Socioeconomic status and the trajectory of self-rated health

Self-Rated Health in Middle Age and Risk of Hospitalizations and Death: Recurrent Event Analysis of the ARIC Study

BACKGROUND

Self-rated health is a simple measure that may identify individuals who are at a higher risk for hospitalization or death.

OBJECTIVE

To quantify the association between a single measure of self-rated health and future risk of recurrent hospitalizations or death.

PARTICIPANTS

Atherosclerosis Risk in Communities (ARIC) study, a community-based prospective cohort study of middle-aged men and women with follow-up beginning from 1987 to 1989.

MAIN MEASURES

We quantified the associations between initial self-rated health with risk of recurrent hospitalizations and of death using a recurrent events survival model that allowed for dependency between the rates of hospitalization and hazards of death, adjusted for demographic and clinical factors.

KEY RESULTS

Of the 14,937 ARIC cohort individuals with available self-rated health and covariate information, 34% of individuals reported "excellent" health, 47% "good," 16% "fair," and 3% "poor" at study baseline. After a median follow-up of 27.7 years, 1955 (39%), 3569 (51%), 1626 (67%), and 402 (83%) individuals with "excellent," "good," "fair," and "poor" health, respectively, had died. After adjusting for demographic factors and medical history, a less favorable self-rated health status was associated with increased rates of hospitalization and death. As compared to those reporting "excellent" health, adults with "good," "fair," and "poor" health had 1.22 (1.07 to 1.40), 2.01 (1.63 to 2.47), and 3.13 (2.39 to 4.09) times the rate of hospitalizations, respectively. The hazards of death also increased with worsening categories of self-rated health, with "good," "fair," and "poor" health individuals experiencing 1.30 (1.12 to 1.51), 2.15 (1.71 to 2.69), and 3.40 (2.54 to 4.56) times the hazard of death compared to "excellent," respectively.

CONCLUSIONS

Even after adjusting for demographic and clinical factors, having a less favorable response on a single measure of self-rated health taken in middle age is a potent marker of future hospitalizations and death.

Impact of Socioeconomic Status on Delivery System Effectiveness

The socioeconomic status (SES) component of the Social Vulnerability Index ranks US counties based on the SES of county residents and was used to evaluate the impact of SES on the performance of the health care delivery system. Using Medicare fee-for-service data, the performance of the health care delivery system was evaluated based on population measures such as per capita hospital admissions, quality of care measures such as surgical mortality, postacute care measures such as readmissions, and service volume measures such as posthospitalization nursing home and rehabilitation admissions. Substantial differences in delivery system performance across SES populations were observed.

Social vulnerability, medical care access and asthma related emergency department visits and hospitalization: An observational study

BACKGROUND

The Social Vulnerability Index (SVI) is a publicly available dataset to identify communities in greatest need of resources.

OBJECTIVE

To examine the utility of using the county-level SVI as predictors of asthma-related outcomes.

METHODS

We used the American Community Survey-derived SVI and the National Environmental Public Health Tracking Network - Query Tool to retrieve data for all counties with available SVI data and at least one matched outcome of interest. Then, we tested SVI as a predictor for emergency department visits (EDV) and hospitalizations, with investigating disparities in primary care physician (PCP) density and emergency department physicians (EDP) density. Linear and logistic regression models were used.

RESULTS

Compared to counties of the lowest SVI quartile, counties of mid-low, mid-high, and highest SVI quartiles had 1%, 4%, and 5% higher odds of asthma-related EDV per 10,000 population, respectively, and 4%, 21%, and 24% higher odds of asthma-related hospitalization per 10,000 population, respectively. Moreover, the data showed an apparent resources mismatch between the EDP densities per 10,000 populations and the SVI quartiles, and the effect of the county level SVI on the asthma-related EDV and hospitalization is not strongly affected by PCP or EDP densities.

CONCLUSION

The counties with the highest SVI -and the most vulnerable to asthma hazards- have a lower coverage of PCP and EDP. Interventions directed to address persistent social vulnerability would offer the opportunity of primary prevention with less exhaustion for the medical resources.

Effect of Socio-Economic Status on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy

Background: Lower socioeconomic status (SES) has been correlated with poor survival rates and surgical outcomes following lung cancer resection. This study sought to determine whether this disparity exists perioperatively in lung cancer patients following robotic-assisted video-thoracoscopic pulmonary lobectomy. 

Methods: We retrospectively reviewed 447 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Ten patients were excluded due to incomplete data. We used median income by residential ZIP code as a surrogate for SES status and grouped patients based on whether ZIP-based median income was less than (Group 1) or greater than (Group 2) 300% of the federal poverty income level. The effects of SES status groups on incidence of postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were evaluated by the logistic regression model and Inverse Gaussian regression model, respectively.

Results: Without adjustment, Group 1 tended to have a higher rate of postoperative complications, with 54% of patients experiencing complications compared to 34% of patients in Group 2 (p=0.007). Median chest tube duration and hospital LOS were also significantly longer in Group 1 than in Group 2 (p=0.034). In multivariable logistical regression analysis, while controlling for covariates and considering effect modifications, lower SES was significantly and positively associated with postoperative complications (odds ratio (OR)=1.98, p=0.039). Preoperative chronic obstructive pulmonary disease (COPD) was also a positive and significant predictor of postoperative complications (OR=1.89, p=0.017), chest tube duration (p=0.020), and LOS (p=0.010).

