Approaches to modeling self-rated health in longitudinal studies : best practices and recommendations for multilevel models

Self-rated health (SRH) is an outcome commonly studied by demographers, epidemiologists, and sociologists of health, typically measured using an ordinal scale. SRH is analyzed in cross-sectional and longitudinal studies for both descriptive and inferential purposes, and has been shown to have significant validity with regard to predicting mortality. Despite the wide spread use of this measure, only limited attention is explicitly given to its unique attributes in the case of longitudinal studies. While self-rated health is assumed to represent a latent continuous and dynamic process, SRH is actually measured discretely and asymmetrically. Thus, the validity of methods ignoring the scale of measurement remains questionable. We compare three approaches to modeling SRH with repeated measures over time: linear multilevel models (MLM or LGM), including corrections for non-normality; and marginal and conditional ordered-logit models for longitudinal data. The models are compared using simulated data and illustrated with results from the Health and Retirement Study. We find that marginal and conditional models result in very different interpretations, but that conditional linear and non-linear models result in similar substantive conclusions, albeit with some loss of power in the linear case. In conclusion, we suggest guidelines for modeling self-rated health and similar ordinal outcomes in longitudinal studies.