Elsevier

Social Science & Medicine

Volume 68, Issue 2, January 2009, Pages 260-265
Social Science & Medicine

Short report
Are self-reports of health and morbidities in developing countries misleading? Evidence from India

https://doi.org/10.1016/j.socscimed.2008.10.017Get rights and content

Abstract

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual's assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross-sectional logistic regression analyses were carried out on a nationally representative population-based sample from the 1998 to 1999 Indian National Family Health Survey (INFHS); and 1995–1996 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill-health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.

Introduction

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. In an influential editorial, Amartya Sen argued that there is a fundamental disconnect between an individual's subjective perception of their health and the objective or actual health condition that they may have (Sen, 2002, Sen, 1993). According to Sen, because an individual's assessment of their health is directly contingent on their social experience, socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits (Sen, 2002). For instance, an individual with no formal knowledge of diseases but residing in an area with substantial disease burden that has inadequate social infrastructure facilities may be inclined to treat disease symptoms as “normal” given their lack of awareness, and therefore, health expectation. Sen, therefore, reasons that perceptions and self-reports of health – which he refers to as the “internal” view of health – can be “extremely misleading” as they obscure the true extent of health deprivation more likely to be captured through “objective” or “external” assessments (Sen, 2002).

The empirical test of the validity of self-reported health and morbidity measures in developing countries is based on examining the association between socioeconomic status (SES) and self-reported health and morbidity measures. If a positive (or a null) association between SES and self-reports of poor health/morbidities is observed such that high SES individuals report higher (or the same) prevalence of ill-health compared to low SES individuals, then such evidence has been used to cast doubt on the use of self-reported measures of health or disease status in population-based surveys. In a recent paper Manesh and colleagues used a similar approach to assess social gradients in mothers' report of diarrhea among children and argued that reported measures of morbidities are misleading, based on the absence of an observed association (Manesh, Sheldon, Pickett, & Carr-Hill, 2008). For instance, in arguing against the use of self-reported health measures, Sen compared aggregated self-reported morbidity rates and life expectancy between two Indian states – Kerala and Bihar, with Kerala reporting considerably higher rates of morbidities despite experiencing the highest level of longevity, while Bihar with low levels of longevity reporting lower rates of morbidities (Sen, 2002). The argument was that Bihar, with a substantially illiterate population and meager health provision, may have a very low perception of illness, even though there is likely to be substantial disease burden as reflected in Bihar's low life expectancy figures. Conversely, Kerala, with high levels of literacy and better health provision, is relatively well positioned to identify and perceive morbidities. As Sen put it, “in this charmed internal comparison”, Bihar would be incorrectly identified as “healthy” when compared to Kerala. Others have also used this motivation to criticize the use of self-rated health (King et al., 2004, Salomon et al., 2004).

It may be noted that the aggregated data on morbidity rates reported by Sen in his 2002 editorial, is from the “mid-1970s” (Sen, 2002). Indeed, the data from more recent years on life expectancy and self-reported morbidities in Kerala and Bihar show that Bihar not only has lower life expectancy as compared to Kerala, it also has higher levels of self-reported morbidities, as one would expect (Fig. 1).

We examined the most recent, large-scale and nationally representative disaggregated data to investigate the association between education and various self-reported poor health/morbidity measures in India; a country classified by the World Bank as a “low income” economy, with a per capita gross national income of $875 or less, in 2005 (Bank, 2005). We tested whether there is, in fact, an inverse association (as expected) between SES (as measured by educational attainment) and self-reported ill-health in India. If the direction of the educational gradient is counter to our hypothesis – or if no association is observed – this would tend to lend credence to the view that self-rated measures of health are inherently untrustworthy in this developing country setting.

Section snippets

Methods

We used two data sources for the study: the 1998–1999 Indian National Family Health Survey (INFHS), (IIPS, 2000) – a large representative cross-sectional survey of households and individuals aged <1 to 95 years; and the 1995–1996 and 2004 Indian National Sample Survey (INSS) of households and individuals (Government of India, 1998, Government of India, 2006).

Four separate and different types of self-rated ill-health were analyzed from the two data sources. The INFHS obtained self-reported

Results

Using the highest educational attainment category as reference, in the INFHS sample, individuals who had no formal education reported higher levels of any self-reported morbidity (OR 1.49, 95% CI 1.42–1.56) even after adjusting for age, sex, caste, urban/rural status and economic standard of living. The association followed an inverse gradient; as educational attainment decreases the odds of reporting morbidities increase (Fig. 2). The inverse educational gradient was also observed when we

Discussion

Contrary to the prevailing view that there is a positive (or null) association between measures of SES and self-reported poor health/morbidities in less-developed countries, we found that those with less education are more likely to report specific morbidities, sickness and overall poor health in India. We also found that conditional on the same levels of objective health condition, low educated women are more likely to report the presence of any specific morbidities compared to those with

Acknowledgment

S. V. Subramanian is supported by the National Institutes of Health Career Development Award (NHLBI K25 HL081275). We acknowledge the support of Macro International (www.measuredhs.com <https://www.webmail.hsph.harvard.edu/redirect?http://www.measuredhs.com>) and the Indian National Sample Survey Organization for the use of their data.

References (24)

  • S.V. Subramanian et al.

    Patterns, distribution, and determinants of under- and overnutrition: a population-based study of women in India

    American Journal of Clinical Nutrition

    (2006)
  • W. Bank

    Country classification

    (2005)
  • O. Baron-Epel

    Self-reported health

  • A. Deaton

    Counting the world's poor: problems and possible solutions

    World Bank Research Observer

    (2001)
  • D. Filmer et al.

    Estimating wealth effects without income or expenditure data or tears: Educational enrolment in India

    (1998)
  • E. Frankenberg et al.

    Self-rated health and mortality: Does the relationship extend to a low income setting?

    Journal of Health and Social Behavior

    (2004)
  • Government of India

    Morbidity and treatment of ailments, NSS 52nd round (July 1995–June 1996)

    (1998)
  • Government of India

    National human development report 2001

    (2002)
  • Government of India

    Morbidity, health care and the condition of the aged, NSS 60th round (January–June 2004)

    (2006)
  • E.L. Idler et al.

    Self-rated health and mortality: a review of twenty-seven community studies

    Journal of Health and Social Behavior

    (1997)
  • IIPS

    National family health survey 1998–99

    (2000)
  • International Institute for Population Sciences & World Health Organization (IIPS and WHO)

    Health system performance assessment: world health survey, 2003

    (2006)
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