Conclusions: Lower median income is associated with a greater number of postoperative complications following pulmonary resection for lung cancer when controlling for covariates.

Difficulty and help with activities of daily living among older adults living alone during the COVID-19 pandemic: a multi-country population-based study

Background

Older adults who live alone and have difficulties in activities of daily living (ADLs) may have been more vulnerable during the COVID-19 pandemic. However, little is known about pandemic-related changes in ADL assistance (such as home care, domiciliary care) and its international variation. We examined international patterns and changes in provision of ADL assistance, and related these to country-level measures including national income and health service expenditure.

Methods

We analysed data covering 29 countries from three longitudinal cohort studies (Health and Retirement Study, English Longitudinal Study of Aging, and Survey of Health, Ageing and Retirement in Europe). Eligible people were aged ≥50 years and living alone. Outcomes included ADL difficulty status (assessed via six basic ADLs and five instrumental ADLs) and receipt of ADL assistance. Wealth-related inequality and need-related inequity in ADL assistance were measured using Erreygers’ corrected concentration index (ECI). Correlations were estimated between prevalence/inequality/inequity in ADL assistance and national health-related indicators. We hypothesized these measures would be associated with health system factors such as affordability and availability of ADL assistance, as well as active ageing awareness.

Results

During COVID-19, 18.4% of older adults living alone reported ADL difficulties (ranging from 8.8% in Switzerland to 29.2% in the USA) and 56.8% of those reporting difficulties received ADL assistance (ranging from 38.7% in the UK to 79.8% in Lithuania). Females were more likely to receive ADL assistance than males in 16/29 countries; the sex gap increased further during the pandemic. Wealth-related ECIs indicated socioeconomic equality in ADL assistance within 24/39 countries before the pandemic, and significant favouring of the less wealthy in 18/29 countries during the pandemic. Needs-related ECIs indicated less equity in assistance with ADLs during the pandemic than before. Our hypotheses on the association between ADL provision measures and health system factors were confirmed before COVID-19, but unexpectedly disconfirmed during COVID-19.

Conclusion

This study revealed an unequal (and in some countries, partly needs-mismatched) response from countries to older adults living alone during the COVID-19 pandemic. The findings might inform future research about, and policies for, older adults living alone, particularly regarding social protection responses during crises.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02799-w.

Geographic Barriers Affect Follow-Up Care in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

Follow-up care in head and neck cancers (HNC) is critical in managing patient health. However, social determinants of health (SDOH) can create difficulties in maintaining follow-up care. The study goal is to explore how SDOH impacts maintenance of HNC follow-up care appointments.

METHODS

A systematic retrospective chart review of 877 HNC patients diagnosed in the past 10 years a safety-net tertiary care hospital with systems to help reduce care disparities. Cohort groups were identified and compared against protocols for follow-up. Data were analyzed using analysis of variance, chi-square tests, Fisher's exact tests, two-sample t-tests, and simple linear regression.

RESULTS

The average length of follow-up time in months and average total number of follow-ups over 5 years were 32.96 (34.60) and 9.24 (7.87), respectively. There was no significant difference in follow-up care between United States (US) versus non-US born and English versus non-English speaking patients. Race/ethnicity, county median household income, insurance status, and county educational attainment were not associated with differences in follow-up. However, living a greater distance from the hospital was associated with lower follow-up length and less frequency in follow-up (P < .0001).

CONCLUSION

While income, primary language, country of birth, race/ethnicity, insurance status, and markers of educational attainment do not appear to impact HNC follow-up at our safety-net, tertiary care institution, and distance from hospital remains an important contributor to disparities in care. This study shows that many barriers to care can be addressed in a model that addresses SDOH, but there are barriers that still require additional systems and resources. Laryngoscope, 2021.

Socioeconomic status and health behaviors as predictors of changes in self-rated health among older persons in Israel

There is a considerable body of scientific knowledge about factors associated with self-rated health (SRH), a common measure of health status. However, less is known about the factors associated with changes in SRH over time. In order to fill this gap, the aim of the current study was to examine a combination of socioeconomic, psychosocial, and health behaviour variables in explaining changes in SRH among older adults. The study used data from two time periods in Israel of the Survey of Health, Aging and Retirement in Europe (SHARE) to analyse the predictive contribution of Time 1 socioeconomic, psychosocial and behavioural variables and changes in these variables over time to changes in SHR. The sample included 1,549 older persons interviewed at baseline (years 2009-2010) and four years later (year 2013). Using bivariate and multivariate regression models, the findings show that 26 percent and 23 percent of the participants reported either improvement or a deterioration in their SRH, respectively. Decline in SRH was predicted by a combination of Time 1 socioeconomic (subjective assessment of a household's ability to make ends meet), psychosocial (QoL and in trust in people), and behavioural factors (moderate physical activity) and decline in these factors over time. The findings demonstrate that changes in those variables make an additional significant contribution for explaining changes in SRH. The findings suggest that in addition to identification of low SES, poor psychosocial and behavioural factors as risk factors to poor SRH changes in these factors should be monitored among older populations.

