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Self-rated health: from epidemiology to patient encounter
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In epidemiology self-rated health is often measured as people’s subjective answer to a question “How is your health in general?” or “How is your general health compared to persons of your own age?”. The answers have a strong association with significant medical outcomes such as death, diabetes, coronary heart disease, functional ability and depression, medical diagnoses and how these are perceived. The overarching aim of this thesis was to investigate if and how a use of the epidemiologists’ tool of self-rated health might aid GPs in practising medicine with a holistic perspective, contextually sensitive and taking into account the patients’ medical and personal histories.

Methods: In Paper I, I used semantics to elucidate the meaning of self-rated health. Data came from the Northern Sweden Monica Project 1990–1999. In Paper II, with data from the MONICA Project in 1999–2009, I used ordinal regression to investigate associations between self-rated health, medical factors, psychosocial factors and emotions. In Paper III, I used data from the Västerbotten Intervention Programme 1990–2004 in Cox regression analyses to investigate the relationship between self-rated health and standard risk factors for the outcome myocardial infarction. Paper IV is a qualitative study from seven primary care health centres. Actual consultations were audio-recorded and analysed with systematic text condensation, measuring apportionment of speaking time and by taking into account GPs’ assessments of using a question about comparative self-rated health in a consultation.

Results: In Paper I, I found “health” in questionnaires being understood not through definitions of health but through associations of the word “health” with “sense relations”, that are important connotations of the word “health”. Age-comparative self-rated health was semantically clearer as it pointed towards comparison with a reference group. In Paper II, emotions of anxiety or depression and discontent with personal economy were associated with lower self-rated health and were common in the population. Paper III established self-rated health as an independent risk factor for myocardial infarction when adjusted for standard risk factors. In the qualitative Paper IV, self-rated health affected consultations, increased patients’ speaking time in relation to doctors’ when discussing self-rated health and elicited reactions, sometimes with strong language. Reflections ensued that could give vivid descriptions of function, life circumstances and resources or obstacles in handling symptoms and illnesses.

Conclusion: Comparative self-rated health constitutes a feasible tool in general practice, particularly in taking account of patients’ medical and personal histories. It is holistic, sensitive to psychosocial factors. It is useful to solicit information on risk and the patient’s feelings related to an illness/disease, and to encourage the patient’s active reflection on functional abilities, life situation, health and health strategies. However, self-ratings are not to be seen as a standard procedure in all consultations.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2015. , 73 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1756
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
URN: urn:nbn:se:umu:diva-109404ISBN: 978-91-7601-337-3 (print)OAI: oai:DiVA.org:umu-109404DiVA: diva2:856933
Public defence
2015-10-30, Aulan, Sunderby sjukhus, Luleå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-10-02 Created: 2015-09-26 Last updated: 2015-10-01Bibliographically approved
List of papers
1. A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study
Open this publication in new window or tab >>A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study
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2012 (English)In: BMC Medical Research Methodology, ISSN 1471-2288, E-ISSN 1471-2288, Vol. 12, 154Article in journal (Refereed) Published
Abstract [en]

Background: Self-Rated Health (SRH) correlates with risk of illness and death. But how are different questions of SRH to be interpreted? Does it matter whether one asks: “How would you assess your general state of health?”(General SRH) or “How would you assess your general state of health compared to persons of your own age?”(Comparative SRH)? Does the context in a questionnaire affect the answers? The aim of this paper is to examine the meaning of two questions on self-rated health, the statistical distribution of the answers, and whether the context of the question in a questionnaire affects the answers.

Methods: Statistical and semantic methodologies were used to analyse the answers of two different SRH questions in a cross-sectional survey, the MONICA-project of northern Sweden.

Results: The answers from 3504 persons were analysed. The statistical distributions of answers differed. The most common answer to the General SRH was “good”, while the most common answer to the Comparative SRH was “similar”. The semantic analysis showed that what is assessed in SRH is not health in a medical and lexical sense but fields of association connected to health, for example health behaviour, functional ability, youth, looks, way of life. The meaning and function of the two questions differ – mainly due to the comparing reference in Comparative SRH. The context in the questionnaire may have affected the statistics.

Conclusions: Health is primarily assessed in terms of its sense-relations (associations) and Comparative SRH and General SRH contain different information on SRH. Comparative SRH is semantically more distinct. The context of the questions in a questionnaire may affect the way self-rated health questions are answered. Comparative SRH should not be eliminated from use in questionnaires. Its usefulness in clinical encounters should be investigated.

Place, publisher, year, edition, pages
BioMed Central, 2012
National Category
Family Medicine Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-64328 (URN)10.1186/1471-2288-12-154 (DOI)000313577600001 ()
Available from: 2013-01-23 Created: 2013-01-23 Last updated: 2017-12-06Bibliographically approved
2. What does age-comparative self-rated health measure?: A cross-sectional study from the Northern Sweden MONICA Project
Open this publication in new window or tab >>What does age-comparative self-rated health measure?: A cross-sectional study from the Northern Sweden MONICA Project
2016 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 44, no 3, 233-239 p.Article, review/survey (Refereed) Published
Abstract [en]

