Intern
ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
V
o
l.3
,
No
.2
,
Jun
e
2
014
, pp
. 69
~80
I
S
SN
: 225
2-8
8
0
6
69
Jo
urn
a
l
h
o
me
pa
ge
: h
ttp
://iaesjo
u
r
na
l.com/
o
n
lin
e/ind
e
x.ph
p
/
IJPHS
The Determinants and Subsequent
Effect
of
Self-
R
at
ed Health
Status on Survival amon
g Elderl
y Am
eri
c
ans
Guangming Ha
n
Departm
e
nt o
f
E
p
idem
iolog
y
,
Universit
y
of
Nebr
aska Medical Ce
n
t
er,
Om
aha,
NE,
US
A
Article Info
A
B
STRAC
T
Article histo
r
y:
Received
Ja
n 31, 2014
Rev
i
sed
Ap
r
20
, 20
14
Accepted
May 26, 2014
The m
a
in
aim
of this stud
y is
to ex
p
l
ore
the
patt
erns, d
e
ter
m
inants and
subsequent mortality
pr
ediction
of change
in self-rated health in
the elder
l
y
American population
.
To ach
ieve this
purpose, we cons
tructed logistic
regression models and Cox proportional
h
a
zard regression models with the
complex survey dataset from the Nation
a
l Second Longitudin
a
l Stud
y
o
f
Aging (LSOA II
) to calcu
lat
e
th
e odds ratios (OR)/ hazard r
a
tio
s (HR) and
confiden
ce
inter
v
als (CI) of r
i
sk factors. Our
results show th
at ch
ronic
disease conditio
n and difficu
lty in dail
y
activ
ities are the main
reasons for
change
in s
e
lf-r
ated h
eal
th s
t
a
t
u
s
. F
u
rtherm
ore,
change
in s
e
lf-r
ated h
eal
th
has significant impact on surviv
al fun
c
tion
in th
e eld
e
rly
populations. When
change in self-r
ated health status
was consider
ed, self-rated h
ealth was a
stronger and
more flexible pr
edictor
of mortality
for
eld
e
rly
populations
.
These find
ings will provide
im
portant info
rm
ation to est
a
blis
h effec
tiv
e
strateg
i
es for pr
olonging lifespan b
y
im
proving
self-rated h
ealth status for
elder
l
y
populatio
ns.
Keyword:
Self-rated health
Mo
rtality
Chronic diseas
e
El
derl
y
p
o
pul
a
t
i
o
n
Copyright ©
201
4 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Gua
n
gm
i
ng Ha
n,
Depa
rt
m
e
nt
of
Epi
d
em
i
o
l
ogy
,
Uni
v
ersity of
Nebras
ka Me
dical Center,
Om
aha, NE
,
U
S
A.
Em
a
il: g
u
a
ng
min
g
.
h
a
n
@
un
m
c
.edu
1.
INTRODUCTION
Po
pul
at
i
o
n agi
ng i
s
bec
o
m
i
ng an i
n
c
r
easi
n
g im
port
a
nt
i
ssue w
o
rl
dwi
d
e
.
In t
h
e
U.S
,
t
h
e el
der
po
p
u
l
a
t
i
on
(a
g
e
6
5
y
ears a
n
d
el
der
)
i
s
39
.6
m
i
ll
i
on i
n
2
0
0
9
, a
n
i
n
crease
of
4.
3 m
i
l
l
i
on,
or
1
2
.
5
% si
nce
1
9
9
9
.
That m
eans one in eve
r
y eight, or
12
.9%
of
t
h
e
p
o
p
u
l
a
t
i
on i
s
a
n
el
de
r Am
erican [1]. The
world’s
elde
r
population is
projected to tri
p
le from
516 m
illion in
2
009 to
1.53 billion
in 2050 [2]. T
h
er
e
f
ore, prom
oting
heal
t
h
a
n
d
p
r
ol
on
gi
n
g
l
i
f
e
are
im
port
a
nt
p
ubl
i
c
heal
t
h
i
s
s
u
e
i
n
el
de
r
po
p
u
l
a
t
i
on.
Effect
i
v
e
p
r
om
ot
i
o
n
heal
t
h
a
n
d
pr
ol
o
n
g
i
n
g l
i
fe i
n
el
de
r
p
o
p
u
l
a
t
i
o
n
de
pe
nd
o
n
i
m
port
a
nt
adva
nces
i
n
ou
r u
n
d
erst
a
n
d
i
ng
of i
t
s
ri
s
k
f
act
ors.
Se
lf-rat
ed health is a
hea
lth
m
easure
base
d on the
re
sponse t
o
the s
i
m
p
le
q
u
e
stio
n, “How
do
you
f
eel?
”
. C
u
m
u
la
tive evide
n
ce s
u
ggests that
self-rated
h
ealth
is a stron
g
ind
e
p
e
nd
en
t
p
r
ed
icto
r fo
r health
ou
tco
m
es su
ch
as m
o
rb
id
ity an
d m
o
rtality [3
],[4
].
Furth
e
r stud
ies
hav
e
sh
own
th
at self-
rat
e
d
heal
t
h
st
at
us co
nt
ai
ns
m
o
re im
port
a
n
t
pr
og
n
o
st
i
c
i
n
f
o
rm
at
i
on t
h
a
n
phy
si
ci
an
-as
s
essed
heal
t
h
st
at
us
[5]
,
[6]
.
The
r
e
f
ore
,
self-r
ated health
has bec
o
m
e
an extensive m
easure of h
ealth
in
h
ealth
re
search
[7
]-[
9
]
.
In
addition, a re
port has s
h
own that change
in s
e
lf-rate
d health is a stronge
r pr
edictor of m
o
rtalit
y than self-rated
health at baseline and at the
m
o
st r
ecent observation [10]. Self-rate
d hea
lth
is a change
able risk fact
or for
death
because self-rate
d healt
h
, as a s
u
bject
ive feeling
of a pers
on, re
fle
c
ts not only one pe
rs
on’s physical
an
d
p
h
y
si
o
l
og
ical h
ealth
stat
u
s
, bu
t also
on
e p
e
rson’s p
s
ych
o
s
o
c
ial h
e
alth
statu
s
, su
ch
as qu
ality o
f
life,
incom
e
and
education [11]. T
h
ere
f
ore,
exp
l
oratio
n
s
of t
h
e
determin
an
ts that
have
a si
gni
ficant effect
on self-
rated
health an
d cha
n
ge in se
lf-rate
d health
status l
eadin
g
to establishin
g
effective str
a
tegies f
o
r
pr
olo
n
g
i
n
g
l
i
f
e i
n
el
de
r
p
o
pul
at
i
o
n a
r
e
ve
ry
i
m
port
a
nt
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S
Vo
l.
3
,
N
o
.
2
,
Jun
e
201
4 :
6
9
– 80
70
The p
u
r
p
ose of the p
r
ese
n
t study
is to
assess th
e pat
t
ern o
f
cha
n
g
e
in self-rated
health, th
e
determ
inants that affect self-rated
heal
t
h
, and t
h
e c
h
an
ge
of sel
f
-rat
e
d h
eal
t
h
st
at
us and su
bse
que
nt
m
o
rt
al
it
y
p
r
ed
ictio
n am
o
n
g
co
mm
u
n
ity-d
welling
el
d
e
r
Am
erican
s.
2.
MATE
RIAL
S AND METHODS
The
dat
a
use
d
i
n
t
h
i
s
st
u
d
y
were
o
b
t
a
i
n
ed
fr
om
t
h
e 19
9
4
-
2
00
0 Sec
o
n
d
L
o
n
g
i
t
u
di
nal
St
udi
es
o
f
Agi
ng (
L
S
O
A
II), a p
u
b
licly available database. T
h
e su
rv
ey
'
s
design
a
n
d
pr
oce
d
u
r
es have been pu
b
lished
el
sewhe
r
e [
12]
,[
13]
. I
n
b
r
i
e
f,
t
h
e LS
OA II
is a collaborati
v
e effort betw
een the National Center for Health
Statistics (NC
H
S) an
d th
e
Natio
n
a
l
In
stitu
te
o
n
Ag
ing
.
Th
e go
als
of th
e
LSOA II stud
y are to b
e
tter
u
n
d
e
rstand
d
i
sab
ility p
a
th
ways an
d
i
n
terrel
a
tio
n
s
h
i
p
s
b
e
t
w
een
d
e
term
in
an
ts and
fun
c
tio
n
a
l
o
u
t
co
m
e
s
a
m
o
ng
eld
e
r
adu
lts. Th
e LSOA
I
I
is a lo
n
g
itud
i
n
a
l
stu
d
y
w
ith
a natio
n
a
lly r
e
p
r
esen
tativ
e sam
p
le co
n
s
istin
g
of
9
,
447
civ
ilian
n
o
n
-
i
n
stitu
tio
n
a
lized
p
e
rson
s, 70
years of ag
e an
d
eld
e
r at th
e ti
me o
f
th
eir b
a
selin
e in
terv
iew. Th
is
b
a
selin
e in
terview, also
k
nown
as th
e Second
Su
pp
lem
e
n
t
on
A
g
i
n
g (S
O
A
I
I),
was c
o
n
duct
e
d i
n
t
h
e
p
e
ri
o
d
o
f
1
994
–19
96
. Th
e LSOA
I
I
follo
w
e
d th
is coh
o
r
t
o
f
p
a
r
ticip
an
ts
th
roug
h two
fo
llo
w-up in
terv
iews du
ri
n
g
th
e
p
e
r
i
o
d
s
of
19
97
–19
98
and
19
99–
200
0. The stud
y sam
p
le h
a
s b
e
en
link
e
d w
ith th
e
N
a
tio
n
a
l
D
eat
h
I
n
d
e
x
(NDI), called th
e LSOA II Li
n
k
e
d
M
o
rtality File (CDC
2
0
0
6
).
Th
e
LSOA II Li
n
k
e
d
M
o
rtality File p
r
o
v
i
d
e
s
m
o
rtality follow-up
data from the
date of SOA II interview (1994-
1996) through
Decem
ber 31, 2006.
