthstatusor other
chronicconditionswith no weightingfor covariateswhich play a role in mortality
severity.All but threestudieswithelderly prediction, so mostof thefactorsmentioned
samplesalso containedmeasuresof function- in Table 1, especiallythe relativelynovel
ing whichrangedfroma few itemsabout ones suchas parentallongevity or feelingsof
limitationsin activitiesof daily living to loneliness,carrysignificant mortality risksof
extensivescales of functioning and disability theirown.
(e.g., Wolinskyand Johnson1992). Addi- Table 1 shows odds ratiosand associated
tionalhealthstatusindicators, at leastsomeof 95 percentconfidenceintervalsforindepen-

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26 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
dent effectsof self-ratings in multivariateforgood and fairand notforpoorratingsof
analyses. Some studies report an initial health.This mayimplya different processby
association of self-ratingswith mortality which women incorporateinformation into
whichdiminishesas additionalhealthstatus theirself-ratings.
covariates are enteredinto the equation; Univariatedistributions of self-ratings of
however,in quitea fewcases, self-ratings are healthdo notdiffer formenandwomen(U.S.
simplyincludedincidentally as one of a setof Department of Health and Human Services
healthstatusindicators,and no attention is 1995), andmenandwomenappearto referto
givento decomposingtheireffects.In Table thesame criteriawhenaskedto explaintheir
1, odds ratios for self-ratedhealth are ratingsof health(Krauseand Jay1994). This
reportedfromthe finalstep of the analysis, is intriguing becausewhilewomenexperience
fora comparison of thepoorestwiththebest morenonfatalchronicand acute conditions
level (usually "excellent") the respondent (Verbruggeand Ascione 1987), theyappar-
couldchoose.In all butfourstudiesself-rated entlydo notnecessarily judge themselves to
healthholds an independent effectwhenall be in worse health as a result of these
covariatesareentered.The resultsalso almost conditions-a valid conclusionin light of
always show a dose-responsepatternsuch theirbetterlongevity(Leventhal1994). One
thattheprobabilityof deathis highestforthe study(Fylkesnesand F0rde 1991), showed
categoryof extreme"poor" health,less for that models which contain diseases and
"fair" health,and so on (McCallum,Shad- medications,symptoms, physiologicalmea-
bolt,and Wang [1994] is an exception).The sures,and healthpracticemeasuresexplain
highestoddsratiosarereported bySchoenfeld moreof thevariancein self-ratings of health
et al. (1994), fromtheirsample of highly for womenthantheydo for men. Women
functioning elderly:"Poor" reportedhealth may be judging conditionsin light of a
increasedtheriskof mortality 93.5 timesin lifetime ofmoreprevalent healthproblems, or
the subsampleof this group that had no in comparisonwithotherwomenwho also
apparentmedicalproblems.For moststudies experiencemanyconditions.If poor ratings
odds ratiosrange from1.5 to 3.0 for the of health by men reflect more serious
extremeriskcategory;the odds of mortality conditions,and if more of the variancein
forpoor self-rated healthoftenexceed those women'sself-ratings is explainedby existing
forsmokersor maleswhentheyare reported conditions, it is clearwhymen'spoorratings
in thesame study. are more predictiveof mortality than are
Blankboxes in Table 1 show studieswith women'spoorratings.
no significantmultivariate effectsfor any To sumup, in 23 ofthe27 studiesin Table
levelof self-ratedhealthor foranysubgroup. 1, thefindings are consistentand effectsizes
Thereare fourof these:Deeg et al. (1989); are quitelarge; self-ratings of health,which
Parker,Thorslund,and Nordstrom(1992); take only seconds to obtain in a survey
Grand et al. (1990); and Wolinskyet al. interview, reliablypredictsurvivalin popula-
(1993), from the Netherlands,Sweden, tions even when knownhealthrisk factors
France,and the UnitedStates,respectively. havebeenaccountedfor.Thesefindings have
In each of thesecases, self-ratedhealthwas had the effectof conferring a retroactive
predictiveof mortality at thebivariatelevel, significanceon three decades of social
buttheintroduction of covariatesreducesthe scientificresearch(Angel and Thoits 1987;
associationto nonsignificance. Two of the Haberman1969; Maddox 1962; Suchman,
fourhad medicalevaluations,the othertwo Phillips,and Streib 1958). From the first,
includedonly self-reports of currenthealth interdisciplinary studiesof healthhave shown
statusas covariates.These studieswill be thatthereare discrepanciesbetweenglobal
examinedin moredetailbelow. self-ratingsand medicallyobtainedhealth
The uniqueeffectofself-rated healthon the statusinformation and thatthesediscrepan-
predictionof mortalityseems to be more cies were oftenassociatedwith social and
apparent formenthanforwomen;fiveof the demographic factorssuch as genderor age.
seven studies that estimatedrisk ratios Such findings implythatsurveyrespondents'
separatelyby genderfoundstronger effects perceptionsof healthstatusare holistic;they
formen. One of theremaining two (McCal- include information on medical status,but
lumet al. 1994) founda significant effectfor thatinformation is evaluateddifferently by
women,aftercontrolswereentered,butonly menand womenin different social positions,

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 SELF-RATED HEALTH AND MORTALITY 27
with different referencegroups providing ease. Regardingexistingillness, in most
different socialcomparisons. The significance studiesrespondents wereasked to reportthe
of these findingsfor social scientificap- presenceof specific(usually chronic)dis-
proachesto understanding healthcan hardly eases. Evenwhenthemostcommonandmost
be exaggerated. severeconditions are included,theyprobably
What are thesesensitivemeasurestelling do not exhaustthepossibilities.Two of the
us? How does one explainthese extremely studiesthatfullyaccountedforthe indepen-
consistent findings? In orderto understandthe denteffectof self-rated healthon mortality
mechanismsat workin the association,we incorporated physician ornurseexaminations.
nextproposea set of interpretations of the In one of them(Deeg et al. 1989) theresult
data,withparticular attentionto thenegative maybe due to a confound:Self-rated health
cases and whattheycan teachus. was operationalized as good or poor subjec-
tive health,but subjectswere also asked if
theyperceiveda declinein theirhealth,and
POSSIBLE INTERPRETATIONS bothshowbivariateassociationswithmortal-
ity. In the final multivariate analysis,with
bothmeasuresincluded,self-perceived health
(1) Self-ratedhealthis a moreinclusive declineis stillsignificant, butthe subjective
and accuratemeasureofhealthstatusand healthratingis not. This findingconcerning
healthriskfactorsthanthecovariatesused. declinemaybe a keyone and we examineit
later.
Interviewer: Whatwentthrough yourmind On the otherhand,if physicianexamina-
whenyouratedyourhealthas "fair"? tionsare betterat pickingup earlysymptoms
Respondent:Well, my health . .. see that's of seriousillness,we would expectstudies
a hard question,it dependson differentwhich included such data to show fewer
things.As faras myweightI feelthatit's independent effectsof self-rated health.In
very,verypoorbutas faras mycholesterol fact,threeotherstudiesalso includedphysi-
I thinkit's absolutelyexcellent,125, is cian examinations and all foundsignificant
excellent.Butwhenyousaythingslikemy effects for self-ratedhealth beyond the
kneesare hurting me, somedaystheyare, physicianratings.In one of them (Pijls,
some days they'renot. My knees are in Feskens, and Kromhout1993), a complete
poor conditionbut my heartis in good set of cardiovascularrisk factorswas as-
condition.My anklehurts'cause I brokeit sessed, includinganthropometric measure-
lastyear.ButI feelgood 'cause I can walk. ments,electrocardiograms, blood pressure,
You can't really say, let's just say one serum cholesterol(HDL), dietaryhistory,
specificthing,but if you'retalkingabout smoking,minutesof exercise,hospitaldis-
generalstuff,I have to say, oh, I maybe chargeinformation, cumulativeincidenceof
excellenthealthwisein one way,and very cardiovascular diseaseduringthefiveyearsof
poorhealthwise in anotherway. follow-up,use of medications,and family
Interviewer: So when you average it all historyof chronicdisease, particularly heart
out? disease.In thisinvestigation, self-rated
health
Respondent:It's rightin the middle.It's was a significantpredictorof five-year
like those shades of grays betweenthe all-cause mortality when all the above risk
blackand white.So I can't say everythingfactors weretakenintoaccount,butitwas not
aboutme is poorand noteverything about a significant predictor of heartdiseasedeaths
me is excellent.(Idler,unpublished data) consideredby themselves.One could argue
(a) Self-ratedhealthcapturesthefullarray on the one hand thatan equally thorough
of illnessesa personhas and possiblyeven assessment ofriskfactorsfortheothercauses
symptoms of disease as yetundiagnosedbut of death could have removedthe all-cause
presentinpreclinicalor prodromalstages. mortality finding,butriskfactorsforcancer
Even theextensivesets of covariatesused and otherleadingcauses of deathare notas
in thestudiesin Table 1 do notentirely rule well understood, and indeedfamilyhistory of
out this possibility.As for disease in stroke,hypertension, diabetes, and cancer
preclinicalstages, very few of the studies were assessed.
asked specificallyabout symptoms,which In addition,two studieslooked at healthy
potentiallycould indicateundiagnoseddis- individuals. Rakowski,Mor,andHiris(1991)

