Reasons behind individuals’ self-ratings of health: an analysis of responses to an open-ended survey question

BACKGROUND: Self-rated health (SRH) is one of the most widely used indicators in population health research, yet the meanings respondents attach to this global item remain insufficiently understood. This study examines how individuals justify their SRH assessments and whether the domains invoked vary systematically by health status and sociodemographic position. The aim was to clarify what respondents mean when they rate their health and to identify patterns in the salience of bodily, psychological, social, and lifestyle-related aspects of health. METHODS: We used a mixed-methods design based on representative survey data that combined a standard SRH item with an open-ended follow-up question asking respondents to explain their rating in their own words. Open responses were coded into thematic health domains and analyzed quantitatively across subgroups defined by age, gender, income, and health status. RESULTS: SRH emerged as a domain-weighted judgment. Acute bodily complaints and chronic conditions were the most common justifications overall, particularly among respondents in poorer health. In contrast, "very good" health ratings were more often linked to emotional well-being, social relations, and broader functioning. Older respondents referred more frequently to chronic disease burden and functional capacity, whereas younger respondents more often emphasized acute symptoms and social relations. Women gave greater weight to affective states and caregiving responsibilities. Higher-income respondents referred less to chronic disease and more to emotional well-being than lower-income respondents. CONCLUSIONS: SRH should be interpreted neither as a purely biomedical indicator nor as a uniformly integrated biopsychosocial assessment. Its meaning is context-dependent and shaped by respondents' health status, social roles, and socioeconomic position. This has implications for the interpretation and comparability of SRH across population groups.