Mo
rtality ascertain
m
e
n
t
is b
a
sed
prim
arily
u
pon
d
eat
hs p
r
ev
iou
s
ly id
en
tified
during
o
n
e
o
f
t
w
o
fo
l
l
o
w
-up
in
terv
iews, i
n
1
997
-19
9
8
an
d 1
999
-20
0
0
,
an
d
resu
lts
from a p
r
ob
ab
ilistic
m
a
tch
b
e
tween
LSOA II an
d
NDI
death certificat
e records. Li
n
k
ag
e o
f
th
e LSOA II surv
ey
p
a
rticip
an
ts
with
th
e NDI prov
id
es th
e opp
ortun
ity
to conduct a vast array of outcom
e
st
udi
es desi
g
n
e
d
t
o
i
nvest
i
g
at
e t
h
e associ
at
i
on
of a
wi
de vari
et
y
o
f
heal
t
h
f
acto
r
s
w
ith
m
o
r
t
ali
t
y. I
n
t
h
e
p
r
esen
t st
ud
y,
o
f
th
e 9,44
7 su
bj
ects, th
er
e w
e
r
e
5
,
39
9 r
e
spo
n
d
e
n
t
s who
answere
d
bot
h
self-rated heal
th
qu
est
i
o
ns at
basel
i
n
e a
n
d
19
9
9
-
2
00
0 i
n
t
e
rvie
ws. T
h
ese
res
p
ondents i
n
clude
4,
80
7 w
h
i
t
e
A
m
eri
cans, 49
8 Af
ri
can Am
eri
cans a
n
d
94 classified as
“ot
h
e
r
”.
The m
easure of self-rated
hea
lth
in LSOA II was a single questio
n aske
d
at each interview: “
W
oul
d
yo
u
say you
r
health
in
g
e
n
e
r
a
l is ex
cellen
t
, v
e
r
y
goo
d, good
, f
a
i
r
, or
p
o
o
r
?
”
. Respo
n
s
es to
th
is qu
estion
w
e
r
e
code
d 1 t
h
r
o
u
gh
5, res
p
ect
i
v
el
y
.
C
h
ro
ni
c d
i
sease con
d
i
t
i
ons o
f
de
pressi
on
, cat
aract
s, gl
auc
o
m
a
, bl
i
ndne
ss
,
d
eafn
e
ss, o
s
teo
poro
s
is, d
i
abetes, arthritis, b
r
on
ch
itis
or
e
m
p
h
y
sem
a
, h
y
p
e
rten
si
o
n
, asth
m
a
, h
eart disease,
stroke and ca
ncer are
defi
ned according to
participa
n
ts
’
s
e
lf-re
ports of physician
diagnos
ed disease at
each
in
terv
iew (“wh
eth
e
r a d
o
ctor to
ld
you
th
at
yo
u
h
a
d
art
h
ritis…”). Th
e
measu
r
e of activ
ity o
f
d
a
ily liv
in
g
diffic
u
lties was assessed by the num
b
er of ite
m
s
a
t
each in
terview: “Because of a hea
lth or physical problem
,
d
o
you
h
a
v
e
ANY
d
i
fficu
lty
?
”
Th
e ite
m
s
in
clu
d
e
d
:
b
a
th
i
n
g
or showering, d
r
essing
,
eatin
g, g
e
tting
in
an
d
o
u
t
of
be
d
or
chai
rs,
wal
k
i
n
g
,
us
i
ng t
h
e t
o
i
l
e
t
,
pre
p
ari
n
g
y
o
u
r
o
w
n
m
eal
s, sho
p
p
i
n
g
fo
r
gr
oceri
e
s a
n
d
pe
rso
n
al
i
t
e
m
s
,
m
a
nagi
n
g
y
o
u
r
m
oney
,
usi
n
g t
h
e t
e
l
e
p
h
o
n
e,
doi
ng l
i
g
ht
ho
use
w
or
k,
m
a
nagi
n
g
y
o
u
r
m
e
di
cat
i
on. S
o
ci
al
activ
ities were d
e
term
in
ed
usin
g respo
n
s
es to
th
e qu
estio
n
s
at each
i
n
terv
iew: “Di
d
y
o
u g
e
t t
o
g
e
t
h
er wit
h
f
r
i
end
s
or
n
e
igh
bor
s
?
” an
d “D
id
y
o
u
g
e
t t
o
g
e
th
er
with
rel
a
tiv
es?
”
For
association analysis bet
w
een
se
l
f
-
r
at
ed heal
t
h
(
o
r c
h
ange i
n
sel
f
-rat
e
d heal
t
h
) a
nd
dem
ogra
phi
c
charact
e
r
i
s
t
i
c
or ri
sk fact
or
, w
e
const
r
uct
e
d l
ogi
st
i
c
re
gressi
on m
odel
s
. T
h
ese l
ogi
st
i
c
reg
r
essi
o
n
m
odel
s
were
co
nstru
c
ted
to
calcu
late th
e od
d
s
ratio
s (OR
)
and
con
f
i
d
ence intervals (C
I)
of dem
o
graphic cha
r
acterist
i
c and
risk
fact
o
r
s.
All th
e od
d
s
ratio
s were adj
u
sted
with
de
m
ograp
hi
c fac
t
ors,
fam
i
ly
factors, s
o
cial factors,
p
e
rson
al h
ealt
h
b
e
h
a
v
i
ors
facto
r
s, d
i
fficu
lti
es in
d
a
ily
activ
ities and
ch
ron
i
c d
i
seases
v
a
riab
les.
For surv
i
v
al
analysis,
Cox proportional hazard regression
m
odel
was
const
r
ucte
d for
exam
ining the
effects of self-rated
h
ealth
o
r
ch
ang
e
in self-rated h
ealth
v
a
riab
l
e
s.
An
alyses
were co
ndu
cted
b
y
u
s
ing
SAS software
(versi
on
9.2, SAS In
stitu
te, Cary, NC). A two-
sided p-val
u
e
<.05
was c
o
nsidere
d
t
o
be stat
istically signifi
cant.
3.
RESULTS
3.
1. Ch
ar
acter
i
sti
c
s
o
f
P
a
rti
c
i
p
ant
s
at ba
sel
i
n
e
In t
a
bl
e
1, t
h
e
sam
p
l
e
i
n
cl
ud
ed
3,
39
1
w
o
m
e
n a
n
d
2
,
0
0
8
m
e
n wi
t
h
a
n
a
v
era
g
e a
g
e
of
75
.5
1 y
e
a
r
s
(SD=
5.
2
5
)
.
Th
e
m
a
jori
t
y
wer
e
Whi
t
e
Am
eri
can (
n
=4
,8
0
7
,
89
.0
4%
). O
f
t
h
e 5,
3
99
part
i
c
i
p
ant
s
,
78
5(
1
4
.
5
4
%
)
p
a
rticip
an
ts rep
o
rted
as self-rated
e
x
cel
l
e
nt
heal
t
h
st
at
us
,
1,
55
2
(
2
8
.
7
5%)
p
a
rticip
an
ts rep
o
rted
as self-rated
very
g
o
o
d
hea
l
t
h
st
at
us, 1,
9
7
4
(
3
6.
56%
) par
t
i
c
i
p
ant
s
re
p
o
rt
ed
as
sel
f
-
r
at
e
d
go
o
d
heal
t
h
st
at
us, 86
3
(
1
5
.
9
8
%
)
p
a
r
ticip
an
ts r
e
p
o
r
t
ed
as self
-r
ated
f
a
ir
health
statu
s
and
22
5(4
.
1
7
%
)
p
a
rticip
an
ts r
e
p
o
r
t
ed
as self-
r
a
ted
poor
health status.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S
I
S
SN
:
225
2-8
8
0
6
The Det
e
r
m
i
n
a
n
t
s
an
d S
ubse
q
uent
Ef
f
ect
of
S
e
l
f
-
rat
e
d He
al
t
h
St
at
u
s
on
S
u
r
v
i
v
al
...
.
(
G
u
a
n
g
mi
ng
H
a
n)
71
T
a
bl
e 1. Ch
ar
acteri
s
t
i
c
s
o
f
par
t
i
c
i
p
an
ts
i
n
ba
seline
surv
ey,
LSOA
II bet
w
een 19
94
a
n
d
199
6
Characteristic
Mean (
S
D)
or number (
%
)
Characteristic
Mean (
S
D)
or number (
%
)
Age 75.
51
(
5
.
25)
Nu
m
b
er
of chr
onic disease
0=853(
15.
8
0
%)
1=1,
276(
23.
6
3
%)
2=1,
265(
23.
4
3
%)
3=941(
17.
4
3
%)
4=552(
10.
2
2
%)
5=305(
5.
65%)
6=133(
2.
46%)
7
=
5
0
(
0
.
9
3
%
)
8=20(
0.
37%)
9=3(
0.
06%)
10=1(
0.
02%)
Gender
M
a
le=2,
008
(
37.
19%)
Fem
a
le=3391 (
62.
81%)
BM
I 25.
53
(
4
.
39)
Race
W
h
ite A
m
e
r
ican=
4
,807 (89.04%)
Afr
i
can Am
er
ican
=498 (
9
.
22%)
Other
=
94 (
1
.
74%)
E
ducation
E
l
em
entar
y
school=339 (
6
.
28%)
M
i
ddle school=86
7
(
16.
06%)
High school=2,
6
6
1
(
49.
29)
College=1,
532 (
2
8
.
38%)
I
n
co
m
e
L
e
ss than $20,
000
=2,
877 (
53.
29%)
$20,
00
0 or
m
o
r
e
=2,
522 (
46.
71%)
Nu
m
b
er
of difficul
t
y
in
daily activities
0=4,
028(
74.
6
1
%)
1=563(
10.
4
3
%)
2=238(
4.
41%)
3=163(
3.
02%)
4=108(
2.
00%)
5
=
9
1
(
1
.
6
9
%
)
6=54(
1.
00%)
7
=
4
6
(
0
.
8
5
%
)
8=40(
0.
74%)
9
=
2
6
(
0
.
4
8
%
)
10=15(
0.
28%)
11=14(
0.
26%)
12=13(
0.
24%)
M
a
r
ital status
M
a
rr
ied=2,
853 (
52.
84%)
W
i
dowed=2,
018 (
37.
38%)
Divor
ced=276 (
5
.
11%)
Never
m
a
rr
ied=252
(
4
.
64%)
Fam
i
ly
r
e
lationship
L
i
ving alone= 1,
82
3(
33.
77%)
L
i
ving with spouse
=
2,
922(
54.
12%)
L
i
ving with other
=
654(
12.
11%)
Together with frie
nds
or
neighbor
s
Together with
relatives
Yes= 4,
083(
75.
63
%)
No= 1,
316(
24.
37
%)
Yes= 4,
226(
78.
27
%)
No= 1,
173(
21.
73
%)
Exercise
Sm
oking
Alcohol consu
m
ption
Yes=2,
328 (
43.
12
%)
No=3,
071 (
56.
88
%)
Never
s
m
oked=2,
9
46 (
54.