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28 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
looked at the LongitudinalStudyon Aging thatseverityvaries,over timeand between
(LSOA), excluding individuals reportinga high- individuals.Any disease thathas an impact
riskmedicalconditionor difficulty in instru- on functioning, such as heart disease or
mentalactivities of dailyliving(IADL), thus arthritis, will show a large variancein the
leaving1,252of theoriginalsampleof 4,199 severityof symptomsrelated to it. This
self-respondents atbaseline.Lessfavorable self- differential weightingmay be more fully
ratedhealth significantlypredicted mortalityover capturedby self-ratings than dichotomous
a relativelyshortperiodoftwoyearswithin this diagnosticcategories.
healthygroup,beyondcontrolsforfunctional Anotheraspectnot fullycapturedmay be
bodymassindex,sociodemographic
ability, vari- the effectsof comorbidity. There may be
ables,and socialsupport.Schoenfeld andcol- complexinteractions betweenconditions,or
leagues(1994)rana similar testusingdatafrom the effectof a "criticalmass" of health
thehigh-functioning elderlysampleoftheMac- problems,thatare not fullyreflectedby an
Arthur FieldStudyof SuccessfulAging.Self- additivemeasureof chronicdisease. Comor-
ratedhealthhad a verystrongeffect(adjusted bidityis theruleratherthantheexceptionat
OR of19.6forpoorvs. excellent health),which olderages: Patrick(1987) foundchronically
becameevenstronger whenthesubgroup that ill personslivinginthecommunity to havean
had one or fewerchronicdiseaseswas tested averageof threemedicalconditions, and the
separately (see tab. 1). Self-reportsof medical number of conditions to increasewith age. No
conditions andevenmedicalexaminations could study has tested the association between
be wrongas wellas incomplete, butitis hardto self-rated healthandinteractions ofconditions
explaintheentire association thisway,whichin but there is evidence for the impact of such
effectleavesself-rated healthto "correct"the interactions on survival. For example, factors
such as comorbidity and functionalstatus,but
misdiagnosis.It is moreplausiblethatself-
nottheseverity of trauma, were predictive of
ratings ofhealthinthese"healthy"individuals
survival among elderly patientsafterhip
capturedsomething beyondtheirknownmed-
fracture (Poor, Jacobsen,and Melton1994).
ical history.
A personmaybe able to assess theimpactof
A look at the findingsfrom another
thesefactorsandtheirinteractions withhealth
perspectivealso suggeststhat existingill- status eventssuchas a hipfracture,
following
nesses and symptomscannot provide a yetthisinformation is nottypically measured.
sufficient explanation.If the existenceof Beyond that,Stenback(1964) suggested
preclinical,unmeasuredillness entirelyex- thatthe patient,in contrastto thephysician
plainedtheeffect ofself-ratings ofhealth,one (or surveyinstruments), has access to sensa-
wouldexpectthemostpowerful effectsin the tionscomingfromwithinand givingriseto a
shortterm,withsteadilydiminishing effects generalbody feelingcalled caencesthesis. It
as follow-up periodsincrease.But as Table 1 maybe that"thewholeis morethanthesum
shows, Mossey and Shapiro (1982) found of the parts" and while researchersare
similarriskratiosfortheearlierand thelater measuring theparts,respondents have access
partsofthefollow-up; riskratiosbasedon the to thewhole.
LSOA are similarfora four-year (Wolinsky (c) Self-rated healthreflects familyhistory.
and Johnson1992) and a six-yearfollow-up Idler and Kasl (1991) suggested that
(Rakowskiet al. 1993); and riskratiosare self-assessments of healthreflecta personal
still quite high and statistically significantestimateof longevity.This estimatemay be
even in studieswith the longestfollow-up based notonlyon knowledgeof therespon-
periods (e.g., Shahtahmasebi, Davies, and dent's own currenthealth,but also on the
Wenger 1992; Appels et al. 1996). Taken knowledgeoffamilialriskfactors.A family's
together,the impressivenumberof studies vulnerability to specificdiseases and pattern
withlong follow-upperiodsand a varietyof of longevityrepresentsa social source of
covariatessuggeststhatthisexplanation may knowledgethat grows as people age and
notbe sufficient in itself. experiencethe deaths of firstgrandparents
(b) Self-ratings ofhealthrepresent complex and thenparents.A well-known longitudinal
human judgmentsabout the severityof studyof a cohortof 184 graduates ofHarvard
current illness. Universityhas found that actual ancestral
Most of thesestudiesdid not weightthe longevityis stronglyassociated with the
illnessesin anyway,althoughitis quiteclear chronicphysicalillness and mortality this