Trajectories of Subjective Health: Testing Longitudinal Models for Self-rated Health From Adolescence to Midlife

Self-rated health (SRH) is ubiquitous in population health research. It is one of the few consistent health measures in longitudinal studies. Yet, extant research offers little guidance on its longitudinal trajectory. The literature on SRH suggests several possibilities, including SRH as (1) a more fixed, longer-term view of past, present, and anticipated health; (2) a spontaneous assessment at the time of the survey; (3) a result of lagged effects from prior responses; (4) a function of life course processes; and (5) a combination of the preceding. Different perspectives suggest different longitudinal models, but evidence is lacking about which model best captures SRH trajectory. Using data from the National Longitudinal Study of Adolescent to Adult Health and the National Longitudinal Survey of Youth, we employ structural equation modeling to correct for measurement error and identify the best-fitting, theoretically guided models describing SRH trajectories. Results support a hybrid model that combines the lagged effect of SRH with the enduring perspectives, fitted with a type of autoregressive latent trajectory (ALT) model. This model structure consistently outperforms other commonly used models and underscores the importance of accounting for lagged effects combined with time-invariant effects in longitudinal studies of SRH. Interestingly, comparisons of this latent, time-invariant autoregressive model across gender and racial/ethnic groups suggest that there are differences in starting points but less variability in SRH trajectories from early life into adulthood.

Neighborhood Ethnic Composition and Self-rated Health Among Chinese and Vietnamese American Immigrants

Immigrants tend to live in areas with higher co-ethnic density, and the effect of neighborhood ethnic composition could be particularly salient for health. This study explored associations between neighborhood ethnic composition and self-rated health among Asian immigrants. We analyzed data collected at baseline from 670 Chinese and Vietnamese immigrants enrolled in a lifestyle intervention trial. Residential addresses were geocoded and combined with neighborhood socio-demographic profiles based on census data. We used generalized estimating equations to examine neighborhood ethnic composition and self-rated health. Independent of individual-level factors, living in neighborhoods more densely populated by whites was associated with poor/fair self-rated health. Neighborhood household income and density of participants' own ethnic group were not associated with poor/fair self-rated health. More research is warranted to disentangle reasons why Chinese and Vietnamese immigrants living in white-concentrated neighborhoods reported poorer self-rated health, including investigating effects of discrimination, relative deprivation, and availability of social resources.

Possible associations between callers' degree-of-worry and their socioeconomic status when contacting out-of-hours services: a prospective cohort study

Background

Telephone triage within out-of-hours (OOH) services aims to ascertain the urgency of a caller’s medical condition in order to determine the correct type of health care needed, ensuring patient safety. To improve the triage process by increasing patient-centred communication, a triage tool has been developed, whereby callers are asked to rate their degree-of-worry (DOW) as a measure of self-evaluated urgency. Studies show that low socioeconomic status (SES), being single and non-Western ethnicity are associated to low self-rated health and high morbidity and these factors may also be associated with high DOW. The aim of this paper was to examine if low SES, being single and non-Western ethnicity were associated to high DOW of callers contacting OOH services.

Methods

A prospective cohort study design, at the OOH services for the Capital Region of Denmark. Over 2 weeks, 6869 of 38,787 callers met the inclusion criteria: ≥18 years, patients themselves or close relative/friend, reported DOW, had a valid personal identification number and gave informed consent. Callers were asked to report their DOW (1 = minimal worry to 5 = maximal worry), which was dichotomized into low (1–3) and high (4, 5) DOW and linked to data from electronical medical records and Statistics Denmark. Socioeconomic factors (education and annual household income), marital status and ethnicity were assessed in relation to DOW by logistic regression.

Results

High DOW was reported by 38.2% of the participants. Low SES (low educational level; OR 1.5, 95% CI 1.3–1.7 and low annual household income; 1.5, 1.3–1.6) was associated with high DOW and so too was being single; 1.2, 1.1–1.3 and of non-Western ethnicity; 2.9, 2.5–3.4.

Conclusions

Knowledge of the association of low SES, marital status as single and non-Western ethnicity with high DOW among callers to OOH services may give call handlers a better understanding of callers’ DOW. If this does not correspond to the call handler’s perception of urgency, this knowledge may further encourage patient-centred communication, aid the triage process and increase patient safety. A better understanding of socioeconomic variables and their relation to callers’ DOW gives direction for future research to improve telephone triage of OOH services.

An overview of adult dental fee exemptions in NHS primary dental care in England

Aims To explore the current landscape of NHS primary dental care services for fee-exempt adult patients and observe attendance, band claiming and geographical patterns.Materials and methods Data were analysed from FP17 claims submitted to NHS Business Services Authority from 2006-2019.Results Fee-exempt adult patients in 2018-2019 account for 23.7% of all adult claims in NHS primary dental care. This percentage has decreased year-on-year since 2011-2012 from 31.5%. In 2018-2019, there were significantly fewer band 1 claims for fee-exempt adult patients (36.0%) compared to their fee-paying counterparts (58.3%). Treatment needs appear to be higher for fee-exempt adult patients since more band 2 and 3 treatment claims were completed (49.0%) compared to fee-payers (30.8%). Band 3 claims were three times higher for fee-exempt adult patients.Discussion Adults with fee exemptions must be able to access timely oral health services since they appear to have higher treatment needs than fee-payers. The areas with the highest proportion of fee-exempt adult patients reflect relative levels of deprivation across regions in England. Barriers to access must be reduced to fully engage all groups of patients and improve oral health.Conclusion Oral health inequalities appear to exist between fee-paying and fee-exempt adult patients. The post-pandemic world will offer a unique opportunity to reassess NHS dental services.