Aims: Self-rated health comprehensively accounts for many health domains. Using self-ratings and a knowledge of associations with health domains might help personnel in the health care sector to understand reports of ill health. The aim of this paper was to investigate associations between age-comparative self-rated health and disease, risk factors, emotions and psychosocial factors in a general population. Methods: We based our study on population-based cross-sectional surveys performed in 1999, 2004 and 2009 in northern Sweden. Participants were 25-74 years of age and 5314 of the 7500 people invited completed the survey. Comparative self-rated health was measured on a three-grade ordinal scale by the question How would you assess your general health condition compared to persons of your own age?' with the alternatives better', worse' or similar'. The independent variables were sex, age, blood pressure, cholesterol, body mass index, self-reported myocardial infarction, stroke, diabetes, physical activity, smoking, risk of unemployment, satisfaction with economic situation, anxiety and depressive emotions, education and Karasek scale of working conditions. Odds ratios using ordinal regression were calculated. Results: Age, sex, stroke, myocardial infarction, diabetes, body mass index, physical activity, economic satisfaction, anxiety and depressive emotions were associated with comparative self-rated health. The risk of unemployment, a tense work situation and educational level were also associated with comparative self-rated health, although they were considerably weaker when adjusted for the the other variables. Anxiety, depressive emotions, low economic satisfaction and a tense work situation were common in the population. Conclusions:Emotions and economic satisfaction were associated with comparative self-rated health as well as some medical variables. Utilization of the knowledge of these associations in health care should be further investigated.

Place, publisher, year, edition, pages
London: Sage Publications, 2016
Keyword
cardiovascular disease, comparative self-rated health, diabetes, emotions, ordinal regression analysis, population based study, psychosocial factors, risk factors
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-109147 (URN)10.1177/1403494815618554 (DOI)000373591600003 ()26644159 (PubMedID)
Note

Originally published in manuscript form.

Available from: 2015-09-21 Created: 2015-09-21 Last updated: 2017-05-23Bibliographically approved
3. Self-rated health and standard risk factors for myocardial infarction: a cohort study
Open this publication in new window or tab >>Self-rated health and standard risk factors for myocardial infarction: a cohort study
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2015 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, e006589Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate the relationship between self-rated health, adjusted for standard risk factors, and myocardial infarction.

Design: Population-based prospective cohort study.

Setting: Enrolment took place between 1990 and 2004 in Västerbotten County, Sweden

Participants: Every year, persons in the total population, aged 40, 50 or 60 were invited. Participation rate was 60%. The cohort consisted of 75 386 men and women. After exclusion for stroke or myocardial infarction before, or within 12 months after enrolment or death within 12 months after enrolment, 72 530 persons remained for analysis. Mean follow-up time was 13.2 years.

Outcome measures: Cox regression analysis was used to estimate HRs for the end point of first non-fatal or fatal myocardial infarction. HR were adjusted for age, sex, systolic blood pressure, total cholesterol, smoking, diabetes, body mass index, education, physical activity and self-rated health in the categories very good; pretty good; somewhat good; pretty poor or poor.

Results: In the cohort, 2062 persons were diagnosed with fatal or non-fatal myocardial infarction. Poor selfrated health adjusted for sex and age was associated with the outcome with HR 2.03 (95% CI 1.45 to 2.84). All categories of self-rated health worse than very good were statistically significant and showed a dose–response relationship. In a multivariable analysis with standard risk factors (not including physical activity and education) HR was attenuated to 1.61 (95% CI 1.13 to 2.31) for poor self-rated health. All categories of self-rated health remained statistically significant. We found no interaction between self-rated health and standard risk factors except for poor self-rated health and diabetes.

Conclusions: This study supports the use of self-rated health as a standard risk factor among others for myocardial infarction. It remains to demonstrate whether self-rated health adds predictive value for myocardial infarction in combined algorithms with standard risk factors.

Keyword
Self-rated Health, Cox regression, Cohort, Risk Factors, Myocardial Infarction
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-100224 (URN)10.1136/bmjopen-2014-006589 (DOI)000363455400020 ()25681313 (PubMedID)
Available from: 2015-02-26 Created: 2015-02-26 Last updated: 2017-12-04Bibliographically approved
4. GPs asking patients to self-rate their health: a qualitative study
Open this publication in new window or tab >>GPs asking patients to self-rate their health: a qualitative study
2015 (English)In: British Journal of General Practice, ISSN 0960-1643, E-ISSN 1478-5242, Vol. 65, no 638, e624-e629 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: In epidemiological research, self-rated health is an independent predictor of mortality, cardiovascular diseases, and other critical outcomes. It is recommended for clinical use, but research is lacking.

AIM: To investigate what happens in consultations when the question 'How would you assess your general health compared with others your own age?' is posed.

DESIGN AND SETTING: Authentic consultations with GPs at health centres in Sweden.

METHOD: Thirty-three planned visits concerning diabetes, pain, or undiagnosed symptoms were voice-recorded. Dialogue regarding self-rated health was transcribed verbatim and analysed using a systematic text condensation method. Speaking time of patients and doctors was measured and the doctors' assessment of the value of the question was documented in a short questionnaire.

RESULTS: Two overarching themes are used to describe patients' responses to the question. First, there was an immediate reaction, often expressing strong emotions, setting the tone of the dialogue and influencing the continued conversation. This was followed by reflection regarding their functional ability, management of illnesses and risks, and/or situation in life. The GPs maintained an attitude of active listening. They sometimes reported a slight increase in consultation time or feeling disturbed by the question, but mostly judged it as valuable, shedding additional light on the patients' situation and making it easier to discuss difficulties and resources. The patients' speaking time increased noticeably during this part of the consultation.

CONCLUSION: Asking patients to comparatively self-rate their health is an effective tool in general practice.

Place, publisher, year, edition, pages
British Journal of General Practice, 2015
National Category
Family Medicine
Identifiers
urn:nbn:se:umu:diva-108085 (URN)10.3399/bjgp15X686557 (DOI)000361840400009 ()26324500 (PubMedID)
Note

Funding: County Council of Norrbotten (references NLL-302621; NLL-363851; NLL-300901).

Available from: 2015-09-03 Created: 2015-09-03 Last updated: 2017-12-04Bibliographically approved

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