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SELF-RATED HEALTH AND MORTALITY 29
cohortexperienced by thetimetheyreached withinthe longitudinal design of the study
their late sixties (Vaillant 1991). Three and not based on retrospective recall of the
studies in Table 1 contained measures of respondents. Thomas et al. (1992) predicted
familyhistoryor longevity;two of these mortality fromhealth,depression,and socio-
studiesshow an independent effectof self- demographics. Whenchangesin problemsof
ratingsremainingwhen familyhistoryis dailylivingand in healthconditionsover24
takeninto account(Borawski,Kinney,and monthswereenteredin an analysispredicting
Kahana 1996; Pijls et al. 1993), and one mortality withinthe nextyear,the effectof
studydoes not (Deeg et al. 1989). This baselineself-rated healthbecameweaker,but
inconclusiveness is not surprising since an was still Svardsuddand Tibblin
significant.
effectof familyhistorythroughself-rated (1990) interviewed andexamineda sampleof
healthwould probablynotbe based directly 945 60-year-oldmen in Sweden, with a
on theage parentsdiedortheillnesstheydied follow-upafterseven years and recordsof
from,but on an interaction betweenthese mortality up to 15 years. Men who had a
factsand the person'scurrenthealthstatus, deterioration of two or more points on a
age, andbehavioralriskfactors.Approaching 7-pointscale of perceivedhealthfromage 60
theage at whichhis fatherdied froma heart to 67 weremuchmorelikelyto die inthenext
attackmayhave a strongnegativeimpacton eightyears (p < .0001). Strongerevidence
the self-rating of a man if bothhe and his basedon further analysesoftheLSOA datais
fatherwereoverweight and smokers.On the presented by Wolinskyand colleagues(Wo-
otherhand,a long-livedfamilyhistory could linskyet al. 1993; Wolinsky,Callahan,and
fostera sense of invulnerability to illness. Johnson1994). Deterioration in basic ADL
Neithercase is an exampleof unmeasured (p < .001) and lower body function(p <
current healthstatusoftheindividual.Rather, .005) between1984 and 1986 were signifi-
it is an area of information about health cantpredictors ofmortalitybetween1986and
historywhich could be incorporatedin 1988 and substantially improvedthe overall
surveys. fit of the model. They also led subjective
(2) Self-rated healthis a dynamicevalua- healthstatusto lose itsstatistical significance.
tion,judgingtrajectory and notonlycurrent This is evidencethatself-ratings ofhealthare
levelofhealth. fundamental indicatorsof declinesin health
and functioning, ratherthan simplecurrent
Respondent(in nursinghome): When it assessments, andthismayaccountformostof
(health)failed,I began to realize whenI theirindependent effecton mortality.
was well I had a different outlook on
(3) Self-ratedhealthinfluencesbehaviors
things.Whenmyhealthfailed,I got so I thatsubsequently affecthealthstatus.
was neglectful (ofmyself).I lostinterest in
everything, and I didn't want to keep Respondent:I know if you're doing
going.(Powers1988:304) exercisethenover timeyou startto feel
better,and I knowdayswhenI've feltsort
Anotherreasonforthe independent effect I
ofblahandI've beenat home,sometimes
of self-ratings of health is that they may
just take the vacuum cleaner and start
reflecta dynamic,ratherthanstatic,perspec- working,and beforelong I startto feel
tiveon health;peoplemaybe judgingdecline better. .. I thinkthephysicalactivity does
(orimprovement) in variousaspectsofhealth. do somethingto make you feel better.
It may be a decline in theiractual health (Litvaand Eyles 1994:1087)
status; a decline in their bodily reserve,
reflectedby a generalslowingdown of the (a) Poor perceptions ofhealthmaylead to
a
body;or perceived increasein susceptibilityless engagement in preventive practicesor
to disease. On theotherhand,a trajectory of self-care.
improvement froman earlierperiodof illness Adultswithpoorerperceivedhealthmaybe
or disability maybe evidentto therespondent less engagedin preventive healthpracticesor
but not to themomentary externalobserver. self-care that contribute to betterhealth.
Most of the studies predictedmortalityLamb,Roberts,andBrodie(1990) foundthat
fromone-timebaseline measuresand thus sportsparticipants had betterperceptions of
couldnotmodelchangesin health.Onlytwo healththana matchedsampleof nonpartici-
studiesincludeda measureofchangethatwas pants.Elderlypeople withpoor perceptions
assessed in both cases by the researchers of healthmay also be less likelyto be very

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 30 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
activeor to exercise,and inactivity has been and social networks have been coveredquite
shown to acceleratefunctionaldecline and well by thecontrolvariablesin moststudies
predictmorbidity (Moret al. 1989;Rakowski since theyhave directeffectson morbidity
and Mor 1992). Otherpoor healthpractices and mortality. Still,self-ratedhealthmaybe
suchas smokingandheavyalcoholconsump- moreaccuratein reflecting the adequacyof
tionare also associatedcross-sectionally with theseresourcesto meetfutureneedsand not
poorperceptions ofhealth(HirdesandForbes only theirabsolutelevel, whichis typically
1993; Segovia,Bartlett, and Edwards1989). the measure.Indeed, Sugisawa, Liang, and
Haug, Wykle, and Namazi (1989) have Liu (1994) found that social supportand
shown that older respondentswith better social participation have indirecteffectson
perceivedhealthweremorelikelyto engage mortality throughself-rated health,but that
in self-care,controllingfor chroniccondi- social contactsand maritalstatushad neither
tions, symptoms,and psychosocialfactors. directnorindirect effects.
Hence, one reason for the influenceof The importanceof social resourcesfor
self-rated healthmay be thatthese ratings individuals'self-ratings mayalso comein the
reflectother factorsindicativeof healthy formof availabilityof social comparisons.
lifestylesand utilizationpractices.One or Externalsocial resourcesprovideopportuni-
anothermeasureof healthpracticesis in- ties for healthcomparisons;researchwith
cludedin 13 of the27 studies. patientsampleshas shownthatthesetendto
(b) Poorperceptions ofhealthmayproduce be selectivelydownwardcomparisons,with
nonadherence toscreening recommendations,otherswhose healthis worse (Breetveltand
medication, and treatment. Van Dam 1991;Wood,Taylor,andLichtman
Olderindividuals whoperceivetheirhealth 1985). The consequence is an effective
as poormaybe preoccupied withtheircurrent enhancingof feelingsof relativewell-being,
and perhapsmore visible and functionallywhichcould perhapsfacilitaterehabilitation
limiting healthconditions,so theyneglectto or recoveryefforts.
engage in preventivemeasures such as (b) Self-ratedhealth may also reflect
mammography screening, to takemedication within-person resources.
for conditionssuch as hypertension, or to Negativeassessments of healthmaystimu-
followinstructions regardingdiet and exer- late the neurologicalsystemin ways that
cise. This neglect of either primaryor compromise theimmunesystem,thusleaving
secondary preventionmay facilitate the the individualmore susceptibleto future
progressof disease processesand eventually diseaseandloweringthechanceof successful
resultin earlierdeath.No studies,however, recoveryfromit. Depressionmay be one
examinewhether self-ratedhealthmayreflect indicatoror mediatorof such a process.
compliancewithmedicalcare and advice. Severalothermeasuresin thestudies,suchas
(4) Self-ratedhealthreflectsthepresence controlover health, that are conceptually
or absence of resourcesthatcan attenuate similarto self-ratings showeffects on mortal-
declinein health. itythatoverlapwiththatof self-rated health.
They may reduceor eliminatethe effectof
Respondent: My leg. That'stheonlything
but also help us interpret
self-ratings, the
that'sholdingme back. I feel good. And
meaningof self-rated healthas a predictor
of
when I look around. . . I'm not sick.
mortality.Lack of projectsforthefuture was
Believe me, some of thesemenand ladies
foundto havea significant independent effect
aroundhere. .. I'm notsick.I don'twanta
on mortality,beyondhealthmeasures,mak-
brag, but I wouldn'twanta be the way
ing theeffectof self-rated healthnonsignifi-
someofthesepeoplearethathaftabe here.
cant(Grandet al. 1990). The effectoflackof
(Powers1988:303)
projectsforthefuture mayalso be explained
(a) The externalsocial environment may as reflecting a trajectory of declininghealth
providesuchresources. moreaccuratelythanself-rated healthdoes.
Justas self-ratedhealth may reflectan Bleak ideas of the futureare one of the
assessmentof internal levels of resistance,it elementsof the "cognitivetriad"of depres-
may also indicatean evaluationof external sion (Beck 1967); if this specificaspect of
resourcesforcopingwithfuture illness.Many depressionhas a negativeimpact on the
possibleindicators of externalresourcessuch immune system, it may well become a
as income,education,living arrangements,self-fulfilling prophecy.