57%)
Cur
r
e
nt s
m
oker
=
4
89 (
9
.
06%)
Form
er s
m
oker=1,936 (
35.
85%)
M
i
ssing=28 (
0
.
5
2
%
)
Yes=1,
008 (
18.
67
%)
No=4,
391 (
81.
33
%)
Self-
r
a
ted health status
E
x
cellent=785(
14.
54%)
Very
Good=1,
552(
28.
75%)
Good=1,
97
4(
36.
56
%)
Fair
=863(
15.
98%)
Poor
=225(
4.
17%)
Region
Nor
t
heast=1,
155
(
21.
39%)
M
i
dwest=1,
478 (
27.
38%)
South=1,
73
9 (
32.
2
1
%)
W
e
st=1,
027 (
19.
02%)
SD: Standar
d
deviations
3.
2. T
h
e ef
fect
s o
f
dem
o
gr
ap
hi
c char
ac
teri
sti
c
or
ri
sk
fac
t
or
o
n
sel
f
-ra
t
ed he
al
th
st
at
us
Alth
oug
h
sel
f
-rated
h
e
alth
statu
s
is a sub
j
ectiv
e f
eeling, it can reflect the pers
on’s
phy
siological or
phy
si
cal
heal
t
h
st
at
us. As s
h
o
w
n i
n
t
a
bl
e 2,
peo
p
l
e
wi
t
h
m
o
re c
h
r
o
ni
c di
s
ease con
d
i
t
i
o
n
s
or m
o
re di
f
f
i
c
ul
t
y
i
n
d
a
ily activ
ities
were
g
e
n
e
rally
m
o
re lik
ely
to
repo
rt “fair” or “p
oo
r”
h
e
alth
con
d
ition
.
In
o
r
d
e
r to
co
m
b
at
t
h
ese “s
pu
ri
o
u
s
rel
a
t
i
o
n
s
hi
ps
”, re
gre
ssi
o
n
a
n
al
y
s
i
s
was
co
nd
uct
e
d
.
We c
onst
r
uct
e
d t
h
e
l
ogi
st
i
c
reg
r
e
ssi
on
m
o
d
e
l f
o
r
v
a
r
i
ab
le o
f
sel
f
-r
ated
h
ealth
status (
e
x
cellen
t
,
v
e
r
y
g
ood
,
g
ood
w
e
r
e
co
d
e
d
as
1
,
f
a
i
r
and
poor
w
e
r
e
code
d as
0)
. A
s
sh
ow
n i
n
t
a
b
l
e 3, com
p
are
d
t
o
part
i
c
ip
an
ts with
ou
t chronic d
i
sease cond
itio
n
o
r
d
i
fficu
lty in
d
a
ily activ
ities
,
p
a
rticip
an
ts with
d
e
p
r
ess,
o
s
teopo
ro
si
s, diab
etes, arthritis, em
p
h
y
se
m
a
,
h
y
p
e
rten
sion
,
h
eart,
cancer
, di
f
f
i
c
u
l
t
y
of eat
i
ng, di
ffi
c
u
l
t
y
of w
a
l
k
i
ng a
nd
di
f
f
i
c
ul
t
y
of sh
o
ppi
ng are
gen
e
ral
l
y
m
o
re l
i
kel
y
t
o
repo
rt “fair”
o
r
“po
o
r”
h
ealth
statu
s
. In
add
itio
n
t
o
chro
n
i
c
d
i
sease co
nd
itio
n and
d
i
fficu
l
t
y in
d
a
ily activ
ities,
othe
r dem
ogra
phic c
h
aracteri
s
tic and ri
s
k
f
actors
were al
so sig
n
ificantl
y
correlated
w
ith self-rate
d
health
status. For e
x
a
m
ple, co
m
p
ared with
wh
ite American
, African
-
Am
erican
s were less lik
el
y to
repo
rt th
ei
r self-
rated he
alth status as “excell
e
nt”, “ve
r
y good”
, or “
goo
d”. Particip
an
ts with
less educatio
n
or less
in
co
m
e
were m
o
re likely to
repo
rt th
eir self-rated h
ealth
as
“fai
r” or “poor”
.
Exercise a
n
d
getting toget
h
er with
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S
Vo
l.
3
,
N
o
.
2
,
Jun
e
201
4 :
6
9
– 80
72
friends or nei
g
hbors ha
d positive effects on self-rate
d heal
t
h
status for pa
rticipants
(OR is 1.326 for exe
r
cise,
OR
i
s
1.
58
4 f
o
r get
t
i
ng
t
oget
h
er wi
t
h
f
r
i
e
n
d
s or
nei
g
h
b
o
rs
).
T
a
bl
e 2.
T
h
e
e
ffec
t
s of
num
b
er
o
f
chr
o
ni
c di
sease or di
ff
i
c
ul
ty
i
n
d
a
i
l
y
acti
vi
ti
es on S
e
l
f-ra
t
ed
he
al
t
h
status
Self-
rated health status at baseline
Self-
rated health status at baseline
No
Of
chronic
disease
Excellen
t
(%)
Ver
y
Good
(%)
Good
(%)
Fair
(%)
Poor
(%)
No
of
diffic
u
lty
in daily
activities
Excellen
t
(%)
Ver
y
Good
(%)
Good
(%)
Fair
(%)
Poor
(%)
0
28.
25
34.
70
30.
48
5.
74
0.
82
0
17.
68
33.
42
36.
99
10.
90
1.
02
1 19.
28
36.
52
34.
17
9.
25
0.
78
1
6.
22
20.
78
43.
52
25.
04
4.
44
2 13.
04
30.
67
38.
50
15.
18
2.
61
2
4.
62
13.
03
36.
97
36.
97
8.
40
3
9.
78
24.
23
41.
45
19.
87
4.
65
3
4.
29
12.
88
35.
58
31.
90
15.
34
4
5.
80
18.
66
40.
94
26.
45
8.
15
4
7.
41
8.
33
22.
22
40.
74
21.
30
5
1.
97
18.
36
37.
70
30.
82
11.
15
5
5.
49
7.
69
27.
47
34.
07
25.
27
6
2.
26
9.
77
32.
33
37.
59
18.
05
6
1.
85
14.
81
18.
52
35.
19
29.
63
7
0.
00
4.
00
22.
00
34.
00
40.
00
7
4.
35
10.
87
23.
91
30.
43
30.
43
8
0.
00
0.
00
30.
00
40.
00
30.
00
8
5.
00
7.
50
17.
50
30.
00
40.
00
9
0.
00
0.
00
0.
00
66.
67
33.
33
9
0.
00
7.
69
34.
62
23.
08
34.
62
10
0.
00
0.
00
0.
00
0.
00
100.
00
10
6.
67
13.
33
26.
67
33.
33
20.
00
11
11
0.
00
7.
14
0.
00
71.
43
21.
43
12
12
7.
69
0.
00
23.
08
15.
38
53.
85
T
a
bl
e
3.
T
h
e
ass
o
ci
a
t
i
o
n
o
f
sel
f-r
ated
he
al
th
and
dem
o
g
r
aphi
c c
h
ar
ac
teri
sti
c
or ri
sk
f
a
ct
or
Demographic char
acteristic or
risk factor
OR
(
9
5
%
CI)
Demographic char
acte
ristic or risk factor
OR
(
95%
CI)
AGE
1.
009
(
0
.
990 1.
028)
DE
PRE
S
SE
D (
Yes vs No)
0.
597
(
0
.
441 0.
809)
**
GE
NDE
R
(Fem
ale vs M
a
le)
1.
007
(
0
.
814 1.
246)
CAT
A
RAC
T
S (Yes vs No)
1.
074
(
0
.
883 1.
308)
RACE
Black
v
s
Wh
ite
0.
539
(
0
.
408 0.
713)
**
*
GL
AUC
OM
A (
Y
es vs No)
0.
798
(
0
.
589 1.
082)
Other vs W
h
ite
0.
858
(
0
.
426 1.
729)
BL
I
N
DNE
S
S (
Y
es vs No)
0.
815
(
0
.
565 1.
178)
BM
I
1.
010
(
0
.
990 1.
031)
DE
AFNE
SS (
Y
es
vs No)
0.
902
(
0
.
706 1.
153)
M
A
RIT
A
L
_
ST
ATUS
OST
E
OPOROSI
S
(
Y
es vs No)
0.
649
(
0
.
483 0.
872)
**
Divor
ced vs Mar
r
i
ed
1.
171
(
0
.
641 2.
141)
DI
ABET
E
S
(
Y
es
vs No)
0.
656
(
0
.
507 0.
848)
**
Never
m
a
r
r
i
ed
vs M
a
r
r
i
ed
1.
161
(
0
.
626 2.
152)
ART
H
RIT
I
S (
Y
es
vs No)
0.
663
(
0
.
549 0.
799)
**
*
W
i
dowed vs Mar
r
i
ed
1.
174
(
0
.
710 1.
941)
E
M
PHYSEM
A
(
Y
es vs No)
0.
547
(
0
.
413 0.
725)
**
*
E
DUCAT
I
ON
AST
H
M
A
(
Y
es vs
No)
0.
764
(
0
.
535 1.
092)
E
l
e
m
entary
s
c
hool vs
college
0.
453
(
0
.
307 0.
669)
**
*
HYPE
R
T
E
N
SI
ON (
Y
es vs
No)
0.
702
(
0
.
587 0.
840)
**
High school vs college
0.
720
(
0
.
569 0.
913)
**
HE
ART (
Y
es vs No)
0.
409
(
0
.
334 0.
501)
**
*
M
i
ddle school
vs college
0.
493
(
0
.
368 0.
659)
**
*
ST
ROKE
(Yes vs
No)
0.
730
(
0
.
533 1.
000)
I
N
CO
ME
L
e
ss than $20,
000 vs
$20,
00
0 or
m
o
r
e
0.
665
(
0
.
541 0.
817)
**
*
CANCE
R
(
Y
es vs
No)
0.
793
(
0
.
631 0.
995)
*
RE
L
A
T
I
ONSHI
P
DI
FFI
C
U
L
T
Y_BAT
H
ING (
Y
es
vs No)
0.
732
(
0
.
510
1.
050)
L
i
ving alone vs L
i
ving with
spouse
1.
068
(
0
.
643 1.
776)
DI
FFI
C
U
L
T
Y_DRE
SSI
NG (Yes vs
No)
0.
733
(
0
.
471 1.
142)
L
i
ving with other
vs L
i
ving
with spouse
0.
863
(
0
.
506 1.
471)
DI
FFI
C
U
L
T
Y_E
A
T
I
NG (Yes vs No
)
0.
