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RESEARCH |
Beverly Sibthorpe is with the National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory. Ian Anderson is with the VicHealth Koori Health Research and Community Development Unit, University of Melbourne, Melbourne, Victoria, Australia. Joan Cunningham is with the Menzies School of Health Research, Darwin, Northern Territory, Australia.
Correspondence: Requests for reprints should be sent to Beverly Sibthorpe, PhD, National Centre for Epidemiology and Population Health, Australian National University, ACT 0200, Australia (e-mail: beverly.sibthorpe{at}anu.edu.au).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. This study assessed the validity of a global measure of self-assessed health among Indigenous Australians.
Methods. Logistic regression was used to identify factors associated with self-assessed health in a nationally representative sample.
Results. Among 8782 adult respondents, poorer self-assessed health was strongly associated with several factors, including age, number of health conditions, and recent health actions. The association with health conditions was attenuated when the respondent's primary language was not English.
Conclusions. Self-assessed health may be a valid measure among indigenous Australians whose primary language is English. However, although the measure draws on common experiences of health and illness, it may obscure differences in how people incorporate these experiences into social actions.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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There are 2 general approaches to subjective health assessment. The first involves the use of multiple items, covering a number of dimensions of health, that may be designed to sum to a single index. In the second approach, a single global question is used. Global questions also appear in many validated multi-item instruments, including the General Health Questionnaire3 and the Short-Form Health Survey,4 and have been found to correlate with multi-item instruments such as the Nottingham Profile.5 Because of their simplicity, ease of administration, and validated performance, global questions are now in widespread use.
In the Australian National Health Survey of 1989–1990, a global measure was included for the first time. Indigenous Australians at that time composed approximately 2% of the population, and because they were not oversampled, there were insufficient data for meaningful analysis. In 1994, the Australian Bureau of Statistics conducted the first national survey of Indigenous Australians—the National Aboriginal and Torres Strait Islander Survey, or NATSIS—and included a global item on self-assessed health, making adequate data available for the first time. However, questions had long been raised about the appropriateness of using mainstream indicators in assessing health and well-being among Indigenous Australians, not least because Indigenous people are believed to have a different concept of health than other groups (National Aboriginal Health Strategy Working Party, A National Aboriginal Health Strategy [unpublished report], 1989). In this article, we distill analyses published by the Australian Bureau of Statistics6 to examine the validity of the global measure with this population.
The health status of Indigenous Australians is worse than that of non-Indigenous Australians.7, 8 In the period 1991 through 1996, estimated life expectancies were 56.9 years for Indigenous men (vs 75.2 years for all Australian men) and 61.7 years for Indigenous women (vs 81.1 years for all Australian women).7 As Kunitz has shown, health among this population is also relatively worse than that of Indigenous peoples in comparable colonial countries.9 For example, life expectancy at birth among Maoris is 8 years less than that among other New Zealanders.10 The 5 major causes of death among Indigenous Australians are, in descending order, circulatory diseases, injury and poisoning, respiratory diseases, neoplasms, and endocrine–metabolic disorders (including diabetes).7
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Respondents were asked the following question: "In general, would you say that your health is excellent, very good, good, fair, or poor?" Information was also sought on self-reported diseases and conditions, illness and health actions taken in the previous 2 weeks, use of medications, and days off due to illness. Other information collected related to family and culture, education and training, housing, employment and income, and law and justice.
In the present analysis, responses to the self-assessed health question were collapsed into 2 categories: poor or fair and good, very good, or excellent. The relationship between fair or poor health and age was examined, and the results were compared with similar data derived from approximately 54 000 Australians participating in the 1995 National Health Survey.12
SAS (version 6.12; SAS Institute, Inc, Cary, NC) was used in conducting logistic regression (forward selection) analyses exploring the relationship between self-assessed health and factors that might reasonably be expected to be associated with self-assessed health. All analyses involved weighting appropriate to the sampling design, and the estimates presented are weighted estimates of the entire Indigenous adult population.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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.
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).
Overall, the percentages of males and females reporting fair or poor health were similar to those reporting fair or poor health in the 1995 Australian National Health Survey (16.3% and 16.7%, respectively).12 When the data were stratified by age, however, differences were apparent in both the male and the female groups (Figure 1). Much higher percentages of Indigenous subjects in the 35- to 44-year and 45- to 64-year age groups reported fair or poor health. Furthermore, although age was a significant predictor of self-assessed health status in both populations, the percentages of National Health Survey respondents reporting fair or poor health steadily increased with age, whereas the percentages of Indigenous Australians reporting fair or poor health were actually lower in the oldest age group (
65 years) than in the 55- to 64-year group (Figure 1).
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. After adjustment for other factors, age, long-term health conditions, recent health actions, need for assistance due to long-term disability, primary language spoken, and employment status were strongly associated with self-assessed fair or poor health. Number of self-identified long-term health conditions showed a strong trend of increasing odds of reports of fair or poor health with increasing number of conditions. Those who did not speak English as their main language were less likely to report their health as fair or poor, even after adjustment for other factors.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Our findings are consistent with the expectation that poorer self-reported "objective" health measures would be associated with poorer self-assessed health and that the demographic factors associated with poorer health status in other populations8, 14 (e.g., education) would also be associated with poorer health in this population. As expected, age was significantly associated with reports of fair or poor health as well; however, the relationship was attenuated by other factors.