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SELF-RATED HEALTH AND MORTALITY 31

Similarly,Wolinskyet al. (1993) founda relationship betweenself-ratings ofhealthand

significanteffecton mortality forperceived mortality. Thereis a pointwhenreplication
controloverhealththatwas independent and becomesredundancy.
strongerthanthatof self-rated health,and It is the audienceof thisjournal, social
both effects became nonsignificant once scientistsinvolvedin thestudyofhealth,who
declinesin functionalabilitywere entered. shouldhave themostcreativeideas fornew
Loss of controlmayalso be botha trigger for studies.New approachesmustcome froman
processes having negative impact on the openness to many methodsand research
immunesystemand a markerfordeclining designs,small-scaleandlarge,cross-sectional
health status. However, with our present and longitudinal, observational and directed,
knowledgeit is premature to commentabout qualitative andquantitative. In a recentessay,
To evenbeginto assessthe StanislavKasl arguesthatin manyareas of
thesepossibilities.
meritof such suggestions, moreresearchon researchon the healthof the elderly,the
possible relationsof self-ratedhealth to secondaryanalysis of large data sets has
immunemarkers is clearlyneeded. become "the repeated examinationof a
In summary, this list of possible mecha- smallishset of independent and dependent
nismsleads to a simpleobservation: A very variables[which]drivesus away fromour
longlistofvariablesis requiredto explainthe goal ofexpandingourunderstanding . . . as a
effectof one brief4- or 5-pointscale item: basis foropeningup new areas of research
"How in general would you rate your and giving us hints about promisingnew
health?"! This item is a most powerful variablestheymay be particularly infertile"
self-assessment, combiningmyriadfactors (Kasl 1995:S191). He proposesa new ap-
frommanydifferent domainsof life. Very proach, nestingsmall-scale studies within
rarelyin the social sciencesdoes one item largerones and designingthemto answer
achievesuch a status,beinghighlyvalid in specific questions, ratherthan depending
predicting a substantively outcome opportunistically
significant on the data alreadyavail-
beyondsuch impressive"attacks"aimed at able. Othermultiple-method approaches,par-
rulingit out. Viewed fromthisangle, it is ticularlythose integrating qualitativeand
completelyirrelevant whetherthe goodness- quantitative data collection techniques,
of-fitof models predictingmortality stays shouldalso be veryfruitful forthe studyof
roughlythe same withor withoutself-rated self-rated health.
health;its significant effectis impressive, Thus we concludethispaperwithanother
regardlessof whetherit operates as an list,a non-mutually exclusiveandnonexhaus-
indicatorof some unmeasuredprocess or tive one, of ways we could findout more
simplyas a mosteffective summary of all the about self-ratedhealth,by askingdifferent
othermeasures. questionsand usingdifferent methods.
1. Begin by studying outcomesotherthan
Thisis an areawherethesecondary
mortality.
THE NEXT STAGE OF STUDIES data analysisapproachwouldstillbe useful,
and a small numberof studieshave already
We havepresented theresultsof 27 studies appearedin theliterature. As we saw above,
of the same independentand dependent functional abilitywas frequently assessed at
variablesandincludedonlythosewithsimilar baselinein themortality studies,and several
samplecharacteristics and covariates.Rarely studieshave now takenit as an endpointin
do authorsof a literature reviewenjoy such itself.Poor self-rated healthis reported to be
comparability of studydesigns,letalonesuch an independentpredictorof declines in
consistency of findings.It makesthetaskof functioning in studiesfromFrance(Grandet
summarizing the findingsless a matterof al. 1988),Finland(Jylha1993), GreatBritain
decidingwheretheweightoftheevidencelies (Jagger,Spiers, and Clarke 1993), Japan
or whichstudydesignsneedto be fine-tuned, (Haga et al. 1995), and the UnitedStates
and morean opportunity to speculateabouta (IdlerandKasl 1995;Kaplanet al. 1993;Mor
new generationof researchquestions.We et al. 1994). Follow-upperiodsrangedfrom4
would argue that researchersare fast ap- to 10 years. Otherstudycharacteristics are
proaching, if notalreadyreaching,thelimits similarto thosein themortality studiesbythe
of what secondaryanalysisof these large, same authors.Two studiesin whichfindings
longitudinal data sets can tell us about the were negative were those of Mor and

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 32 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
associates (1989) and Markides and Lee nonsurvivors in nursinghomesin Newfound-
(1990), withtwo and eightyearsof follow- land,Canada.
up. We notethatmanyof thestudiesincluded
Clearly thereare many othermorbidity in this review are actuallyof the "special
measureswhichcould be studied.Morbidity population"oftheaged; infact,a majority of
outcomesthatare also mortality riskswould those included under communitystudies
be of greatestinterest:In additionto func- includeonly elderlypersons.This is partly
tional ability,new cases of heartdisease, because of tradition; thestudiesof self-rated
cancer, stroke,or diabetesmightbe suffi- healthreallybeganwiththeelderlysamplein
cientlynumerousto study.We would also the Duke LongitudinalStudies of Aging
include other health-related outcomes on (Maddox 1962), and manyhave appearedin
whichtherehas been someresearch,suchas the gerontology journals. It is also partly
hospitalizationsor nursinghome admissions pragmatic; mortality studiescan be performed
(Blaxter 1985; Mutranand Ferraro 1988; with much shorterfollow-upperiods in
Wolinsky,Stump,and Johnson1995). elderlypopulations.But the studyof self-
2. Study special populations. Several ratingsof healthamongtheelderlyhas been
studieshaverecently
interesting appearedthat especially interestingbecause older people
look at theeffectof self-ratings of healthin have been shownto be more optimisticin
special populationssuch as nursinghome theirself-ratings than youngerrespondents
residents or patientswitha particular disease; (Maddox and Douglass 1973; Rakowskiand
these studiesalso frequently take outcomes Cryan 1990) and to hold more holistic
otherthanmortality. All ofthesestudiesraise definitions of health(van Maanen 1988), for
issues of studydesignand measurement of reasonswhichcouldbe due to aging,cohort,
outcome,makingthemmore complexthan or periodeffects(Idler 1993).
themortality studies.An earlyexamplewas 3. Use qualitativeapproaches.Throughout
fromMaland and Havik (1988), who found this review we have insertedrelevantpas-
that returnto work six monthsafter a sages that capture,in a respondent'sown
myocardialinfarctionwas related to the words, a conceptwe wantedto illustrate.
Withoutdiscussingthemdirectly,we hope
patient's retrospective rating of self-rated
theyhave alreadysuggestedtheconsiderable
healthat discharge,of global healthbefore
potentialfor this approachto uncoverthe
theheartattack,andoffuture health.Another
multifaceted meaningsrespondentsconvey
studyof therole of self-ratings of healthin withtheirown
words.Thereare just a few
recoveryfrom hip fracture,stroke, and qualitative
studiesof self-ratings of health.
myocardialinfarction by Wilcox, Kasl, and The study by Jylha(1994) is
interesting
Idler (1996) obtainedself-ratings of health because it shows transcripts of taped inter-
beforetheeventoccurred(respondents were viewsin whichrespondents wereasked only
already part of the New Haven EPESE to respondto the scale; the negotiating and
sample)andat six weeksandsix monthsafter discussingthatgoes on tellsa greatdeal about
the event. Their findingsshowed thatsix- boththerealityof theinterview situationand
week post-eventratings(but not pre-event the meaningof self-ratings. Groves, Fultz,
ratings)predictedrecoveryat six months, andMartin(1992) andKrauseandJay(1994)
even when the severityof the respondent's present coding of qualitative data from
medicalconditionand level of functioning at cross-sectionalconveniencesamplesof non-
six weeksweretakenintoaccount.Wolinsky elderlyrespondents but no directtext.Both
andFitzgerald (1994) also studiedhipfracture studiesfindprimarily physicalhealth-related
patientsand foundthatLSOA respondents meanings, including presence/absenceof
whohad fractured a hiphad a higherriskof a healthproblems,functioning, positive/nega-
secondhipfracture iftheyhadpoorperceived tivehealthbehaviors,and healthserviceuse
health.Dasbach et al. (1994), in a studyof whenrespondents were asked to expandon
diabeticsin Wisconsin,foundhighermortal- theirclosed-endedresponse.Borawskiet al.
ity rates associated with poor perceived (1996) present longitudinaldata from a
health,particularly among those with late- randomlyselectedsample of elderlyretire-
onsetdiabetes.Stones,Dornan,and Kozma mentcommunity residents.
Theyfinda more
(1989) also found that perceived health complexset of meanings,includingphysical
significantly differentiated survivorsfrom health focused, health transcendent ("I'm