Do the determinants of self-rated health vary among older people with disability, chronic diseases or both conditions in urban Colombia?

Our study aimed to identify the main determinants of self-rated health for individuals aged 60 years or older in Bogotá, Colombia, and if those determinants vary between groups. Data was obtained from the Demographic Health Survey 2011 for Bogotá. Logistic regression models were estimated to identify the determinants of excellent/good self-rated health among people aged 60 years or older living in Bogotá. Moreover, a subgroup analysis was conducted seeking to identify if the determinants changed between groups (men, women, persons with disability, with chronic disease(s), and persons with both disability and chronic disease(s)). The likelihood of reporting an excellent/good self-rated health health decreases when the individual has a disability, a chronic disease or reports that their household income is not enough to cover the basic needs. On the other hand, the odds of reporting excellent/good self-rated health increase when the individual is more educated and reports to receive family support. The subgroup analysis showed that although some determinants are only associated with one group (age with chronic diseases), in general, three main determinants stood out: years of education, socioeconomic status variables and receiving family support. The determinants of self-rated health for older adults in Bogotá differ according to the disability and the chronic disease status. Thus, public policies aiming to improve the levels of health and quality must consider the impacts of those characteristics on individuals' perceptions of their own health.

Neighborhood-level measures of socioeconomic status are more correlated with individual-level measures in urban areas compared with less urban areas

PURPOSE

We tested the hypothesis that individual- and neighborhood-level measures of socioeconomic status (SES) are more concordant in urban than rural areas, and we used the previously established association between obesity and self-rated health to illustrate the effect of residual confounding by individual-level SES when only neighborhood-level SES is considered.

METHODS

Using data from two population-based surveys, we calculated Spearman's rank correlations between household income and neighborhood socioeconomic advantage across eight Pennsylvania counties. We applied multivariable Poisson regression models with robust variance estimates to estimate the degree to which individual SES confounds the association between obesity and self-rated health when the analysis accounts for neighborhood SES only, and we examined how this confounding varied by county urbanicity.

RESULTS

Concordance between household income and neighborhood advantage increased with county urbanicity (ρ = 0.16-0.26 vs. 0.31-0.45 vs. 0.47 in medium metro/micropolitan, suburban, and large metro counties, respectively), while confounding by individual SES on the obesity and self-rated health association decreased with urbanicity (15%-22% vs. 6%-13% vs. 3% in medium metro/micropolitan, suburban, and large metro counties, respectively).

CONCLUSIONS

Individual- and neighborhood-level SES measures are poorly correlated outside of urban areas, suggesting that neighborhood-level measures inadequately account for individual SES in rural settings.

Self-rated health after stroke: a systematic review of the literature

BACKGROUND

Self-rated health (SRH) allows for comparison and identification of the health status of various populations. The aim of this study was to conduct a systematic review of the literature to expand the understanding of SRH after stroke.

METHODS

This systematic review was registered with PROSPERO (CRD42017056194) and conducted according to PRISMA guidelines. Studies published until December 2018 that evaluated the SRH of adults with stroke were included.

RESULTS

Of the 2132 identified studies, 51 were included. Only four studies had experimental designs (7.8%). In 60.7% of the studies, SRH was assessed by variations on direct questions (i.e., general and comparative SRH). Analog visual scales and quality of life instruments were also used to evaluate SRH, but there is no consensus regarding whether they are appropriate for this purpose. The results of cross-sectional and longitudinal studies revealed significant associations between poor SRH and stroke as well as between SRH, function, and disability. The power of SRH to predict stroke mortality is still uncertain. Two interventions (a home-based psychoeducational program concerning stroke health care and family involvement in functional rehabilitation) effectively improved SRH.

CONCLUSIONS

Direct questions are the most common method of evaluating SRH after stroke. Studies reported significant associations between the SRH of individuals with stroke and several relevant health outcomes. However, few experimental studies have evaluated SRH after stroke. Interventions involving health education and family involvement had a significant impact on SRH.

Socioeconomic factors impact quality of life outcomes and olfactory measures in chronic rhinosinusitis

BACKGROUND

Healthcare disparities related to socioeconomic factors may adversely impact disease states and treatment outcomes. Among patients with chronic rhinosinusitis (CRS), the impact of socioeconomic factors on outcomes following endoscopic sinus surgery (ESS) remains uncertain.

METHODS

Adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between March 2011 and June 2015. Socioeconomic factors analyzed included household income, insurance status, years of education completed, race, age, and ethnicity. Income was stratified according to the Thompson and Hickey model. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Brief Smell Identification Test (BSIT) were completed preoperatively and postoperatively.

RESULTS

A total of 392 patients met inclusion criteria. Higher age and male gender were associated with better mean preoperative SNOT-22 scores (both p < 0.02), whereas Medicare insurance status and male gender were associated with worse preoperative mean BSIT scores (both p < 0.02). Postoperatively, higher household income ($100,001+/year) and lower age were associated with a greater likelihood of improving at least 1 minimal clinically important difference (MCID) on SNOT-22 scores (OR = 2.40 and 1.03, respectively, both p < 0.05), while no factors were associated with increased odds of achieving a MCID on BSIT scores.

CONCLUSIONS

Preoperative olfactory function and postoperative quality of life (QOL) improvement were associated with metrics of socioeconomic status in patients with CRS electing ESS. The odds of experiencing a clinically meaningful QOL improvement were more than twice as likely for patients with the highest household income level compared to other income tiers. Further investigation is warranted to identify barriers to postoperative improvement.

