March 2001, Vol. 7, No. 1

Aging
Cultural Factors May Affect Personal Health Assessments

When researchers survey older people they commonly ask, “How would you rate your current health? Would you say that it is excellent, very good, good, fair, or poor?” The response to this question, referred to as self-assessed health, has been shown in various studies to provide a relatively accurate gauge of a person’s actual health. One study, for instance, showed self-assessed health to be a better predictor of mortality outcomes than a patient’s medical records. What conditions determine people’s judgments of their own health? Are the determinants of health similar in different countries? Are levels of self-assessed health similar in different countries after accounting for objective measures of health? Answering these questions would improve the ability of researchers to write health survey questions, compare the health of populations in various countries, and make policy recommendations.

Population Council demographer Zachary Zimmer and his colleagues explored the complexities of self-assessed health among elderly people in the Philippines, Taiwan, and Thailand. The researchers used data from a series of surveys conducted in these three Asian countries in 1996. Survey participants were aged 50 years and older and were chosen to be nationally representative.

The researchers evaluated the effect of a number of variables. Among objective measures of health, they looked at such functional items as ability to walk inside the home, dress, and lift objects. They also considered the presence of such chronic health conditions as high blood pressure, diabetes, and arthritis. The research team controlled for such demographic characteristics as age, sex, and whether residence was urban or rural. The team took note of such socioeconomic factors as education, number of household possessions (as a measure of income), and employment. The investigators took into account the extent of each person’s social network, for example whether they were married, had children, or lived with someone. Finally, the researchers factored in the effects of such unhealthy behaviors as smoking and excessive drinking.

Cross-cultural differences
The researchers found considerable variation in the way that older adults in the three countries assess their health. Overall, assessments were most likely to be favorable in Taiwan and least likely to be favorable in the Philippines. The team had expected this outcome, in part because Taiwanese are more likely than Thais or Filipinos to live in urban areas, and thus may have better access to health care. The investigators also found that objective measures of health, such as functional ability and chronic conditions, are correlated with self-assessed health in each country. The addition of virtually any chronic condition, for example, was accompanied by a downgrade in self-assessed health.

When the investigators performed a statistical analysis, however, they uncovered a striking “country effect.” Controlling for all the delineated variables, levels of self-assessed health are relatively similar between Taiwanese and Thais, but differ significantly from those in the Philippines. The probability of an older adult without any documented health problems reporting very good or excellent self-assessed health is 66 percent in Thailand and 60 percent in Taiwan, but only 25 percent in the Philippines. As these older adults experience increasing illness, their assessments decrease most sharply in Thailand and Taiwan, eventually becoming similar in all three countries. “Basically, unhealthy people in any of these countries are unlikely to say they’re doing well,” says Zimmer.

Many factors might explain the divergent health claims made in these countries. “Thailand has very good health programs for elderly people, and that could make people more positive about their health,” speculated Zimmer. “Conversely, the Philippines has very poor health care for the elderly, which may make people more pessimistic.” It is also possible that elderly Filipinos truly are in poorer health than their counterparts in Thailand and Taiwan, but that the objective measures used in these surveys were not sufficiently discriminating to detect the differences.

Cultural factors may play a big role in how people assess their health. People in the Philippines, for instance, may be more modest about their health than are people in Thailand or Taiwan. Religion may also play a role. Thailand and Taiwan are predominantly Buddhist countries, while the Philippines is largely Catholic.

“We have to recognize when we use this question that there may be cultural influences on how people assess their health,” says Zimmer. “People’s views on their health may be influenced by who they are rather than how they feel.” The research team suggests that in order to clarify the cause of these variations, future research should expand upon the variables studied and investigate subtle cultural factors that may determine self-assessed health.

Source
Zimmer, Zachary, Josefina Natividad, Hui-Sheng Lin, and Napaporn Chayovan. 2000. “A cross-national examination of the determinants of self-assessed health,” Journal of Health & Social Behavior 41(4):465–481.

Outside funding
U.S. National Institute on Aging

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