Göran Waller

Self-rated health and standard risk factors for myocardial infarction: a cohort study

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 self-rated 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.

A cross-sectional and semantic investigation of self-rated health in the northern Sweden MONICA-study

BackgroundSelf-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.MethodsStatistical 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.ResultsThe 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.ConclusionsHealth 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.

What does age-comparative self-rated health measure? A cross-sectional study from the Northern Sweden MONICA Project

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.

GPs asking patients to self-rate their health: a qualitative study

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.

Self-rated health in general practice: a plea for subjectivity

I think many GPs with some experience recognise that a major problem in medical practice is not always the medical problem in itself. It is the subjective side of the matter, the patient’s ideas, and possibilities of handling the situation of illness, disease, and functional impairment that are the challenges. None of this was focused on in my medical training and continuous medical education. However, there is now a solid mass of research emphasising the importance of the patient’s subjective side of the matter. Paying attention to the patient’s own assessment of health is important not only as a sign of interest and empathy; it can also be crucial in assessing prognosis, guide consultations to important questions, and guide efforts in handling diseases. All these are lessons learned from research on self-rated health. GPs can confidently use and adopt this research in clinical encounters and clinical research. ### Outcomes Outcomes such as mortality, cardiovascular disease, stroke, lung disease, arthritis, functional impairment, depression, and developing diabetes type 2 and its prognosis are associated to self-rated health.1–3 ### Better than doctors’ ratings Self-rated health is a better predictor of future health (good health assessed as no symptoms of disease or minimal impairment if symptoms present) than doctors’ ratings.4 It also adds information beyond a doctor’s ordinary clinical evaluation.1,5 ### Comprehensive There are innumerable factors affecting patients’ health. Self-rated health is a comprehensive way to assess the patient’s situation.1 Self-rated health can guide doctors and their patients in …

Time trends of comparative self-rated health in adults aged 25–34 in the Northern Sweden MONICA study, 1990–2014

Self-rated health (SRH) accounts comprehensively for many health domains. The aim of this paper was to investigate time trends and associations between age-comparative self-rated health and some known determinants in a general population aged 24–34 years. Population-based cross-sectional surveys were performed in 1990, 1994, 1999, 2004, 2009 and 2014 in Northern Sweden. Out of 3500 invited persons, 1811 responded. Comparative SRH 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/similar”. Over the period 1990 to 2014, the percentage of women rating comparative SRH as “worse” increased steadily, from 8.5% in 1990 reaching 20% in 2014 (p for trend 0.007). Among men, this pattern was almost the opposite, with increasing proportions rating “better” (p for trend <0.000). Time trends for physical activity in leisure time; length of education; Body Mass Index; anxiety; depressive emotions and satisfaction with economy showed a similar pattern for men and women. Factors that might contribute to the development of time trends for comparative SRH are discussed.