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 SELF-RATED HEALTH AND MORTALITY 33
fine,exceptfor. . ."), attitudinal/behavioral respondent's health.Theyfoundthatrespon-
("I don't let thingsbotherme"/"I don't get dents who chose to do the interviewin
enoughexercise"),externally focused("Doc- Spanishratedtheirhealthconsiderably more
torstellme I'm fine"),and nonreflective ("I poorlyand thattheratingsweremuchmore
just feel thatway") meanings.These more discrepantwiththe physician'srating,than
complicatedexplanations of self-ratings,
and thosewhodid theinterview in English.Their
those in Powers (1988) and van Maanen interpretation was not that the Spanish-
(1988) reflect the greaterprevalence of speakingrespondents were morehypochon-
chronicconditionsamongthe aged and the driacal,butthat"forMexican-Americans and
ambiguityof many conditionsthatcan be PuertoRicans the adjectivesassociatedwith
seenbyelderlypeopleas aging-related, rather normalhealth differfrom those used by
thanmedical. non-Hispanic[s]"(Angel and Guarnaccia
The complexmeaningrespondents offerfor 1989:1234). One can see in the frequency
theiranswersunderscoresthe strength and tablesthat"fair" is the normative category
weakness of global items, in researchon for the Spanish interview,while most En-
self-ratedhealth,orin otherrelatedareassuch glish-speaking respondents chose "good." A
as qualityof lifeor lifesatisfaction.
Psycho- verysimilarcase of cross-cultural differences
metriciansand otherswho believe thatthe in a single studyoccurs in the studyby
errorassociatedwithsingleitemsis unaccept- Appelset al. (1996), in whichthenormative
ably high regardglobal ratingitems with category forLithuanians is "poor,"whileitis
suspicion.The problemwith global items, "good" for the Dutch. The image of
fromthispointof view, is thatresearchers "normal"healthin a societycan be thought
have no idea of, or controlover,theareasof of as the entrypoint into these response
life respondents are assessing.On the other scales. Such cross-cultural differences make
hand, Gill and Feinstein(1994:624), in an the consistencyof the findingsfrom the
article assessing quality of life measures, international studiesall themoreremarkable.
concludethatglobalratings"offerinvestiga- Otherinvestigations could begin withthe
tors the most overtlysensible approach" surveyinstrument itself.Areresponsesto the
because they allow a full expressionof a self-rated healthquestionaffected in anyway
patient'svalues and preferences. They con- bytheircontextin thesurveyinstrument? Are
clude that"unlikebeauty,whichrestsin the responsesto thisquestiondifferent when it
eye of the beholder, quality of life is appearsafter,ratherthanbefore,a chronic
inherently an attributeof the patient(or illnesschecklist? Do respondents changetheir
'beholdee')." Because qualitativeapproaches self-ratings of healthif asked to rate them-
in the social sciencesare uniquelysuitedto selves again at the end of the interview?
seeing the world throughthe eyes of the These are not just questionsabout survey
beholdee,theyshouldproveextremely useful methods, as important as thosemaybe (Tanur
in the nextstage of research.In the social 1992); theyraisethequestionof whether the
sciences we oftenthinkof qualitativeap- presenceof conditionsprimarily affectssub-
proachesas exploratory phases of research, sequent judgmentsof overall health, or
whichprecede,rather thanfollow,large-scale whetherthe perceptionof conditionsitself
quantitative studies.In thiscase, though,the mightnotbe affected by a morefundamental
pendulumshouldswingtheotherway. evaluationof underlying healthstatus(Fein-
4. Studythe cognitive/cultural processes berget al. 1985).
associated withthesejudgmentsof health. A thirdarea of studywith a cognitive
Qualitativeapproachescan tell us aboutthe emphasiswould be an examinationof the
meaningsrespondents supply,but theremay process of reference-group comparisons,
be additionalinfluenceson theirrepliesthat whichmanyauthorshave identifiedas the
theycannottell us about.For example,two fundamental process by which such self-
studiesraise important issues about cross- ratingsare made (Angel and Thoits 1987;
culturaldifferencesthatwouldbe inaccessible Feinberget al. 1985; Suls and Wills 1991).
to mostrespondents. In thefirst,Angel and Peopleuse reference groupsto identify others
Guarnaccia(1989) examinedresponsesto the by theirmembership in social categoriesand
global self-ratedhealthitemin the Hispanic then comparethemselvesto these socially
HANES, which also had, for comparison similar and dissimilarothers; this is an
purposes,a physician'sglobal ratingof the especially powerfulidea with respect to