Although the percentage of NATSIS respondents reporting fair or poor health was similar to the percentage for the Australian population as a whole, this apparent similarity was due to confounding by age. Age-specific comparisons of fair or poor health status reflect observed health differentials between the 2 groups; thus, relatively larger proportions of Indigenous Australians report fair or poor health in those age groups with the greatest levels of excess mortality. In areas with adequate data quality, rate ratios for all-cause mortality are 6.9 and 7.8, respectively, among men and women aged 35 to 44 years and 6.0 and 6.7, respectively, among men and women aged 45 to 54 years.7
It is possible that among Indigenous Australians of middle age, self-assessed health may be a reasonable predictor of health outcomes. Other studies have shown that global measures of self-assessed health predict mortality in the elderly after a range of health, demographic, and social factors have been controlled.15–17 In the present study, the decline in the percentage of subjects reporting fair or poor health in the oldest age group may be explained by the relatively high level of mortality in the younger age groups, which results in a relatively healthy group of survivors attaining older age.
The observed relationship between not speaking English as a primary language and fair or poor self-assessed health among NATSIS respondents is inconsistent with morbidity and mortality data. In Indigenous Australia, not speaking English as a main language is a fair proxy for geographic remoteness of residence, and Indigenous Australians living in remote areas (approximately 20% of the Indigenous population) do not enjoy better health than those living in towns and cities. It is likely that the study terms and constructs had different meanings for this group than for Indigenous Australians for whom English had been a first (and often only) language for generations.
Moreover, misunderstandings may have been exacerbated by the style and social context of the data collection. In addition, social or physical distance from health services may have reduced the likelihood that people were given the illness labels that might otherwise have been given to them. All of the factors just mentioned may help to account for the finding that the percentages of subjects with 3 or more long-term health conditions who rated their health as fair or poor were lower among those whose first language was not English (male difference: 50% vs 67%; female difference: 37% vs 55%).6
In conclusion, this analysis shows that a global self-assessed health question may be a valid measure for Indigenous Australians whose main language is English. However, care should be taken not to overinterpret the findings. Arguably, concepts of health do not exist as a simple continuum leading to more biomedical constructions.
Furthermore, the observed link between self-assessed health and more "objective" health measures should not be taken uncritically to mean that cultural factors do not play a role in shaping understandings of illness or in framing health actions. Regardless of the acquisition of illness labels, both self-care and consumption of health services may be organized in culturally distinct ways. For example, in some Aboriginal cultural contexts (including groups whose primary language is English), interpersonal relationships and relationships with homelands have been identified as part of a complex set of notions related to "well-being" that may influence health care actions.18 Thus, self-assessed health measures, although drawing on common experiences of health and illness, may still obscure significant differences in how people understand and respond to these experiences or incorporate them into social action.
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Acknowledgments |
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Joan Cunningham's work was supported by a fellowship from the Menzies Foundation.
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Footnotes |
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Accepted for publication February 23, 2001.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Epstein A. The outcomes movement—will it get us where we want to go? N Engl J Med.1990;323:266–270.[Medline]
3. Goldberg D. The Detection of Psychiatric Illness by Questionnaire. London, England: Oxford University Press Inc; 1972.
4. Ware J, Sherbourne C. The MOS 36-Item Short-Form Health Survey (SF-36). Med Care. 1992;30:473–483.[Medline]
5. Rowan K. Global questions and scores. In: Jenkinson C, ed. Measuring Health and Medical Outcomes. London, England: UCL Press; 1994:54–76.
6. Cunningham J, Sibthorpe B, Anderson I. SelfAssessed Health Status, Indigenous Australians [occasional paper]. Canberra, Australian Capital Territory: Australian Bureau of Statistics and National Centre for Epidemiology and Population Health; 1997.
7. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra, Australian Capital Territory: Australian Bureau of Statistics; 1999.
8. Australia's Health 2000. Canberra, Australian Capital Territory: Australian Institute of Health and Welfare; 2000.
9. Kunitz S. Disease and Social Diversity: The European Impact on the Health of Non-Europeans. New York, NY: Oxford University Press Inc; 1994.
10. King A. The Future Shape of Primary Health Care: A Discussion Document. Wellington, New Zealand: Ministry of Health; 2000.
11. National Aboriginal and Torres Strait Islander Survey 1994: Detailed Findings. Canberra, Australian Capital Territory: Australian Bureau of Statistics; 1995.
12. Australia's Health 1996. Canberra, Australian Capital Territory: Australian Institute of Health and Welfare; 1996.
13. Angel R, Thoits P. The impact of culture on cognitive structure and illness. Cult Med Psychiatry. 1987;11:465–494.[Medline]
14. Macran S, Clarke L, Sloggett A, Bethune A. Women's socio-economic status and self-assessed health: identifying some disadvantaged groups. Sociol Health Illness.1994;16:182–208.
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McCallum J, Shadbolt B, Wang D. Self-rated health and survival: a 7-year follow-up study of Australian elderly. Am J Public Health.1994;84:1100–1105.
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Idler E, Angel R. Self-rated health and mortality in the NHANES-I epidemiologic follow-up study. Am J Public Health. 1990;80:446–452.
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Pijls L, Feskens E, Kromhout D. Self-rated health, mortality and chronic diseases in elderly men. Am J Epidemiol.1993;138:840–848.
18. Mobbs R. In sickness and health: the sociocultural context of Aboriginal well-being, illness and health. In: Reid J, Trompf P, eds. The Health of Aboriginal Australia. Sydney, New South Wales: Harcourt Brace Jovanovich; 1991:292–325.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