Associated Factors of Self-Rated Mental Health Status in Southwestern Iran: Using SCAD Regression Model in a Population-Based Study

This study aimed to investigate the association between self-rated mental health (SRMH) and current health status of an Iranian population. A cross-sectional study was conducted on 3400 individuals selected through random sampling in Shiraz, Iran between January 2014 and March 2015. Data were gathered through face-to-face interviews. Statistical analyses were performed using the SPSS 19.0, and R.3.1.2 software was used for SCAD penalized logistic regression. The mean age of the participants was 38.5 (± 14.1 years). There were significant relationships between better SRMH and younger ages (p < 0.001), and between better SRMH and better self-rated physical health (p < 0.001). Individuals with poor SRMH were more likely to have signs and symptoms of medical diseases. SRMH, a component of self-rated health, was related to a variety of health problems in our study population. Therefore, paying attention to SRMH and mental well-being could be useful in making decision about implementation of preventive measures.

Measuring disability: a systematic review of the validity and reliability of the Global Activity Limitations Indicator (GALI)

Background

GALI or Global Activity Limitation Indicator is a global survey instrument measuring participation restriction. GALI is the measure underlying the European indicator Healthy Life Years (HLY). Gali has a substantial policy use within the EU and its Member States. The objective of current paper is to bring together what is known from published manuscripts on the validity and the reliability of GALI.

Methods

Following the PRISMA guidelines, two search strategies (PUBMED, Google Scholar) were combined to identify manuscripts published in English with publication date 2000 or beyond. Articles were classified as reliability studies, concurrent or predictive validity studies, in national or international populations.

Results

Four cross-sectional studies (of which 2 international) studied how GALI relates to other health measures (concurrent validity). A dose-response effect by GALI severity level on the association with the other health status measures was observed in the national studies. The 2 international studies (SHARE, EHIS) concluded that the odds of reporting participation restriction was higher in subjects with self-reported or observed functional limitations. In SHARE, the size of the Odds Ratio’s (ORs) in the different countries was homogeneous, while in EHIS the size of the ORs varied more strongly. For the predictive validity, subjects were followed over time (4 studies of which one international). GALI proved, both in national and international data, to be a consistent predictor of future health outcomes both in terms of mortality and health care expenditure. As predictors of mortality, the two distinct health concepts, self-rated health and GALI, acted independently and complementary of each other. The one reliability study identified reported a sufficient reliability of GALI.

Conclusion

GALI as inclusive one question instrument fits all conceptual characteristics specified for a global measure on participation restriction. In none of the studies, included in the review, there was evidence of a failing validity. The review shows that GALI has a good and sufficient concurrent and predictive validity, and reliability.

Variability in self-rated health trajectories from adolescence to young adulthood by demographic factors

Self-rated health (SRH) is a robust measure of general health status and an indicator of where and when to target disease prevention efforts-especially in adolescent populations when clinical endpoints are rare. This study's purpose was to model SRH trajectories from ages 13 to 31 and identify whether and when differences between demographic groups emerge. We employed a conditional latent growth model of SRH in December 2016 using a nationally representative sample of 11,512 adolescents from the National Longitudinal Study of Adolescent to Adult Health data collected in 1994-2008. The average SRH trajectory is curvilinear: SRH increases until age 21 and then decreases. This trajectory contains significant between-individual variability in the intercept and linear slope. Males and self-identified non-Hispanic Blacks had higher SRH at age 13 but experienced steeper linear declines than their demographic counterparts. Individuals who grew up in households without two parents and whose parents did not graduate college had consistently lower SRH compared to those living in households with two parents and whose parents graduated college. Self-rated health is not stable over the span of early adolescence to young adulthood; demographic factors account for differences in individual variability around the starting point and overtime changes in SRH. Because these differences are apparent as early as age 13years, prevention efforts targeting demographic-based disparities should occur early in life.

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

Background

Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes.

Methods

Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care Plan™ integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model.

Discussion

Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful.

Trial registration

Clinicaltrials.gov: NCT02588664; October 23, 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0907-1) contains supplementary material, which is available to authorized users.

Socioeconomic Status, Health Behaviors, Obesity and Self-Rated Health among Older Arabs in Israel

Socioeconomic inequalities in health are well documented. Recently, researchers have shown interest in exploring the mechanisms by which measures of SES operate through it to impact SRH, such as material, psychosocial and behavioral factors. To examine the relationships between SES indicators and self-rated health (SRH); and to determine whether health behaviors and obesity mediate the association between SES indicators and SRH. A secondary analysis of data previously collected through the third survey of socioeconomic and health status of the Arab population in Israel, in which the SRH of 878 Arab-Israelis age 50 or older were analyzed using logistic regression. The results showed that higher education level and current employment in old age are associated with better SRH. However, neither subjective economic status nor family income was associated with SRH. Greater physical activity was found to be related to good\very good SRH, while obesity was associated with less than good SRH. Finally, health behaviors (physical activity) and obesity were revealed as mediators between SES indicators (education and employment status) and SRH. The results highlight the importance of high education level and employment status in old age to reduce health inequalities. The findings also show that the relationship between SES and SRH can operate through behavioral mechanisms (i.e., physical activity) and their consequences (i.e., obesity), that can, however, be changed in old age.

