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the interview below, Drs. Ellen Idler and Yael Benyamini
discuss their highly cited paper, "Self-rated health and
mortality: a review of twenty-seven community studies," (J.
Health Soc. Behavior 38[1]: 21-37, March 1997). According
to the ISI
Essential Science Indicators
Web product, this paper is currently ranked at #8 among Social
Science papers published in the past decade, with 424
citations to date. Dr. Idler’s record of highly cited papers
in this field includes 12 papers cited a total of 741 times to
date, and Dr. Benyamini’s record of highly cited papers in
this field includes 5 papers cited a total of 457 times to
date. Dr. Idler is a Professor at the Institute for Health,
Health Care Policy and Aging Research of Rutgers University in
New Jersey. Dr. Benyamini hails from the Bob Shapell School of
Social Work at Tel Aviv University in Israel.
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Why do you think your paper is highly
cited?
Idler: It is a review paper, to which we contributed several
of the original empirical studies. That makes it a convenient
way for an author to refer to a large group of studies, so I'm sure
it gets a lot of cites for that reason. But beyond that, this
paper was the first to really draw attention to the phenomenon of
this single item ("Is your health excellent, very good, good,
fair, or poor?") that predicts mortality so well, even when
detailed objective measures of health status are accounted
for. The finding was buried pretty deep in some of these
studies; the item had been included somewhat accidentally in some of
the studies, and sometimes the finding could be seen in the tables
but it was not the point of the article, and not much was made of it
by the authors. So the JHSB paper drew attention to a
whole group of studies in a new way.
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“It
soon became apparent that there is a wealth of epidemiological data showing that self-rated health is a valid measure and that, although there is evidence of its relation to a wide variety of health measures, its validity has been most often substantiated in relation to
mortality.”
~Yael Benyamini
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Benyamini : First, our paper represents the first attempt for a
comprehensive review of a large number of studies of the self-rated
health-mortality association that were published between 1982 and
1996. Second, our review extends beyond a simple summary of the
existing findings. I believe it is also the most comprehensive effort
at laying out the possible explanations for these intriguing findings
and the directions for future research.
What are the circumstances which led you to your work?
Idler: It's an interesting story. I was a graduate
student at Yale, in epidemiology and sociology. One day I was
in a faculty office in the School of Public Health, waiting for my
professor to finish a phone call, and I was leafing through the new American
Journal of Public Health that had just come in the mail and was
sitting on his desk. I saw the article by Jana Mossey and
Evelyn Shapiro, the first one to report the finding, and I felt
absolutely electrified by it. It represented several trends in
what was just becoming known as psychosocial research—the validity
of the person's point of view and the connection between the
perception of the social/psychological environment and health.
My own dissertation research was, however, on religion and health,
and it would be several years until I could take this other
direction with my work. At the time it was something I only
dreamed of. But back to the day I saw the article—what I
didn't know at the time was that Jana Mossey had been a postdoc at
Yale when she did the research (on data from Canada), so in fact the
study had been done in the building where I was at the time.
Benyamini : I became
intrigued by the self-rated health phenomenon as a doctoral student
and decided to focus on it for my dissertation research, which was
conducted under the advisorship of Dr. Howard Leventhal. Dr. Ellen
Idler introduced me to this topic and shared with me her immense
knowledge on the subject. In preparation for the dissertation, I
reviewed practically everything that has been written about self-rated
health (not only about its relationship with mortality). It soon
became apparent that there is a wealth of epidemiological data showing
that self-rated health is a valid measure and that, although there is
evidence of its relation to a wide variety of health measures, its
validity has been most often substantiated in relation to mortality.
As a social and health psychologist, educated in recognizing the
myriad biases in people’s self-judgments, I was interested in
figuring out how and why this judgment of one’s health is so valid.
This led us to proposing explanations for the epidemiological
findings.
Would you describe the significance of this work for your
field?
Idler: The finding that self-ratings of health as Excellent,
Very good, Good, Fair, or Poor are extremely good predictors of
mortality has been remarkably consistent from one study to another—and
there are more than 70 of these studies now, far more than the 27
that were reviewed in the 1997 JHSB paper. It is also
notable that such studies have come from so many countries around
the world, in Europe, Japan, Australia, Israel, and North
America. It is a single question, translated many different
ways, and yet the results are the same. The significance of
this work is still developing. Its applications in clinical
research are only beginning to be appreciated.
Benyamini: I believe it provides both a comprehensive review of
the current literature on self-rated health and mortality (along with
an addition to the review published two years later in Research on
Aging) and a framework for thinking about the findings and
deriving testable hypotheses.
Where has this research gone since the publication of your
paper? Where do you see it going 10 years from now?
Idler: In 1997, we reviewed 27 papers that had appeared since
1982. More than twice that many have appeared since then, a
steady increase in the rate that does not seem to have abated.
One of the reasons for the rapid appearance of these studies,
besides the inherently interesting topic, is the fact that most are
secondary analyses of data; the studies were able to be done in
rapid succession because the item was available in a large number of
already-completed longitudinal population health surveys.
Progress in the research has been made in the improvement of
statistical methodology, from logistic regression to proportional
hazards models, in the expansion of the countries/languages of the
data, and in the measurement of covariates for health status.
Some of the most interesting new research in this field is in the
clinical applications, and insights that can be gained for
quality-of-life research. The possibility for doing qualitative
research, to elicit the respondent's point of view on health, has only
begun to be explored. Some very interesting new studies have
examined self-ratings of health at the very end of life, finding them
to be continuously sensitive to changing health states. In
addition, the association of self-ratings of health with biological
indicators is a promising new direction for understanding what people
are reporting when they respond to this question in surveys.
Benyamini: It is important to distinguish between research that
has used self-rated health as a proxy measure for health status, in
the absence of more detailed measures, and research that allows for
identifying the unique effects of self-rated health, independent from
other health measures. It is the latter type of research that expands
our understanding of self-rated health. It is difficult to tell where
this research is going. I know where I would like it to go. I would
like to see more studies that test possible links between these
subjective perceptions and physiological measures and thus provide
insights as to the causal mechanisms underlying its predictive
validity. I would also like to see more social-cognitive research
aimed at identifying the information-processing and decision-making
procedures that people use to reach a global judgment of their health.
Finally, it would be interesting to link this vast research on global
perceptions of health with the rapidly growing literature on
perceptions of specific health threats and diseases.
What lessons would you draw from your work to share with the
next generation of researchers?
Idler: If you find a study that really excites you, do your
best to understand why. If you can articulate the reasons for
your own fascination, you will be outlining the next stages for the
research, and also convincing others of its importance.
Benyamini: First, interdisciplinary work is highly recommended
as an enriching and productive experience. I learned a lot from
working with Dr. Idler, who is a sociologist, and Dr. Leventhal, who
is a psychologist, and later on from my work with a group of
sociologists and epidemiologists in Israel. Second, any field of
research benefits from diversity, not only in disciplines but also in
research methods (quantitative versus qualitative) and cultures, and
self-rated health is a good example of this principle.
Ellen L. Idler, Ph.D., Professor
Institute for Health, Health Care Policy and Aging Research
Rutgers, The State University of New Jersey
New Brunswick, NJ, USA
Yael Benyamini, Ph.D.
Bob Shapell School of Social Work
Tel Aviv University
Tel Aviv, Israel
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