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 34 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
healthjudgmentsbecause the fundamentalthatan individual'shealthstatuscannotbe
social categoriesof gender,race, ethnicity, assessedwithoutit.
age, and social class carrysuch objectively
differentmortality(and morbidity)risks.
Above we arguedthatan age-basedcompari- REFERENCES
son was probablyimplicitin all self-ratings,
but are othersocial categoriesused as well? Angel, Ronald and Peter Guarnaccia. 1989.
An additionalissue lies in the directionof "Mind, Body, and Culture: Somatization
healthcomparisons.An interesting studyby AmongHispanics." Social Science and Medi-
Smith, Shelley, and Dennerstein(1994) cine 28(12):1229-38.
showsthatAustralianwomenwho ratetheir Angel, Ronald and Peggy Thoits. 1987. "The
Impactof Cultureon theCognitiveStructureof
healthas betterthantheir(age/sex)peershad Illness." Culture,Medicine, and Psychiatry
morecomplexdefinitions ofhealththanthose 11:465-94.
who rated their health worse, but this Appels, A., H. Bosma, V. Grabauskas,A.
cross-sectionaldesign does not resolve Gostautas,and F. Sturmans.1996. "Self-Rated
whetherit was the complexdefinitions that Health and Mortalityin a Lithuanianand a
led to thebetterevaluations,or theotherway Dutch Population."Social Science and Medi-
around. In sum, there are many things cine 42(5):681-89.
respondents can tellus abouthow theymake Beck, Aaron T. 1967. Depression: Clinical,
thesejudgmentsbut probablymany things Experimental,and TheoreticalAspects. New
theycannot;multiplemethodsare neededto York:Harper& Row.
Berkman,Lisa and S. Leonard Syme. 1979.
revealthecomplicated andsubtlemeaningsof "Social Networks,HostResistance,andMortal-
self-ratingsof health. ity:A Nine-YearFollow-UpStudyof Alameda
CountyResidents."AmericanJournalofEpide-
miology109:186-204.
SUMMARY Blaxter,Mildred.1985. "Self-DefinitionofHealth
Statusand Consulting Rates in Primary Care."
In 1973, George Maddox wrote that QuarterlyJournalofSocial Affairs1:131-71.
of health"clearlymeasuresome- Borawski,ElaineA., Jennifer
self-ratings M. Kinney,andEva
thingmore-and something less-than objec- Kahana. 1996. "The Meaningof OlderAdults'
tivemedicalratings"(Maddox and Douglass Health Appraisals: Congruencewith Health
Statusand Determinant of Mortality."Journal
1973:92). This review has been about the of Gerontology: Social Sciences 51B(3):S157-
something more" thatthisglobal itemmea- 70.
sures,whichin effectcedes controlover its Breetvelt,I.S. and F.S.A.M. Van Dam. 1991.
exact meaningto the respondent.We have "Underreporting by CancerPatients:The Case
revieweda setofstudiescarefully selectedfor of Response-Shift." Social Science and Medi-
theirexemplaryresearchdesignsand repre- cine 32(9):981-87.
sentativeness and foundthat, in the great Chipperfield,JudithG. 1993. "Incongruence
majority add something BetweenHealthPerceptionsand HealthProb-
of cases, self-ratings
moreto theprediction of mortality.We have lems." Journalof Agingand Health5(4):475-
also foundthatsecondarydata analysesare 96.
Dasbach, Erik J., Ronald Klein, Barbara E.K.
approachingsomethingof an impasse in Klein, and Scot E. Moss. 1994. "Self-Rated
understanding what thatsomethingmore is Healthand Mortality in People withDiabetes."
and that other approaches,only some of American JournalofPublicHealth84:1775-79.
whichhave been suggestedhere,are needed Deeg, DorlyJ.H., RobertJ. van Zonneveld,Paul
forprogressto be made. J.vanderMaas, andJ. Dik F. Habbema.1989.
We concludethatself-ratings represent a "Medical and Social Predictorsof Longevityin
sourceof veryvaluabledataon healthstatus. theElderly:TotalPredictive Value and Interde-
Global self-ratings,whichassess a currently pendence."Social ScienceandMedicine29(11):
unknownarrayof perceptionsand weight 1271-80.
them accordingto equally unknownand Feinberg,Stephen,ElizabethLoftus,and Judith
Tanur. 1985. "CognitiveAspects of Health
varyingvalues and preferences, providethe SurveyMethodology:An Overview."Milbank
respondents' viewsofglobalhealthstatusin a MemorialFund Quarterly 63(3):547-64.
way thatnothingelse can. We would argue Fylkesnes,Knutand Olav H. F0rde. 1991. "The
thattheglobalratingrepresents an irreplace- Troms0 Study: Predictorsof Self-Evaluated
able dimensionof healthstatusand in fact Health-Has Society Adopted the Expanded

This content downloaded from 141.211.4.224 on Mon, 15 Jun 2015 21:44:48 UTC
All use subject to JSTOR Terms and Conditions
SELF-RATED HEALTH AND MORTALITY 35

HealthConcept?"Social Scienceand Medicine . 1995. "Self-Ratings of Health: Do They

