Self-rated Health and Some of Its Determinants among the Elderly in Rural Areas in Egypt

Self-rated health (SRH) is a subjective assessment of individual health status that has been well documented as a reliable predictor of functional disability and mortality in aged populations. A house to house survey conducted aiming to investigate self-rated health and some of its determinants among the elderly in two rural areas in Egypt; Dhayf and Carabigo Villages. A pre-designed interviewing questionnaire was utilized to collect information about socio-demographic data, social relations, health related variables, lifestyle, and functional abilities of the elderly. A single-item measure was utilized to assess SRH. The total number of the available elderly in the 2 villages was 99. Results revealed that poor SRH was reported among 41.4% of all elderly in the 2 villages while good SRH was reported among 58.6%. The independent predictors of poor SRH among the elderly were being principally cared by others, higher number of utilized medications, insufficient income, and lack of practicing physical exercise. Being cared principally by others was independent predictor of poor SRH among both sexes, while insufficient income and dependency in one function or more of activities of daily living (ADL) were independent predictors among elderly females only. Further studies are recommended. Socioeconomic development, health promotion and protective interventions should be accomplished to enhance functional independence and physical activities among the elderly. Preventive activities should be adopted to deal with chronic diseases and to prevent polypharmacy among the elderly.


INTRODUCTION
(3) Moreover, SRH was found to be a predictor of mortality in a middle-aged population and contains information that is not entirely reflected in underlying medical conditions and risk factors. (4)The relationship with mortality is robust, persisting across race and sex and after controlling for socioeconomic status and comorbidity.
Possible mechanisms include knowledge of past and current health experiences, implicit comparisons with people of similar age and health status, and the effect of perceived health on personal health Bull High Inst Public Health Vol.37 No. 2 [2007]   behaviour, which, in turn, influences health outcomes (5) .SRH has exceptional predictive validity in at least two respects.For one, it predicts mortality very well and even performs better than an array of disease-specific indicators. (6,7)Secondly, SRH anticipates treatment behaviour accurately. (8)SRH is not only a spontaneous assessment of one's health status and related practices; like a self-concept, but it may be regulated by efforts to achieve one's relatively important health-related goals. (9)(12) Different surveys (13- 16) revealed that age, chronic disease, functional status, inability to go out alone, physical exercise, and health care coverage, have considerable effects on SRH of the elderly.In addition, gender and rural-urban differences in SRH of the elderly were found in other studies. (17,18) f-rated health is among the most pervasive measures of health in the social sciences.Its popularity comes mainly from the fact that it is easy to include in surveys. (8)Despite of that, studies of SRH among elderly population in Egypt is scarce.So, the aim of this study is to investigate self-rated health and some of its determinants among the elderly in rural areas in Egypt.

Dhayf Village:
The with response 5. SRH is an easy tool to be conducted in surveys and respondents appear to have little difficulty in rating their health from "excellent" to "poor." (8)atistical analysis (21,22) Analyses were performed using the