468
(
0
.
230 0.
953)
*
FRI
E
NDS (Yes vs
No)
1.
584
(
1
.
304 1.
923)
**
*
DI
FFI
C
U
L
T
Y_BED1 (
Y
es vs
No)
0.
725
(
0
.
514 1.
024)
RE
L
A
T
I
VE
S
(
Y
es
vs No)
0.
952
(
0
.
769 1.
178)
DI
FFI
C
U
L
T
Y_WAL
K
ING
(
Y
es vs
No)
0.
464
(
0
.
362 0.
595)
**
*
E
X
E
RCISE
(
Y
es v
s
No)
1.
326
(
1
.
104 1.
592)
**
DI
FFI
C
U
L
T
Y_T
O
I
L
ET
1 (
Y
es vs No
)
1.
627
(
0
.
956 2.
769)
SM
OKE
(Yes vs
No)
0.
751
(
0
.
563 1.
003)
DI
FFI
C
U
L
T
Y_ME
AL
S1
(
Y
es vs
No)
0.
830
(
0
.
514 1.
339)
AL
COHOL
(
Y
es v
s
No)
1.
242
(
0
.
962 1.
604)
DI
FFI
C
U
L
T
Y_SHOPPI
NG (Yes vs
No)
0.
456
(
0
.
324 0.
640)
**
*
RE
GI
ON
DI
FFI
C
U
L
T
Y_MONE
Y1
(
Y
es vs
No)
1.
194
(
0
.
666 2.
142)
M
i
dwest vs Nor
t
heast
1.
019
(
0
.
790 1.
316)
DI
FFI
C
U
L
T
Y_T
E
L
E
P
HONE(
Y
esvs
No)
0.
667
(
0
.
389 1.
144)
South vs Nor
t
heast
0.
838
(
0
.
654 1.
072)
DI
FFI
C
U
L
T
Y_HOUSEW
OR
K (Yes vs
No)
0.
757
(
0
.
483 1.
188)
W
e
st vs Nor
t
heast
0.
971
(
0
.
727 1.
297)
DI
FFI
C
U
L
T
Y_ME
DI
CAT
I
O (
Y
es v
s
No)
0.
968
(
0
.
515 1.
822)
Odds r
a
tios (
O
R)
f
o
r
(
e
xcellent,
ver
y
good
and
go
od)
se
lf-
r
a
ted
health and
their
95% con
f
ide
n
ce inter
v
als (
C
I
)
,
m
odel adjusted
for
other
dem
ogr
aphic, disease conditions and
other
r
i
sk factor
s.
***p<0.
0
001,
*
*
p
<
0.
01,
*p<0.
05.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S
I
S
SN
:
225
2-8
8
0
6
The Det
e
r
m
i
n
a
n
t
s
an
d S
ubse
q
uent
Ef
f
ect
of
S
e
l
f
-
rat
e
d He
al
t
h
St
at
u
s
on
S
u
r
v
i
v
al
...
.
(
G
u
a
n
g
mi
ng
H
a
n)
73
3.
3. Th
e p
a
tte
r
n of c
h
ange
d
respon
s
es
to s
e
lf-rated
he
alth ques
t
ion
Sel
f
-
r
at
ed h
eal
t
h
st
at
us w
oul
d cha
n
ge aft
e
r
an i
n
di
vi
d
u
al
’s
phy
si
cal
, p
h
y
s
i
o
l
ogi
cal
,
or
ps
y
c
hos
oci
a
l
heal
t
h
st
at
us
c
h
an
ge
d
ove
r t
i
m
e. As s
h
o
w
n
i
n
t
a
bl
es
4 a
nd
5, a
su
bst
a
nt
i
a
l
pr
o
p
o
r
t
i
o
n o
f
part
i
c
i
p
a
n
t
s
(
5
9.
07
%)
change
d their
reporte
d
healt
h
status
afte
r
a 6-year
follow-up, 39.17%
d
o
wn
grad
ed
t
h
eir self-rated h
ealth
st
at
us and
19
.
8
8
%
up
g
r
ade
d
t
h
ei
r sel
f-rat
e
d heal
t
h
st
at
us
. A
m
ong
part
i
c
i
p
ant
s
wh
o r
a
t
e
d t
h
ei
r heal
t
h
as
“excellent” at
baseline, 70.45% cha
nge
d
t
h
eir rating
;
m
a
k
e
it th
e least stab
le of th
e 5 self-rated
h
ealth
l
e
v
e
ls.
On
ly
5
1
.56
%
p
a
rticip
an
ts wh
o rep
o
rted their h
ealth
as “p
oor” at b
a
selin
e ch
ang
e
t
h
eir rating
;
m
a
k
i
n
g
it the
m
o
st
st
abl
e
l
e
vel
of 5 sel
f
-rat
e
d heal
t
h
cat
eg
ori
e
s. I
n
ad
di
t
i
on,
42
.9
1%
p
a
rt
i
c
i
p
ant
s
cha
nge
d rat
i
n
gs
b
y
onl
y
o
n
e
lev
e
l,
wh
ile 16
.1
6%
o
f
t
h
e p
a
rticip
an
ts ch
ang
e
d
th
ei
r ratin
g
s
b
y
m
o
re th
an on
e lev
e
l.
Table
4. The
pattern of c
h
ange
d response
s
to self-r
ated
heal
th questi
on by c
a
te
gories
Self-rated health
I
n
terview (
1994-
1996)
Self-rated health
I
n
terview (
1999-
2000)
E
x
cellent Very
Good
Good
Fair
Poor
E
x
cellent 14.
54%(
7
8
5
)
4.
30%(
232)
5.
87%(
317)
3.
09%(
167)
0.
80%(
43)
0.
48%(
26)
Very
Good
28.
75%(
1
5
52)
2.
89%(
156)
10.
96%(
5
9
2
)
10.
09%(
5
4
5
)
3.
45%(
186)
1.
35%(
73)
Good
36.
56%(
1
9
74)
1.
57%(
85)
7.
35%(
397)
16.
80%(
9
0
7
)
8.
00%(
432)
2.
83%(
153)
Fair 15.
98%(
8
6
3
)
0.
39%(
21)
1.
33%(
72)
4.
20%(
227)
6.
85%(
370)
3.
20%(
173)
Poor
4.
17%(
225)
0.
07%(
4
)
0.
20%(
11)
0.
57%(
31)
1.
30%(
70)
2.
02%(
109)
T
o
tal 100.
00%(
5
399)
9.
22%(
498)
25.
73%(
1
3
89)
34.
77%(
1
8
77)
20.
39%(
1
1
01)
9.
89%(
534)
Percen
tag
e
(n
u
m
b
e
r)
Table 5.The pattern of
changed
re
sponses to
self-rated
hea
l
th question by lev
e
ls
Interview
(
1994-
1996)
Change
d level of s
e
lf-rated health
I
n
terview (
1999-
2000)
-
4
-
3
-
2
-
1
0
1 2
3 4
Excellent
14.
54%
(
785)
0.
48%
(
26)
0.
80%
(
43)
3.
09%
(
167)
5.
87%
(
317)
4.
30%
(
232)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
Very
Good
28.
75%
(
1552)
0.
00%
(0
)
1.
35%
(
73)
3.
45%
(
186)
10.
09%
(
545)
10.
96%
(
592)
2.
89%
(
156)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
Good
36.
56%
(
1974)
0.
00%
(0
)
0.
00%
(0
)
2.
83%
(
153)
8.
00%
(
432)
16.
80%
(
907)
7.
35%
(
397)
1.
57%
(
85)
0.
00%
(0
)
0.
00%
(0
)
Fair
15.
98%
(
863)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
3.
20%
(
173)
6.
85%
(
370)
4.
20%
(
227)
1.
33%
(
72)
0.
39%
(
21)
0.
00%
(0
)
Poor
4.
17%
(
225)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
0.
00%
(0
)
2.
02%
(
109)
1.
30%
(
70)
0.
57%
(
31)
0.
20%
(
11)
0.
07%
(4
)
Total
100.
00%
(
5399)
0.
48%
(
26)
2.
15%
(
116)
9.
37%
(
506)
27.
17%
(
1467)
40.
93%
(
2210)
15.
74%
(
850)
3.
48%
(
188)
0.
59%
(
32)
0.
07%
(4
)
Percen
tag
e
(n
u
m
b
e
r)
3.4.
De
terminants that
affec
t
the ch
ange of
self-rated
he
alth status
Altho
u
gh m
a
ny
stu
d
ies h
a
ve f
o
un
d th
at self-ra
te
d health
is
ass
o
ciated with dem
ogra
phic
charact
e
r
i
s
t
i
c
s or ri
s
k
fact
o
r
s,
no st
u
d
y
has
expl
ore
d
t
h
e determinants that affect
the change in self-rated
health status.
There
f
ore,
we
are ex
p
l
or
ing w
h
ich
f
actor
s, su
ch
as d
e
m
o
gra
phic c
h
ara
c
teristic, change of
phy
si
cal
, p
h
y
s
i
o
l
o
gi
cal
o
r
psy
c
ho
soci
al
heal
t
h
st
at
us
, have
a sign
ifican
t effect on
ch
an
g
e
in
self-rated
health
status. In table
6, we co
nstr
u
c
ted the logistic regres
si
o
n
m
odel f
o
r
variab
les of cha
nge
in self-rate
d h
ealth
statu
s
(
dow
ng
rad
e
or
up
gr
ade v
e
r
s
u
s
no
chan
g
e
)
.