32(2):141-46. Also PredictChange in FunctionalAbility?"
Gill, ThomasM. and Alvan R. Feinstein.1994. JournalofGerontology: Social Sciences50B(6):
"A CriticalAppraisalof theQualityof Quality- S344-53.
of-LifeMeasurements." Journalof theAmeri- Idler, Ellen L., StanislavV. Kasl, and Jon H.
can MedicalAssociation272(8):619-26. Lemke. 1990. "Self-EvaluatedHealth and
Grand,A., P. Grosclaude,H. Bocquet,J. Pous, MortalityAmongthe Elderlyin New Haven,
and J.L. Albarede.1988. "PredictiveValue of Connecticut, and Iowa and Washington Coun-
Life Events, PsychosocialFactors and Self- ties, Iowa, 1982-1986." AmericanJournalof
RatedHealthon Disabilityin an ElderlyRural Epidemiology 131(1):91-103.
FrenchPopulation."Social Science and Medi- Jagger, CarolandMichaelClarke.1988. "Mortal-
cine 27(12):1337-42. ityRisksin theElderly:Five-YearFollow-Upof
. 1990. "Disability, Psychosocial Factors a Total Population."International Journalof
and MortalityAmong the Elderlyin a Rural Epidemiology 17(1):111-14.
FrenchPopulation."Journalof ClinicalEpide- Jagger,Carol, N.A. Spiers,and Michael Clarke.
miology43(8):773-82. 1993. "Factors Associated with Decline in
Groves,RobertM., NancyH. Fultz,andElizabeth Function,Institutionalization,and Mortality of
Martin.1992. "DirectQuestioning AboutCom- ElderlyPeople." Age and Ageing22:190-97.
prehension in a SurveySetting."Pp. 49-61 in Jylha,Marja. 1993. "Self-Assessments of Health
QuestionsAboutQuestions:Inquiriesinto the PredictFunctionalAbilityin Ten-YearFollow-
CognitiveBases of Surveys,edited by J.M. Up." Presentedat the 46th Annual Scientific
Tanur.New York:RussellSage. Meeting of the GerontologicalSociety of
Haberman,P.W. 1969. "The Reliabilityand America,November.
Validityof the Data." Pp. 343-83 in Poverty . 1994. "Self-Rated Health Revisited:
and Health:A SociologicalAnalysis,editedby Exploring Survey InterviewEpisodes with
J. Kosa, A. Antonovsky, and I. Zola. Cam- ElderlyRespondents."Social Scienceand Med-
bridge,MA: HarvardUniversity Press. icine39(7):983-90.
Haga, Hiroshi,HiroshiShibata,Yasuo Suyama, Kaplan, George A. and TerryCamacho. 1983.
Kazuo Suzuki,KiyoshiIwasaki,Takao Suzuki, "PerceivedHealthand Mortality: A Nine-Year
and Seiji Yasumura.1995. "Self-RatedHealth Follow-Upof theHumanPopulationLaboratory
as a Predictor of ActiveLife in theCommunity Cohort." AmericanJournalof Epidemiology
Elderly." Japanese Journalof Epidemiology 117(3):292-304.
5(1): 11-15. Kaplan,GeorgeA., WilliamJ.Strawbridge, Terry
Haug, Marie R., May L. Wykle,and Kevan H. Camacho,and RichardD. Cohen. 1993. "Fac-
Namazi. 1989. "Self-Care Among Older torsAssociatedwithChangein PhysicalFunc-
Adults." Social Science and Medicine 29(2): tioningin the Elderly:A Six-YearProspective
171-83. Study."JournalofAgingand Health5:140-53.
Hirdes,JohnP. and WilliamF. Forbes. 1993. Kaplan, Giora, Vita Barell, and Ayala Lusky.
"FactorsAssociatedwith the Maintenanceof 1988. "SubjectiveStateof Healthand Survival
Good Self-Rated Health."JournalofAgingand in Elderly Adults." Journalof Gerontology
Health5(1):101-22. 43(4):S1 14-20.
Ho, Suzanne C. 1991. "Health and Social Kasl, StanislavV. 1995. "Strategiesin Research
Predictorsof Mortalityin an ElderlyChinese on Healthand Aging:LookingBeyondSecon-
Cohort." AmericanJournalof Epidemiology daryData Analysis."Journalof Gerontology:
133:907-21. Social Sciences50B(4):S191-93.
House, James, Karl L. Landis, and Debra Krause,Neil M. and Gina M. Jay.1994. "What
Umberson. 1988. "Social Relationshipsand Do Global Self-RatedHealthItemsMeasure?"
Health."Science241:540-45. Medical Care 32(9):930-42.
Idler, Ellen L. 1993. "Age Differences in Self- Krzyzanowski,Michal and Miroslaw Wysocki.
Assessments ofHealth:AgeChanges,CohortDif- 1986. "The Relationof Thirteen-Year Mortality
ferences, or Survivorship?" JournalofGerontol- toVentilatory Impairment andOtherRespiratory
ogy:Social Sciences48(6):S289-300. Symptoms:The Cracow Study."International
Idler,Ellen L. and RonaldJ. Angel. 1990. "Self- JournalofEpidemiology 15:56-64.
RatedHealthandMortality intheNHANES-IEp- Lamb,K.L., K. Roberts,and D.A. Brodie. 1990.
idemiologicFollow-UpStudy."AmericanJour- "Self-Perceived HealthAmongSportsPartici-
nal ofPublicHealth80(4):446-52. pantsand Nonparticipants." Social Scienceand
Idler, Ellen L. and Stanislav V. Kasl. 1991. Medicine31(9):963-69.
"Health Perceptionsand Survival:Do Global LaRue, Asenath,Lew Bank, Lissy Jarvik,and
Evaluationsof Health Status Really Predict MonteHetland.1979. "HealthinOld Age: How
Mortality?"Journal of Gerontology:Social Do Physicians'Ratingsand Self-Ratings Com-
Sciences46(2):S55-65. pare?"Journalof Gerontology 34(5):687-91.

This content downloaded from 141.211.4.224 on Mon, 15 Jun 2015 21:44:48 UTC
All use subject to JSTOR Terms and Conditions
36 JOURNALOF HEALTH AND SOCIAL BEHAVIOR
Leventhal, Elaine, A. 1994. "Gender and PfeifferEric. 1970. "Survival in Old Age:
Aging:Womenand TheirAging." Pp. 11-35 Physical,Psychological,and Social Correlates
in Psychological Perspectiveson Women's of Longevity."JournaloftheAmericanGeriat-
Health, editedby V.J. Adesso, D.M. Reddy, ric Society18:29-38.
and R. Fleming.Washington,DC: Taylor & Pijls, Loek T., Edith J.M. Feskens,and Daan
Francis. Kromhout. 1993. "Self-Rated
Health,Mortality,
Litva, Andreaand JohnEyles. 1994. "Healthor and ChronicDiseases in Elderly Men: The
Healthy: Why People Are Not Sick in a ZutphenStudy,1985-1990." AmericanJournal
SouthernOntarianTown." Social Science and ofEpidemiology 138(10):840-48.
Medicine39(8):1083-91. Poor, Gyula, StevenJ. Jacobsen,and L. Joseph
Maddox, GeorgeL. 1962. "Some Correlatesof Melton. 1994. "Mortality FollowingHip Frac-
Differences in Self-Assessmentof HealthStatus ture." Pp. 91-109 in Facts and Research in
Amongthe Elderly."Journalof Gerontology Gerontology 1994, editedby B.J. Vellas, J.L.
17:180-85. Albarede,and P.J. Garry.New York: Springer.
Maddox, GeorgeL. and ElizabethB. Douglass. Powers,BethelA. 1988. "Self-Perceived Health
1973. "Self-AssessmentofHealth:A Longitudi- of ElderlyInstitutionalized People." Journalof
nal Study of Elderly Subjects." Journalof Cross-CulturalGerontology 3(3):299-321.
Healthand Social Behavior14:87-93. Rakowski,Williamand CynthiaD. Cryan.1990.
Mxland, John G. and Odd E. Havik. 1988. "AssociationsAmong Health Perceptionsand
"Self-Assessment of HealthBeforeand Aftera Health Status Within Three Age Groups."
Myocardial Infarction."Social Science and JournalofAgingand Health2(1):58-80.
Medicine27:597-605. Rakowski,Williamand VincentMor. 1992. "The
Markides,KyriakosS. and David J. Lee. 1990. Associationof PhysicalActivitywithMortality
"Predictorsof Well-Beingand Functioning in AmongOlderAdultsin theLongitudinal Study
Older Mexican Americansand Anglos: An of Aging (1984-1988)." Journalof Gerontol-
Eight-YearFollow-Up." Journalof Gerontol- ogy:Medical Sciences47(4):M122-29.
ogy:Social Sciences45:569-73. Rakowski,William, VincentMor, and Jeffrey
McCallum, John, Bruce Shadbolt, and Dong Hiris. 1991. "The Associationof Self-Rated
Wang. 1994. "Self-RatedHealthand Survival: HealthwithTwo-YearMortality in a Sampleof
A 7-Year Follow-Up Study of Australian Well Elderly."Journalof Aging and Health
Elderly."AmericanJournalof Public Health 3:527-45.
84(7):1100-5. Rakowski,William,JohnA. Fleishman,Vincent
Mor, Vincent,JohnMurphy,Susan Masterson- Mor, and Sharon A. Bryant. 1993. "Self-
Allen, CynthiaWilley,AhmadRazmpour,M. Assessmentsof Health and MortalityAmong
ElizabethJackson,David Greer, and Sidney OlderPersons:Do QuestionsOtherThanGlobal
Katz. 1989. "RiskofFunctional DeclineAmong Self-RatedHealthPredictMortality?" Research
Well Elders."Journalof ClinicalEpidemiology on Aging15(1):92-116.
42(9):895-904. Schoenfeld,David E., LyndaC. Malmrose,Dan
Mor, Vincent, Victoria Wilcox, William Ra- G. Blazer, Deborah T. Gold, and Teresa E.
kowski,and Jeffrey Hiris. 1994. "Functional Seeman. 1994. "Self-RatedHealthand Mortal-
TransitionsAmongtheElderly:Patterns, Predic- ityin the High-Functioning Elderly-A Closer
tors and Related Hospital Use." American Look at HealthyIndividuals:MacArthur Field
JournalofPublicHealth84(8):1274-80. Studyof SuccessfulAging."Journalof Geron-
Mossey, Jana M. and Evelyn Shapiro. 1982. tology:MedicalSciences49(3):M109-15.
"Self-RatedHealth: A Predictorof Mortality Segovia, Jorge,Roy F. Bartlett,and Alison C.
Among the Elderly." AmericanJournal of Edwards. 1989. "The Association Between
PublicHealth72(8):800-8. Self-AssessedHealth and Individual Health
Mutran,Elizabethand KennethFerraro. 1988. Practices."CanadianJournalof Public Health
"Medical Need and Use of Services Among 80:29-38.
OlderMen and Women."Journalof Gerontol- Shahtahmasebi,Said, Richard Davies, and G.
ogy:Social Sciences43(5):S162-71. ClareWenger.1992. "A Longitudinal Analysis
Parker,Marti G., Mats Thorslund,and Marie- ofFactorsRelatedto Survivalin Old Age." The
Louise Nordstr6m. ofMortal-
1992. "Predictors Gerontologist32(3):404-13.
ityfortheOldest-Old.A 4-Year Follow-Upof Singer, Eleanor, Robin Garfinkel,Steven M.
Community-Based Elderly in Sweden." Ar- Cohen, and Leo Srole. 1976. "Mortalityand
chivesof Gerontology and Geriatrics14:227- Mental Health: Evidence fromthe Midtown
37. ManhattanRestudy.Social Science and Medi-
Patrick,Donald L. 1987. "Commentary: Patient cine 10:517-25.
Reports of Health Status as Predictorsof Smith,AnthonyM.A., Julia M. Shelley, and
PhysiologicHealth Measures in ChronicDis- Lorraine Dennerstein. 1994. "Self-Rated
ease." ChronicDiseases 40(Suppl. 1):37-40S. Health:BiologicalContinuum or Social Discon-