How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study

Introduction: Clinician perceptions of patients with low socioeconomic status (SES) have been shown to affect clinical decision making and health care delivery in this group. However, it is unknown how and if low SES patients perceive clinician bias might affect their health care. Methods: In-depth interviews with 80 enrollees in a state Medicaid program were analyzed to identify recurrent themes in their perceptions of care. Results: Most subjects perceived that their SES affected their health care. Common themes included treatment provided, access to care, and patient-provider interaction. Discussion: This study highlights complex perceptions patients have around how SES affects their health care. These results offer opportunities to reduce health care disparities through better understanding of their impact on the individual patient-provider relationship. This work may inform interventions that promote health equity via a multifaceted approach, which targets both providers and the health care system as a whole.

Socioeconomic status, frailty, and subjective well-being: A moderated mediation analysis in elderly Chinese

The study examined the mechanisms underlying the link between socioeconomic status and subjective well-being and explored the role of social activities using a representative sample of older adults ( N = 2773) in Shanghai, China. Results show that frailty mediated the relationship between socioeconomic status and subjective well-being, and social activities moderated the model, such that the mediation effect of frailty was significant only when social activities were lower. Moreover, the moderated mediation model was significant only for women, not for men. Findings highlight the importance of addressing frailty of older adults and promoting social activities (especially for elderly women) in future interventions.

Association of perceived neighborhood problems and census tract income with poor self-rated health in adults: a multilevel approach

Neighborhood problems constitute sources of chronic stress that may increase the risk of poor self-rated health. The associations of census tract level income and perceived neighborhood problems with self-rated health were examined in Florianópolis, Santa Catarina State, Brazil (1,720 adults). Odds ratios (OR) and their 95% confidence intervals (95%CI) of poor self-rated health were estimated through multilevel models. Residents in census tracts in the lower and intermediate tertiles of income reported poorer health than those in the highest tertile. OR of reporting poorer health was 2.44 (95%CI: 2.35- 2.54) in the higher tertile of social disorder (adjusting for mental health). The chances of reporting the poorer health with neighborhood problems ranged from 1.07 (95%CI: 1.03-1.11) to 2.02 (95%CI: 1.95-2.10) for the higher tertile of social disorder (physical health) and physical problem (health-related variables). Perceived neighborhood problems were independently associated with poor health. The perception of a neighborhood among its residents should be considered by health policymakers.

The components of self-perceived health in the Kailali district of Nepal: a cross-sectional survey

Self-perceived health is a health measure with well-established links with mortality, healthcare services utilization, and future health. Various components of self-perceived health have been identified in different populations. In this study, we aimed to investigate the components of self-perceived health in a Nepali population. This was a cross-sectional survey conducted in the Kailali district of Nepal in 2014. The sample was initially consisted of 309 households, representative of the population of one municipality and one village; however, 304 participants were included in the analyses. Information on socio-demographic characteristics, health condition, satisfaction with healthcare services, psychological factors, and health behaviors was extracted. Logistic regression analyses were carried out to identify putative components of self-perceived health. Among the 304 respondents, 244 (80.3%) and 60 (19.7%) perceived their health as good and poor, respectively. Middle age and lower satisfaction with healthcare services were associated with worse self-perceived health, accounting for 10.3% of variance. No regular exercise, drinking, smoking, and being unhappy were also related with worse self-perceived health, after adjustment for age and satisfaction level. In the final model, however, drinking status did not significantly contribute. Our findings support previous findings that individuals with positive health behaviors and psychological wellbeing are more likely to perceive their health better. This study may direct public health policies toward more targeted interventions.

Benefits gained, benefits lost: comparing baby boomers to other generations in a longitudinal cohort study of self-rated health

POLICY POINTS: Despite beliefs that baby boomers are healthier than previous generations, we found no evidence that the health of baby boomers is substantially different from that of the previous or succeeding cohorts. The effects of increased education, higher income, and lower smoking rates on improving self-rated health were nearly counterbalanced by the adverse effect of increasing body mass index (BMI). Assumptions that baby boomers will require less health care as they age because of better education, more prosperity, and less propensity to smoke may not be realized because of increases in obesity.

CONTEXT

Baby boomers are commonly believed to be healthier than the previous generation. Using self-rated health (SRH) as an indicator of health status, this study examines the effects of age, period, and birth cohort on the trajectory of health across 4 generations: World War II (born between 1935 and 1944), older baby boomers (born between 1945 and 1954), younger baby boomers (born between 1955 and 1964), and Generation X (born between 1965 and 1974).

METHODS

We analyzed Canada's longitudinal National Population Health Survey 1994-2010 (n = 8,570 at baseline), using multilevel growth models to estimate the age trajectory of SRH by cohort, accounting for period and incorporating the influence of changes in education, household income, smoking status, and body mass index (BMI) on SRH over time.

FINDINGS

SRH worsened with increasing age in all cohorts. Cohort differences in SRH were modest (p = 0.034), but there was a significant period effect (p = 0.002). We found marked cohort effects for increasing education, income, and BMI, and decreasing smoking from the youngest to the oldest cohorts, which were much reduced (education and smoking) or removed (income and BMI) once period was taken into account. At the population level, multivariable analysis showed the benefits of increasing education and income and declines in smoking on the trajectory of improving SRH were almost counterbalanced by the effects of increasing BMI (obesity).