Sev
e
r
a
l
stable variabl
e
s, suc
h
as ge
nde
r, race
, education,
regi
on a
n
d i
n
c
o
m
e
, and ch
an
ged
va
ri
abl
e
s,
suc
h
as age
,
c
h
an
ge
d B
M
I,
chan
ge
d exe
r
ci
se, cha
n
ged
fri
end
s
,
ch
ang
e
d
relativ
es, ch
ang
e
d
d
i
fficu
lty in
d
a
ily ac
tiv
ities
an
d
ch
ang
e
d ch
ron
i
c d
i
sease co
nd
itio
n
s
, were
include
d in t
h
is m
odel. As
shown i
n
tabl
e 6, a
g
e,
ge
nder, race,
educ
ation, re
gion a
n
d inc
o
m
e
were
not
significa
ntly associated
with cha
nge
in
self-rated h
e
alth
statu
s
. Ju
st as
p
a
rticip
an
ts
with
d
i
fficu
lty in d
a
ily
activ
ities o
r
ch
ron
i
c d
i
sease con
d
ition
s
were m
o
re lik
ely rep
o
rt to
be “fair”
o
r
“p
oor” h
ealt
h
statu
s
,
p
a
rticip
an
ts wi
th
ch
an
g
e
from “n
o
d
i
fficu
l
t
y
” to
“d
i
fficu
lty” in
d
a
ily act
iv
ities o
r
ch
ang
e
fro
m
“n
o
r
m
a
l” to
“diseases” we
r
e
m
o
re likely
to cha
nge thei
r self-rate
d h
ealt
h
status to d
o
w
n
g
r
a
de
. Fo
r exam
ple, participants
were lik
ely to d
o
wn
grad
e their self-r
at
ed
heal
t
h
f
o
r cha
nge
d
di
f
f
i
c
ul
t
y
of
wal
k
i
n
g
,
c
o
o
k
i
n
g m
eal
s, hear
t
d
i
sease an
d stro
k
e
. Con
tinu
o
u
s
d
i
fficu
lty o
f
d
r
essing
an
d to
ilet was also
m
o
re lik
ely to
d
o
wn
grad
e th
eir self-
rated
h
ealth
st
atu
s
. Very
in
t
e
restin
g
l
y, p
a
rticip
an
ts
w
ith
release fro
m
d
i
fficu
lty in
d
a
i
l
y activ
ities, s
u
ch
as
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S
Vo
l.
3
,
N
o
.
2
,
Jun
e
201
4 :
6
9
– 80
74
eatin
g
an
d b
e
d
,
w
e
r
e
m
o
r
e
lik
ely to
upgr
ad
e th
eir
statu
s
.
Par
ticip
an
ts w
ith
r
e
lease f
r
o
m
su
sp
endin
g
or
m
i
sdi
a
gn
osi
s
wi
t
h
di
abet
es o
r
em
phy
sem
a
were
also m
o
re
likely to upgra
de thei
r status
.
T
a
bl
e
6.
T
h
e
ass
o
ci
a
t
i
o
n
be
tw
een ch
an
ge
i
n
sel
f-r
ate
d
h
e
al
th
a
nd d
e
m
ogr
ap
hi
c ch
ar
acteri
s
t
i
c
OR
9
5
%
CI
D
o
wngr
ad
e
OR
9
5
%
CI
Upgrade
OR
9
5
%
CI
Downgra
d
e
OR
9
5
%
CI
Upgrade
Age
0.
997
(
0
.
977
1.
017)
1.
021
(
0
.
997
1.
044)
Change dif
f
iculty
telephone
Gender
(F vs M)
0.
869
(
0
.
714
1.
056)
0.
920
(
0
.
730
1.
160)
2 vs 1
1.
172
(
0
.
785
1.
750)
1.
511
(
0
.
941
2.
426)
Race
3 vs 1
0.592
(0.139
2.
528)
1.
056
(
0
.
271
4.
122)
Black vs W
h
ite
1.
170
(
0
.
852
1.
607)
1.
127
(
0
.
778
1.
634)
4 vs 1
0.
424
(
0
.
146
1.
231)
0.
900
(
0
.
278
2.
913)
Other
s
vs
W
h
ite
0.
905
(
0
.
431
1.
904)
1.
248
(
0
.
553
2.
815)
Change dif
f
iculty
housewor
k
E
ducation
2 vs 1
0.
674
(
0
.
408
1.
114)
1.
162
(
0
.
616
2.
189)
Ele
m
en
ta
ry
v
s
college
1.
319
(
0
.
838
2.
075)
1.
300
(
0
.
763
2.
213)
3 vs 1
0.
991
(
0
.
423
2.
321)
1.
457
(
0
.
643
3.
300)
M
i
ddle vs college
0.
962
(
0
.
710
1.
302)
1.
054
(
0
.
746
1.
490)
4 vs 1
0.
751
(
0
.
281
2.
011)
0.
853
(
0
.
278
2.
615)
High vs college
0.
992
(
0
.
814
1.
209)
0.
956
(
0
.
757
1.
208)
Change dif
f
iculty
m
e
dication
Region
2 vs 1
1.
594
(
0
.
940
2.
703)
1.
324
(
0
.
691
2.
538)
M
i
dwest vs
Northeast
1.
143
(
0
.
897
1.
457)
1.
170
(
0
.
883
1.
551)
3 vs 1
0.
542
(
0
.
100
2.
946)
0.
199
(
0
.
031
1.
274)
South vs Nor
t
heast
0.
998
(
0
.
785
1.
268)
1.
070
(
0
.
810
1.
413)
4 vs 1
1.
496
(
0
.
466
4.
798)
0.
374
(
0
.
083
1.
687)
W
e
st vs No
r
t
heast
1.
117
0.
863 1.
446
0.
891
(
0
.
652
1.
217)
Change cataracts
In
co
m
e
(
L
ess than $20,
00 vs
$20,
00
0
or
m
o
r
e
)
1.
121
(
0
.
935
1.
344)
1.
063
(
0
.
858
1.
318)
2 vs 1
0.
951
(
0
.
763
1.
187)
0.
873
(
0
.
668
1.
139)
Change BM
I
3 vs 1
1.
010
(
0
.
768
1.
329)
1.
312
(
0
.
976
1.
762)
Decrease
vs no
change
1.
021
(
0
.
789
1.
323)
0.
954
(
0
.
705
1.
292)
4 vs 1
1.
172
(
0
.
905
1.
519)
0.
813
(
0
.
589
1.
121)
Increase vs no
change
0.
943
(
0
.
714
1.
245)
1.
016
(
0
.
736
1.
402)
Change glauco
m
a
Change exer
cise
2 vs 1
1.
418
(
0
.
961
2.
093)
1.
148
(
0
.
717
1.
838)
2 vs 1
0.
835
(
0
.
649
1.
073)
0.
861
(
0
.
644
1.
151)
3 vs 1
1.
602
(
0
.
814
3.
154)
1.
273
(
0
.
569
2.
846)
3 vs 1
1.
147
(
0
.
890
1.
477)
0.
764
(
0
.
553
1.
054)
4 vs 1
0.
905
(
0
.
620
1.
322)
0.
943
(
0
.
608
1.
464)
4 vs 1
0.
905
(
0
.
734
1.
116)
0.
946
(
0
.
744
1.
204)
Change blind
n
ess
Change fr
iends
2 vs 1
1.
042
(
0
.
706
1.
537)
0.
973
(
0
.
603
1.
571)
2 vs 1
1.
084
(
0
.
740
1.
588)
0.
827
(
0
.
538
1.
271)
3 vs 1
0.
451
(
0
.
159
1.
277)
0.
675
(
0
.
247
1.
846)
3 vs 1
1.
169
(
0
.
831
1.
644)
0.
849
(
0
.
577
1.
250)
4 vs 1
0.
904
(
0
.
536
1.
523)
1.
212
(
0
.
673
2.
182)
4 vs 1
1.
187
(
0
.
871
1.
620)
0.
956
(
0
.
681
1.
343)
Change deafness
Change r
e
latives
2 vs 1
1.
064
(
0
.
833
1.
359)
1.
042
(
0
.
780
1.
391)
2 vs 1
0.
896
(
0
.
620
1.
295)
0.
835
(
0
.
545
1.
280)
3 vs 1
0.
914
(
0
.
564
1.
483)
0.
886
(
0
.
507
1.
546)
3 vs 1
0.
865
(
0
.
614
1.
218)
0.
845
(
0
.
572
1.
248)
4 vs 1
0.
983
(
0
.
717
1.
348)
0.
883
(
0
.
609
1.
281)
4 vs 1
0.
875
(
0
.
655
1.
170)
0.
877
(
0
.
632
1.
217)
Change osteop
or
os
is
Change dif
f
iculty
bathing
2 vs 1
1.
130
(
0
.
874
1.
461)
1.
083
(
0
.
794
1.
476)
2 vs 1
0.
866
(
0
.
598
1.
254)
1.
271
(
0
.
818
1.
975)
3 vs 1
0.
956
(
0
.
500
1.
829)
1.
419
(
0
.
728
2.
766)
3 vs 1
1.
231
(
0
.
552
2.
744)
1.
663
(
0
.
752
3.
678)
4 vs 1
1.
178
(
0
.
814
1.
707)
1.
206
(
0
.
791
1.
839)
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S
I
S
SN
:
225
2-8
8
0
6
The Det
e
r
m
i
n
a
n
t
s
an
d S
ubse
q
uent
Ef
f
ect
of
S
e
l
f
-
rat
e
d He
al
t
h
St
at
u
s
on
S
u
r
v
i
v
al
...
.
(
G
u
a
n
g
mi
ng
H
a
n)
75
OR
9
5
%
CI
D
o
wngr
ad
e
OR
9
5
%
CI
Upgrade
OR
9
5
%
CI
Downgra
d
e
OR
9
5
%
CI
Upgrade
4 vs 1
0.
593
(
0
.
295
1.
193)
0.
896
(
0
.
419
1.
915)
Change diabetes
Change dif
f
iculty
dr
essing
2 vs 1
1.
177
(
0
.
793
1.
747)
0.
981
(
0
.
590
1.
632)
2 vs 1
1.
245
(
0
.
834
1.
858)
0.
739
(
0
.
433
1.
261)
3 vs 1
0.
812
(
0
.
300
2.
195)
3.
310*
*
(
1
.
385
7.
907)
3 vs 1
1.
288
(
0
.
563
2.
948)
0.
902
(
0
.
381
2.
134)
4 vs 1
0.
760
(
0
.
549
1.
051)
1.
168
(
0
.
821
1.
663)
4 vs 1
3.
058*
(
1
.
262
7.
413)
2.
270
(
0
.
865
5.
956)
Change arthritis
Change dif
f
iculty
eating
2 vs 1
0.
946
(
0
.
746
1.
199)
0.
834
(
0
.
623
1.
116)
2 vs 1
1.
003
(
0
.
596
1.
686)
1.
536
(
0
.
834
2.
827)
3 vs 1
0.
683
(
0
.
469
0.
993)
1.
117
(
0
.
753
1.
656)
3 vs 1
1.
627
(
0
.
310
8.
533)
5.
427*
(
1
.
290
22.
824)
4 vs 1
0.
819
(
0
.
660
1.
016)
0.
910
(
0
.
708
1.
170)
4 vs 1
0.
421
(
0
.
075
2.
358)
0.
480
(
0
.
072
3.
214)
Change em
phy
s
e
m
a
Change dif
f
iculty
bed
2 vs 1
0.
983
(
0
.
651
1.
483)
0.
961
(
0
.
573
1.
610)
2 vs 1
1.
009
(
0
.
747
1.
362)
0.
833
(
0
.