This content downloaded from 141.211.4.224 on Mon, 15 Jun 2015 21:44:48 UTC
All use subject to JSTOR Terms and Conditions
SELF-RATED HEALTH AND MORTALITY 37
tinuity?"Social Science and Medicine39(1): British and AmericanElderly." Journal of
77-83. AdvancedNursing13:701-9.
Stenback,Asser. 1964. "Physical Health and Verbrugge, Lois M. and FrankJ. Ascione. 1987.
PhysicalDisease as ObjectiveFact and Subjec- "Exploringthe Iceberg: Common Symptoms
tiveExperience."Archivesof GeneralPsychia- andHow PeopleCare forThem."MedicalCare
try11:290-301. 25(6):539-69.
Stones,M.J., BrendaDornan,and AlbertKozma. Wannamethee,Goya and A.G. Shaper. 1991.
1989. "The Predictionof Mortality in Elderly "Self-Assessment ofHealthStatusandMortality
InstitutionResidents."Journalof Gerontology: in Middle-AgedBritishMen." International
PsychologicalSciences44(3):P72-79. JournalofEpidemiology 20:239-45.
Suchman,EdwardA., BernardS. Phillips,and Wilcox,Victoria,StanislavV. Kasl, and Ellen L.
GordonF. Streib. 1958. "An Analysisof the Idler. 1996. "Self-RatedHealth and Physical
Validity of Health Questionnaires."Social Disability in Elderly Survivorsof a Major
Forces 36:223-32. MedicalEvent."JournalofGerontology: Social
Sugisawa,Hidehiro,JerseyLiang, and Xian Liu. Sciences51B(2):S96-104.
1994. "Social Networks,Social Support,and Wolinsky,FredericD. and JohnF. Fitzgerald.
MortalityAmong Older People in Japan." 1994. "SubsequentHip FractureAmongOlder
Journalof Gerontology: Social Sciences49(1): Adults." AmericanJournalof Public Health
S3-13. 84(8):1316-18.
Suls, Jerryand Thomas A. Wills. 1991. Social Wolinsky,FredericD. and RobertJ. Johnson.
Comparison:Contemporary Theoryand Re- 1992. "PerceivedHealthStatusand Mortality
search.Hillsdale,NJ:LawrenceErlbaumAsso- AmongOlder Men and Women." Journalof
ciates. Gerontology 47(6):S304-12.
Svdrdsudd,Kurt and Gdsta Tibblin. 1990. "Is Wolinsky,FredericD., Christopher M. Callahan,
Qualityof Life Affecting Survival?"Scandina- and Robert J. Johnson. 1994. "Subjective
vianJournalofPrimaryHealthCare I(suppl.): HealthStatusand Mortality in theElderly."Pp.
55-60. 13-27 in Facts and Research in Gerontology
Tanur,JudithM. 1992. QuestionsAbout Ques- 1994, editedbyB.J. Vellas, J.L. Albarede,and
tions: Inquiries into the CognitiveBases of P.J. Garry.New York:Springer.
Surveys.New York:RussellSage Foundation. Wolinsky,FredericD., TimothyE. Stump,and
Thomas, Cynthia,Howard R. Kelman, Gary J. RobertJ. Johnson.1995. "HospitalUtilization
Kennedy,Chul Ahn, and Chun-yongYang. Profiles Among Older Adults Over Time:
1992. "DepressiveSymptomsand Mortality in Consistency and VolumeAmongSurvivorsand
Elderly Persons." Journal of Gerontology: Decedents." Journalof Gerontology:Social
Social Sciences47(2):S80-87. Sciences50B(2):S88-100.
U.S. Department of Healthand HumanServices. Wolinsky,FredericD., Christopher M. Callahan,
1995. Health UnitedStates 1994. Hyattsville, JohnF. Fitzgerald,and RobertJ. Johnson.
MD: PublicHealthService. 1993. "Changes in FunctionalStatusand the
Vaillant,George E. 1991. "The Associationof Risks of SubsequentNursingHome Placement
AncestralLongevitywith SuccessfulAging." and Death." Journalof Gerontology:Social
Journalof Gerontology: PsychologicalSciences Sciences48(3):S93-101.
46(6):P292-98. Wood, Joanne V., Shelley E. Taylor, and
van Maanen,HannekeM.Th. 1988. "Being Old RosemaryR. Lichtman.1985. "Social Compar-
Does Not Always Mean Being Sick: Perspec- ison to BreastCancer." Journalof Personality
tiveson Conditionsof Healthas Perceivedby and Social Psychology 49(5):1169-83.

Ellen L. Idler is associateprofessorin the Departmentof Sociologyand at the Institute

forHealth,
HealthCare Policy,and AgingResearchat RutgersUniversity. She is currentlyinvolvedin several
studiesof psychosocialfactorsin healthand aging,including
theroleof religionin recoveryfromheart
surgery,and thehealthperceptions of minorityelderly.

Yael Benyaminiis currently

a visitingscholarat Tel-AvivUniversity,
Israel,anda researchconsultant
at
theRutgersAgingand HealthStudy,RutgersUniversity, New Jersey.Her researchinterestsinclude
of healthand illness,representations
self-perceptions of and copingwithchronicillness,optimism,and
pessimism.

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