CONCLUSIONS

We found no evidence to support the expectation that baby boomers will age more or less healthily than previous cohorts did. We also found that increasing BMI has likely undermined improvements in health that might have otherwise occurred, with possible implications for the need for health care. Period effects had a more profound effect than birth cohort effects. This suggests that interventions to improve health, such as reducing obesity, can be targeted to the entire, or a major portion of the, population and need not single out particular birth cohorts.

Patterns and causes of health inequalities in later life: a Bourdieusian approach

This study explores the relationship between social class and health change in older people in a path analysis, using data from the English Longitudinal Study of Ageing (n = 6241) in a Bourdieusian theoretical framework. Bourdieu drew a distinction between the occupational characteristics by which people are classified and the secondary properties of class that relate to lifestyle (economic, cultural and social capitals). Our path model includes both occupational and secondary characteristics of objective social class as well as a measure of subjective social class. We investigate the effects of the predictors on change in three health outcomes (self-rated health, number of symptoms of depression and number of difficulties with the activities of daily living). The analysis adds to Bourdieusian research by showing how the effects of objective social class on health are partially mediated by perceived social status. It also adds to substantive research on the relationship between class and health by suggesting that class-related health inequalities do persist for older people, even for those who are not in paid employment. It suggests that a large amount of the effect of occupation on the health of older people is not direct but indirect; through their personal wealth and lifestyle.

Functional status declines among cancer survivors: trajectory and contributing factors

OBJECTIVE

This study aimed to quantify functional status (FS) trajectories pre- and post-diagnosis of cancer, FS trajectories among cancer-free individuals, and factors affecting FS.

MATERIALS AND METHODS

Self-reported FS, scored from 0 (worst) to 100 (best), of Atherosclerosis Risk in Communities (ARIC) Study cohort participants diagnosed with incident cancer (lung (N=303), breast (N=374), prostate (N=529), colorectal (N=228)), and cancer-free participants (N=11,155) over 15 years was examined. FS was evaluated in two ways: 1) until death or follow-up year 15 (Model 1) and 2) same as survivorship model except that a FS value of zero was used for assessments after death to follow-up year 15 (Model 2). Mean FS at discrete time points were used to generate FS trajectories. Differences in repeated measures of FS were assessed using linear growth models.

RESULTS

Within one year after diagnosis, FS scores declined compared to the cancer-free group, except for prostate cancer. FS continued to decline beyond one year after lung or colorectal cancer diagnosis. FS was lower in all cancer groups, except prostate, compared to the cancer-free group (Model 1: lung -4.76, breast -2.28, colorectal -2.55; Model 2: lung -2.36, breast -2.46, colorectal -2.31). Predictors of decreased FS score independent of cancer diagnosis included low education, comorbidities, obesity, smoking, lack of health insurance, and age.

CONCLUSION

FS in all incident cancer groups declined during the first year post-diagnosis, which could be due to intensive treatments. Targeting factors related to FS declines could improve health outcomes for patients with cancer.

Trajectory of overall health from self-report and factors contributing to health declines among cancer survivors

PURPOSE

This study aims to quantify trajectories of overall health pre- and post-diagnosis of cancer, trajectories of overall health among cancer-free individuals, and factors affecting overall health status.

METHODS

Overall health status, derived from self-rated health report, of Atherosclerosis Risk in Communities cohort participants diagnosed with incident cancer [lung (n = 400), breast (n = 522), prostate (n = 615), colorectal (n = 303)], and cancer-free participants (n = 11,634) over 19 years was examined. Overall health was evaluated in two ways: (1) overall health was assessed until death or follow-up year 19 (survivorship model) and (2) same as survivorship model except that a self-rated health value of zero was used for assessments after death to follow-up year 19 (cohort model). Mean overall health at discrete times was used to generate overall health trajectories. Differences in repeated measures of overall health were assessed using linear growth models.

RESULTS

Overall health trajectories declined dramatically within one-year of cancer diagnosis. Lung, breast, and colorectal cancer were associated with a significant decreased overall health score (β) compared to the cancer-free group (survivorship model: lung-7.00, breast-3.97, colorectal-2.12; cohort model: lung-7.63, breast-5.07, colorectal-2.30). Other predictors of decreased overall health score included low education, diabetes, cardiovascular disease, and age.

CONCLUSIONS

All incident cancer groups had declines in overall health during the first year post-diagnosis, which could be due to cancer diagnosis or intensive treatments. Targeting factors related to overall health declines could improve health outcomes for cancer patients.

Trajectories of self-rated health in people with diabetes: associations with functioning in a prospective community sample

Background

Self-rated health (SRH) is a single-item measure that is one of the most widely used measures of general health in population health research. Relatively little is known about changes and the trajectories of SRH in people with chronic medical conditions. The aims of the present study were to identify and describe longitudinal trajectories of self-rated health (SRH) status in people with diabetes.

Methods

A prospective community study was carried out between 2008 and 2011. SRH was assessed at baseline and yearly at follow-ups (n=1288). Analysis was carried out through trajectory modeling. The trajectory groups were subsequently compared at 4 years follow-up with respect to functioning.

Results

Four distinct trajectories of SRH were identified: 1) 72.2% of the participants were assigned to a persistently good SRH trajectory; 2) 10.1% were assigned to a persistently poor SRH trajectory; 3) mean SRH scores changed from good to poor for one group (7.3%); while 4) mean SRH scores changed from poor to medium/good for another group (10.4%). Those with a persistently poor perception of health status were at higher risk for poor functioning at 4 years follow-up than those whose SRH scores decreased from good to poor.

