Course 13: Self-Reported Health and Morbidities

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with skepticism.(1) One of the most commonly used indicators of overall health in general population surveys is the simple question “how is your health in general?”, with generic responses such as “very good” or “excellent” to “poor” or “very poor”. The prevailing view is that this categorical variable does not provide a thorough enough assessment for public health policy decisions, and may often lead to misleading results.(2) Eminent Indian economist Amartya Sen has argued that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual’s assessment of one's own health is directly dependent on social experiences.(3) A person’s own understanding of his or her health may not agree with the appraisal of medical doctors.(4) Recently, the external view of physicians has come under scrutiny for taking a distanced and less sensitive view of patient illness and health.(5),(6) At the same time, it has also been argued that the health views of the public are quite often inadequately informed. Although the two views can certainly be combined, the differences between the two perspectives can sometimes be in opposition.(7)

It is generally agreed that a patient’s internal view should not be dismissed. Pain is a matter of self perception. However, a patient’s internal assessment may be seriously limited by his or her social experience and knowledge about health. For example, a person brought up in an area with many diseases and less medical care may consider or simply accept certain symptoms as “normal” when they are actually preventable.(8) In general health surveys, patients may also report having diseases for which they have not been officially diagnosed. In a study by Baker et al., patients with inadequate functional health literacy were consistently more likely to report poor health than patients with adequate reading skills.(9) Additionally, inadequate health literacy has been associated with higher levels of self-reported diabetes(10), which in many cases may be inaccurately self-assessed.

In a paper by Manesh et al., it was argued that reported measures by mothers about their childrens' diarrheal illness is misleading since there is not an observed association.(11) In an article by Amartya Sen, it is argued that self reported morbidity has severe limitations and can be extremely misleading. Sen considered the different states of India, which have very diverse medical conditions, mortality rates, educational achievements, etc. Sen compared the socioeconomic states and self-reported morbidities of the states of Kerala and Bihar.(12) He notes that Kerala has the highest levels within India of literacy (nearly universal for the young) and longevity (a life expectancy of about 74 years). Kerala also has the highest rate of reported morbidity among all Indian states. He contrasts this with the state of Bihar, which has extremely poor and inadequate medical and educational facilities, but the lowest rates of reported morbidity in India.(13),(14),(15),(16) Sen reasons that there is much evidence that Indian states with greater provision of education and better medical and health facilities are better equipped to diagnose and perceive their own illness and the illness of others. Sen argues that Biharis with extremely limited medical care and high rates of illiteracy have a very low perception of illness, even though there may be a high prevalence of illness. He also describes a comparison of the United States and Kerala, which shows that the United States has even higher reported rates for the same illnesses in comparison to Kerala.(17) His prevailing argument is that if we rely on self-reported morbidity alone, we would rank the United States as the least healthy, followed by Kerala, with Bihar having the highest level of health.(18)

Conversely, a study by Subramanian et al. tested whether there is actually an inverse association between socioeconomic status (measured by educational attainment) and self-reported illness in India. Subramanian and colleagues found that, regardless of the nature of the self-reported health issue, it was consistently found that those with low or no education were significantly more likely to report morbidities or perceive poor health, compared to those with higher levels of education. These findings are in stark contrast to the views expressed by Sen. They also report that low educated women are more likely to report the presence of specific morbidities. Also, socially disadvantaged groups in India have also been observed to have a higher prevalence of self-reported unhealthy behaviors (such as tobacco and alcohol use).(19)

Thus, with these two contrasting ideas on the reliability of self-reported morbidities, we are left at an impasse. While Subramanian and colleagues describe that self-reported illness is not correlated with socioeconomic status, Sen’s argument may still have validity. Indeed, certain self-reported conditions and poor health ratings may be a result of other unobserved conditions. Thus, to strike a balance, the skepticism surrounding the use of self-reported health measures in developing countries should be kept in mind, but should not completely trump the practice of self-reported illness. “While efforts to collect ‘objective’ health data should be encouraged, this need not come at the cost of discounting the use of self reports of health and morbidity.” (20) More detailed studies using complete health status measures are required to determine whether the association between literacy and health is valid. Additionally, individual questions and health status scales need to be validated in low-literate patients to ensure that any differences in reported health do not merely result from differences in response styles between patients with low literacy and those with adequate reading ability.(21) Researchers must understand that self-report of illness can in fact be an important tool, but should not be fully relied upon. Self-reported illness must be considered in the context of education, availability of health facilities, and public awareness of illness.(22)

Footnotes

(1) Subranmanian S.V., Subramanyam M.A.,  Selvaraj S., Kawachi I. Are self-reports of health and morbidities in developing countries misleading? Evidence from India (2009) Social Science and Medicine. 68 (2), pp. 260-265.

(2) Van Doorslaer E., Jones A.M. Inequalities in self-reported health: Validation of a new approach to measurement (2003) Journal of Health Economics. 22 (1), pp. 61-87.

(3)Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.

(4)Ibid

(5) Kleinman A. “The illness narrative: suffering, healing and the human condition.” New York: Basic Books, 1988.

(6) Kleinman A. “Writing at the margin: discourse between anthropology and medicine.” Berkeley: University of California Press, 1995.

(7) Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.

(8) Ibid

(9) Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027-1030

(10) Schillinger D., Grumbach K., Piette J., Wang, F., Osmond, D., Daher, C., Palacios, J., Sullivan, G.D., and Bindman, A.B. Association of Health Literacy With Diabetes Outcomes. JAMA. Jul 2002; 288: 475 - 482.

(11) Manesh, A. O., Sheldon, T. A., Pickett, K. E., & Carr-Hill, R. (2008). Accuracy of child morbidity data in demographic and health surveys. International Journal of Epidemiology. 37(1), 194–200.

(12) Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.

(13) Sen A. Positional objectivity. Philosophy and Public Affairs. 1993; 22: 126-145.

(14) Sen A. Mortality as an indicator of economic success and failure. Economic Journal. 1998; 108: 1-25

(15) Sen A. Commodities and capabilities. Amsterdam: North Holland, 1985; republished, Delhi: Oxford University Press, 1999.

(16) Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.

(17) Chen L, Murray C. Understanding morbidity change. Population and Development Review. 1992; 18(Sep): 481-504

(18) Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.

(19) Subranmanian S.V., Subramanyam M.A.,  Selvaraj S., Kawachi I. Are self-reports of health and morbidities in developing countries misleading? Evidence from India (2009) Social Science and Medicine. 68 (2), pp. 260-265.

(20) Ibid.

(21) Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027-1030

(22) Sen, A. (2002). Health: perception versus observation. BMJ. 324(7342), 860–861.