DISCUSSION
Global self-evaluations of health have proven to be sensitive predictors of morbidity and mortality. (9)Studies have shown that SRH varies from country to another.The level of self-rated good health varied from 30 to 60% among the elderly in different areas of Latin America. (12)In Japan, (10) 64.4% of non-institutionalized aged persons answered that they were healthy, while 28.8% were not.In Finland, (11) about half the participants (75 years or older) self-rated their health as good or unusually good.On the other hand, more than two-thirds of the elderly rated their health as fair or poor in Spain. (23)The present study also revealed that 58.6% of the elderly rated their health as good, while 41.4% rated it as poor (Figure1).Racial and cultural factors may lead to variations of SRH in different studies. (24,25)Urban and rural differences in SRH were also found. (18)The present study also revealed that there was a statistically significant difference in the level of SRH between the elderly in the two included rural areas in the univariate analysis (figure 1).However, this difference disappeared in the multivariate analysis (table 4).So, this difference may be due to other confounders.It was postulated that observed regional difference in SRH may be related to the influence of socio-demographic and environmental factors, and level of awareness concerning certain health conditions. (18)Among the sociodemographic variables investigated, age was found to be significantly associated with SRH; but with inconsistent results among different age groups.In China, (14) SRH was found to be significantly associated with age group, where elderly aged 100 years and over reported a more positive health status than did persons aged 80 to 89 and 90 to 99 years.On the other hand, compared with those who were 85 years of age or older, a high health status was reported among those aged between 75 and 84 years, but not those aged 65 to 74 years. (10 )The present study also sowed with primary education or more, and among unmarried than married elderly.
However, like age, all the differences were not statistically significant.Females and those of lower education were also found to have poorer SRH in other studies. (14,23,26)e present study also revealed that previous occupation was significantly associated with SRH, where the highest prevalence of poor self-rating was found among housewives, followed by farmers compared to other jobs (table 1).This is consistent with the study done in China, (14) where non-agricultural professionals reported more positively rated their health status than did farm labours.Other studies (24, 27) also documented a relation between SRH and occupation.It was suggested that the association between traditional measures of socioeconomic status, such as educational level and occupational status, and poor self-rated health is mediated through other socioeconomic conditions such as experiences of being belittled, economic hardship, and lack of social support. (28)The present study also revealed that , among all socioeconomic variables studied, insufficient income was the only significant and independent predictor of poor SRH both at univariate (table1) and multivariate analysis among all elderly and among elderly females ( table 4).This was also found in different studies. (29,30)In addition to providing means for purchasing health care, higher incomes can provide better nutrition, housing, and recreation which may affect SRH. (31)ncerning social support, the present study showed that elderly persons with poor relations with their spouse and children had higher, but insignificant, rate of poor SRH.A North American longitudinal study showed that children's emotional and instrumental support has beneficial effects on survival and psychological wellbeing of parents, particularly when the elderly experience widowhood or declining health. (32,33) he authors stated that older parents prefer to be functionally autonomous for as long as possible but support from children becomes important at times of crisis.Other studies carried out in the US have found no (34) or negative consequences of children's support on the morale and mental health of elderly parents. (35,36) 1).Moreover, being cared by others than self was found to be the only independent predictor for poor SRH which remained consistent in the three models (among all elderly and among both sexes; table 4).Also, perceived control over life was also found to be strongly related to SRH and physical functioning in Russia. (37)ing in the same direction, dependency in functional abilities (ADL) was significantly associated with poor SRH in the present study (table 3).This is consistent with the results of many studies. (10,26,31,38)However, dependency in one function or more of ADL and not IADL was independent predictor of poor SRH only among elderly females in the present study (table 4).This was also previously found among elderly men, where those with disabilities in IADL had no different health ratings than those without disabilities.However, those with disabilities in mobility and ADL had an odds ratio of 4.7 for poor self-rated health. (39)ADL is more basic than IADL and it seems that its impairment may lead to more distress and poorer SRH than impairment in IADL.This impact may be even more sever among females, which bear the whole burden of the family especially in rural areas, which need support in their basic daily life activities; as appeared in the present study (table 4).
Going further step in physical abilities, it was found that practicing physical exercise outside the home (walking) was significantly associated with SRH in the present study.Those who were going out frequently for walking (once/day or more) had the lowest rate of poor SRH compared to those going out less frequently and those not going at all (table 2).This is consistent with many other studies (10,11,17,24) .
The present study also revealed that lack of physical activity is an independent predictor of poor self-rated health among the elderly.Unlike physical activity, smoking didn't appear to be significantly associated with poor SRH in the present study (table 2).This is not consistent with the results of other studies, (17,24) which revealed that smokers had a less favourable health category than nonsmokers.However, the first study (17) found the relation of poor SRH with heavy smoking and the second one (24) included only women.Smoking is still uncommon among females in rural areas in Egypt, and the relation between heavy smoking and SRH was not investigated in the present study as only a few elderly were smokers (table 2).Some of the inconsistencies between the result of the present study and others may also be attributed to the small number of included elderly in the present study.
A study done in USA, (40)  Among these are necessity for periodical visit to hospitals and clinics, (10,38) number and type of chronic diseases and symptoms, (11,38,41) depressive symptoms and cognitive capacity (11,24) .The present study also revealed that elderly reported higher -Number of outpatient visits and of hospital admissions during the past 3 months had high but insignificant rate of poor SRH.Also those with higher number of chronic diseases and higher number of medications had higher significant rate of poor SRH (table 2).However, only higher number of utilized medications (3 or more) was independent predictor of poor SRH among all elderly (table 4).This was also found in other studies (42,43) Higher number of utilized medications may be more bothering to the elderly than the disease itself, especially if these diseases are asymptomatic.

RECOMMENDATIONS
Methods.A community based cross sectional study targeting the elderly population (60 years and above) in two rural areas was conducted during the period from March to May 2003.These two areas were Dhayf and Carabigo villages (Ezbet Al-Haj Mahmoud); which are near to Alexandria Governorate.These two villages have approximately similar environmental and socioeconomic conditions except for the presence of some air pollution due to nearby factory and deficiency of some governmental services in Carabigo village.This survey was done during the field training of the High Institute of Public Health (HIPH) aiming at the assessment of Mohamed Mohei El-Din M Makhlouf 329 the environmental, social, and health status of the population of these villages as a preliminary step for their development.Cartographers first mapped the area and identified the target houses.The work was done through a house-to-house survey conducted by trained investigators under the supervision of the staff of HIPH.The areas in the 2 villages were screened and the total number of the houses was determined.
investigated elderly people's ratings of the importance of health-related factors to their selfassessments of health.The results revealed that factors indicating overall functioning/vitality were rated highly by all participants, while factors indicating current disease were rated highly by people reporting poor/fair SRH.Also, several studies have shown that illness related variables are strong predictors of poor SRH.
Figure ( 1) : Distribution of elderly according to self rated health and villages