566
1.
224)
3 vs 1
0.
944
(
0
.
597
1.
493)
1.
645*
(
1
.
038
2.
606)
3 vs 1
0.
832
(
0
.
410
1.
691)
2.
233*
(
1
.
203
4.
144)
4 vs 1
1.
170
(
0
.
734
1.
865)
1.
110
(
0
.
826
2.
850)
4 vs 1
0.
572
(
0
.
314
1.
043)
0.
982
(
0
.
520
1.
856)
Change asth
m
a
Change dif
f
iculty
walking
2 vs 1
0.
862
(
0
.
498
1.
495)
0.
652
(
0
.
326
1.
305)
2 vs 1
1.
691*
*
*
(
1
.
318
2.
170)
0.
927
(
0
.
674
1.
274)
3 vs 1
0.
701
(
0
.
379
1.
297)
0.
495
(
0
.
235
1.
045)
3 vs 1
0.
902
(
0
.
529
1.
537)
1.
097
(
0
.
644
1.
866)
4 vs 1
0.
680
(
0
.
412
1.
124)
1.
125
(
0
.
654
1.
935)
4 vs 1
0.
955
(
0
.
634
1.
439)
1.
069
(
0
.
684
1.
671)
Change hy
per
t
ension
Change dif
f
iculty
toilet
2 vs 1
1.
097
(
0
.
870
1.
383)
0.
924
(
0
.
695
1.
228)
2 vs 1
1.
386
(
0
.
886
2.
170)
0.
944
(
0
.
526
1.
693)
3 vs 1
0.
903
(
0
.
597
1.
365)
1.
278
(
0
.
825
1.
980)
3 vs 1
1.
138
(
0
.
421
3.
078)
0.
641
(
0
.
240
1.
711)
4 vs 1
0.
843
(
0
.
689
1.
031)
0.
880
(
0
.
697
1.
113)
4 vs 1
4.
071*
*
(
1
.
455
11.
388)
0.
565
(
0
.
154
2.
075)
Change hear
t
Change dif
f
iculty
m
e
als
2 vs 1
1.
809*
**
(
1
.
401
2.
334)
0.
911
(
0
.
650
1.
277)
2 vs 1
1.
970*
*
(
1
.
187
3.
268)
0.
615
(
0
.
315
1.
197)
3 vs 1
0.
935
(
0
.
648
1.
349)
1.
402
(
0
.
965
2.
037)
3 vs 1
2.
671
(
0
.
806
8.
850)
1.
295
(
0
.
371
4.
523)
4 vs 1
0.
922
(
0
.
693
1.
226)
0.
755
(
0
.
534
1.
068)
4 vs 1
2.
264
(
0
.
782
6.
551)
1.
651
(
0
.
527
5.
173)
Change str
oke
Change dif
f
iculty
shoppi
ng
2 vs 1
2.
390*
**
(
1
.
552
3.
682)
0.
779
(
0
.
413
1.
469)
2 vs 1
1.
372
(
0
.
964
1.
954)
0.
741
(
0
.
470
1.
167)
3 vs 1
0.
802
(
0
.
511
1.
259)
1.
249
(
0
.
784
1.
990)
3 vs 1
0.
484
(
0
.
196
1.
199)
1.
931
(
0
.
946
3.
938)
4 vs 1
0.
582
(
0
.
218
1.
553)
0.
462
(
0
.
125
1.
705)
4 vs 1
0.
936
(
0
.
482
1.
817)
1.
600
(
0
.
812
3.
154)
Change cancer
Change dif
f
iculty
m
oney
2 vs 1
1.
438
(
0
.
893
2.
318)
0.
579
(
0
.
271
1.
238)
2 vs 1
1.
074
(
0
.
686
1.
680)
1.
268
(
0
.
748
2.
150)
3 vs 1
0.
917
(
0
.
718
1.
171)
0.
851
(
0
.
638
1.
133)
3 vs 1
0.
317
(
0
.
049
2.
053)
0.
824
(
0
.
131
5.
192)
4 vs 1
0.
841
(
0
.
494
1.
431)
0.
859
(
0
.
455
1.
624)
4 vs 1
1.
144
(
0
.
374
3.
498)
1.
072
(
0
.
333
3.
449)
Odds r
a
tios (
O
R) for
(
downgr
ade or
upgr
ade)
changed self-
r
a
ted h
ealth an
d their
95% confid
ence inter
v
als (
C
I
)
,
m
odel adjusted f
or
other
dem
ogr
aphic, disease conditions and
other
r
i
sk factor
s. ***p<0.
00
01,
**
p<0.
01,
*p<0.
05.
1 r
e
pr
esents “No” at baseline
and “No”
at
1999-
2
000;
2 r
e
pr
esents “No” at bas
e
line a
nd “Yes” at 1999-
2
000;
3 r
e
pr
esents “Yes” at
baseline and “No” at
1999-
2
000;
4 r
e
pr
es
ents
“Yes” at baseline and “Yes” at 1999-
2000.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
I
J
PH
S
Vo
l.
3
,
N
o
.
2
,
Jun
e
201
4 :
6
9
– 80
76
3.
5.
Ch
an
ge i
n
sel
f-r
ate
d
he
a
l
th st
a
t
us
an
d
survi
val
an
al
y
s
i
s
Of the
5,399 participan
ts
within a twel
ve-year
follow-up
, 2,647(49.03%) we
re
decease
d
by
Decem
ber
31, 2006. We
di
d survival function
e
s
tim
a
tion
to
com
p
are a
n
a
l
ysis of pa
r
ticipants with different
v
a
lu
es of ch
ang
e
in self-rated
h
ealth
. As sh
own
in fi
g
u
re 1A, t
h
ere was h
i
gh
er m
o
rtality in
do
wng
r
ad
e an
d
u
pgrad
e
g
r
ou
ps th
an
g
r
o
u
p
with
ou
t self-rated
h
ealth
ch
an
g
e
.
Wh
en
the ch
ang
e
d
levels were tak
e
n
in
to
account, t
h
e
highe
r the
level
cha
nge
d, the
worse t
h
e s
u
rvival function
(p<
0
.0001)
for
all cha
nge
d levels
vers
us
n
o
c
h
a
n
ge
(fi
g
u
r
e
1B
).
As
sh
o
w
n
i
n
t
a
bl
e 7
,
C
o
x
p
r
op
o
r
t
i
onal
haz
a
rd
re
gres
si
o
n
m
odel
al
so s
h
owe
d
th
e sam
e
resu
lts.
Self-rated
h
ealth
h
a
s
b
e
en
sho
w
n
a st
rong
pred
ictor
o
f
m
o
rtality. Ch
an
g
e
in
self-rated
health
is also
sh
owed
to
b
e
a p
r
ed
icto
r
o
f
su
rv
iv
al fun
c
tio
n. Th
en
, th
is
raises th
e qu
estio
n
,
wh
at are
th
e resu
lts wh
en
self-
rated health is
assessed for
m
o
rtality when taking ch
a
n
ge in self-rated health
status into account
?
T
o
exam
i
n
e t
h
i
s
, we co
nst
r
uct
e
d
and e
v
al
uat
e
d t
h
e C
ox m
odel
s
bet
w
ee
n sel
f
-
r
at
ed he
al
t
h
an
d su
bse
q
uence
heal
t
h
outc
o
m
e
s when incorporating cha
nge
d self-rated
health
expe
rience
with the
m
o
st recent self-rate
d health
condition. Ta
ble 8 showe
d
the results
of Cox proportional hazard re
gre
ssion m
odels 1-4 on the associa
tion
b
e
tween
self-rated
h
ealth
and
m
o
rtalit
y a
t
th
e b
i
v
a
riate
lev
e
l. Mo
d
e
l 1
represen
ts self-rated
h
ealth
statu
s
at
baseline. M
o
d
e
l 2 re
prese
n
ts
self-rate
d
health status
in
a
n
intervie
w
d
u
r
ing 1
9
9
9
-
2
0
0
0
.
The value of chan
g
e
in
self-rated
h
e
alth
was con
s
id
ered
in Mod
e
l 3
and
4
.
C
o
mp
ared
with
self-rated h
ea
lth
at
b
a
selin
e, self-rated
h
ealth
at
th
e interv
iew of 19
99
-20
0
0
was a stron
g
e
r p
r
ed
ict
o
r of m
o
rtalit
y. Fu
rth
e
rm
o
r
e, wh
en
ch
ang
e
in
self-
rated
h
ealth
st
atu
s
was con
s
i
d
ered
, sel
f
-rated
h
ealth was a stron
g
e
r an
d
m
o
re flex
ib
le
p
r
ed
icto
r
of mo
rtality.
W
i
t
h
each
additio
n
a
l 1 un
it
o
f
d
eclin
e in self-rated
h
ea
lth
,
p
a
rticip
an
ts with a
d
o
wn
gr
a
d
ed
ch
an
g
e
o
f
s
e
lf
-
r
a
ted
h
ealt
h
w
e
r
e
m
o
r
e
lik
ely
to
d
i
e th
an
p
a
r
ticip
an
ts w
ith
an
upg
r
a
d
e
d
ch
an
g
e
o
f
sel
f
-r
ated
h
ealth(
H
R=1.647
vs 1.
3
5
5
)
. M
o
dels 3 an
d 4 take cu
rre
nt self-rate
d health
status and hi
story
self-
r
ated health cha
n
ge int
o
account
for m
o
rtality prediction.
Fi
gu
re 1.
T
h
e effect
s of
cha
n
ge of
self-rated h
ealth
on
su
rviv
al fu
n
c
tion
Th
ere
was
h
i
gh
er m
o
rtality i
n
downg
rad
e
an
d
up
grad
e gro
u
p
s
th
an
g
r
oup
withou
t self-rated
h
ealth
chan
ge wi
t
h
P
<
0.
00
0
1
(
d
i
ff
-
1
:
do
w
n
g
r
a
d
e;
0:
no c
h
an
ge;
1:
up
gra
d
e i
n
Fi
gu
re 1
.
A
)
.
Whe
n
t
h
e l
e
ve
l
s
were
t
a
ken i
n
t
o
acc
ou
nt
, t
h
e hi
g
h
e
r
t
h
e l
e
vel
cha
nge
d,
t
h
e
wo
rs
e t
h
e s
u
r
v
i
v
al
fu
nct
i
o
n (
p
<
0
.
