EN QUE GOBIERNO PUEDE SER JUEZ EL SOBERANO

Unlike physical disease, diagnosed cases of psychiatric disorders are likely to dramatically underrepresent the extent of chronic psychiatric illness within the community: both the nature and circumstances surrounding

psychological problems often preclude a formal diagnosis (also see Appendix 5.B). Consequently, the study relied on a short form of the General Health Questionnaire (GHQ) to identify those with high levels of psychological distress (Goldberg, 1972) A total of 10 items were used to create the

indicator: since the measure is not identical to Goldberg's 12 item scale it is probably a weaker indicator of psychological distress.

The original experimental work upon which the GHQ was devised sought to discover those features which distinguished psychiatric patients as a class from individuals in the community who considered themselves to be 'healthy'. It has been extensively tested throughout the world, and researchers have concluded that it is a valid indicator of non-psychotic psychiatric illness that represents strong feelings of depression, anxiety and social dysfunction (Goldberg and Williams, 1988). A sensitivity level

(proportion of true cases correctly identified) of 87 per cent and a specificity level (proportion of true normals correctly identified) of 91 per cent have been found in Australia using the 12-item form (Tennant, 1977). Typically, the items making up the measure are homogeneous (Goldberg and

Williams, 1988). The present study came to the same conclusion (Kuder- Richardson-20 coefficient = 0.83).

A total of 57 per cent of respondents in the study scored in a normal range of 0 to 1. Another 29 per cent scored between 2 and 5, suggesting that they were somewhat psychologically unstable, while 14 per cent scored within a range of 6 to 10, implying that they were very unstable. In relation to age, GHQ scores were worse for the youngest and oldest women. This association

5 Two questions on Goldberg's short form of the 12 items were dropped because respondents in the pilot study felt that the items 'have you been feeling reasonably happy, all things considered?' and 'have you been able to face up to problems?' were repeating items 'have you been feeling unhappy or depressed?' and 'have you felt that you couldn't overcome your difficulties?'.

most probably represented the effects of the dramatic events that typically happen to these respondents: young women experience leaving the

parental home, marriage and motherhood for the first time; while after age 45 years there is a greater risk of disease, divorce, death of parents and

children leaving home. Also, a weak to moderate relationship was found between chronic disease and the GHQ. This was expected since people with chronic conditions often report psychological distress (Goldberg and

Williams, 1988; Roberts et al, 1990), while the experience of mental instability can be related to many factors with or without the presence of physical disease (Pearlin, 1989). For example, after controlling for chronic disease women who were widowed, separated or divorced tended to report higher levels of poor mental health than other women. The GHQ was only administered in the Follow-up Study, and therefore conclusions about causal associations with other variables are limited.

5.3 Lay evaluations of health

The measure employed was a single question that was asked both in the 1986-87 and 1990 surveys:^

W o u l d you say your overall health is excellent, good, fair or poor?

Various forms of this question, which is among the most frequently assessed health perceptions in epidemiological and gerontological research, have been used in the literature (Ware et al., 1978). Table 5.3.1 shows the distribution of responses for selected age groups within a number of

samples. It can be seen that most women report 'good' health, and that the proportion with 'fair' or 'poor' health dramatically increases for women in the middle years of their life, a time when chronic diseases become more prevalent.

Most studies have investigated the behaviour of self-rated health in disease or mortality models for old people. The common belief has been that

self-assessed health, although substantially associated with physical health.

6 In the Follow-up Survey the question was asked at the beginning of the health section and was followed by an open-ended question about why the resplendent had answered as she did (see Q49(a) in Appendix 3.A). The more direct questions on physical diseases, mental health and risks factors were asked later on. Thus, responses to the self-rated health question were obtained without the interviewer's drawing attention to the respondent's health problems.

provides an estimate of subjective life expectancy over and above more medical indicators of health (Mossey and Shapiro, 1982; Cockerham et al., 1983; Idler and Kasl, 1991; McCallum et al., 1992). Self-rated health for younger people has been defined as an indicator of chronic disease

(Goldstein et al., 1984). A study in Norway by Fylkesnes and Forde (1991) used a large sample of men and women aged from 20 to 60 years to examine predictors of self-evaluated health and found that somatic illness and

disease related to the musculo-skeletal system were the best predictors for either sex, with leisure activities and workload also being important.

Table 5.3.1

Percentage distributions of self-rated health within selected-age groups for various samples^

Self-rated health

20-29 Age Group (years) 30-39 40-59

EXCELLENT AFP 1986-«7 NHS 1989-90 Follow-up 1986-87 GOOD AFP 1986-87 NHS 1989-90 Follow-up 1986-87 FAIR TO POOR AFP 1986-87 NHS 1989-90 Follow-up 1986-87 TOTAL FOR EACH SAMPLE NO. OF RESPONDENTS AFP 1986-87 NHS 1989-90 Follow-up 1986-«7 33.8 34.5 33.2 52.6 53.3 54.9 13.6 12.2 11.8 100% 477 3001 87 40.7 37.5 39.9 48.5 50.6 49.4 10.8 11.9 10.8 100% 562 2958 97 28.9 28.1 28.3 48.7 49.8 51.4 22.3 22.1 20.3 100% 639 3877 107

^AFP - 1986-87 Australian Family Project metropolitan data; NHS - 1989-90 National Health Survey metropolitan data;

Follow-up - self-rated health obtained in 1986-87 from Sydney Follow-up respondents. All three samples had similar demographic characteristics, although Follow-up respondents tended to have fewer migrant women renting their home in 1986-87. This difference had no effect on the distributions of self-rated health.

Fylkesnes and Forde concluded that a main dimension of self-assessed health had to do with the individual's perceptions of physical performance. In addition, they mentioned significant age differences, with diseases and medications more important in explaining self-rated health for middle-aged women. Idler and Angel (1990) examined a cross-section of people aged between 23 and 74 years in the United States of America from 1971 to 1975 and followed the respondents up in 1982 to 1984. They investigated the ability of self-rated health to predict survival over the follow-up period. It was found that mortality risks increased for women with progressively poorer self-perceptions of health, although once socio-demographic

characteristics, health risk behaviours and medical diagnoses were adjusted for it was found that self-evaluated health no longer was significant in predicting survival.

Another body of research has examined the relationship between

self-assessed health and open-ended explanations of what health is (Calnan and Johnson, 1985; Blaxter, 1990). A strong relationship has been found consistently between the two, although the nature of the association has varied between studies. For example, Calnan and Johnson (1985) found the presence or absence of illness, the feeling of being energetic or not, and good and poor lifestyles distinguished between being healthy and unhealthy. On the other hand, Blaxter (1990) found a large proportion of those with 'fair' or 'poor' health (19%) were unable to describe what being healthy meant,

probably a result of her choice to ask only about positive aspects of health. She also found that being healthy was conceived differently over the life course: young women tended to speak more about fitness, vitality and ability to cope; women in their middle years used more complex concepts emphasizing total mental and physical well-being; and older women tended to think in terms of function. Barsky (1988) believes that this life course effect is likely to have been accentuated by the recent campaign to improve the general public's knowledge of risk factors, disease and methods of

prevention; and as a result, many have come to feel less secure about their health and more worried about the possibility of disease.

In order to get a better understanding of the components that respondents in the present study used to assess their health, self-evaluations are explained using specific indicators that include physical and mental health, as well as

physiological risk factors (see Appendix 5.D for more detail), and open-ended responses from discussions with respondents' about their health ratings. It is expected that the components of self-rated health are multidimensional, and that their importance varies by birth cohort.