Conclusions

SRH is an important predictor for poor functioning in diabetes, but the trajectory of SRH seems to be even more important. Health professionals should pay attention to not only SRH per se, but also changes in SRH over time.

The association between excess weight and comorbidity and self-rated health in the Italian population

PURPOSE

To evaluate the association of obesity with comorbidity and with subjective health perception in a large sample representative of the Italian population and how the association differs by age and gender.

METHODS

Cross-sectional data were obtained from nine waves of the "Multipurpose Household Survey," conducted by the Italian National Institute of Statistics. Self-reported height and weight, six weight-associated diseases and self-rated health (SRH) were evaluated on 352,020 subjects aged 20 to 89 years. Comorbidity was defined as the presence of two or more diseases.

RESULTS

The prevalence of comorbidity was significantly different between obese and normal weight subjects in all age categories. SRH was worse in obese subjects than in those of normal weight; this difference persisted, at least in females, into older ages.

CONCLUSIONS

Obesity is associated with comorbidity and self-rated health; this association varies across ages and genders. The results found for obese subjects of a given age category were similar to (or worse than) those found for older normal weight subjects of the next age class. For comorbidity, this was true both in males and in females of all the considered age categories; for SRH, this was true in particular for females and younger males.

Self-rated health trajectories in the African American health cohort

BACKGROUND

Self-rated health taps health holistically and dynamically blends prior health histories with current illness burdens and expectations for future health. While consistently found as an independent predictor of functional decline, sentinel health events, physician visits, hospital episodes, and mortality, much less is known about intra-individual changes in self-rated health across the life course, especially for African Americans.

MATERIALS/METHODS

Data on 998 African American men and women aged 50-64 years old were taken from a probability-based community sample that was first assessed in 2000-2001 and re-assessed 1, 2, 3, 4, 7, and 9 years later. Using an innovative approach for including decedents in the analysis, semi-parametric group-based mixture models were used to identify person-centered group trajectories of self-rated health over time. Multivariable multinomial logistic regression analysis was then used to differentiate the characteristics of AAH participants classified into the different group trajectories.

RESULTS

Four self-rated health group trajectories were identified: persistently good health, good but declining health, persistently fair health, and fair but declining health. The main characteristics that differentiated the self-rated health trajectory groups from each other were age, education, smoking, morbidity (angina, congestive heart failure, diabetes, and kidney disease), having been hospitalized in the year prior to baseline, depressive symptoms, mobility limitations, and initial self-rated health.

CONCLUSIONS

This is the first study to examine self-rated health trajectories separately among African Americans. Four qualitatively distinct self-rated health group trajectories were identified that call into question the accuracy of prior reports that a single, average self-rated health trajectory for African Americans adequately captures their within-group heterogeneity.

Educational attainment is associated with atrial fibrillation symptom severity

BACKGROUND

Atrial fibrillation (AF), the most common arrhythmia encountered in clinical practice, is often managed with a rhythm control strategy. Despite the emphasis on symptom relief as the motivation for a rhythm controlling strategy in AF, it remains unclear what factors affect the patient's experienced severity of AF symptoms. We hypothesize that demographic variables may affect AF symptom severity as many AF symptoms (palpitations, dyspnea, fatigue) are nonspecific and may require particular patient insight.

METHODS

We assessed demographic variables, cardiac and noncardiac comorbidities, AF burden, and AF-specific self-reported symptom severity in a cohort of 300 outpatients with AF presenting to outpatient electrophysiology clinics.

RESULTS

In unadjusted analyses, decreased educational attainment, unemployed working status, and non-Caucasian race were associated with worsened AF symptom severity. After adjusting for potential confounders, the association of decreased educational attainment with worsened AF symptom severity persisted.

CONCLUSIONS

Possible links between these demographic features and AF symptom severity are socioeconomic status and health literacy. Further study into the relationship between educational attainment and AF symptom severity is warranted.

Determinants of self-rated health in a representative sample of a rural population: a cross-sectional study in Greece

Self-rated health (SRH) is a health measure related to future health, mortality, healthcare services utilization and quality of life. Various sociodemographic, health and lifestyle determinants of SRH have been identified in different populations. The aim of this study is to extend SRH literature in the Greek population. This is a cross-sectional study conducted in rural communities between 2001 and 2003. Interviews eliciting basic demographic, health-related and lifestyle information (smoking, physical activity, diet, quality of sleep and religiosity) were conducted. The sample consisted of 1,519 participants, representative of the rural population of Tripoli. Multinomial regression analysis was conducted to identify putative SRH determinants. Among the 1,519 participants, 489 (32.2%), 790 (52%) and 237 (15.6%) rated their health as "very good", "good" and "poor" respectively. Female gender, older age, lower level of education and impaired health were all associated with worse SRH, accounting for 16.6% of SRH variance. Regular exercise, healthier diet, better sleep quality and better adherence to religious habits were related with better health ratings, after adjusting for sociodemographic and health-related factors. BMI and smoking did not reach significance while exercise and physical activity exhibited significant correlations but not consistently across SRH categories. Our results support previous findings indicating that people following a more proactive lifestyle pattern tend to rate their health better. The role of stress-related neuroendocrinologic mechanisms on SRH and health in general is also discussed.