0
0
0
1
)
f
o
r al
l
c
h
an
ge
d
lev
e
ls v
e
rsu
s
no
ch
an
ge (d
i
f
f4
-4
: d
o
wn
grad
e 4
lev
e
ls; -3: d
o
w
ng
rad
e
3 lev
e
ls; -2
: d
o
wng
r
ad
e
2
levels; -1
:
do
w
n
g
r
a
d
e 1
l
e
vel
;
0:
no
cha
nge;
1:
up
gra
d
e 1 l
e
vel
;
2:
u
p
g
r
a
d
e 2
l
e
vel
s
;
3:
u
p
g
ra
de
3
l
e
vel
s
;
4:
up
g
r
ade
4
lev
e
ls in
Figu
re 1
.
B
)
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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S
I
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:
225
2-8
8
0
6
The Det
e
r
m
i
n
a
n
t
s
an
d S
ubse
q
uent
Ef
f
ect
of
S
e
l
f
-
rat
e
d He
al
t
h
St
at
u
s
on
S
u
r
v
i
v
al
...
.
(
G
u
a
n
g
mi
ng
H
a
n)
77
T
a
bl
e
7. T
h
e
e
ffec
t
s
of
ch
an
ge
of
sel
f-r
a
t
e
d
he
al
th
on
h
a
z
a
rd ra
ti
os
Hazard Ratio
95%
Ha
zard RatioCI
P-value
Changed level of s
e
lf-
r
a
ted health(
3
levels)
Downgr
ade vs
no change
1.
583
1.
453 1.
725
<.
0001
Upgr
ade vs
no change
1.
186
1.
065 1.
321
0.
0019
Changed level of s
e
lf-
r
a
ted health(
9
levels)
-
4
vs
0
5.
010
3.
339 7.
518
<.
0001
-
3
vs
0
3.
060
2.
466 3.
796
<.
0001
-
2
vs
0
1.
938
1.
707 2.
201
<.
0001
-
1
vs
0
1.
372
1.
247 1.
510
<.
0001
1 vs
0
1.
143
1.
017 1.
285
0.
0255
2 vs
0
1.
299
1.
050 1.
606
0.
0158
3 vs
0
1.
500
0.
941 2.
391
0.
0886
4 vs
0
6.
847
2.
563 18.
287
0.
0001
Changed level of s
e
lf-
r
a
ted health in
9 levels: -
4
: downgr
ade
4 levels; -
3
:
downgr
ade 3 levels; -
2
: downgr
ade 2 levels;-
1: down
grade 1
level; 0: no change; 1: upgr
ade 1 level; 2: upgr
ade 2
levels; 3: upgr
ade 3 levels; 4: upgr
ade 4 levels.
T
a
bl
e
8. T
h
e
e
ffec
t
s
of
sel
f-r
ate
d
he
al
th
w
i
th ch
an
ge
o
f
s
e
l
f-ra
t
ed
he
al
t
h
l
e
vel
on
haz
a
rd r
a
ti
os
Model
variable
Change
d level of
self-rated health
Hazard Ratio
95%
Haza
rd Ratio CI
P-value
1
Baseline self-
r
a
ted
health
1.
282
(
1
.
236 1.
331)
<.
0001
2
The m
o
st recent
se
lf-rated
hea
lth
1.513
(1.459
1.568)
<.0001
3
The m
o
st recent
se
lf
-rated
health
-
1
1.
647
(
1
.
549 1.
751)
<.
0001
0
1.
563
(
1
.
462 1.
670)
<.
0001
1
1.
355
(
1
.
225 1.
499)
<.
0001
4
The m
o
st recent
se
lf
-rated
health
-4
NA
-
3
1.
568
1.
007 2.
441
0.
0466
-
2
1.
747
1.
514 2.
016
<.
0001
-
1
1.
553
1.
440 1.
676
<.
0001
0
1.
563
1.
462 1.
670
<.
0001
1
1.
441
1.
283 1.
619
<.
0001
2
1.
520
1.
160 1.
992
0.
0024
3
1.
356
0.
525 3.
505
0.
5294
4 NA
Changed level of s
e
lf-
r
a
ted health in
m
ode
l 3: -
1
: downgr
ade; 0: no change; 1: upgr
ade.
Changed level of self-
r
a
ted health in
m
od
el 4:
-
4
: downgr
ade 4 l
e
vels; -
3
: downgr
ade 3 levels; -
2
:
downgr
ade 2 leve
ls; -
1
: downgr
ade
1 level; 0: n
o
ch
ange; 1: u
pgr
ade
1 level
;
2: upgr
ade 2 levels; 3: upgr
ade 3 levels; 4: upgr
ade 4 levels.
4.
DIS
C
USSI
ON
In t
h
is study,
we e
x
am
ined the cha
n
ged
patte
rn of self-rated hea
lth a
m
ong com
m
unity-dwelling
eld
e
r
A
m
er
ica
n
s
d
u
r
i
ng
a
per
i
od
b
e
t
w
een 1
994
an
d
200
0. Furt
herm
ore,
we systematically assess
ed the
associated fact
ors that a
ffect
self-rate
d hea
lth and th
e c
h
ange
of sel
f
-
r
a
ted health sta
t
us an
d su
bse
que
nt
m
o
rtality predi
c
tion
with sel
f
-rated
hea
lth a
n
d c
h
ange i
n
sel
f
-rated
health.
As an
im
p
o
r
tan
t
risk
factor fo
r
d
eath, self-rated
h
ealth
is
d
e
term
in
ed
b
y
sev
e
ral
facto
r
s. In
g
e
neral,
an indi
vidual’s
m
e
dical health stat
us an
d/
o
r
phy
si
cal
fu
nct
i
on are m
a
jor f
act
ors t
h
at
co
n
t
ri
but
e t
o
sel
f
-
r
a
t
i
n
g
h
ealth
[1
4
]
.
Ou
r resu
lts provid
e
furt
he
r evi
d
ence t
h
at people with m
o
re
chronic diseas
e conditions
or
m
o
re
d
i
fficu
lty in
daily act
iv
ities
were
g
e
n
e
rally
m
o
re lik
ely t
o
rep
o
rt “fair” o
r
“p
oo
r”
h
e
alth
co
nd
itio
n
t
h
an
t
h
e
p
e
op
le with
less ch
ro
n
i
c d
i
seases o
r
less d
i
fficu
lty in
d
a
ily a
c
tiv
ities. Fu
rtherm
o
r
e,
m
e
d
i
cal h
ealth
statu
s
, su
ch
as d
e
p
r
essi
o
n
,
o
s
teopo
ro
sis,
diab
etes, art
h
ritis, em
p
h
y
se
m
a
,
h
y
p
e
rten
sion, h
eart d
i
sease, can
cer,
and
p
hysical
fu
nctio
n, suc
h
as diffic
u
lty
eating, wal
k
in
g o
r
sh
op
pin
g
, are
significantly
associated with
self-rate
d healt
h
. I
n
ad
d
ition
to
ch
ro
n
i
c
d
i
sease con
d
ition
and
d
i
fficu
lty in
d
a
ily activ
ities, so
me d
e
m
o
g
r
ap
h
i
c ch
aracteristic, su
ch
as race, educa
tion and income are si
gnificantly correlated with self-ra
t
ed
health status [15]. Furtherm
ore,
health
behavi
ors, s
u
c
h
as
exe
r
cise, and s
o
cial
activ
ity are als
o
ass
o
ciated
wi
th self-related
health.
Because it reflects an indivi
dual’s
curre
nt medical, physical and psyc
hosocial health status, self-
rated
h
ealth
is
lik
ely to
ch
an
ge ov
er tim
e. Ou
r
resu
lt sh
ow
ed t
h
at
59
% o
f
part
i
c
i
p
a
n
t
s
c
h
an
ge
d t
h
ei
r
re
po
rt
e
d
health status af
ter a 6-y
ear f
o
llow
-
u
p
,
39%
d
o
w
n
gra
d
e
d
the
i
r self-rate
d he
alth status and
20
% u
p
g
r
ade
d
their
self-rate
d healt
h
status. A
b
ou
t 40% o
f
y
o
u
ng
peo
p
le
cha
nge
d their self
-rated
health o
v
er a 4
-
y
ear p
e
ri
o
d
[1
6]
,[
1
7
]
.
F
o
r
a sh
ort
-
t
e
rm
peri
o
d
,
o
n
e st
u
d
y
re
po
rt
ed t
h
at
onl
y
a
b
o
u
t
15
% o
f
resp
o
nde
nt
s c
h
an
ge
d t
h
ei
r sel
f
-
rated healt
h
aft
e
r a one m
onth follow
up [18]
. Recently, another study show
ed t
h
at about
40%
of
respondents
chan
ge
d t
h
ei
r
heal
t
h
r
a
t
i
ng a
b
o
u
t
1 m
ont
h l
a
t
e
r d
u
e t
o
di
f
f
e
rent
i
n
t
e
rvi
e
w
set
t
i
ngs
[1
1]
.
There
f
ore,
al
t
h
ou
g
h
indivi
duals
’ se
lf-rate
d
health
status will c
h
a
nge
ove
r
tim
e,
the cha
n
ge i
n
s
e
lf-rate
d
health will va
ry de
pe
ndi
ng
on
po
p
u
l
a
t
i
on
and
peri
od
of
f
o
l
l
o
wi
ng t
i
m
e. For e
x
am
pl
e, a subst
a
nt
i
a
l
pr
op
o
r
t
i
on
of
par
t
i
c
i
p
ant
s
(f
rom
15%
to
4
0
%) changed
th
eir repo
rt
ed
h
ealth
status b
e
twee
n
th
e d
i
fferen
t
in
terv
iews an
d
resp
on
se reliab
ilit
y was
rel
a
t
e
d t
o
s
o
ci
o-
dem
ogra
phi
c
fact
ors
,
su
ch
as age, i
n
c
o
m
e
and e
d
ucat
i
o
n
[1
9]
-[
2
1
]
.
As
fo
r el
der
p
o
p
u
l
at
i
o
n
,
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
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:
2
252
-88
06
I
J
PH
S
Vo
l.
3
,
N
o
.
2
,
Jun
e
201
4 :
6
9
– 80
78
althou
g
h
pa
rticipants ca
n cha
nge i
n
b
o
th
dir
ections, m
o
re
participa
n
ts wi
ll change t
h
eir
self-rate
d healt
h
f
r
om
h
i
gh
er lev
e
l to
lo
wer lev
e
l.
Ju
st as sel
f
-rated
h
ealth
, ch
an
g
e
in
sel
f
-rated
h
ea
lth
is al
so
a
risk fact
or fo
r m
o
rtality
. Th
erefore,
expl
oratio
n
of
the determ
inan
ts of c
h
an
ge in
self-rate
d
heal
th status is ver
y
im
portant. A
lthou
g
h
cha
n
g
e
s in
self-rate
d healt
h
for short-term
peri
ods
refl
ect
m
o
re unrel
iability [11],[18
],[19], c
h
anges in self-rate
d health
fo
r lon
g
-
term
peri
ods
reflect
m
o
re health status chan
ge
[
22]
,
[
2
3
]
.
Ou
r
results sh
o
w
that, n
o
t like self-rate
d
health, s
o
m
e
dem
ogra
phic
characte
r
istic, such as
a
g
e
,
ge
nde
r, rac
e
,
ed
ucat
i
on a
nd i
n
com
e
, are n
o
t
significa
ntly associated
with chan
ges
of s
e
lf-rate
d healt
h
for c
o
m
m
u
n
ity-dwelling elder
Am
ericans. In
ag
reem
en
t with
th
e fi
n
d
i
n
g
s
fro
m
Fin
n
i
sh
[2
2
]
,[23
], d
i
fficu
lties in
d
a
ily activ
ities are sig
n
i
fican
tly asso
ciated
with
self-rated h
ealth
for elder Am
er
ican
s.
Fo
r ex
am
p
l
e, p
a
rticip
an
ts were lik
ely to
do
wng
r
ad
e th
ei
r self-
rat
e
d heal
t
h
fo
r cha
nge
d di
ffi
cul
t
y
of wal
k
i
n
g
,
co
oki
ng m
eal
s, heart
di
se
ase and st
r
o
ke.
Very
i
n
t
e
rest
i
ngl
y
,
p
a
rticip
an
ts wi
th
release from d
i
fficu
lty in
d
a
ily activ
ities, su
ch
as eatin
g
and
bed, were m
o
re lik
ely to
u
pgrad
e t
h
eir statu
s
. Con
tin
uou
s d
i
fficu
lty o
f
d
r
essi
ng
and
t
o
ilet also
was
m
o
re lik
ely to
d
o
wn
grad
e th
eir self-
rated
h
ealth
statu
s
wh
en
co
m
p
ared
with
p
a
rticip
an
ts witho
u
t
ch
an
g
e
d
d
i
fficu
lty in
d
a
ily activ
ities. Ju
st as
with
d
i
fficu
lty in
daily activ
ities, p
a
rticip
an
ts
were m
o
re lik
el
y to
downgrade th
eir self-rated
h
ealth
status wh
en
their m
e
dical
health status change
d
from “norm
a
l” to
“diseases”, s
u
ch
as heart di
sease and stroke. In
ad
d
ition
,
p
a
rticip
an
ts with
release fro
m
su
sp
end
i
ng
or
m
i
sd
iagno
sis with
d
i
ab
etes or em
p
h
y
se
m
a
we
re also
m
o
re lik
ely to
up
grad
e th
ei
r statu
s
. Tog
e
ther, ch
ron
i
c
d
i
sease cond
itio
ns and
d
i
fficu
lties in
d
a
ily activ
ities
were the m
a
in reasons for cha
nge i
n
self-rated
h
ealth
statu
s
. Alth
ou
gh
th
e
mech
an
ism
is
n
o
t
well und
ersto
od,
b
o
t
h
p
a
in
an
d p
a
rticu
l
ar fu
nctio
n
a
l d
i
fficu
lties asso
ci
ated
with
th
ese ch
ron
i
c d
i
sease co
nd
itio
n
s
may b
e
in
vo
lv
ed
in
the asso
ciatio
n
b
e
tween
self-rated
h
ealth
st
atus and c
h
ronic diseases
[
24],[
25
]. Th
er
efor
e, fo
r
t
h
ese el
derl
y
p
e
opl
e
wi
t
h
pai
n
o
r
f
u
nct
i
onal
di
ffi
c
u
l
t
y
, nec
e
ssary
sy
n
d
r
o
m
e
t
r
eatm
e
nt
,
and
p
h
y
s
i
cal
sup
p
o
rt
are essential for im
proving their self-ra
te
d health status. In
addition, if a
n
indivi
dual downgra
d
es
he
r/his
self-
rated
h
ealth
wi
th
n
o
app
a
ren
t
reason
,
h
e
r/h
i
s p
h
y
sio
l
o
g
i
cal
, p
h
y
sical or psych
o
l
o
g
i
cal health
co
nd
itio
n n
eed
to
b
e
re-estim
a
t
ed
.
Al
t
h
o
u
gh m
a
ny
st
udi
es ha
v
e
expl
ore
d
t
h
e rel
a
t
i
ons
hi
p
bet
w
ee
n sel
f
-rat
e
d
heal
t
h
and s
u
rvi
v
al
fu
nct
i
o
n, fe
w
h
a
ve ex
pl
o
r
e
d
t
h
e rel
a
t
i
o
nshi
p
bet
w
ee
n cha
n
ged sel
f
-
r
at
ed
heal
t
h
st
at
us a
nd s
u
rvi
v
al
fu
n
c
t
i
on o
r
the relations
hip betwee
n self-rated
health and s
u
rvival
function
whe
n
taking account
into cha
n
ged se
lf-rat
e
d
h
ealth
co
nd
ition
.
Our
resu
lts
clearly sh
owed
th
at ch
ang
e
in
self-rated
health
h
a
v
e
a si
g
n
i
fican
t im
p
act o
n
sur
v
i
v
al
fu
nct
i
on i
n
t
h
e el
derl
y
po
pul
at
i
o
n.
No m
a
t
t
e
r
wh
eth
e
r p
a
rticip
an
ts
up
grad
e or
do
wng
r
ad
e th
ei
r self
-
rated health
,
participa
n
ts w
ith chan
ge in
self-rate
d
he
alth status ha
d a signi
fican
tly
decreased
sur
v
ival
fu
nctio
n
whe
n
com
p
ared
wit
h
peo
p
le
with
out c
h
a
n
g
e
in
self-rate
d
health status
d
u
r
in
g
a 6
-
y
ear
f
o
llo
w-
up
.
According to Cox
proportional hazard
re
gression m
odels, each additional 1
unit of
de
cline in baseline self-
rated health, participants were
1.282
tim
es
m
o
re
likely
to die.
W
i
t
h
each additiona
l 1 unit of
decline i
n
the
m
o
st recent self-rated
health
,
participa
n
ts were 1.513 tim
e
s
m
o
re likel
y to die. C
o
nsistent with the
study by
Han
et
al
[
26]
,
o
u
r st
udy
pr
o
v
i
d
es
f
u
rth
e
r ev
id
en
ce th
at al
th
ou
gh
wh
at particip
an
ts
repo
rt th
ei
r cu
rren
t self-
rated
h
ealth
to b
e
is im
p
o
r
tan
t
, how th
ey arriv
e
at t
h
eir c
u
rrent self-rated healt
h
f
r
om
pre
v
i
o
us sel
f
-r
at
ed
h
ealth
is also
very i
m
p
o
r
tan
t
.
Fo
r ex
am
ple, whe
n
c
h
ange i
n
self-rated
he
a
lth
statu
s
was
co
nsid
ered
, t
h
e resu
lts
were stro
ng
er
an
d m
o
re flexib
le.
W
i
t
h
each
ad
d
ition
a
l
1 un
it of
d
ecline in
m
o
st recen
t
self-rated
health
,
participa
n
ts with a dow
n
g
ra
d
e
d cha
nge
of s
e
lf-rate
d health
were m
o
re lik
ely
to die
than
participants w
ith an
u
pgr
a
d
ed
ch
ang
e
o
f
s
e
lf
-r
a
t
ed
h
e
a
lth
. The
r
efore, t
h
e m
o
st rece
nt self-rat
e
d
h
ealth
is a
m
o
re p
r
ed
ictive v
a
lu
e
wh
en
coo
p
e
ratin
g with ch
ang
e
in
self-rated
health
.
Sev
e
ral li
mitat
i
o
n
s
in
th
is stu
d
y
shou
ld
b
e
tak
e
n
in
to
acco
un
t. First, t
h
e racial
m
a
k
e
u
p
o
f
th
e
p
opu
latio
n
is
no
t ev
en
ly d
i
stri
b
u
t
ed
,
93
%
p
o
p
u
l
ation
is
wh
i
t
e Am
erican
s,
an
d on
ly 7
%
po
pu
latio
n is African
Am
ericans. Se
cond,
beca
use
the LSOA
II st
udy
doe
s not in
clud
e labo
rat
o
ry
d
a
ta, we
were un
ab
le to
ex
am
in
e
whet
her a
n
y
b
i
om
arkers co
uld be the
pote
n
tial
m
e
diator
s of the ass
o
ciations
betwee
n self-rate
d health a
n
d
death in
Am
e
r
ican populati
o
n. Fi
nally, because the
data for this
study cam
e from
comm
unity-dwelling
part
i
c
i
p
a
n
t
s
, i
n
di
vi
d
u
al
s
wi
t
h
severe
di
sease
st
at
us, s
u
ch
as
hos
pi
t
a
l
i
zed
pa
t
i
e
nt
s, m
a
y
not
ha
ve
been
i
n
cl
ude
d
in
th
is su
rv
ey
d
a
taset. Str
e
ngth
s
of
th
is
study in
clu
d
e
t
h
e
u
s
e
o
f
a pr
ospectiv
e coh
o
r
t
desig
n
t
h
at inv
o
lv
es a
represen
tativ
e
sam
p
le o
f
elderly p
e
op
le livin
g
i
n
th
e c
o
m
m
unity. Responses
rates a
r
e hi
gh and c
o
m
p
lete
m
o
rtali
t
y ev
alu
a
tio
ns were
fo
und
u
s
ing
the Nation
a
l Death
In
dex
syste
m
wh
ich m
i
n
i
m
i
zes p
o
t
en
tial d
eat
h
certificate reporting bias.
Desp
ite so
m
e
li
mitatio
n
s
, th
e resu
lts fro
m
t
h
is stu
d
y
p
r
o
v
id
e furth
e
r ev
i
d
en
ce t
h
at ch
ro
n
i
c d
i
sease
co
nd
itio
ns and d
i
fficu
lties in
d
a
ily activ
ities
are th
e m
a
in
r
eason
s fo
r ch
an
g
e
i
n
self-rated
h
ealth
statu
s
in
th
e
elderly Am
erican population. T
h
ere
f
ore,
for these
el
de
rl
y
peo
p
l
e
wi
t
h
chr
o
nic dis
ease conditions and
diffic
u
lties in daily activities,
necessa
ry
syndrom
e
treat
m
e
nt and physical
support are e
s
sential for im
p
r
oving
th
eir self-rated
h
ealth
status.
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